21
Mission Valley Medical Center Physicians Group Practice:
The Rumor
Noorullah Ahktar, Mary Langdon, David O’Brien, and Ron Jimenez
Amid a forest of southern California technology start-ups and dot-coms, a century-old healthcare institution delivers health care to the neediest of Mission Valley’s residents.
Mission Valley Medical Center (MVMC) has managed to maintain an “open door”
policy since 1876. Providing quality medical care under the strict auspices of Mission County’s oversight has left few resources to support clinical information technology (IT). County resources must be used to meet the information needs of about 4,500 county employees, as well as the 200 employees who make up the medical staff, also known as Physicians Group Practice, Inc. (PGP) members. Historically, PGP physician IT needs have been a low priority for MVMC. As a result, in 1998, PGP began to support these needs first by supplying e-mail services, and now it provides a dedicated staff. With some successes, PGP IT found favor with the medical staff by providing a high level of support. Some overlap with MVMC IT functions resulted in a need for negotiation, which resulted in a “memorandum of understanding” (MoU) being written (Appendix 21.1). The MoU attempted to clarify the roles and responsi- bilities of the MVMC IT department and the PGP IT group. The MoU has been useful, but tensions remain between the two IT staffs. Recently rumors have been circulating that MVMC IT and PGP IT staffs will be merged as the result of a near future reor- ganization. The PGP chief operating officer (COO), Paul Hammer, is faced with a dilemma. He faces his governing board with the possibility of his IT staff being absorbed by MVMC IT in order to streamline services and cut costs. His staff is opposed to this measure, particularly because historically, MVMC IT support has been poor for PGP staff.
PGP Organizational Background
MVMC is part of an integrated delivery system, Mission Valley Health System (MVHS), owned and operated by Mission County. MVMC is composed of a 300-bed hospital and extensive outpatient facilities and provides the full spectrum of inpatient tertiary care services. MVHS also supports ambulatory and community health services, public health services, mental health services, alcohol and drug services, and a medical call center that provides nurse triage/advice and scheduling services 24 hours a day, 7 days a week year-round. MVMC serves a population of approximately 2.8 million of varied ethnicity and socioeconomic status.
All the physicians belong to PGP, which came into existence from the hospital’s need to provide billing services for professional services rendered by the medical staff.
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MVMC and PGP are funded solely by Mission County. A PGP board of directors is elected from among the physician staff annually by the physician stockholders who govern PGP.
The PGP
PGP was preceded by a not-for-profit organization known as the Medical Staff Cor- poration (MSC). MSC was organized to support education and research activities at the medical center. In 1966, MSC started providing additional administrative services, including billing Medicare for physician services, providing secretarial services for the physicians at MVMC, and purchasing and administering physician benefits in addition to those they received as Mission County employees. As MSC grew in complexity, it became clear that its not-for-profit status was not the proper legal structure for pro- viding administrative services. To address this deficiency, PGP replaced MSC in 1975.
Although organized as a for-profit organization, PGP has never distributed a profit.
All PGP income comes from the county via an annual budgeting process that allows for reimbursement of only direct operating expenses. PGP has a nominal amount of working capital (approximately $500,000), which is used to cover accounts payable and staff compensation between county disbursements.
In addition to providing a wide range of clinical services, MVMC is a teaching hospital. Even though there is no formally organized academic faculty practice, PGP performs many of the administrative services seen at a teaching institution. PGP has continued to grow in size and complexity and provides MVMC with many additional administrative services, which are described below. PGP has 200 physician stockhold- ers and an administrative staff of 120. The ratio of employees to physicians has dimin- ished over time, indicating increasing staff productivity. PGP staff provide the support required by physicians, who are not only clinicians serving patients, but also teachers of medical students, medical/surgical residents, clinical researchers, and administrators of the various departments and divisions of the medical center.
Services provided by PGP include the following:
1. Provide support staff and management for physician shareholders and MVMC clinical departments.
• Management of supplies and services
• Physician recruitment
• Preparation for accreditation surveys, including JCAHO
• Program planning
• Marketing
• Management of physical space
• MVMC contract management (agreements for services)
• Intra- and interdepartmental communications
• Scheduling of physicians and patients
• Liaison with all MVMC departments
• Medical secretarial support
• Residency program coordination
• Support of continuing medical education programs, research, and educational grants
2. Billing, collecting, and reporting of MVMC physicians’ services.
• Acts as MVMC’s billing agent for professional services
• Provides management reports to chairs and chiefs of clinical departments and divisions
• Reports to the patient business services department of MVMC information regarding physician professional services
• Purchase and administration of physician benefits 3. Provision of IT via PGP IT services (PGP IT).
In 1996, PGP hired a new COO, Paul Hammer, who quickly became aware of the division between physicians and MVMC IT. Based on what he heard from doctors, as well as direct observation of the MVMC IT department, he was not confident that MVMC IT in its then-current form could take care of the IT needs of physicians.
He soon learned that MVMC IT services had historically neglected doctors, had not been interested in them, had not viewed them as customers, and had said, “The IT personnel at all levels did not have an understanding of the nature of medical practice either in a hospital or a medical practice.”
However, that level of understanding may be maturing. Rupert Silas, MVMC CIO, recently joined MVHS and has made advances on many fronts for nonphysician issues but recognizes the need for an increased role of MVMC IT adopting physicians in the larger context of customer service to the organization as a whole.
Two years ago Mr. Hammer and the PGP business office manager discussed the opportunity to consolidate the billing/collection functions of PGP (which consist of 25 percent of PGP’s work) with MVMC billing/collection. He knew that, as the COO of PGP, part of his role was to come up with an alternative to the business office (i.e., billing/collection) as an important and “visibly valuable” reason for the continued exis- tence of PGP.
Thus, Mr. Hammer proposed to various committees and individuals, including the newly formed medical informatics committee of the organized medical staff, the MVMC IT service, the hospital director, and finally the PGP board of directors, that PGP take on the task of developing an IT service for member doctors only. All the major stakeholders approved of this proposal, and Mr. Hammer responded by hiring a consulting firm to create a strategic plan for the new vision for the PGP IT staff. The plan would include a strategy for integrating the PGP billing/collection services with the appropriate counterpart at MVMC. This is scheduled to occur over the next 1 to 2 years. When the merger occurs, many of the smaller-scale functions that PGP billing provides will likely disappear.
PGP’s recent implementation of PGP IT services grew out of the increasing infor- mation needs of the physicians. MVMC recently began installing a new core informa- tion system that would permit physician access to the system from their desktops rather than at common workstations. This improved functionality has increased physician pro- ductivity and satisfaction. Unfortunately, the information services department (ISD) of MVMC often failed to provide physicians with the needed hardware and support to facilitate this transition. Because of increasing physician dissatisfaction, PGP’s board of directors instructed PGP to provide these services directly to physicians. This has led to increased tensions between the PGP IT and MVMC IT services.
This controversy led to the aforementioned MoU that delineates the roles of PGP IT services and MVMC IT. Since PGP IT is based in PGP, physicians believe that they now have a stronger voice in meeting their information needs. In addition, the MVMC chief medical officer of the hospital has provided PGP with political support in its efforts to provide a personal computer (PC) on every physician’s desktop. PGP IT has grown quickly and now has its own help desk.
The IT Environment
From the point of view of the MVMC staff physicians, MVMC IT has not proven itself to be an asset to patient care. The reason for this is that the core attending staff, PGP members, historically have been poorly supported in the area of IT by MVMC. PGP has filled the void and has begun to extend the scope of its services to the physician staff at MVMC to include IT support.
Physician involvement in IT projects has grown over the years. Two-and-one-half years ago, a physician liaison was hired at MVMC IT to bridge the chasm between the IT department and the clinical staff. The medical informatics committee of the medical staff serves as a vehicle for dialog through its quarterly meetings. Recent issues of dis- cussion have included policy on the use of electronic signature and the impact of the Health Insurance Portability and Accountability Act (HIPAA) on clinical practice. In addition, PGP hosts a weekly IT advisory group meeting to further discuss issues of IT support from the point of view of the physician. Its membership includes PGP physi- cians, PGP COO Paul Hammer, the PGP IT chief, and representatives from the PGP administrative support staff.
With all that has been accomplished by the larger organization, still less than half of the PGP physician staff have ready access to PCs at their desks. Common workstations remain the main venue for physician access to the core clinical systems and to e-mail.
The PGP IT six-member team is in the process of assessing the PC and cabling needs of the remaining PGP physicians who do not have desktop PCs.
One of the significant functions PGP has performed is providing the clinical staff with Internet access and e-mail capability. With the successful implementation of e-mail services, PGP clinical staff are looking forward to PGP IT providing more advanced services such as support for wireless network access and funding for acquir- ing a group software license for online clinical knowledge management services.
PGP doctors see these tools, and perhaps others as they are developed in the future, as being essential in the years to come to assist with providing more efficient, com- prehensive, safer patient care; keeping up with and maintaining the standard of care that is evolving in the private and university sectors in the region; assisting with ongoing research projects; improving the functioning of MVMC in an increasingly competitive healthcare environment; and enhancing the image of MVMC.
The Rumor
Of late, rumors have emerged indicating there may be a movement afoot for the hos- pital IT department and the PGP IT department to merge. A view has been expressed by some hospital executives questioning the rationale for the existence of PGP IT serv- ices at all. PGP doctors are extremely concerned that the small gains obtained through the help and support of PGP IT will be lost if PGP IT were dismantled. Although the MoU was signed with the intent to clearly define IT responsibilities, a few points are vague enough to have the doctors feeling that PGP IT services could become sub- servient to the IT needs of the hospital.
Opinions differ among the medical staff. One PGP physician, an internist and a member of the physician council for implementation, claims, “PGP physicians have functioned without any elaborate information technology for a long time and have learned to get patient-related information through other sources. Even if the merger of the two results in less IT support, physicians will still be able to get the same infor- mation through other means and provide the same level of care.”
A core group of doctors has met with the PGP IT advisory group and Mr. Hammer to express their concerns. They know the advisory group and Mr. Hammer are both strong advocates for PGP IT. The doctors anticipate that the advisory group and Mr.
Hammer will be against the merger and want the doctors’ support. The PGP doctors want Mr. Hammer to act proactively to pursue the rumor to verify or refute it. If the rumor is substantiated, the doctors will press Mr. Hammer to fight any attempt for PGP’s IT services to become subservient in any way to hospital IT services.
Mr. Hammer is also aware of how the rumor is affecting his own IT staff at PGP.
The manager of IT services, who reports to him, is quite clear that he will resign should the merger occur. One technician and an administrative assistant may also leave. Other non-IT services PGP staff have become very nervous as well.
Question
What should Paul Hammer do?
Analysis
1. Distrust and communication breakdown. This is the prime issue between PGP IT and MVMC IT, as well as between PGP physicians and MVMC IT. There is a long history of apparent neglect of the IT needs of PGP physicians by MVMC IT. Regard- less of the facts, the important point is the strong perception on the part of PGP physi- cians that they have been (and will continue to be) treated as second-class citizens in the IT realm. While both parties are aware of this issue and a MoU has been gener- ated, there is still an undercurrent of deep skepticism beneath the surface. This distrust has resulted in a further communication breakdown between PGP IT and MVMC IT.
2. Survival of PGP as a relatively autonomous body within the MVMC system. Dis- trust and a communication breakdown have created paranoia, to a certain extent, about PGP’s survival as a strong physician representative and advocacy group. Rumors of a merger between the respective IT departments have heightened this sense of vulner- ability. This stems from the fact that historically PGP was separated from the rest of MVMC because its billing operations were handled by PGP IT. Now that these oper- ations are being merged, a certain influential faction of PGP physicians feels that diverting the PGP IT functions to solely serve and represent their growing IT demands (and thus keeping it separate) will not only ensure committed IT service but will also continue to give it leverage and a voice within the MVMC system.
3. Technological issues. Regardless of PGP and its IT department’s preference for maintaining as much autonomy as possible, it is the MVMC IT that provides the fun- damental network backbone. And it is MVMC IT that PGP IT will need to depend on to invest in and expand this infrastructure. The choice of hardware and software com- ponents for PGP functions depends on this irrevocable tie. It is regarding this vital tech- nological aspect that dialog appears to have been inadequate.
Epilogue
Rumors of a merger between the IT factions of MVMC and PGP turned out to have more than a grain of truth. In the 2 years since the case was written, PGP was dissolved by Mission County and all former PGP functions, including management of IT resources in support of the physician staff of MVMC were assumed by MVHS infor-
mation services. The PGP COO, Paul Hammer, resigned, as did the PGP chief of IT.
The balance of the PGP employees, those in both administrative and IT roles, were absorbed into the MVMC ranks at equal status.
The customer service orientation of the MVMC CIO and his execution on the MoU with the physician staff, then under PGP, proved to be the right approach to convinc- ing the medical staff to accept direct IT support services from MVMC information services. In fact, many physicians noticed a dramatic positive change as physicians used desktop control and permission to install software replaced the fully locked-down con- figuration of the former PGP desktop standard.
The dissolution of PGP ultimately served to improve overall IT support for the medical staff of MVMC.
Appendix 21.1 PGP/MVMC Memorandum of Understanding Between the PGP Information Systems Department and the MVMC Information Systems Group
The Mission Valley health and hospital system information service department is a department of the Mission Valley health system (or enterprise), which owns, operates and maintains the Enterprise information systems, networking, computing and data communications infrastructure. This infrastructure is used by PGP, Inc. PGP, Inc. is a private corporation owned by a majority of the employed physicians at MVMC. PGP IS provides insurance billing services to the county and to the clinical departments of which they are members. These support services include information systems and technology services.
This MoU defines the responsibilities of the MVMC and PGP information services.
Definitions
PGP-supported PC
A personal computer used exclusively by a PGP employee or a PGP physician in his or her primary office.
Non-PGP-supported PC
A personal computer used by a county employee in a shared workspace and supported by MVMC information services.
Identification of Equipment
All PGP-supported PCs, printers, and other peripherals are identified by an affixed label on which is printed “PGP IS.”
Responsibilities of PGP IS
1. Exercise the sole administration of user accounts in the HHS domain, including adding, deleting, and modifying user accounts.
2. Exercise primary control over, and the maintenance of, all PGP servers and other equipment.
3. Manage and control installation, upgrading and maintenance of all software applications of PGP servers and PCs.
4. Install additional PGP servers in order to accommodate business growth and technical advancement.
5. Provide a help desk and other technical user support.
6. Adhere to MVMC IS standards and policies.
7. Notify MVMC IS in a timely manner when server or global PC issues arise.
8. Participate in the planning and execution of upgrading servers.
9. Participate in the planning and execution of software upgrades.
Responsibilities of MVMC IS
1. Execute its duties in support of the MVMC mission effectively and efficiently in collaboration with its partners of which PGP is one.
2. Allow PGP unlimited and uninterrupted access to its servers and domains.
3. Provide requisite data communications support and network access.
4. Coordinate with the PGP IS help desk on work order requests.
5. Provide PGP IS with space sufficient out carry out its mission.
6. Notify PGP IS in a timely manner when server or global PC issues arise.
