San Mateo County CIO: The hard part of health IT is information governance

San Mateo County Health System in California may be adjacent to the technology hotbed of Silicon Valley, but you’d be wrong to assume it’s on the cutting edge of health IT. Instead, it has what the system’s chief information officer called a “spaghetti conundrum.”

“We have four electronic health record (EHR) systems,” said CIO Eric Raffin, speaking at the American College of Healthcare Executives (ACHE) Congress in Chicago. “We have two large case management systems. These systems, essentially, don’t interoperate today, and as much as everyone would like to, it is extremely hard to do that and it’s extremely expensive.”

In a public health system where the primary programs are treating Medicaid, uninsured and dual-eligible patients, investment in a new EHR system isn’t coming anytime soon, so Raffin said it needed “stepping stones.” Namely, it needed an information governance strategy.

Raffin said he first tried a simple guide to managing the system’s information by setting a specific vision and principles. It was primarily centered on making info easy to find, access and use so IT resources aren’t going to waste.

That simple management strategy, however, didn’t get any traction.

“It fell flat because it didn’t come with anything else,” Raffin said. “So I decided … I’ve got to find some sort of theme that resonates more, day-to-day, with what we’re doing in San Mateo County with our clients and the environment we work in—and that is where waste management comes into the equation.”

What the system did was adapt the principles of waste management—reduce, recycle and reuse—for its information governance strategy. Since workers within the health system are familiar with that way of thinking by living in a county with laws like a ban on plastic shopping bags, Raffin said this theme stuck with employees.

The three stages, all of which are still in progress, have their own sets of priorities. For the “reduce” phase, for example, Raffin said the system has been focused on eliminating duplication of patient records with a Master Person Index and reducing how the number of applications workers need open or how many mouse clicks they’re performing in order to see a complete patient profile across four separate EHRs.

The “reuse” phase included investing in a health information exchange—something Raffin said had only been approved by the county the morning of his ACHE presentation.

The last phase, “recycle,” is especially important to a public system like San Mateo, where the additional socioeconomic data available from other county departments could help inform care. Eventually, this phase could help the system utilize predictive analytics in the future.

“In order to live in this world, where everyone’s saying you need actionable analytics, you better have a really good framework and understand where all your information is and whether or not you trust all of it,” Raffin said.

The system is making progress on acting on these themes, Raffin said. He now chairs the IT governance board, which has helped institute policies on user registration and readying for HIE.

But the old, disjointed IT principles have continued to create challenges. For example, when the system examined what it could do with race and ethnicity information which may affect its revenue streams, it discovered there were no standardized ethnicity choices for staff to enter at check-in. Instead, workers had typed in over 3,000 distinct ethnicities, ranging from misspellings (e.g., “Europen”) or head-scratching descriptions such as “Exotic.”

It may make for a funny anecdote, but Raffin said it can have a serious impact on the system’s quality reporting.

“If you have, say, 75,000 folks in your potential denominator for performance measure, and then you have 3,000 ethnicity entries (when) you’re trying to report out on ethnicity, guess what you can’t do?” Raffin said. “You can’t have denominator of 75,000 because you have to rule all of this stuff out.”

This happened, Raffin said, because no one had explained the importance of this information to lower-level staff members entering a patient’s ethnicity. The solution will be a new patient registration system which matches up with the new information governance strategy.  

“Really, it wasn’t hard to do the technology parts once we worked out the governance parts first,” Raffin said.