Episode 125: How to Lead IT Transformations in Community Health

Coffee with Coker is a healthcare business podcast from the Coker Group that focuses on solutions to help healthcare organizations effectively navigate the changing healthcare industry landscape. Welcome back to Coffee with Coker. This is Gabriel Harry, Vice President, IT Operations here at the Coker Group. I have with me Tim Harper, Senior Manager and PMO extraordinaire, and we're honored to have with us as our guest, Gary Noseworthy, CEO of Community Health Access Network or we like to refer to them as CHAN.

Gary, welcome to the show. Thank you, Gabriel. It's a pleasure to be here. So today we'll just have a brief discussion on some of the projects that we've worked with CHAN over the last two and a half years.

But Gary, I'd like to pause and give you an opportunity to introduce yourself and give us a little bit of background on Community Health Access Network or CHAN. Sure. Thank you, Gabriel. But, it turns out that, I've only been with CHAN two and a half years.

And at the beginning of my tenure, this project was a month old that we've been working on. But for background with CHAN, CHAN has been, as we like to say, modernizing healthcare information technology solutions for community health centers since 1995. CHAN was founded by, principally, by two FQHCs, in southeastern New Hampshire. And we resided in a space occupied, we occupied a space by one of those FQHCs in Newmarket, New Hampshire for the last 28 years, except until last year where we were forced to move due to a flood.

During that time, CHAN has established a collection of health centers through our HRSA grant, 29 health centers from Texas to Minnesota to Vermont, New Hampshire. And now eight of those health centers are participating with CHAN in support of the Athena One EHR. This has been a big transformation, even in the time since I've been here. We were previously on the Athena Centricity products for six health centers, and we've added a few in this process.

Great. Thanks so much for that background, Gary. Yeah, I remember when we kicked this project off, how excited both Tim and I were to be working with you and just really getting to flex our muscles in the FQHC and CHC market, knowing that you all have some very unique requirements as it relates to some of your compliance and regulations that are a little bit different than private practices out in the marketplace. And I think we were initially charged to help support your vendor vetting initiative to really find out exactly which vendors in the marketplace were really front runners or trendsetters in the FQHC and CHC marketplace.

And with that, I think we were able to identify a handful of qualified vendors to help you make your selection. And move forward from there, and just holistically looking at the project, it just continue to evolve through our vendor vetting operational assessments. Even partnering with you all through your implementation of your selected software systems, through supporting CHAN as well as your health centers in terms of getting prepared for, your transition as well as through go live and post go live optimization.

So, I really like to kind of start from the beginning and really find out just understand from your perspective. How important was it for you to have each vendor in your selection process? Respond to the unique requirements for your FQHC and Community Health Center. I think that was a very important step.

It allowed us to compare and contrast, of course, what the various vendors had to offer. We were coming into this, as I mentioned earlier, from the Athena Centricity product. It was an on premise solution that CHAN managed for, at that time, the six health centers who were participating, and just to see what was offered. By in particular NexGen or Athena or Epic, I think eClinical Works was part of this process as well.

It gave us a very good understanding of what was out there and contrasting against the on premise solution that we were already using. It also allowed the health centers to better understand the differences between them and having the documented quotes and participation of the various vendors allowed us to go back and negotiate and leverage certain features and whatnot that the health centers felt that they needed to have. But I think it was a very important element of this entire project.

Yeah, definitely. Giving us the ability to compare and contrast solutions versus the way in which software was developed and implemented into different strategies across those vendors. The unique service offerings, as you mentioned, are definitely items that need to be considered when looking at vendors in the marketplace. And you did touch on some of the negotiation advantages and having those in writing from each of those vendors.

Were you able to identify any advantages that you gained by having them put those responses in writing so that you could hold them accountable throughout the process? Absolutely. It's like anything, if you're buying something, you want as many quotes as you can to make an informed decision. And in this case, having them in writing to compare and contrast just amongst us, as we're going through the process of evaluating them turned out to be very important.

And, of course, different health centers had different requirements. Some had leanings in a certain way, but when it came down to comparing technically, which we could see from their proposals, there was a lot of intersection between all of the offerors, the vendors who we looked at. And really discriminating factor was cost and having that all documented and written down to identify that intersection, look at that intersection of feature sets and then compare and contrast cost.

It's pretty hard to get away from that and that we could then use those pieces of information in our negotiations with the individual vendors. And we pretty quickly boiled it down to two leading contenders, and ultimately it became a shoot off between those two contenders. Yeah, we love those shoot out scenarios. So, as a health center controlled network, CHAN is a service provider to your health center members.

And, obviously, your abilities to provide them with supplementary services to your vendors, very important, to the overall relationship and that is very important because of the fact that you are looked at as almost the traffic police in terms of how things operate between the needs of your health centers and your vendor of choice. Strategically, what were some of the objectives that you were looking to seek with the partner that you selected for to support your health center members?

For my chair, it was important to know that we had a true strategic partnership with the vendor that it was in their best interest to help us expand the number of health centers that were participating with that vendor solution. We ended up with Athena and Athena One, and I believe they're actively engaged in helping us grow and expand the network. Of health centers that are using Athena one, and we've already seen results of that, and it truly felt like it was more of an interest in FQHCs in the community than we saw in other competing vendors.

But indeed, I would have to say that Athena has been a good strategic partner for CHAN, and it was the right decision from that regard. Yeah, the, the partnership in terms of growth strategy, we do know that they say in the market, FQHCs kind of roll in packs. Right? So you treat one good, the word spreads, you mistreat another, the word also spreads.

And we've definitely played a significant part in supporting the growth of CHAN, along with Athena's partnership in that. And I think that's a great attribute in terms of Athena's being able to work with you, achieving those objectives. As we talk about FQs and in the world for nonprofits, there's a saying, no margin, no mission, which reminds leadership such as yourself that fiscal responsibility is a requirement for keeping the lights on. How do you see CHAN assisting their health center members to achieve their financial goals as they partner with your services?

It's the power of a cooperative at play. Where we have a number of health centers participating, but individually, none of them could have afforded the cost of going with a particular vendor solution for an EHR. And really, that's a key role of an HCCN in general, as set up by HRSA to help gain economies of scale for HIT solutions like this. So, our relationship with Athena allows us to bring a good pricing model, that's something that's palatable by each of the health centers who are participating.

And with that, are there some other connected services that we can deliver in other offerings that otherwise they would have to do separately and wouldn't be seeing the cost benefit over the economy of scale that they can get through working with CHAN. Great. So, switching gears into looking at how we prepared for implementation, which my colleague here, Tim Harper led, really want to look at the process of really determining what were the unique requirements of each of the health centers.

With community health centers and FQHCs all rolling up to your centralized support, there were. Definitely some unique requirements as each one of them were going to be on boarded while they all have the same requirements from a compliance perspective. They are unique in terms of how they deploy services. Tim was able to parachute in and come down, or I should say come up since we're down here in Georgia, you're up in the Northeast and participate in some of those assessments.

So, Tim, what do you, in terms of your access to the health centers, did you see the importance of being able to perform those individual assessments that you went out there and performed. As we went through vendor vetting at, at that level? You're looking at high level requirements that each of the health centers, uh, it's important each of those health centers. So there's a baseline assumption that, okay, we have some, uh, commonality of need.

When we go in to do the practice assessments, we really start getting, uh, a peek behind the closed doors in terms of, um, the unique operations. Excuse me, rolling packs. They all like any health center. They all have different cultures.

They all have different teams, different skill sets, different things that are important to them. Part of what we tried to do when we went in to do these assessments was identifying inventory with the commonalities are identify some of the risks that we knew we were going to have to mitigate. And then identify the areas where there was differentiation and there was a unique need within each of these health centers. And we discovered quite a few of them.

So we leveraged that information to help inform our strategy going into the implementation. It was a critical step for us and I also think we learned a great deal through that process. Yeah, I would agree with that, Tim. I would say that the Coker Group's participation in this was critical to the success.

It was comforting to me to see the vast experience you brought with Athena and with other competing vendors understood this process and what the health centers would need to move through it. You were able to help us not just with the health centers, but looking at CHAN's own staff and assigning people to roles and jobs. And in the end, I think that was one of the most important things about the process, identifying those people who are leaders and who had technical strengths and so forth.

And you guys were critical to that fortune. It was selfishly one of the intrinsic rewards I get from this work is exactly what you touched on there. I've been lucky enough to be in a position to, to lead transformations, but the thing that amazes me is, regardless of the organization, there's always genius there. And what I mean by genius is there's always a resource that is biased to process, biased to action, good understanding of the holistic organization and how it works.

And in going through a disruptive process like this, it's a great opportunity to realign, discover that talent that you have in inventory and create the opportunity for people to really advance. So for me, I truly appreciate the opportunity to get in there, The trust that was given in the reward of discovering the genius that you have at CHAN. You know, we do indeed. And one of the great rewards for me is to see some of the people who've climbed through the water column very quickly, who are working in different things at CHAN when I came, but have really blossomed and seeing them come forth and take a lead and show humble confidence.

As they're moving forward, it's been very rewarding and I have to credit the group with helping us identify those people and bring them to the fore and that's paying off for us now, because we're getting those compliments for those people and their actions from our health centers. Oh, wow. That's wonderful. It's great to hear It is, it is.

Tim, you were speaking earlier about this, I refer to it as the intersection, but this set of common things that the health centers have often, they would like to portray that they're all very different. I've heard this, not just in this industry, but in other industries. Oh, we're all so different, this solution isn't going to apply to us. There is a very large intersection of features and things that need to be done or offered by a system like this.

very much. But it is the, the unique things for each health center that can really trip up the process is almost the exception work. Right? And it requires some very special attention because some of those things are critically important to the workflows and the success of a health center, but yet they're, they're seen only there.

But the set of those is much smaller than the set of intersection of commonalities that they have. In terms of implementation, the optimization, the things we went through when we came back with the assessments, we boiled those down into an implementation strategy. And at the beginning of the project, identifying the specific outcomes for the project, when you first read the implementation plan. What percentage of success would you have given us?

Sixty, seventy percent. It's a tall mountain to climb, I felt. And largely, because of the previous subject we were on, there were many of these unique things, and the health centers felt that those things dominated how this should go, rather than trying to leverage that large set of intersections. But I thought this is almost a bridge too far given the skill sets of CHAN's staff.

We've repurposed and found some true gems that have come to the top as I said earlier, as well as the health centers. And again, I had at that point, I'd only been here a year and plus when we were embarking on this and had those assessments. And I thought, Oh, I'm not sure what the work stream manager set from the health centers is going to look like here. I think the success of it, from my perspective, then was all about the people and the skill sets, both at CHAN and the health centers.

Yeah, fundamentally, at the end of the day, it does really boil down to exactly that. We plan, we identify the risks, we mitigate where we can, but we have to be nimble. If we don't manage the escalations and address the things that come out of left field, the unknown unknowns. And we were, when I look back and reflect on it, I remember at the beginning of the year thinking, my God, there's some technology that's going to be sunset on, you know, 12-31-2023, we best get this thing implemented.

And I know that was my charge and it was important for all of you. And I'm so grateful that the CHAN staff, I mean, everybody stepped up, everybody stepped up and it was and it was important that we had times where it was clear we needed to shore up the skill sets and expertise by others we didn't have. And on more than one occasion, Gabriel and I had conversations about how are we going to get this skill set and you delivered them and the people were always top notch and they complimented and supplemented CHAN's skill sets as well as the health center skill sets.

Very smartly. And without that, there would have been a lot more stumbling through the implementations, I truly believe. And it helped stabilize health centers and CHAN and Athena as we went through the process. It's interesting, just reflecting back on those assessments, you learned so much.

Just through the listening process, those assessments mean being able to identify the skill sets, the unique cultures within each center. It really does. It makes an extraordinary difference in your ability to quickly assess what needs to happen, where the disconnect might be. What are the skill sets we're bringing to the forefront and where the gaps and I can't think of another example where we had 19 years on the same system.

We had such a wide need in transformation, I think, in these sort of opportunities, these transformational opportunities, there's such an incredible opportunity to push people, identify that next skill set to reinforce the value proposition that you're making and align that strategically. And I'm grateful you had the appetite for all of that, especially you were new to the position within a month of coming on. Pretty extraordinary. You use the word culture that I had an interesting experience yesterday.

I visited one of our health centers who has numerous sites. And the CEO was showing us around and a couple of times he mentioned how from site to site, the culture is different, even within that health center, how they view and interpret and use Athena one is different as a result. And that's one health center with mixed culture in this regard. It remains a challenge for us to balance all of those things.

It's something that's pretty hard at the outset of a project and discovery process to identify how do we address these different cultures and how are they going to come into play in the implementation and then post implementation in the longer term use of the product. So, would you characterize your concerns regarding CHAN's future operations? It really is going to hinge now on expanding the number of health centers that are participating with us. With Athena one, it has brought about a transformation to CHAN.

And it's business model and financial model. Previously, we did some work that I would describe as just pass through work, but it was helpful as our work as an HCCN to support the health centers, but less and less, we're able to do that in a meaningful way because of the new financial model that we had to put in place, but I think it's largely driven now by adding more health centers to the collaborative. So just reflecting on the project team, the organization governance structure that we put in place.

How did this contribute or detract from project success? I think, as I've described earlier, it certainly helped us to have your guidance and your experience. And in doing so many of these for different vendors and different systems in the past. And I think having a third party come in to lead something like this is very important for the health centers as well as CHAN and how CHAN is viewed by the health centers and why it's constructed.

But I think in terms of overall governance, you led us through a lot of that. And what would be necessary for success, not only during the lead up to go live implementation, but post implementation, it was certainly helpful because it brought such awareness on the changes from the old the use of the old system to the new system and helping identify what it is the health center was going to be responsible for. What Athena would be responsible for and then what CHAN would be responsible for post implementation.

And that's really a work in progress that continues to change regularly as we identify what health center has what capability, what they're willing to take the lead on and control. And we're still working to converge to the right answer on that. And I'm not sure we ever fully converge because these changes will come and go as health centers change staff and might need extra support and shoring up. But I would say that those are central to the, to the whole process in terms of governance and management of the project.

Again, great opportunities, very disruptive transformations in the organization again, comes back to the people at the end of the day, their willingness to really dive in, adopt, adapt. And the interesting thing is that we have common EHR that can manage a number of these different practices. There's enough commonality there, and there's enough leeway within these EHRs that they can erect the guardrails on the road and keep people from careening in the ditches. It's a great, great space that we're in right now is that I would almost argue that we're getting to a point of commoditization in these EHRs.

And as you guys mentioned earlier and discussed some of the risk associated with any of the projects that, that we would have, we talked some about the internal risks such as our culture, the merging of cultures, the resource allocation, the knowledge transfer, but just to set a backdrop, we had multiple phases that we had to get these several health centers Implemented within a specific timeline and that coordination of resources internally and externally added a different level of pressure.

So, when we talk about the risk, identifying, mitigating and managing the risk anticipated with these projects. How would you describe Coker and CHAN's ability to address those issues? Those that were realized and those were unrealized? I would answer that by going back to a previous comment that I made.

That you brought just in time skill sets to us, because for me, it was about what did CHAN have a skill sets to address a project of this magnitude and you were able to quickly fill in and mitigate that risk of having the people available who needed what I would describe as exquisite skill sets that needed to be brought in, but they weren't the kind of skill sets that we would retain long term. Kind of a classical vendor contractor relationship in that regard, and that to me was the leading concern and you guys helped relieve me of that very quickly when those issues came up.

We greatly appreciate the confidence that you had in us and our abilities to help lead and charter these unnavigated waters for CHAN. I think I know the answer to this, but I'll ask it anyway because you may have touched on it earlier, but what was your greatest surprise that came from this project? The people on CHAN's staff who bubbled to the top. I, as I said, I hadn't been here all that long.

I didn't have a chance to learn and understand where their skill sets were. Um, and I did realize we needed more skill sets in areas that we didn't, but there have been people who have just done marvelously. They've come forth, they've taken responsibility, led work streams, and it's shown brightly and have their level of visibility and respect with the health centers has just gone off exponentially. And that's very rewarding to see.

At that same health center I was visiting yesterday, I heard repeatedly how wonderful CHAN's staff have been in helping them get through this and cited some of the folks by name who I'm thinking of as I described this to you. Yeah, and that's been my greatest satisfaction hearing about that. I thought you would say that. And in my experience over the last 15 or so years, working with FQs, one of the things that I notice is how wonderful Devoted to the community FQ leadership are staff and resources willing to roll up their sleeves because the passion that's required to support the communities that you all service is definitely a job requirement in those health centers.

And I will say, observing from afar, knowing the challenges that you all would be faced with. I don't think there was one health center that didn't have those type of characteristics that were brought to the table from the willingness to just get in there. Dive in head first, make sure the problems are solved, address issues, whether they were, they were new or foreign. That dedication to your community was definitely recognized throughout this project and I know your communities are blessed to have you all supporting them.

Yeah, I definitely thought you were going to say the people and I guess I was right there. Indeed. So, Gary, if you could change one thing in that project, what would it be? I would have pumped the brakes.

I would have pumped the brakes very early going, we embarked on this project with not much by way of budget or plan or legal instruments between the parties. And I, what I didn't describe earlier is in my background, I've had ample experience in executive leadership with enterprise legacy migrations in the health space, but in other industries as well. And I realized very quickly. This is going to be expensive, and this is way outside of what I see is available in CHAN's budget and the skill sets, but you guys help bail us out on those.

As I've said, and we had to do some reorganization of the staff that we had in order to focus skill sets and leverage the ones that we did have. But I would have slowed this down a little bit, even though we were under pressure that the legacy system, there were some sun setting potentials out there. And, and we've managed to get through that, but I would have asked that everybody just take a breath here and take a little bit extra time to plan this out because a lot happened in a very compressed period of time.

One thing I didn't see. And I should have was that we would have to redo CHAN would have to completely overhaul its financial model. And we did that on the fly while we were negotiating the contract with Athena, once we had, the group had decided, you know, to start working with Athena. And that was pretty tricky.

And we find ourselves modifying our financial model as we go through this now, because that was done very fast. I would have slowed it down. Yeah, and, and, and speaking to that, I think of Athena's delivery models, I think is what caused that requirement to adjust your financial model, their co sourced model, which going back to the vendor vetting, it was one of the unique characteristics that we saw and stood out with the partnership with Athena. It was a base requirement just for partnering with them to show the value for the services that they co source with CHAN as well as the health centers to provide you all the services at a lower up front cost so now that, uh, implementations over we've optimized and continue to optimize, uh, your environments, CHAN has definitely built up its internal team.

So. Since transition from the level of support that we provide, you all took those proverbial training wheels off and allow you all to coast independently. I guess now CHAN's next project or strategy is in the form of growth. Right now that we have the tools, the resources, the support you need to provide your existing members the solutions that they need to continue to serve their communities.

It's now time to look forward to the horizon and see how CHAN can grow and partner with other members in the FQ space. And with that being said, what economies of scale can health centers gain by partnering with your access network? Your HCCN? I would refer back to something I said earlier, and that is leveraging the CHAN multi entity organization agreement with Athena and the pricing that comes with that.

That otherwise they couldn't possibly achieve going in on their own. And for CHAN, this allows the basis of our financial model that this requires us to grow and add additional health centers. In fact, the process, the RFP process that we went through, there were 10 participating health centers, all FQHCs. In that process, ultimately, seven of them decided to move forward with us in Athena one.

Since that time, an additional health center has come forth. It's a lookalike, not an FQHC, and we are underway, adding them to the system. They were a non Athena user. They use EMD, and that's really a great model for how we can grow.

We've used the data that you helped us collect. And for feedback on what we can bring to bear, these are the pitfalls to watch out for. And so far, all of that has worked out very well. That health center should have its go live in September of this year.

And there are some others on the horizon. Some brought to us by Athena to consider to bring into the fold. And that's exciting, but separate from the Athena piece of our business. It's my responsibility to grow CHAN and some other areas, and it's really leveraging off what Athena 1 brings.

My CIO is developing a line of business around managed services, and my senior director of data and analytics is looking to build out a line of business around that, leveraging some of the existing technology that's connected with with Athena one. So these are exciting. These are new things and it's a different way to look at an HCCN and it's almost part of group purchasing organization that health centers can turn to CHAN and find some offerings that we can bring to them so they can get some economies of scale instead of going at their own on their own with their own individual IT support people that they might hire and multi year contracts and so forth.

CHAN has principally a strong collection of it. Uh, expertise, and we can bring that to bear for them in the I. T. Space sounds like you're creating a one stop shop there for, uh, health centers.

And so, yeah, to engage with you, congratulations on the additional health center joining your network. Think a round of applause is warranted Who's leading that onboarding, Gary? CHAN's doing it. CHAN's doing it.

That's right. That's right. The training wheels are off. They're guiding by themselves.

That's right. We're able to do that because you helped train us to do that. And you continue to be patient and understanding working with us. And anytime I call any of you for help and guidance and support.

Always there, and I'm truly grateful for that. I can tell you going into these projects. Having a leader with the time and grade you've had your willingness, your understanding of the interactions, the organizational dynamics, an intrinsic understanding of when you need to step in where we can leverage you for help. I think that was 1 of the critical success factors.

Um, and the reason that we can observe the success that CHAN has had is because of not only your leadership, but the people that were willing to step in, learn, adopt and adapt, but we were going through. So that was phenomenal. Thank you for that. I would second that and your leadership was very much recognized throughout the whole process.

And always a pleasure working with you, Gary. Um, I think this would be a relationship that will exist for days and years and decades moving forward. With or without an implementation on the horizon. I agree.

In closing, how can health centers engage with you if they're looking to seek partnerships as you're looking to grow yourself and other health centers are looking for opportunities to reduce costs, take advantage of the economies of scale, improve support, meet the requirements, the rigorous governmental and state and federal regulatory requirements. How do they engage with Gary and CHAN to seek partnerships with you? They simply reach out to us, and Athena has been also very important in referencing health centers, FQHCs, or look alikes in our direction to build out this CHAN Collaborative around Athena One.

You can find us on the web. You can contact me. My information is out there. You can, again, even work it through Athena and so forth, and our health centers now, those who are maturing in the process.

They're also becoming kind of reference accounts and making awareness of what the opportunity is, which is very important because success will just build on success. Hopefully that's something that will go exponentially as we march through these. They don't need any special contract per se, other than whatever it is that they need. We can build it under our existing multi entity organization agreement with Athena for Athena 1.

For those products, there would be some separate contracts for the individual health center, of course. To bind us together as part of that MEO agreement, but if they want other services, whether they'd be the IT managed services or data and analytics, just simply reach out. We have a partnership agreements that we've had established for many years with our health centers. They're called member agreements, and that's all being revised now, too, as a result of introducing Athena 1 into the mix.

That's the short way. Simply reach out to us. And Gary does pick up his phones. So do you we've had a lot of early morning and late night chats.

Oh, yeah. Oh, yeah. Throughout this. Thank you for that.

Thank you. I think I learned as much in every one of these engagements as everyone else. I love this aspect of it and it was an absolute pleasure working with you and your team. And I look forward to seeing what's next on the horizon for CHAN.

Thank you, Tim. So do I. We're also here if you need us, we're just a phone call away, but Gary, it was definitely an honor and privilege having you on our podcast today, definitely looking forward to continuing to work with you and all the best of luck with Community Health Access Network, also known as CHAN. Thank you.

You look forward to your growth and success as you continue to grow. And I'm looking forward to speaking with you soon. It was my pleasure. We hope you enjoyed that episode of Coffee with Coker, and we thank you for listening.

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