Dr. Bill Fera is a family medicine physician and the Chief Medical Officer of Ernst & Young LLP’s Advisory Health Care practice. With a personal interest in health care quality improvement, he has more than a decade of clinical and information technology leadership experience at academic, community and ambulatory medical centers prior to joining EY. In this interview, he discusses the motivations behind his career path, as well as his views on the importance of implementing and optimizing electronic medical records (EMRs) for quality improvement.
Can you tell me a little bit about your background? Where did you go for your undergraduate studies and what did you major in?
I went to undergrad at the University of Pennsylvania. I was in the Wharton School as well as the College of Arts and Sciences, and received dual degrees in economics and biochemistry.
Why did you choose to go to medical school? Did you have any unique experiences during your medical school that influenced your current career path?
I thought that my first career would actually be in business but I had a series of personal and family health-related crises. As a result, I had a lot of exposure to the medical community and started to develop a passion for medicine. However, I wanted to take the discipline and learning that I got in business school, and apply it to medicine, especially in terms of total quality management and continual quality improvement.
I matriculated at the Medical College of Pennsylvania (now Drexel), and was in the second class of their problem-based learning track. This curriculum gave me exposure to a pilot with the Institute of Health Care Improvement. I was very excited about bringing those quality principles to medicine and thought that it was a complete natural fix. However, I was disappointed to learn that continual quality improvement was very hard to do, because there wasn’t enough data available. I would talk to colleagues who worked in business and they said everything was automated. They could do analyses of anything. But in medicine, I couldn’t tell if we were practicing evidence based medicine in the hospital, or exactly what quality of care we were providing in the practice.
This led me to a path of trying to find ways to acquire data and automate information flow, even if it was just a small project of medication reconciliation using our pharmacy system at our hospital. I later had the opportunity to deploy electronic medical records, in both outpatient and inpatient settings. I actually thought electronic medical records were very difficult to use, and not intuitive, but it was absolutely necessary if we were ever going to get a handle on what was happening in our hospitals and practices. That was the only way that we were going to be able to measure what we were providing in terms of quality, and what we were achieving for our patients.
Why did you choose to pursue family medicine after medical school?
There were probably two main factors. One was just an overall belief that it was the best way to provide medical care to folks at a holistic, family-based level. Getting to know an entire family and everything about them – to understand them as people, appealed to me. If you are taking care of a family unit, you have a much better chance of impacting their overall health by knowing their family dynamics. If, on the other hand, somebody’s already got a disease, and it’s progressed to the point where they’re seeing a specialist, then often times you’re just kind of putting a Band-Aid on things. It’s much harder to stop or reverse things at that point.
Secondly, there was the aspect of adolescent medicine that appealed to me, especially the counseling. Adolescence is when people start making big decisions about drugs or alcohol, smoking, seat belts and sexual health. It just seemed to me that that’s when you could make a big difference in somebody’s life, more so than when they were in their 50s, 60s or 70s. It was about the degree of impact that you could have.
I think that’s when you start making the lifestyle choices, in your exercise and diet, that don’t seem like they’re a big deal. Those habits begin forming during that time.
If we’re seeing someone fairly regularly and they are pre-diabetic, adolescence is when you can stop them, by getting them on a diet and exercise program. There are so many people who don’t understand that you sometimes can actually “cure” your diabetes or prevent it from ever happening in the first place with the proper diet and exercise. I think most people think about diabetes as a disease, that you’ve inherited it and you’re doomed to insulin shots. Whereas if you exercise, lose weight and eat properly, you can very often return to a non-diabetic status.
I think it’s really unfortunate that family medicine isn’t more popular these days because it really is such an important field.
I remember when I was making my decision; I really thought family medicine was going to be the future of medicine, and that everybody would really start to see the benefit of a primary care physician being the “quarterback” of a care team – many of the same concepts that we see today with Patient Centered Medical Homes.. That was when health care reform was on the verge of being passed the first time around in the early ‘90s.
With immense medical school loans, the fee-for-service financial model pushes students into more procedure-based fields. But, hopefully, with these health care reforms, it will get a little better.
It needs to be. We’ve got such a shortage of primary care physicians. Somebody, I can’t remember who it was, but he said, take 80% of the doctors in the US and send them to Africa, and vice versa, and you’d make both systems better. Our reimbursement system really has contributed to an overabundance of specialists and a shortage or primary care doctors.
Could you elaborate a bit on quality measures? I think one of the big problems in health care is maintaining a consistency in the quality of the care that providers give. Are common quality metrics like morbidity and mortality really good measures of health care quality? What I’m really asking is, “What is the quality of common quality measures?”
That’s a great question. Often times the quality measure are really process measures which end up being surrogate measures for the most part. Those are what people chose to measure because that’s what was widely available to collect. The only electronic data that people could reliably draw were admission, discharge and transfer systems, or billing systems. You would get the quality measure of doing a hemoglobin A1C, because that’s all people could measure. But there was nothing in there about what the actual hemoglobin A1C level was – or if it was improving, getting worse, or stable.
Right. For example, for diabetic patients, why is there no data on their medication compliance? How many times did they go to the pharmacy and fill out their prescriptions? Those data points could be important in applying to the bigger clinical picture of health care quality that we’re trying to calculate.
I totally agree, and I think they’re starting to. Ironically, if you went to an insurance company, they have that kind of data, because the member paid for the prescription. If we were to share that information more with the providers, like the way we are starting to see things move with accountable care that will start to create a better picture of somebody’s health.
The first time we tried a managed care approach to health care, it was all based on a financial construct. It actually had to be because that all the data that we had available to track at that time. This time around, we have more clinical data available. As we get more digitized clinical information, we can actually start to collect quality measures in a meaningful way, like you’re suggesting. We need to move away from the surrogate financially based markers and into true clinical markers.
This is from my readings, but I saw that most of the papers about health care quality were talking about morbidity, mortality, readmission rates, etc. But these metrics seem superficial, because they don’t reflect the deeper issues that can account for the quality of health care. However, the deeper issues are difficult to automate, because you know they are not automatable.
If people adopt the electronic medical records more completely, then we will get closer to getting the information that isn’t available right now, to better understand health care quality. When my partner and I began implementing electronic medical records, it was always about quality. We were always benchmarking and reporting back the improvements. We were able to show the improvements once we started measuring.
What did you do after your residency? What kind of work were you doing leading up to your position at EY?
After deploying multiple electronic medical records systems, my partner and I were being asked all the time to consult with vendors or other hospital systems. During that time, I was also on quality boards at the University of Pittsburgh Medical Center and at the UPMC Health Plan. I had great exposure to many large health care systems through this work.
All of those activities ended up creating a lot of competition for my time, and so I eventually began to practice medicine part time. I was doing more strategic consulting in terms of how the electronic medical records and technology would solve business problems.
About five years ago, I was hired by the University of Pittsburgh Medical Center to run their interoperability program, and help launch their consulting business in Europe. I also helped with commercialization of intellectual property through multiple vendor partnerships. With all the travel and the time constraints, I just didn’t think that it was fair to practice medicine anymore. I was a family practice doctor and it wasn’t fair to my patients. It became a big conflict for me, but I eventually decided to stop practicing medicine.
Then about three years ago, when EY was rebuilding its health care practice, I became aware of a potential opportunity there. It was intrigued because I thought it would provide an opportunity to make an impact on a wider scale. . I ended up taking the job to become Chief Medical Officer for in the Advisory Health Care practice.
Can you talk a little bit about your position at EY? What you do on a day-to-day basis?
This actually ties into why EY appealed to me, because it was the only practice that had an integrated payer and provider practice. We have one health care practice, and we’re really focused on getting payers and providers to work more closely together. If you go to most other consulting houses, there are separate payer and provider practices, with separate P&Ls (profit and loss). However, here, we have a totally integrated practice.
On a day-to-day basis, I’ll be working with either payer or provider clients. It’s usually in the context of helping the payers and providers to work better together, to share data better, and build analytic platforms together. We work to create new payment mechanisms that make sense and align around quality. That’s the exciting stuff that I do, and then I have some administrative things that I have to take care of on a daily basis. This work can include helping to monitor the progress of our practice as a whole, or the financials of a specific job. Another fun thing that I get to do is work on leadership materials, such as helping to craft our point of view and our approach to the market, really vocalizing what we’re trying to accomplish as a practice and in the greater scheme of health care reform improvement. I’d say ninety percent of my job is fun and ten percent is the administrative stuff.
How do you think your clinical training and your medical school education play a role in your day-to-day work experiences?
I think having a true appreciation for how difficult it is to be a physician, how difficult it is for payers and providers to find common ground, and how difficult it is to work with these systems. It’s given me a deep understanding that translates into credibility with clients. I have worked in it from both sides.
The other advantage is that I had many roles during my time in practice. I was a medical director at a nursing home. I was president of the medical staff at a rehab hospital. I did house calls. I was a hospice medical director. Not only did I get to see health care from the standpoint of a hospital and a physician’s office, but I also got to see the different spaces, such as skilled nursing facilities and independent living facilities, that are getting to be more and more important. All of those aspects are becoming more crucial with the financial crisis in health care. I was very fortunate that in my practice, I got to experience all of those different types of care.
How do you think your nonclinical career path has created value for you? What value does it add that clinical medicine might not have provided?
You can feel like you don’t have the ability to impact and improve the system when you’re working in a practice or in one hospital system. With my position, there’s an opportunity to impact things on a much broader level. EY has the potential to truly impact the health care system, and help influence the creation of a system that makes more sense.
What is your advice for medical students who are interested in possibly doing the kind of work that you do? How can they get involved?
Look for opportunities in the practice setting and in the hospital setting to do quality improvement projects to be exposed to administration.
Find things that you’re really passionate about. Concentrate on those areas and be open to the other kinds of experiences, and put yourself in a position where you can be involved in those things and see if it’s something that appeals to you. Use your passion to pursue the right career.
When you transitioned from a more traditional clinical path, where things are more set up, to something that was maybe a little less structured, were there any difficulties in that transition?
Depending on who your mentors are or whom you’re surrounded by, people may doubt the more nontraditional paths that you’re taking. You just have to trust your instincts.
When I told the director of my program, who is a fantastic guy, that I was going to pursue a career in consulting around electronic medical records, he said, “Well, once electronic medical records are implemented, then what are you going to do?”
Implementing electronic medical records is just the start of all the improvements that we’re going to make and now we have to do telemedicine, use the information to create whole new payment systems, etc. Electronic medical records are the foundation of it, not the end of it. So take people’s advice and respect them, but also temper their opinions with your own views and beliefs. Just be true to that vision that you have for yourself.
I can’t say it was difficult. I had great support from my wife and family. It was a gradual transition and every step I took made sense. There were some that people would have called a little risky. There’s a leap of faith or two as you pursue a new career that you’re going to have to take.