HIStalk Interviews Howard Landa MD, CMIO, Alameda County Medical Center

Howard Landa MD is CMIO at Alameda County Medical Center of Oakland, CA and vice chairman at AMDIS.

 

Give me some background about yourself and about the medical center.

I got involved with informatics almost out of residency. I started putting a patient list on Lotus 1-2-3 back in the 80s. I really got involved formally in the mid 90s when I was at Loma Linda. We had a great CIO. I talked to him about how the systems didn’t work, so he put me on a committee to fix it. We had three physicians. Basically, I said, “Your system sucks” and he said, “No, your system sucks … here you go.” 

We did an evaluation and we chose Cerner. We implemented Cerner in the mid to late 90s. I left there in 2001 and started working for Kaiser in Hawaii. I’m a pediatric urologist, so I did pediatric urology for them part time and got involved with their implementation of a Kaiser’s homegrown solution at that time, which lasted a few years. It really wasn’t a great product. 

When George Halvorson became the CEO of Kaiser, which I think was in 2003, he looked around and said, “We’re a medical company. We’re not a software company. We should take care of patients and let somebody else design software.” We decided to implement Epic. 

I was one of the lead physicians implementing Kaiser’s first ambulatory attempt for Epic in 2004. That went very well and then I became CMIO in 2005. For five years, we finished up the ambulatory implementation and went live with practice management and inpatient.  

As we were finishing up, I started looking around for something else to do. Alameda reached out to me even before Meaningful Use was capitalized. They were looking for a CMIO. They looked around and said, “Well, look what Kaiser’s doing. Look what Sutter’s doing. Look at what everyone around us is doing. We don’t have anything.”

I joined them in the end of 2009 just after we went live with inpatient for Kaiser and cleaned that up. I’ve been working there for about a year and a half. I joined with a CIO who was in the active process of retiring. We got through six months of treading water, and then when Mark Zielazinski joined us as CIO, we really took off looking to what we were going to do, both inpatient and outpatient.

We decided to go with upgrading Siemens Invision — which was a system that we had and had a contract for a number of years left on it — and to implement Soarian inpatient. Siemens’ partner for the ambulatory space is NextGen, so we signed a contract in February to do the whole kit and caboodle. We are really just getting rolling with starting the workload discussions. I’m actually in Philadelphia taking the training classes.

How did you end up choosing Soarian?

We had the Invision system for all the ancillaries and order transmittal as well as financials, scheduling, and registration. About three years ago, Alameda got a grant to implement nurse documentation. The price that Siemens gave them they couldn’t afford, so they went with McKesson, who gave them a very sweet deal to put in nurse documentation with an eye towards replacing Invision or replacing all of Siemens products in the future if it went well.

We have nurse documentation live on Horizon Clinicals, which works reasonably well. We did a competition between the two. We had doctors look at it. We had a lot of the executives involved with it. Both had advantages, but we had a long relationship with Siemens, which had been stormy in the past, but had gotten much better.

From a financial position, it was the better decision. From the ambulatory side, Horizon Ambulatory was a very young product and very questionable, whereas NextGen was a fairly established ambulatory product. Even thought it was not integrated, it still had very good functionality and we went down that road. It was a very close competition, but finally we chose to stick with Siemens. I would say based on the last six months of negotiations and getting things started, I think it was the right decision.

You had an insider’s look at Epic at Kaiser being used on both inpatient and outpatient and now you’re working with Soarian plus NextGen. Do you feel that’s a comparable package?

I think that from a clinician user, physicians and nurses, I think Epic is an easier-to-use product. It’s a more integrated product. It’s a much more complicated product to build, but it’s a much easier product for the end users.

Soarian and NextGen are going to be simpler to build and maintain. They are a little clumsier. They’re a little more primitive than Epic. But I think that they still provide good functionality and I think they’re going to be easier to train and easier to use than the fancy stuff. The basic functionality, I think, is very solid in Siemens and Soarian. NextGen … I’m only just starting to get into, but so far what I’ve seen I’ve been impressed by.

You’re not giving up anything on the inpatient clinical side to go with Soarian from what you’ve seen?

As I said, I think Epic is a more mature product. It’s much more established. It’s been out there really being used in large places and small places. I think that we’re going to have some real work to make Soarian sing, but I think that the potential is there. I think it’s built on a solid foundation.

I think we’re finally seeing a lot of movement in Soarian. You know, for years there were just a couple of players out there who had it in place. Physician order entry was difficult. But the last year or two, we’re seeing a lot of people implementing Soarian. People going live with order entry. This has really been a huge way of that getting going.

Bringing on people like John Glaser and Marc Overhage is a tremendous comfort. People who really get where this needs to go. I spoke to John on several occasions about his vision, and as usual, John is dead on. I think those are great moves by Siemens in the right direction.

How do you feel about Meaningful Use and your readiness for it?

It’s part of our contract. I fully expect to meet Meaningful Use, probably just in time on the inpatient side, where we’re shooting for the beginning of 2013. It’s an aggressive implementation. We’re basically going to do all of inpatient and all of outpatient between a contract signing in February and implementation and go-lives that start early in 2012 and run through 2012 ending right at the end of the year. That’s a very aggressive take on it, but from everything I’ve seen so far, I think we can make it.

Do components like CPOE concern you?

You know, one of the things about Alameda — and probably the reason I joined — was it’s just an absolutely incredible physician staff. As I said, they were looking to put in a system a year or two before Meaningful Use was out there. That was one of the things that most attracted me. They really got it before the government said, “We’re going to incentivize it.” 

It’s an unusual situation to have a large physician group saying, “We want to do electronic documentation. We want to do electronic order entry.” It’s a residency-run hospital and several large residency programs. Residents and many of the attendings come to our office regularly with, “How come we’re so far behind? How come we’re not there already? How come we can’t do this?” 

That to me is the most exciting. I have very few people who’ll come to me and say, “I can’t believe we’re doing anything this stupid,” which you certainly hear in a lot of organizations.

I have to ask you about the hospital’s turnaround that was profiled in Fast Company. I’m really intrigued by how that’s going and how that impacts what you do. Can you describe the situation before you came and what’s been done to turn things around?

I think it really is a leadership and cultural issue. For years, it was a standard, old-fashioned county hospital. Most people’s take on it is that it takes care of the indigent. It takes care of people who don’t have any choice, so they can’t make the demands on the system. We had to just do the minimum and get along. Why push the envelope? 

Wright Lassiter came in and said, “There’s no reason it has to be this way.” The board was very enthusiastic about making Alameda County a real standout in the world of safety net institutions. He brought in Bill Manns shortly afterward as chief operating officer. Spent a couple of years really trying to get the finances arranged, get rid of old debt, really re-establish relationships.

Over about a 24- or 30-month period, he basically replaced the entire executive team. I’ve been there for a year and a half and I’m one of the more senior people. After Bill and Wright, there’s two or three people who have been around four or five years, but most of the executive team has been around for between one and two years. The chief medical officer came in two or three months before me. The CIO came in six months after me. The CFO and chief nursing officer came in the same time as Mark. The entire executive team is really brand new, picked from a large group of people who have been successful in their respective roles.

The idea that it’s a county hospital merely means it’s a county hospital. We’re looking to actively be a place that people want to come to, and at least on a quality basis and a care basis, compete with the Kaisers and Sutters and the health systems in northern California.

The quality metrics have really risen the last couple of years. Patient satisfaction is still low, as is not too surprising at a county hospital, but is increasing dramatically. The attitude of the front line staff and the executives is that this is going to be a different organization than your run-of-the-mill county hospital. They really want to be the flagship.

When you read that article, it almost sounds too good to be true. Is it really that dramatic and as much a function of leadership as it sounded?

It’s hard to say definitely since I wasn’t there, but certainly when I first came in, I saw some of the people who were in the positions before, especially the CIO. I understand how bad it was. The front line staff wanted to do the right thing, but had very little leadership and very little mentoring. The executive staff kept turning over, so nobody was ever really was able to take hold and create a culture of care quality and financial stewardship and pride.

The front end people definitely have a tremendous amount of pride in what they do, but I think the middle and upper staff in the past was really … it was just a job to them. The people providing care … it’s their community. These are their compatriots and there is a tremendous amount of pride and dedication to that community. You talk to the physicians — and I’ve worked at several county hospitals — and the usual attitude in one of, “It’s a job, I’m here, I’m taking care of people.”

This group is absolutely, incredibly dedicated to taking care of this patient population. It is such a pleasure to see and to work with. I think the leadership was the key, but I think you already had a number of good people, especially on the physician side and the front end clinicians and nurses, who really wanted to make it a showplace.

Are you getting interest from other places that want to know what you’re doing there?

Through the Safety Net Institute in California, which is the local extension center for the county hospitals, we’re meeting with the CIOs and CMIOs twice a year. We’re also actively talking about, since a number are going live with Soarian over the next year or two … we’re going to try to go down and help them with their implementations. We’re talking to Pomona Valley, we’re talking to Riverside, and Kaweah Delta. We’re taking about going down and helping them with their go lives, and they can come up and support us. Trading resources in more of a bartering system. Instead of paying outside consultants to come in for huge dollars, bring in people who really use the system who are in similar institutions. That’s the plan.

Do you think that the problems that the Medical Center had and the solutions that they’ve developed is a sequence that other hospitals are going to be going through with healthcare reform?

I think so and I hope so. It does take a leadership that is willing to take some chances and willing to really try to change culture, which as you know is far more difficult than implementing systems.

Healthcare reform … everyone talks about it and everyone says it’s coming. I’m still unclear exactly how it’s going to pan out and how we’re going to make it work. I think the system has to change if we’re going to manage to provide care to everyone in the nation, not just the indigent. The system is — I don’t want to say broken, although I think it is — but it really has to change to start paying for quality, paying for fair delivery instead of increasing the waste.

That’s one thing I learned working for Kaiser. When I was at Loma Linda, we had a large number of capitated contracts for urology. The Kaiser model of an Accountable Care Organization is where it needs to go. Alameda has about 30 or 40 percent of its patients that are county patients for which we are essentially capitated. We provide the care for a fixed amount and we need to provide ambulatory and specialty and hospitalization care for that group.

The better we take care of them, the better quality we provide, the more we do to keep them out of the hospital and keep them healthier, the better we’re going to do financially and the better they’re going to do medically. I’m a firm believer in that model. My years at Kaiser absolutely convinced me of that.

Other than the obvious applied informatics aspect of Kaiser, when you look at the analytics and information needed to compete and provide good quality outcomes, where do you think the industry is in terms of being able to use data to meet standards that someone will be setting?

I think the whole applied informatics piece is a dual approach. One is we need to be able to provide care and collect the information to take care of the patients in a structured format so we can report on it. Then the other side of it, having a structured data that we can take, review the actual data, and derive from that what is our best direction. How do we provide this care in an effective and efficient model? You need to have both pieces. 

I think we’re seeing proxies for quality now. We’re seeing a number days central lines are in place. We’re seeing a number of pressure ulcers that are avoided. We’re seeing those kind of things, which I consider proxies for quality. What we need to do eventually is come back and say, “Are we really improving the overall quality of life of people who we’re taking care of? Are we increasing lifespan? Are we improving quality of life? Are we doing it at a reasonable cost?”

Those are the kinds of things you really need the analytics to drive. We just don’t have the data at the front end. Where we’ve got these measures that are important, but they really aren’t what we’re trying to accomplish. They’re just proxies for it. The more data we have, the more structured data we can aggregate, the better we can actually ascertain what kind of bang for a buck we’re getting for the money we’re spending .

Any concluding thoughts?

I certainly thought several times before taking this position. There are significant resource challenges for a county hospital. It’s a very interesting place to work, but the people that I’m working with and the drive they have to do the right thing, in my perception, have really made it an incredible experience. I’ve been very happy there.