I was hopping mad when I read that an obscure HHS group had put an end to Peter Pronovost’s US projects involving using simple checklists like “Wash your hands, wear a mask” to remind physicians to help prevent hospital infections, especially since those projects continued in other countries and absolutely saved lives when used. The project’s data collection, even though it did not involve identifiable patient information, was claimed by the Office of Human Research Protections to violate patient consent requirements (notwithstanding the fact that the project was funded by AHRQ, the government’s reseach and quality agency). A fabulous article in The New Yorker is worth a careful read before proceeding here. Peter is the medical director of the Center for Innovation in Quality Patient Care and a professor in the Department of Anesthesiology/Critical Care Medicine at Johns Hopkins University’s School of Medicine. Thanks to Peter for explaining the project to HIStalk’s readers. This is some of the most exciting work I’ve heard of in the elusive task of getting proven research into practice quickly and inexpensively.

Let’s start out some background about you and your work.

I’m an intensive care physician and anesthesiologist. I did a PhD in clinical research and, because I had free tuition, I did a joint degree in health policy and management, really focusing on quality of care. My emphasis has been on bringing more robust clinical research tools to quality improvement. In other words, the belief in that if you’re going to make inferences that care is better, they have to be accurate and truthful and do that in a very practical way.

I’m trying to find the sweet spot between what’s being scientifically rigorous and what’s practical. That’s sometimes no easy feat. We’ve been looking at very practical ways or applied research ways to improve quality of care. The way we do this is that Hopkins is our learning lab. We package programs that we think can improve quality of care. We implement and measure them at Hopkins. If they work, we make them in a scalable way and share them with the broader healthcare community, in this case, with the State of Michigan.

We packaged a program to reduce catheter-related bloodstream infections. The results were just phenomenal. We nearly eliminated these infections — saved the state over $200 million a year, a tremendous number of lives. So I think the model of doing rigorous quality is key.

One of the things that we’re struck with is that biomedical research in this country needs to be broadened. It’s a bit too myopic in that we view science as understand disease biology or finding effective therapies, but then whether we use those therapies or how to delivery those therapies safely and effectively is “the art of medicine”. We’re not really looking at that. What we’ve been doing is to say, “Let’s apply the same rigor of science to the delivery of care so, at the end of the day, we can say whether care is better or not.”

Obviously, a lot of folks will want to talk about your “list method.” What was your reaction when you heard that HSS Office of Research Protection decided that it was unethical and said that the program had to stop?

Shocked. I had submitted it to our IRB, who reviewed it and said, “This is quality improvement, not human studies research,” because we’re not collecting any patient-identifiable information. When they came back to say, “No, you should have had this”, it was quite chilling. I don’t know if you saw their latest statement where they seemed to say, ‘You can go ahead and do Michigan now, but if you do any of the quality improvement work and you collect data, that’s research”. The implications of that for any kind of management effort are just profound.

Every hospital does some sort of ongoing quality studies, chart reviews, audits …

If you read their statement, it would seem that all of those qualify as research.

Nobody’s ever heard of that office. Is their ruling final or can HHS come in and say, “You’ve overstepped your limits”?

This hasn’t been played out yet, so I think they’re still sorting out what’s going to happen.

Wasn’t it true that your original work was funded by AHRQ?

Correct.

So you’ve got one government agency paying you to do the work and the other one that says it’s got to be stopped.

Exactly right. Go figure. And you have the Secretary of Health and Human Services, who publicly said that he is for value-based healthcare purchasing, efforts to improve quality and reduce cost – exactly what this program did. This program is like the poster child for what he’s advocating for.

It makes you wonder whether the government’s role is really protecting people. If you asked one of those patients, I’m pretty sure they would say, “Yes, please use the list.”

Exactly. It’s Mom and apple pie. So, who knows. I think the field erupted with concern with OHRP. There’s so many e-mails to Secretary Leavitt or Congressman saying, “This is absurd. What are we going to do about this?”

Let’s hope that reason will win. Tell me how you came upon this seemingly simple idea of consolidating information into a list.

I’m a practicing doc and, most evidence summaries in medical care, like these long 100-200 page guidelines that are exquisitely detailed and summarize the evidence, but they present them in what’s called a series of conditional probabilities or if-then statements, like, “If a fever, yes, if white count, OK.”

The problem is nobody uses them. I read a book by Gary Klein called Sources of Power, where he looked at how people in ICUs and firefighters and fighter pilots think under pressure. What he says is that no one thinks in conditional probabilities. They stick their head in the data stream and they see patterns. I reflected on that and I said, no wonder we never use these things. It’s not how our brains work. Our brains can only have one conditional probability at a time.

I was studying the aviation world and safety and how they made their progress with with checklists and said, that’s it, we need a checklist. OK, let’s take this 200-page guideline and summarize it. Given the data from our telephone numbers, the most numbers of things we can remember are five, plus or minus two. That why our telephone numbers are seven digits.

I said, OK, let’s take these guidelines and pull out the five, plus or minus two, strongest interventions for reducing infections that have the lowest barrier to use, and word them as behaviors. Behaviors are easier to fix than wording things in vague statements. We pilot tested at Johns Hopkins. The results were quite dramatic and we packaged it in the program and the result is history. The results are so dramatic.

I’m sure there’s more to it than, “Here’s a piece of paper with some stuff on it”. How do you operationalize the list and can you replicate that into other types of interventions?

Absolutely. Summarizing a list is one thing. Getting people to use it is a whole other. That requires a behavior change. We worked on giving people strategies to say, “OK, now that you have this evidence, how could you make sure every patient gets this evidence in your hospital?”

We gave them strategies, like standardize what you do. Create independent checks for things that are important, and when things go wrong, learn. So we said, “There are about eight different pieces of equipment that you need to comply with these CDC guidelines — caps, gowns, masks , gloves. Go store all the equipment in one place. Eight steps down to one.” And people really loved that.

We then said, as an independent check, docs, when you’re putting in these catheters, nurses are going to check to make sure you do it. So, nurses, we want you to assist docs and make sure that they do all these things. When we first said it, the nurses said, “Hey, my job isn’t to police the doctors, and if I do, I’m gonna get my head bit off.” And docs said, “You can’t have nurses second-guessing me in public. It looks like I don’t know something.” To which I said, “Welcome to the human race. You don’t know things.”

I pulled all the teams together and said, “Is it acceptable that we can harm patients here in this country?” And everyone said, “No.” So I said, “How can you see someone not washing their hands and keep quiet? We can’t afford to do that. In the meantime, you can’t get your head bit off, so docs, be very clear. The nurses are going to second-guess you. If you don’t listen to what they say, nurses page me any time day or night, they’re going to be supported. There’s really no way around this. We have to make sure patients get the evidence.”

When it was presented that way, the conflicts melted away, because issues became not ones of power and politics, who’s right and I’m a doc and you’re a nurse, but one of the patients.

Is it hard to assemble an inarguable body of concise items to create the list initially?

Let me tell you what our vision is. It does take some effort. It takes probably about a year and roughly $300,000 to produce a program. What that means is to go from a concept: “I want to eliminate MRSA”. To summarize the evidence; to develop practical ways to measure that in the real world that are valid and sound; develop the performance measures; to get a data base in place; to do what I call the technical work.

We view it very much like a form of pipeline. We have a process to say, “Let’s go from idea to program. We pilot test it at Hopkins, and then we launch it to the broader community.” It’s a very scripted process now. We’ve become more efficient at doing it, and we absolutely need to be, but we have a very clear program of how to translate evidence into practice. The concerning thing is that there’s no darned funding for this. NIH doesn’t fund this kind of work. AHRQ’s budget is so anemic that it can’t really do anything. So we end up with all these therapies that we know will work, but patients get them about half the time in this country.

So does the work that has to be done only have to be done once and then you can just basically pick it up and drop it in everywhere?

Generally, it’s so inefficient and so ineffective for every hospital to do their own programs; to do what I call the technical work. Now these programs require both technical work and what we call adaptive work, or culture change. The culture change is all local. So we summarize the evidence of the checklist and then we go into a hospital and say, “OK, given your own culture and resources, how do you make sure every patient gets this?” And they modify it a little bit, but the technical pieces, the evidence supporting the checklist, the way to measure if it works or not, so the data collection – are all standardized, as they should be. So those are the science pieces that are true that the central group develops. But once you develop them, there’s virtually, minimal, marginal costs to put it in a thousand or ten thousand hospitals.

Other than grant funding, wouldn’t there be other sources of funding, either private or that one hospital will get so much benefit that they’ll pay for it and share it?

Certainly there’s some philanthropy that people now have become interested this with the New Yorker article, but unfortunately there hasn’t been much federal funding in it. I believe insurers ought to be funding this because they get a windfall from this. There’s no doubt they reap substantial benefits.

This is a non-profit effort that you’re leading right?

I’m an academic doc at Johns Hopkins. Exactly right.

Nobody making money off this? Basically, you’re looking for somebody to cover the costs enough so you can roll this out, in essence, for free?

Exactly right. I’m an academic doc, so any grant I get’s just off my salary. No one’s making money off of this.

Surely you’ve gotten a ton of publicity?

There’s certainly been a lot of people that say, “Hey I’m interested in this.” We’re certainly working on a number of angles. There needs to be more than a vision. There needs to be a strategy for this that’s saying, OK, lets take pediatrics, let’s take emergency medicine, let’s take OB, let’s take surgery. Let’s make sure we develop a model that translates evidence into practice. We just have to find some financial support to make it happen.

I guess the cynic in me always says that healthcare’s pretty distinctly profit-seeking in most areas. If there’s no money to be made in better treatment …

I’ve had people who want to make money off of this hounding me. I’m getting called by everyone who’s saying, “You’re onto a goldmine here. You saved the state $200 million. It costs $500,000. That’s a great ROI. Let’s go make money on it.” I personally think that some of these things … This is a not-for-profit tool. The initial thing’s funded with public dollars, it ought to be public good that we put in broadly.

Most of my readers are information technology people. I know you’ve done other work other than just “‘the list”.

We did this kind of naively. I think there’s huge information technology potential. One is automating the checklist into the work process. We had a very hard time monitoring compliance with it because it was paper-based; people lose the forms. There’s enormous opportunity. I’m not an IT guru. That partnership, I think, we need to make stronger. We need to partner with IT people because this could be an automated checklist in a handheld or a variety of formats that is used at the point of care.

The other thing that’s information technology that’s striking is, when we go into these large hospitals and ask what their rates of infections are, virtually none of them have the data stored in a queryable database. Its pathetic. One of the things that we did in this Michigan project was we built a Web-based data entry. They put in each month the number of infections and the number of catheter days so we can calculate the rates. We made it scalable so you could click and see what the rate was in ICU 1, what the rate was in all of in all of your ICUs, what the rate was in your hospital, or your health system, or the whole state.

So we created some architecture to underly this. It was really simple. And hospitals loved it because, for the first time, they had the data in a real-time time, scalable database. It just shows how rudimentary our clinical information systems for data quality are in hospitals. Even a hospital like mine, University of Michigan, they’re not stored. We haven’t invested in a database infrastructure to do these things in a scalable way.

I’m just speculating, but lets say a big systems vendor came to you and said,’ We’ll underwrite five of your programs in return for the ability to distribute them either exclusively or not”. Do you ever see that happening, where a vendor would maybe fund some of your work?

I have. A couple of the big health IT vendors have come. I think that’s a great support. You can see that these things are easily built in to an information system. It’s crazy not to. Instead of having all these pieces of paper around, you click onto “Central Line” and here’s the central line checklist. I’m doing palliative care, here’s the palliative care checklist. So, absolutely, I think there’s great potential for that,

The data management, it sounds simple, but there’s very few hospitals, or any, frankly … I can tell you large systems that have won awards for reducing infections. When I say,”So what’s your infection rates?” they say, “I don’t know.” or “It’s stored on this piece of paper or Excel file.” We haven’t invested in data management for quality reporting and we desperately need to.

There are two key success factors for this project. One is that it was evidence-based so the interventions are for sound evidence. But two, that we had valid measures, that docs believed that data. This wasn’t marketing like so many quality improvement projects are, where it’s “Come look how great I am,” but the emperor has no clothes, or the data has no credibility because there’s no quality control. It’s seemingly poor quality and the inferences are probably incorrect, the inferences about whether care got better. Docs believe this because they say, “Yes, it’s standard definition. Here’s the data. You can look at how much missing data you have. Here’s the data quality.”

In many senses, we created a monster in Michigan because now there’s a hunger in these hospitals for a pipeline, but we don’t have the infrastructure to deliver the pipeline. The docs are saying they love this approach, “Peter, you’ve transformed the state”. The hospital CEOs love it. You have their docs, nurses engaged in quality. The results are good. They’re all excited. So what’s next? Could we do the same model for VRE or MRSA and for palliative care and sepsis and for emergency medicine and for pediatrics? We certainly could, but we don’t have financial support. We have the model to create this pipeline. We’re working on it. We just launched, funded by MHA, a safe surgery project that has the same model. We’re going be looking at safety in surgery with some checklists and things like that.

How many of these do you think there could be? Are there enough solid facts?

Hundreds. Think about it. Stroke care, headache care, acute MI care, arrythmia care, asthma care. Our brain can’t remember all these things, so the key is the medical community responded to that by making these 200-page eviddence summaries, but nobody thinks that way so they’re not used in practice. The simple checklist approach conforms with how we think. I don’t want to trivialize it because the reality is, to summarize 200 pages of evidence into five checklists that are worded into behaviors that are practical but yet scientifically sound, takes some trial and error.

That sweet spot is a big part of what our key to success is. It’s what our shop does well, is that all of our people are clinicians, but trained in research methods. We know both the biases and the evidence and the clinical realities and we try to hone in on that sweet spot. Inevitably we get it wrong and that’s why we pilot test it and revise. So what you serve up is ultimately very practical, very scientifically sound, and usable in a variety of types of hospitals.

The biggest problem in medicine is probably getting stuff out of journals to the bedside. Even if this was short term, it seems there’s a lot of opportunity to use this a vehicle to push out recent findings.

Exactly right. We could translate evidence into practice quickly. The investment, from what you see, is trivial. You can use it throughout the whole world. We have formed a partnership with the World Health Organization to help put these things out more broadly.

The implication is that if the list works, the doctors were doing it wrong up until they had that tool. So basically, are they acknowledging that they’re just overwhelmed and can’t do as good a job unless they have some reminders?

I think what we say is, sure, they were part of this. What we’ve done with this is created a system. So yes, they’re human. Their brain doesn’t remember everything like mine or yours doesn’t. So what you’re alluding to and what I saw was that our pre-condition for using a checklist is the humbleness to say, “I’m not perfect.”

Healthcare wasn’t there five years ago and perhaps some physicians still aren’t there now. What we’ve shown is, when you accept that, like in anything in your life, when you acknowledge a shortcoming, it’s very liberating. You say, “I could use this aid.” And we changed the system to make it easier.

That chlorhexidine that I told you about reduces infection risk by half. But most of the central line kits didn’t have that soap. The doctors and nurses didn’t know how to change the purchasing to get it. So I sent a memo to the CEOs at the hospitals in Michigan at said, “There is a soap called chlorhexidine that that cuts infections by half. It costs pennies. Please make sure its in all of your central line kits. I’m going to e-mail you back in a month to make sure you did it.”

I have no authority over them, but what I found was that, when we did focus groups with them, they all knew safety was a problem. They were all committed to doing things to improve it, but they didn’t know what to do and most of them were to scared to say so, because you don’t get to be a CEO without having answers, right? I said, “OK, I’ll make it easy for you. I’ll send you a task every month. A really concrete task to have you go do it.” One of the tasks was putting the soap in. Lo and behold, a month later, the whole state has this soap in.

You’re an anesthesiologist as a specialty. I still would argue today that the most dramatic quality of improvement that’s ever been done, in any area of medicine, was when anesthesiologist got together and said, “Look. This risk of general anesthesia in surgery in absurd, We’ve got to make it better”. How did that come about and are the same sorts of roadblocks that the anesthesiologists figured out how to get around going to have to be overcome again with the rest of medicine?

What allowed that discussion was that humbleness to say, “We make mistakes. We’re not perfect.” A big part of our work was getting docs to reclassify harm. Most people put harm in what I call “the inevitable bucket.” Things happen because you’re sick or you’re old or you’ve had a big operation or you’re really young. That “bad things happen” kind of colloquialism. What we did is to say, “No, I think a lot of that is in the preventable bucket. Let’s reclassify it.”

When we did these infections, docs said, “We’re at the national average and these are the people infected and there’s nothing we can do about it.” I said, “I don’t know if we can do something about it, but what I do know is that we’re not using these five central evidence-based things in all patients. Let’s out a system in place where every patient gets it and lets see how well these rates go. I may be wrong and they may stay exactly the same, but my hunch is most are preventable. So can we agree that this evidence is strong and we’re going to create a system where patients always get this evidence because we owe it to them.” Of course, docs agreed on that and the results were breathtaking. It really opened them to say, “Wow. Maybe most of these are preventable.”

You also mentioned the airline industry, where early pilots were free spirits who eventually saw the benefit of having conformance to accepted rules. Does the same psychological way that it took to get pilots to give up what they perceived to be their independence need be applied to equally headstrong physicians?

Exactly right. That’s the tension that we have. How much evidence do I need to give up my autonomy? We’re still uncertain about that. As an industry, healthcare is grossly understandarized, compared to that pilots have to use checklists or they won’t be flying. Healthcare is still very much like the Wild West or like Chuck Yeager in The Right Stuff, where we have this cowboy mentality and we’re just beginning to accept that standardization is a key principal to making care safe. We need to do that. I think we have, especially among the younger generation of physicians, broad acceptance that they need to standardize. What the field of quality has to mature is, “How much evidence do I need before I take away your autonomy or, at least, put some restraints on your autonomy?”

I think you did an article, study, or consultant work involving computerized physician order entry. And there were some sky-rocketing error rates that occurred after implementation. What was your conclusion from that, since I’ve got a lot of technology readers?

What we saw is after the implementation of POE, errors went up dramatically. Though I think that publication surprised healthcare workers, they really shouldn’t. We learned this from aviation and other industries, that any time you change a system, you may defend against some errors, but you will inevitably introduce new ones. This always happens. You’re going to create new risks.

I think healthcare approached POE perhaps naively in that they simply sought to replicate the paper world in doing work electronically. Even the forms are alike. We want to make it look the same way. What that does is, it introduces new errors that weren’t there. So you’re substituted handwriting errors for, what I call, choosing one for many. Most physician order entries have drop-down lists because we have ten different doses of morphine. We haven’t standardized those yet. It’s a huge issue. We need to.

So predictably, some people are going to click the wrong box when they do that. It’s guaranteed. It’s part of human nature. It’s cognitively predictable that they will click the wrong box. Or we’ll have other types of errors, so that you’re substituting new types of errors. We probably hadn’t reflected on how to defend against those enough. We’re focused so much on learning the technology, replicating what the paper workflow looks like, that we didn’t simulate or say, “I’m going to introduce these whole bunch of hazards and how am I going defend against that?”

And, much of the decision support tools that really would’ve benefited from these technologies weren’t part of the initial systems. They’re developed in later. That’s not to say I don’t believe in technology. I think POE is a great tool, and it needs to be done, but we have to do it wisely with eyes wide open. Like, anytime I put something in, I’m going to introduce new errors. Let’s try to proactively identify these so we can defend against them.

The second, the significant mistake, is that we under invest in training and support for these systems. Learning a system takes a lot of ongoing training and support and risk reduction. So, as in real-time I introduce and I see a new hazard, how am I going to fix this and defend against it?

One of the absurdities that I see with POE now is the amazing amount of waste and ineffectiveness of having every hospital home-grown their own decision support tools for these systems. So Hopkins, the main hospital spending thousands upon thousand of person-hours designing their own order sets and decision support tools. Those things take a tremendous amount of time and person-hours. If you add those up across the six thousand hospitals in the US that are doing this, the collective cost is outrageous. It would almost be like each air traffic control developing their own technology and system and not working together.

So somehow, I think, the industry needs to begin to say, we have to work smarter. It’s inefficient and ineffective for everyone to be doing their own thing for these tools because good decision support takes a lot of work. It’s just like the curriculum or good safety programs. We’re going to break the bank if every hospital has to invest hundreds of teams of people developing their own. But perhaps our inability to do that is emblematic of the cowboy mentality, that we can’t get the docs in one institution to agree, let alone talk among hospitals. It says how understandardized we are. You don’t want have every airline or every pilot developing their own checklist to say, “No, my checklist is ABCD. Your is this.” There’s an industry standard.

My audience is mostly executives and informatics people. Is there any message you’d like to leave them with as far as informatics and technology in healthcare and error prevention?

Sure. I think that the most important message is that no one group can do this alone. There needs to be greater partnership between clinicians, information technology, and methodologist or safety experts or measurement people, so that we can put programs together that could help clinicians use evidence in interventions and evaluate the extent to which they actually improved care. That’s going require the collaboration of all three of those groups.

One of Denis Baker’s employees e-mailed and said I had to interview him, including a long list of reasons she enjoys working for him. I knew of Denis mostly because of Sarasota’s work with Eclipsys and CPOE and was happy to visit with him by telephone.

Tell me a little bit about yourself and about your job.

I started in healthcare during Vietnam as a Navy corpsman, thinking that I would end up on a ship or a Navy base someplace. Then, out of total ignorance, I realized that I was probably going to end up in the Marine Corps, which I did for short while, but fortunately stayed out of Vietnam.

I got into laboratory medicine and then became a med tech. I worked in a hospital in Portland, Oregon for ten years, in a chemistry department. They were implementing their self-developed lab system. So I got involved interfacing all of the instrumentation to the computer system. This would have been early eighties. Then they thought the computer system was going to support itself, so they were going send me back to the bench. So I jumped to another organization and supported an HBOC Star lab system for a couple of years there.

I ended up being the manager of the clinical systems. Then a new CIO came into the organization and created a new position of Office Automation and End-User Computing Manager, which is the worst title in the world that I can think of. Was it meant, basically, was supporting PCs. It was a four-hospital system back then. They had no centralized support. So I pulled together a good support group for training around PCs.

I left the organization in 1991 and then ended up working for an outsourcing company that has since disappeared, moved to Cincinnati, and worked as a director of IT at one of the suburban hospitals there. Then, ultimately became the CIO for the four suburban hospitals who were part of the system. The whole consulting company crashed. At about that time, the CIO that I worked with in Portland, Jim Turnbull, had since moved down here to Florida and there was a Director of IT position. So I moved down here in 1995. I was the Director of IS for five years. Jim left in 2000 to go to Denver Children’s. I was promoted to CIO.

Your background is as a clinical department end user. Do you think that’s a good background for a CIO to have?

I think it so, because I looked around early on at who the early CIOs were. It seemed to be most of them were promoted directly out of IT and really didn’t have any exposure to the clinical world. I think that has really helped me as the whole shift in the industry is gone to clinical information systems. I can talk the lingo with not only lab folks, but also nurses and other clinical folks. Physicians as well. I think that’s been a leg up.

I think the future for healthcare CIOs in particular is to have a clinical background, whether that’s nursing or one of the ancillaries. I think you really need to understand what happens in a hospital, not just producing bills.

Should the ultimate goal be to have a physician running IT or does it really require that?

I think that physicians bring a certain aspect to the job, but I don’t think they necessarily know how a hospital works. I think they know how their practice works and how they interact with the hospital, but I don’t think they absolutely know what nursing does, or any of the ancillary departments, and what they do.

What do you like most and least about being a CIO?

Most is seeing technology applied to operational improvement in the organization and moving healthcare out of the dark ages. We’ve been on paper for a hundred years and many people have said there are industries that are far beyond us in adoption of IT. With good systems and good implementations, it’s remarkable what you can change within healthcare with IT.

Do you think clinical systems are realizing their potential, or are those systems still a generation away?

My chief medical officer asked a similar question a couple of days ago. He compared it to the automobile industry, where the tires might last for five miles and then you’d have to replace them. He thought that maybe we’d moved now into maybe the thirties or forties as far as automobile technology in comparison.

But I think we’re really in the fifties. I think the systems work, but they don’t have all of the bells and whistles that the current car today would have. It’s going to be an evolving process. We’ve been at this, with the clinical information system, for twelve years and it seems like the work is never done. There’s always something changing and something new. New functionality or, typically, some new regulation or reporting that has to be generated out of your clinical system, so the work never stops.

You never stop implementing a clinical system once you start. That, I guess, one of the downsides. You asked me the pluses and the minuses. I think the downside is, it’d be nice to wrap up a project and move onto another one, but it just never goes away.

Nobody can afford to replace those systems every few years. How important is it for the CIO to establish a relationship with a vendor and stick with them?

Let me start from day one, with negotiations with the vendor. Obviously the vendor’s interested in sales, market value, and stock price, but I think you need to reach a common ground on what you’re trying to achieve. I’m not a big one for really tough, upfront negotiations. I don’t try to nickel and dime them, but I do want performance guarantees. I do want access to senior management. I do want them listening to us as a customer base as to where their systems need to go, and hopefully they’re listening to us. Because you’re right, this system we’ve had for twelve years — I would not want to be here to be the one to replace it. I would not want to go through that agony again.

A lot of places just trade Vendor A for Vendor B while the hospital down the street is trading Vendor B for Vendor A.

Once again, I think it comes down to personalities, and if you can develop a relationship with your vendor at a personal level and not slam your fist on the table every time there’s a hiccup, but thank them for when they help you solve problems … I think that’s the key to the partnership. I think some people get caught up in egos. They’ve negotiated some super-duper contract and the vendor, for whatever reason, is unable to deliver, and potentially the CIO or whoever negotiated is being held accountable for making it happen. So the knee-jerk reaction is, “Let’s go find Vendor B. That’ll work out much better than Vendor A did.”

How much are hospital executives involved in IT decisions?

Well, here, they’re pretty involved. The Chief Operating Officer, my new CEO that’s been here for about two and a half years – both of them have been involved in some pretty major IT implementations where they came from. I think they have a good understanding of technology and what the limits of technology are. Their caution to me and the organization is, “Just because you’ve got a problem doesn’t mean IT necessarily needs to solve it. We need to focus on our workflow and the operational improvement.” And then if there’s an opportunity for IT to get involved and ease that along, that’s probably the best course to take. I think all of my peers within the VP ranks have that same understanding.

How often is IT part of the strategic solution?

It’s hard for me to gauge at this point. We’ve had a new CEO for two and half years. Our Chief Operating Officer, he’s relatively new as well. I think the last thing they look for is an IT solution, but we’re still going through our version of Six Sigma or Lean Management or Process Control Management, whatever you want to call it. And then you take a look at, “OK,is there an opportunity for IT to get involved and help solve that problem?” So as we have a fairly new executive team, I think we’re still working our way through that.

Every CIO wants to run a world class IT operation, but hospitals don’t usually have large IT budgets. How do you choose your battles and stretch your dollars?

Number one, I’ve got a great staff. I have about a hundred people on staff. Being in Sarasota, Florida, it’s fairly easy to recruit good talent to this part of the world. We pay well. So I think that’s the first key, I guess, to making it a success.

I can only think of one project in twelve years that we’ve backed out of. Some of the projects may have taken us a little bit longer or cost us a little bit more than what we thought, but we’ve only had one complete failure in ten or twelve years, out of I don’t know how many projects we’ve been involved in. I think we’ve developed a reputation, as a division, for getting things done on time and relatively on budget. That lends some credibility, not only among my peers at the executive level, but also with staff; and also, even more importantly, with the physicians. If you get them involved in something and it turns out to be a success, you get less and less resistance as you move into other things to implement.,

If you look back two or three years, what projects gave you a lot of bang for the buck or made you glad you did them?

Probably the first one would have been what’s now the Eclipsys Sunrise Clinical Manger. It was created by a company called HealthVision, then called CareVision, the product. We were the first customer. We started to roll it out in 1998 to deal with nursing documentation and physician order entry.

At some point, the voluntary CPOE hovered at about 25%  and finally, nursing got tired of having to deal with the paper and electronic world. Our elected board then told our physicians, “OK, a year from now, it’s mandatory that you put your orders in.” Almost immediately, we saw the percentage starting to rise. We run probably about 80% entered by physicians, 10% verbal, and another 10% written or faxed in.

I think the whole CPOE and at least the beginning of the medication order process of transcription illegibility and so on – that went completely away. It created other problems, but at least it solved the illegibility and who actually ordered something.

Another project that took us a few years, but I think was ultimately a good decision … we needed an ERP system. We looked at Lawson and PeopleSoft and ultimately decided on PeopleSoft. That product has been rock-solid ever since we implemented it, even after the Oracle acquisition. In fact, we’re going through an upgrade to the HR side of this system right now. We had to engage some fairly expensive consultants to help us get it implemented and augment our staff. But I don’t lie awake at night worrying about PeopleSoft at all. It really helped with supply chain management, on the one side, and then we also had some issues with HR and payroll on the other. I think Peoplesoft solved both of those.

Anything on the infrastructure side that turned out to be a good investment of time and money?

Early on, as we implemented the electronic medical record, we were looking for a fairly robust network infrastructure. At the time, about the only thing was available was a technology called ATM. Implementation was good. It provided campus-wide network backbone capability up to gigabit speed. That served us well for a few years, until Cisco and the rest of the world got Ethernet up to speed.

Since then, we’ve gone with Cisco and that’s been rock-solid for us. Built in an awful lot of redundancy to make sure that the network never goes down and, knock on wood, it never goes down. Early on, the intent with the electronic medical record was to maintain all of the records on everybody forever. So we made an early investment with EMC and their technology. This would have been back in 1996 or 1997. We’ve been with EMC ever since. So from a storage perspective, expandability, once again, that’s worked out very well for us.

You made CPOE mandatory in 2003. What advice would you have for hospitals considering doing the same thing?

I‘ve looked at some of the organizations that have tried the voluntary route, but I think you can only do that for a certain period of time before you have to make it mandatory. Like I said, we coasted along for a few years with a 25% compliance and that was driving our nurses nuts. Having to check not only the paper chart, but the electronic chart for recent orders and so on. That’s going to cause quality and safety issues. So at some point, if you’re not making it with the voluntary, I think you better go mandatory.

You’re not going win them over with technology. They’re always going to complain about the time it takes to log on and how much longer it takes to place an order. But after a period of time, in our case ten years, they can look at patient information back to 1998. There’s nothing archived. Everything’s available and I really think they see that as a value in exchange for the whole CPOE piece, but it takes a while for you to build up that database for them to appreciate that.

Are you seeing any impact of the Stark relaxation and are you doing anything with physician office computing?

In a very minor way. We’ve had Siemens’ PACS system since 1996. I think three to four years ago, we implemented Siemens Magic Web, which is the online retrieval of images. They were able to do that within the organization. Obviously, they came to us and said , “OK, we want to see those images in our offices, and by the way, we don’t want to buy any equipment.”

So we were able to seed a few workstations out into some of our specialty physician offices; orthopedic surgeons and so on. That’s all they can do with them, look at our images. They can’t load it up with games and other stuff.

Physicians have the expectation that the hospital should provide them with an office EMR. We’re trying to figure out if our direction should be in that area. Obviously we’d have to charge some nominal fee. On the other hand, as my CEO reminds me, there’s a whole host of other companies out there like eClinicalWorks and so on that are offering ASP models that have relatively reasonable prices. They offer not only EMR, but also practice management.

So why, as an organization, should we get involved in that? The only challenge I have to that is that it would be nice to be able to have longitudinal medical history on our patients, whether they’re seen in an office or in the hospitals. I’m not sure how well some of those ASP offerings could be integrated into what we’ve got. So we’re kind of exploring that right now.

Are you seeing any impact of interoperability?

We’re the only not-for-profit hospital in four counties, surrounded by HCA, Universal, and HMA organizations,and they really have no desire to exchange data. I don’t think it makes sense, from a corporate perspective, for them to get into that. So we’ve really not been too successful in creating a RHIO environment here locally.

I tried to get some money out of the State of Florida. Jed Bush budgeted $10 million to get RHIOs off the ground. I made an application and one of the requirements was that it had to be with a competitor. I tried to make the argument that, in some cases, our physicians are competitors, but the state wasn’t going for that, so I didn’t get any of that money.

How would you say Sunrise is working compared to a year or two ago?

We did the 4.0 upgrade probably close to two years ago. That was probably some of the worst software I’ve ever seen. It took us probably eight months and I don’t know how many hundred patches and service packs to get all of that fixed. But finally, everything settled down and the performance came back.

Two months ago, we did the 4.5 upgrade. That’s was probably the easiest upgrade that we’ve ever experienced. That was real quality software. I think you could see the impact of John Gomez and his development team on the quality of the software they’ve produced.

With Andy Eckhert involved, do you think the direction of the company or its likelihood to success has changed?

Yes. Andy made a few visits here since we were one of the early adopters and I’ve liked the changes he’s made in the company. I’m not sure how successful offshore development is. I’ve never dealt with a vendor who has really relied on that quite a bit. I know they’re expanding their office in India to four or five hundred developers. So hopefully we’ll see, once again, a continued emphasis on quality software when that’s released.

Some of the other changes he’s made is decreasing sales staff and so on, and focusing more on support and development folks. The consultants that we’ve had involved in the 4.5 upgrade … the quality of the individuals, I think, has risen dramatically as well. As I understand it, they have to go through a three-month boot camp to learn the system before they’re ever turned loose on the customer base. I can remember years ago when a new hire would get hired on Friday and be assigned to us to fly in on Monday, knowing little to nothing about the system. They were just here as a body filler. But, like I said, the quality of individuals we’re dealing with now is much better.

Their future success in a having a broad clinical offering like the market wants is based on making Sunrise Pharmacy work. What are your thoughts on that?

I always thought that pharmacy really needed to be, not an interfaced system, but integral to the whole order entry process. Because they didn’t have that product five years ago, when we needed a pharmacy system, we went with McKesson’s Horizon Meds Manager. We had some transition issues with McKesson. So we implemented their system; we interfaced it with a bi-directional interface. That has its own uniqueness and causes its own problems. Now that Eclipsys has a pharmacy component, we’re going through an evaluation of, “OK, where’s McKesson right now? How would their new Meds Manager and Admin-RX compare to an integrated pharmacy module with Eclipsys?” So we’re going through that process this week, comparing and contrasting that.

One of the things I remembered about the hospital is you were one of the first, if not the first, to offer a turnaround time guaranteed time in the ED. Were there technology implications to that strategy?

Actually, no. That was all workflow. A new CEO came in two and a half years ago from Detroit. At least a couple of hospitals had implemented the thirty-minute guarantee. She walked in the door and said, “OK, we’re going to do that here” and turned to the ED folks and said, “Make it happen. Figure it out.” And it really had nothing to do with technology. It was all workflow and handoffs.

Now, somewhat after the thirty-minute guarantee was in place, we purchased the Eclipsys ED module, displaced boards and all that other stuff in there, and I think that helped. Now we’re on ED doing nursing documentation. And then finally, ten years later, asking the ED physicians to do order entry. Back in 1998, they screamed bloody murder, so we started someplace else. So it’s taken us ten years to get back to them. I’m anxious to get that piece wrapped up. But no, the thirty-minute guarantee had nothing to do with technology.

Tell me more about your department.

There’s actually three departments that report to me. I had more at one point, but right now I’ve got Information Systems, which is the pure technology stuff: the servers, the network, PCs, and all of that. There’s about sixty people there. The original project team that implemented SCM has been maintained as a separate department. They used to be all clinicians, with nurses, pharmacists, radiology techs, whatever. Perhaps less so today, but I wanted to maintain a real emphasis that there was a support department called clinical systems. It was responsible for, not only SCM, but now they’ve taken on the rest of the world: radiology, pharmacy, laboratory, all the ancillary systems as well. Their focus is more on the application side, with the IT department really worrying about the infrastructure piece.

We’re about 3.1 or 3.2% of the operating budget. Our routine capital is about $30 million a year and typically we get $5 to $7 million of that, This year, we’ve got $7 million, which is about a quarter of it. In fact, that was one of the attractions when I came down here. I came from an organization whose IT capital budget for four hospitals might be $1 million. When I came down here, my predecessor Jim Turnbull had gone through a planning process and gotten a commitment from the board to spend $50 to $60 million over seven or eight years. So that was a big attraction — being able to do things without scrimping on the basics. And I’ve been able to maintain that capital commitment board and administration. This is my third CEO. I’ve been able to continue the capital investment in IT for the last seven years since I’ve been CIO. So I feel pretty good about that.

With a large amount of money being invested, how do you decide where to spend it and how to justify the ROI that results?

I think I’ve been fortunate. We’ve really never been an ROI organization, which I appreciated as well when I first walked in here. It’s been focused more on what are the problems that the organization needs to solve. What’s the solution to it? How much does it cost? And then it goes into the budget.

I don’t have an IT steering committee. My IT steering committee is my CEO and she can be very direct at times. We had a JCAHO survey a couple of years ago. We ran into a couple of situations that IT could solve and she said, “Go make it happen.” And the real focus over the last eighteen months, if not more, has been on quality and safety. Now that we’re doing CPOE and eliminated the upfront transcription errors, how do we solve the problem of wrong meds, doses, and all that on the back end. That’s why we’re really focused on the barcode administration piece right now.

Are you worried that vendors seem to be moving toward hiring inexperienced employees right out of college?

I can’t say that I’ve seen that within Eclipsys. Most of the people that I’ve interacted with, all the way from implementation consultants to project managers, these people have got a number of years of experience behind them. I’ve seen the comments about Epic and the implementations and so on, but I cannot say I’ve ever seen that with Eclipsys. There always seems to be a requirement that either they have a clinical background and know something about how the department operates. And then they get educated in IT. And as I reflect on our original project team for SCM, that’s the approach we took. We attracted the best and brightest clinicians in the organizations and then took them through the IT training piece. That worked out very well for us. I think it would be very difficult to take some computer science graduate that just got out of school and teach them how a hospital works without a whole lot of supervision and good mentorship and/or project management.

Then we get into my concern about a company that is publicly traded is having to pay attention to what’s going on in Wall Street, and try to come up with, may be not the best model, but the most economical model, and hope that it actually works. I wish there were more healthcare IT companies that were privately owned. I see Wall Street as a huge distraction. A good example — I don’t know if you remember Transition Systems Inc.?

Yes. Eclipsys bought their decision support.

They missed the mark on one quarter. Their stock price dropped and then they got scooped up by Eclipsys. At the core, I think TSI was a good company. I think they had a Cadillac of decision support systems at that time. Through acquisition, good talent left.

That’s what I get tired of — the mergers and acquisitions. When we were looking for radiology systems, Siemens had a partnership with IDX at the time. They didn’t have their own good solution. So we went with IDX for radiology. Then that faded after about two to three years. IDX went to GE, and I can’t say I’ve seen a GE rep in the last two years since the acquisition. So this whole vendor churn and having vendors figure out how the new products that they’ve just acquired are going to integrate with what they’ve got seems like a huge distraction, not only on the front end of the acquisition, but on the back end on how are you going to make this stuff work.

What technologies do you see on the horizon?

I’m not sure I’ve got any original thoughts. I know there’s a lot of negative bias against it, but it occurred to me after Katrina, the paper records in New Orleans were gone and the only organization that seemingly did well at recovery was the VA. They took their backup tapes from their data center in New Orleans to Houston and, within a week, everybody in the nation had access to those records. I was trying to think, since I’m in the potential path of a hurricane as well, what would we do?

The whole idea with smart cards appealed to me. Downloading the CCR from our inpatient systems; providing read-write devices to our physician offices so they can populate it as well. The card isn’t so much the issue. The opportunity is having a redundant data center in Dallas or someplace where all the data is stored. But from a smart card perspective, not only has the core clinical data on that card to be read any place, its also available on some website somewhere. It provides a marketing opportunity for us with our logo all over the face of it. And then from an efficiency point of view, them walking in with their card, we swipe them, they’re registered, and they are done. Then they can go on to their appointment.

One of the issues that I’m not sure is unique to us is the length of time to identify the right patient, get them registered, and double check the insurance information. I believe that smart cards would solve that. Some of the discussions I’ve heard is, “Well, we should be downloading that to people’s cell phones.” Somebody’s always looking for the next technology and we’re really focused on trying to do smart cards this year, but we’ll see how well I do. It’s kind of a data concept, but I think it’s potentially could solve three problems for us.

One of your employees e-mailed me to suggest that I interview you and said, “As long as Denis is the big guy, I will work at SMH.” How do you command that kind of loyalty?

I’m honest with them, sometimes to the point of probably saying things that maybe I shouldn’t. Like most larger organizations, there’s rumor mills all over the place and I want to make sure that my folks hear from me what I think is going on and what the organization is actually doing. So I think, honesty and also being upfront and fair. We’ve had certain situations with employees that have not been popular decisions. So when I go back to explain, to the degree that I can, what the situation was and why that individual no longer works here, they appreciate the fact that I made the right decision. They understand it.

I give them quite a bit of latitude into the decision-making, particularly to my management group. An idea will be thrown out on the table, we’ll talk about it, and sometimes I’ve overridden the consensus decision from the management group, and I’ve tried to explain why I made that decision. I’ve had very little disgruntlement because of that.

Who do you admire in the industry?

I would say John Glaser at Partners. He was way ahead of his time when they started writing their own MUMPS software in, I think, 1988. They’ve always been ahead of the curve as far as development of their clinical systems and the fact that they self-develop them. They’ve got a staff of six hundred or something like that, but to take something massive like that on and be that successful at that large an organization is remarkable.

The same employee that e-mailed me that said that you’re a faithful HIStalk reader. Why is that?

I appreciate the insight. You’re one of my twice-weekly reads and the Brev-It e-mails as well. It gives me an insight into stuff that typically wouldn’t be available to me regarding acquisitions of vendors. Sometimes the rumors are interesting as well. I appreciate the fact that you wait for secondary validation that its true. It’s well written. I think you cover the industry pretty well. Obviously I think you have the trust of your readership. It’s a good read. I guess the other piece that I appreciate is that but you’ve always got the link. The article allows me to go out and find out more about it, so I don’t have to go someplace else.

Is there anything that you wanted to talk about?

I just received the invitation for the Most Wired survey again. I wish somebody would kill that. I’ve seen your comments. I share your sentiments about it.

I’ve talked to some of my peers that have been on the Most Wired list and asked them if they’re really doing some of that, and they said, “Of course not.” So I think somebody needs to audit some of this and put this to rest. Fortunately my CEO doesn’t have a whole lot of belief in it either, so she’s not holding me accountable to what some of the other organizations are doing. Not that there aren’t some good, innovative things going on out there, but having an unaudited survey of what you’re doing … the polling results are in from New Hampshire. Everybody thought they had the pulse on what they thought was going happen and then it changed overnight. So in that case, the pollsters were throwing out the numbers, but the voters really showed up and indicated what reality was. So I wish somebody would do that with the whole Most Wired survey as well.

You may remember Mark Zielazinski from his days as CIO at El Camino Hospital. He responded in 2006 to a reader comment about that hospital’s problems with its Eclipsys Sunrise implementation, which caused great organizational upheaval and nearly got the hospital shut down, according to newspaper accounts. We agreed to do an interview at some point. It’s taken awhile, but we finally had a chance to talk. Mark’s now CIO at Children’s Hospital of Central California. He was trying to get out of the office for a long Friday commute home when we connected, but was gracious enough to spend time with me.

Tell me a little bit about yourself and your job.

I am CIO at Children’s Hospital of Central California, which is the only rural children’s hospital in the United States. It’s actually a pretty big facility. We’re located just outside of Fresno, California, the central valley of California. I think we’re going to be 320-something beds next month. We’re opening up 28 more beds.

Describe your IT shop and how it’s structured.

We’re primarily a Meditech shop. We’ve been a Meditech hospital for 20+ years, so we were an early adapter of the Meditech system back in the mid-eighties, I think.

Beyond Meditech, we have the typical gaggle of supporting systems. We’ve got Picis in the OR. We have Kronos for time and attendance. We’ve got a couple of ancillary systems and KaufmanHall  products for budget and capital. This year we’re going to be replacing our Meditech ERP modules with the Lawson system for ERP. We’ll start implementation this summer and then go live sometime in ‘09. And then for the Meditech products, we’re just starting to do nursing documentation. We’re on the old Magic platform.

We’re doing some things with physicians in ambulatory order management and pharmacy in prescription writing. We’ll upgrade to Client Server in the fall. We’ll start the process this fall. I think that will be done just about the time we go live with the ERP system.

Most readers will remember you from El Camino Hospital. You had problems there with the Sunrise go live and pharmacy department problems on top of that. What lessons did you learn personally from that and what should other vendors and the industry learn?

We did a lot of things right there. I think we were on track with being very successful. I think they’re going to very successful right now. I know Eric Pifer’s there. I think that’s going to go well for him. He’s got a good environment to go from.

We went live in the first part of March 2006. I don’t remember the exact dates, but it was sometime in early 2006. We had missed our initial go-live, which would have been the middle of November 2005. The primary reason for missing was the fact that we couldn’t get our doctors educated. I think the training we had set up for them was about four hours total, in two-hour segments. We actually did it, but we could have done it a little better. We started paying the physicians to attend those classes. We paid them a fixed fee for the two classes. To get the payment, they had to go through and demonstrate proficiency. The lesson is that you have to pay them.

You get so much momentum. We had gone almost three years. We were in the process of building, creating, and moving when we missed our November date. So it was three and half years by the time we went live. I think one of things that’s got to happen is it can’t take that long. You’ve got to find a way to get that stuff to work in such a way that it doesn’t take three years to build a product and get it ready.

This was a place where we had the experience. El Camino had been doing physician-based order entry. They’d been doing nursing charting and documentation. We were doing all that stuff and it still took us a hell of a long time. The products vendors have, and I don’t believe Eclipsys has a monopoly on this problem, are really a tool set. They don’t have a very good set of schematics and plans and starting places for you, as an organization, to be able to drive with that tool set quickly to using it.

You hit the third thing on the head when you said we had department issues in pharmacy.  We really needed to have dealt with that prior to that change. That was a major league change for pharmacy. Even though we were using the pharmacy product, the old E7000 product, it was a pretty manual process without any kind of real automation to it. Even though it was SCM 4.0 and I know everyone talks about the fact that it was an interfaced product versus an integrated product, people have been using interfaced pharmacy products for years and years.

That wasn’t what the issue was there. We had a very serious problem and the pharmacy didn’t do a very good job of managing that. I take some of the hit for that, but I think the organization takes some of the hit for that as well. We ended up actually outsourcing the whole pharmacy management. Once that was done and in place, the vast majority of the issues that were affecting us at the time of go-live and about five months later when we actually did the outsourcing, it kind of disappeared. Not to say that there’s not still learning that’s going on.

Somewhere, I have documents from the original Lockheed-Martin system that ultimately became TDS. It went live in 1971 at El Camino. There was study done in ’75 and another in ’77. They’re really good studies talking about adoption. In six years post go-live of that system, they only had about a 40% participation by physicians. So it’s not something that happened fast back then.

Looking back now, with the benefit of 20:20 hindsight, should the plug have been pulled at El Camino because it wasn’t ready?

I think if we would’ve had the issues in pharmacy fixed, I’m not sure that would have had such a negative impact that it had. I don’t know that the system wasn’t ready at that point. I don’t know if we had made some of the pharmacy outsourcing decisions prior to go live; would we have said at go live, “We aren’t ready”, and would we have experienced the same problems. I don’t think we would have, so I think that was where that all ended.

But I think you’re right. We had a committee, a very large group that included the chief nursing officer, myself, and the chief financial officer, looking at that, making the decision and recommending to the board of directors whether we went live. The three of us made that decision. Primarily myself and the chief nursing officer made the decision to pull the plug on the November go live because we didn’t think we were ready. We had physician input on that committee. The committee was basically a group of 28 people that met as we were getting ready to go live on a very regular basis. Not just weekly, but multiple times per week. We made the decision and took it to the board of directors.

When you left El Camino, you went to Sensitron as the COO there. What did you like and dislike about working in that environment as opposed to a hospital?

I’ve been in the private sector and consulting or working for small companies before. I was employee sixteen with Superior. I was very early on with DAOU systems. I actually went through taking DAOU systems public. So I looked at the opportunity with Sensitron as, here was a start-up company. I’m at that time in my life — I’m fifty today — where I thought, “I could try that one more time”.

They were pretty good folks. They were a service provider for us at El Camino. I knew their technology. The CEO had left the hospital. The guys from Sensitron had come to me and offered me an opportunity to participate in that small company start-up thing. To me, it was one more opportunity for me to do that. I’m not sure how many time you can jump in, try to take something and see where it goes. So it looked like a great opportunity.

We never really got our funding set up appropriately. So for them to continue to carry me would have really put an undue burden on their ability to the R&D kind of work. While I was there, we were able to put out a new product. Sensitron does the wireless automation and collection of vital signs from the devices that you move around from room to room in the hospital. While I was there, we also came up with an ICU product that took information off of the stationary monitors in the ICU. So I was able to get a new product out and help them develop a new version of their existing product, and do some alignments with companies

We struck up a partnership relationship with a portable monitoring company. Then our money dried up. We didn’t have any more money coming in, in terms of investment money. And our sales weren’t keeping up with the payroll. I said, “Look, what we really need to do is continue to build our engineering group and our customer services group. Carrying my salary doesn’t make any sense, guys.” So I told them I was going to go off and do some other things, which is what I did. I went off and did my own consulting and then landed a job here at Children’s.

How would you compare your Meditech shop versus being at El Camino?

It is a little bit different. It’s a little tighter system. Looking at the Client Server version of the product we’re looking to go to and looking at the documentation features, there’s a lot of stuff that … quite frankly, I was surprised at how similar it was to some of the capacities in the SCM that I’d put out there. They’ve come a long way.

The last time I had ever worked on anything at all with Meditech was when I was back with Superior in the late eighties. So I’d been away from it for a pretty long time, but they are still pretty rigid in their product. Quite frankly, they’re pretty rigid in their relationship with their clients. When I got here, we didn’t have a plan to go to Client Server, but we had a strong desire to get to doing a lot more electronic documentation, and ultimately of getting CPOE. As I did my research for the first couple of months I was here, it was pretty clear to me that, in order to do that in a very reasoned fashion on a Meditech platform, you really have to be on a Client Server environment, not on a Magic environment. All of the big groups like St Joe’s and Christus and the guys who just went live in Colorado — they’re all on the Client Server platform.

It’s part of the vendor dilemma, where they’ve got an old legacy product on the Magic side that they’re saying ain’t gonna go away for a while. The reality is that it’s really hard for a vendor to maintain multiple products like that. They’ve got to really get on board with something. I think ultimately they will get to that Client Server platform. I don’t know what’s going on in that market yet to see why they feel they’re going to keep managing both Magic and Client Server, but it’s a pretty bulletproof product set for us.

I think, on the ERP side, it’s pretty darned weak. In this organization, before I’d even got here, they had made the decision they wanted to get off of the Meditech ERP products. On the clinical side and the billing and accounts receivable side, I think it’s a really good product. The market share that they have speaks a little bit to that.

Tell me about your department’s operating statistics.

Historically, the budget runs at about 2.6 or 2.7%. Our fiscal year starts October 1. I came on board just in time to finish up the budget process. We are budgeted to be at about 3.2% this year. As I took the position, one of the things we talked about with the executive team coming on board was that I thought that an organization this size should be nearer 4% of the operating budget in terms of the group. At El Camino I was at 4.7% of the operating budget. So that seems right to me.

I have a director of applications, a director of technology, and the director of HIM reporting to me. I’ve also just hired a director for project management and a director … well, I haven’t hired it, but it’ll be an executive director role, physician liaison. I’ll probably to that either late this fiscal year or the beginning of next fiscal year.

In total FTEs in the applications and technology area right now, we’re about 44. By the end of this year, we’ll be at around 48. Into next fiscal year, we’ll probably be into the mid fifties. I don’t see us being larger than 60 people at the top end.

We’re pretty straightforward in terms of the capital budget. We haven’t done a very good job managing the replenishment of the physical infrastructure. So this year, we were about half of the equipment budget for the hospital on a capital basis, and the lion’s share of that is going into replenishing the physical infrastructure. We’re putting in new networking, new wireless, and getting us onto a program that says we’ll replenish the desktops and all that stuff.

We’ll start to roll out some mobile devices. We really haven’t had much mobile device work here, but we’ve got to get that in place if we’re going to electronic documentation. So we’re going add the C5s and some mechanism for putting up some other type of cards. I think that stuff is all happening.

The other part of the capital budget this year is for the Lawson project. I suspect we’ll be somewhere between 20 and 40% of the capital budget for equipment for the next two or three years. And then we’ll get to a point were we’re between 15 and 20% on an annualized basis. We’ll have a real serious replenishment program in place so that we don’t get stuck in this kind of environment again. The board is aware of and has bought into that process.

We’ve had our first IT steering committee earlier this week. They haven’t had an IT steering committee in about nine years here. The last IT plan was done in 1996. But there’s just some bread and butter kind of things that we have to get done and we’re working on.

You were a mobile device advocate at El Camino. How would you say overall the industry is doing in that whole mobile workforce area?

From what I can see overall, we’re typical healthcare – we’re behind the curve. Lots of other industries have taken over mobility a lot faster than we have in healthcare. I think the idea of a specific medical mobile device, like the C5 … I got to participate in that in a very big way, from the conceptual design phase. We were involved in that at El Camino. So I understand it, I believe in it firmly, but I also believe that there’s not silver bullet solution.

Some people are going to want to use mobile tablets. Some people are going to want to use mobile carts. That’s just a fact of life that we’re going to have to deal with here. I believe its true for about every hospital. But, I think, if you were to look out five or ten years from now, I think mobile computing will be the rule for the way access happens in a hospital. Whereas today, even at El Camino, where we deployed it very, very extensively, we still hadn’t gotten to 50% of the devices being mobile devices. El Camino will be one of the places that gets there the fastest, but it will probably be three or four years more where half or more of the devices are mobile devices. But I believe that is going to happen.

You mentioned voice over IP. We did the Vocera stuff. Here, we use VoIP phones. We don’t have a VoIP infrastructure fully deployed. We’re going to do that. I think that concept of personal communications is going to expand in hospitals. I’m a firm believer that and I think it’s got to happen in hospitals relatively soon, and that is, that we have to issue all of our employees some kind of communications access device.

I use the example of this. My youngest child just went to college. He was at California Polytechnic. In order for him to register for class at Cal Poly, he had to prove to them that he had a computing device that he was going to use. He couldn’t register for class until he’d gone through this process of proving to them that he had this computing device. We hire employees here at the hospital, we don’t have that same approach.

I think, at some point, that’s going to happen at hospitals. We are information providers. That’s what we do as an organization. When you really get down to it, we’re really information dependent workers. At some point, just like when we give you your badge, we’re going to give you some kind of computing device. You’ll be responsible for it and use it for all the interactions you have while you’re at work. I don’t know how far off that is, but I think its something that’s coming.

You were at a great location at El Camino for watching technologies develop. When you look across the technologies that might be promising for healthcare, what things do you like?

I like some of the devices that are bringing everything together. My phone, whether it’s a cell phone or a VoIP phone … that same device is going to be my computer. I think that’s happening. I think, in that device, its going to have this concept of personal recognition. So it’s a personal device. Rather than dialing a telephone number, you’ll just type in my name and it’ll get me via voice or via message. However you want to get me.

We’re going get more and more into monitoring people’s conditions. Do you remember Goldsmith’s book Digital Medicine? If you remember that first chapter, where he writes about a scenario, I guess it was the year 2015. The thing that was the most vivid to me out of that whole chapter that he wrote was the fact the guy who was the patient received his treatment diagnosis and everything without ever being either in a physician office or in a hospital. Pretty impressive. I think there are technologies that are coalescing to allow us to do that. They’re going to happen pretty soon. We’re at that tipping point for that stuff to happen. Its a combination of being able to monitor inputs and get information out of folks, without it being necessarily an invasive process, in terms of diagnosing things. Then having a mobile workforce that gets out to deliver care to the patients or the people, wherever they are.

Do you see that as a growing role for a CIO?

I think so. It’s really got to be more upstream and visionary. I haven’t done day-to-day operations for a long, long time. In fact, I’m not sure I’d be qualified to do day-to-day operations. It’s more of a vision, planning and really working with the executive team and the board to get a sense of what’s out there.

A lot of folks say we’re supposed to manage our vendors. One of the main roles of the CIO is to work and manage vendors and vendor relationships. I don’t think that’s a part of my job, but a bigger part of my job, I think, is kind of like what I did when I was with El Camino and Intel … building a partnership where we do interesting things together and bring that to the organization.

That process is what we went through to conceptually design the C5 and see it come out. I was pretty non-involved with the process and outcomes. I worked with the nurses and doctors, but I got them to work with designers and engineers and watch the output. I kind of guided it. I wouldn’t say I was completely out of it, but I wasn’t into the integral processes of that.

Nurses and doctors were just jazzed. There’s no other way to describe it. They were really jazzed that there was someone listening to them and trying to figure out things that they could do. I think that’s the role the CIO needs to play to facilitate those types of activities. Because once those people are jazzed like that about the technology and what’s happening, they start to think about how to change processes to make that stuff allow them to give better care, deliver quality and those type of things. Otherwise, if they’re not involved and jazzed by that process that way, they look at it as just another set of changes coming down on top of them.

When you think about how busy and how difficult it is for the clinicians with increasing activity and increasing volumes, they’re just getting creamed. The last thing they want is another set of changes. So somehow, you’ve got get them jazzed about that in order for them to say, “OK. I can see how this fits in. I can see how I can modify my normal work process to do it this way which will be better. It’ll be better for the patient. It’ll be better for me. Everyone will benefit.” You’ve got to figure out how to get them into that. That’s the role the CIO’s got to play.

What are the biggest problems and opportunities that CIOs face?

Trying to compete for what I believe is going to be a shrinking capital dollar. That’s going to be a huge challenge for them. Secondly, it’s going to be the political challenge of trying to change from simple vendor relationships to partnerships that allow real change to occur. The technology changes are not going be done from within the hospital. You’re going to have to bring technologies from outside the hospital, more likely from outside of healthcare, and apply them in a hospital setting and in a healthcare setting in such a way that brings success to the organization. These are huge challenges for a CIO.

Let’s get to know you better. I’ll give you an item and you tell me what you favorite of that item is. TV show: I watch football. I don’t watch TV other than sports. Sports team: Chicago Bears. Food: Veal chops. City: Verona, Italy. Music: Chuck Mangione. I’m a jazz guy, but I like his horn. Vacation destination: The Orient. I married a Chinese woman. My wife is Taiwanese. I love the Orient. HIMSS conference event: The keynote. Hobby: Bicycling.

Who do you admire in the industry?

Dave Garets. I’ve known him for a long time. Bill Childs and Bill Bria. Those are guys I really admire.

Is there anything that you wanted to talk about that I didn’t ask you?

I know there are a lot of folks I’ve talked with recently. The folks from McKesson are like, ‘What’s going on with Eclipsys?” I did a lot of work before Eclipsys was formed, I did a lot of work when I was at Superior with TDS. So I had a long experience with that company. When I was at Superior, each of the executives had a vendor they were responsible for. I’ve also had a lot of stuff that I’ve done with Cardinal. I guess the one thing that I would tell you about me that people probably don’t know; when I was at El Camino, IT was a big part of my job, but we were completely outsourced there. I was the only non-outsourced employee at El Camino in IT. IT, while it was a big thing, it probably only took about 35-45% of my time.

The remainder of my time there, I was responsible for materials management, all of our purchasing, central distribution, central sterilization. I did a lot of other stuff, which was very intriguing to me. I learned more about hospital management in 5-6 years I was at El Camino by having direct responsibility for that stuff. That was a lot of fun. I did some neat stuff and I learned about logistics distribution. I actually did some work with MIT. We had two graduate students with their teams come out to do work on our logistics stuff. I think we did a lot of neat things in information technology at El Camino. On the supply side, I think we did some even crazier and neater things. As far as I know, we were the first hospital in the United States to go from a six- or seven-day supply delivery schedule to a three-day supply delivery schedule. We did some neat stuff around that. I learned a lot of that stuff that I didn’t know that I’d ever get a chance to do. I really enjoyed that.

Hi, this is Inga. Shaun O’Hanlon, MD works for EMIS, the largest supplier of EHR products to primary care docs in the UK. Mr. H and I were intrigued by his note: “I really enjoy reading your website. There are stunning similarities and differences between the EHR functionality in the US and that in the UK. There is undoubtedly room to learn as, underneath it all, we are all caring for patients.”

Thanks, Shaun, for providing some great insights. “Whilst” I had a bit of a struggle understanding the accent and the British-isms, it was a fun conversation that got me thinking about what we could learn from the UK model and what aspects we independent-minded Yanks would never embrace.

Give me some background information about you. 

I am a physician by background. I qualified from Cambridge in 1986 and I pursued a career in hospital medicine in cardiology. Then I decided to be a General Practitioner (GP), which is the UK equivalent of family practice. I spent 13 years being a GP in Guildford, just south of London, which I loved. My interest in healthcare informatics products started after working on a smart card project in 2000. Since then, I have been working for EMIS in healthcare informatics.

The company I work with today provides the GP EMR for 60% of patients in the UK, so it is a fairly prevalent system. Largely, it will do everything for EMR, management recall, appointment scheduling, and orders, all done through a single application. Billing is included, but in the UK it’s not that important. The economy is such that the government pays for healthcare through the National Health Service (NHS) and there is very little pay for services aside from some hospital ones. 99% of it is free. Well, not free – it’s paid for by taxes. [laughs] There is a secondary insurance market, used mostly for second opinions.

There is little competition for patients in General Practice because there is a match between doctors available and the number of patients. The government is generally reluctant to set up new practices. Since 1947, GPs have set up partnerships of five to 10 clinicians. That practice has a contract with the government to provide all General Practice services to their patients.

Can you give me UK Healthcare 101?

The practices are largely where they have been for many, many years. GPs have a geographic catchment area for patients. Although there may be several practices in one area, the competition is not widespread, as the government tries to match the number of doctors available to the number of patients. To set up a new practice, you have to have a pretty strong case and show local need. It is therefore fairly uncommon. The number of GP physicians is fairly stagnant.

We are now seeing some attempts to try to bring in private providers to improve patient access to healthcare. The number of doctors is relatively low and you have some big companies trying to provide an alternative model of providing care. Some of the bigger healthcare providers are trying to set up private clinics, as there is a perception that the GPs are stuck in their ways and innovation is needed.

Most GPs offer office hours from 8 to 6. Outside those normal office hours, service is provided predominantly by “out of hours” or emergency facilities. This is a problem for patients who are in employment, especially those who commute, and need to see their doctor early or late in the day. This has triggered a desire to find more innovative ways to provide care.

Patients are registered at a particular practice, which usually contains five to 10 physicians, equating to 6,000 to 12,000 patients per practice. Everyone who lives in the UK has one GP. The practice will provide all their primary care, including managing all their prescriptions, tests, and referrals. If you are on holiday, you can see someone temporarily, but your records will remain with your GP where you live.

So if I live in the country and commute to the city and need to see a doctor, I can’t see one in the city?

Right. Not very easily. A bit rubbish, isn’t it? They are considering creating a concept of dual registration to enable commuters to have a city doctor. The model now is one of a monolithic cradle-to-grave record. That has many advantages for continuity of care, cost containment, and quality care delivery. You begin to worry if you fragment a patient’s record, then you fragment care and may have dual care, redundant tests, and increased cost. In order to offer dual registration, you have to be able to share records around as well.

What is overall state of technology?

If you are a GP, every practice will have an electronic record on one of three or four available systems. That information will be held in a largely codified, structured manner. It will include a full medical history and all consults. It will include problems or diagnoses, all results, tests, prescriptions, and letters, resulting in a full, rich record that is fairly advanced in its structure.

The information is now transferable electronically between GPs in a structured format. If you move to a different location, then your record will follow you. What happens at the moment is that the record is held in a server in a practice or an enterprise with central service. When you move, your record transfers. There is a national standard that allows you to transfer the record around. We have a national messaging service that relays the messages from the practice database service to the receiving service. You request the records and you receive them the next day. A copy is extracted to the new practice. The patient’s complete medical record is sent and then imported in a coded format.

You indicated that there are stunning similarities and differences between EMR functionality in the US and UK.

A lot of my experience from that side of the pond comes from Canada. I find it quite difficult to talk about specifics because I haven’t been on the hospital side in US. But there are a lot of similarities around the need to share information. There is this conception that the GP performs one role and the hospital performs another role. The result is that information silos exist with pieces of paper — referral letters, outpatient letters, etc. — connecting them.

The other similarity, very macro, is that we are seeing increased focus on what patients want to know about themselves. Up until recently, this has been resticted due to technical issues. There also exists a kind of a high-handed attitude that patients can’t have their records by some clinicians.

We have brought the patient into the loop and now offer them access to their records, appointments, and electronic ordering of prescriptions. We have hundreds of thousands of patients using EMIS Access for just this every month. Projects like Healthvault will further enable this citizen involvement across the globe.

Suppliers are realizing that the real benefit of their data is sharing with other providers. People are sharing data between different systems. You need your applications to work together. Now that there is increased requirement to look at the lab system and radiology, interoperability has been become the core business that companies are beginning to focus on. We work hardest at determining how to share data and what data should look like. By sharing information everything works better. Everyone’s data is much richer when it is shared. Interoperability is the key to future EMRs.

To interoperate, you have to have standards. Unless you come up with agreed standards, you can’t have interoperability. Standards for coding data, messaging data, and viewing data.

EMIS has adopted SNOMED-CT as it does appear to be becoming the universal standard for record coding. We are working quite hard to understand SNOMED-CT because, whilst it is very advanced and offers granularity and breadth not found elsewhere, it is not a straightforward taxonomy, either for data entry or for reporting. So, new and innovative ways of entering data will need to be designed.

Message standards are now generally focused around HL-7. In the UK, we have adopted V3 XML, but our Canadian teams are now using V2 as well

Data display standards are equally important. Microsoft has been working with NHS and some suppliers like EMIS in defining a Common User Interface for healthcare applications. Their approach is to help establish a set of evidence-based standards for display and entry of healthcare data which is platform and location independent. The program is in its early days, but they are beginning to look at some of the challenges that SNOMED-CT and citizen records have on the healthcare user interface

Is the UK ahead of the US in terms of technology?

In certain areas, we appear to be in a luxurious position of having a national approach of how medical record and information should be used in the National Health Service and in Connecting for Health. We are mandating the use of HL-7 and are required to adopt these technologies and standard so we can share information between systems. It is putting us in good stead in some respects, but central control can be slow and laborious and does not always follow business drivers. If you don’t have an economy with that central control, the supplier sets standards based on business drivers, which can be more adaptive to the changing market.

Anyone would be well to learn from the issues that the UK has in providing a national EMR solution. There are a lot of lessons learned about standards and where they do and don’t work and how to go about implementing them

What is the state of adoption for EMRs in the UK?

Hospitals primarily use PAS, patient administration systems, PACS, and order systems. All have back-end billing systems to make sure they get paid by NHS. A lot of them rely on paper records for the medical record piece, although some use components of EMRs.

It’s a very mixed bag in terms of hospital adoption of EMR. Cerner is a big player and being employed, though it is going slower than they would have hoped due to implementation issues. Localizing the product has taken time and effort, as the requirements in a UK hospital are different than an American hospital. They are also going into sites with mixed technology and systems. That isn’t my area of specialty, so I can’t really comment further. iSoft also has a product called Lorenzo which is a single system for GP and hospital, but the full release has been delayed for several years.

How are EMRs funded?

It is all paid for by the government. In General Practice, they are provided through an NHS agency. The clinicians have a choice of systems, which was assured after a lot of pressure from the clinicians as the government didn’t want initially to offer that. The current situation is that the GP can pick the EMR solution they wish, so long as it fulfills a set of basic and interoperability requirements.

There is a also a big move to central hosting and enhanced data sharing across regions, if you like, so you can share between hospitals and physicians. What you call RHIOs — it is exactly like that, driven by the government. Some physicians think it’s a good idea, whilst some are concerned with losing control of their data. Others might argue it’s the patient’s data and that it is up to them who sees what information. The legal status is somewhere in between, that the doctors are the guardian of patient data.

Personally, I think the citizens have different expectations about their records. Most patients would be startled if they knew the hospitals couldn’t see the information that GP has, that historically it couldn’t be shared for technical and non-technical reasons. The non-technical reasons revolve around clinicians and administrators not wanting to mobilize data, sometimes for legitimate security reasons, whilst at other times, they are scared of someone seeing “their” data.

Some concerns are rational and some not rational. There is a need for putting solutions in place to encourage the sharing of data on terms they feel acceptable with. A patient can say, “I don’t want this one piece of information shared” and control who can see what. At the end of the day, the patient has to be able to see that. If you put in technology controls, then the clinician is the guardian and the patient controls who has the access. That has to be the way going forward. We need more control with the citizen and less with the clinicians whilst respecting that the clinician needs some controls because he is a stakeholder in the information, too.

Are physicians receptive to technology?

How you get clinicians to adopt EMR is a really interesting question. Before I went on the industry, side I tried to evangelize GPs about importance of coding data. I suspect 25 to 30% understood that and took it as a trigger for change. It has to be easy to do and have a business case behind it for it to be a success.

Prescriptions and repeat medications – the computer is very good for that. Appointment scheduling – no doubt that the computer helps. But what the government did over here was put part of the remuneration for the doctors based on how they are providing for the patients. Twenty percent of GP income is now around achieving targets for quality of care. For example, patients with heart disease have a certain level of cholesterol and blood pressure that the clinician should achieve to trigger the quality care payments.

The key is that if you see 10,000 patients, then there is no way you can collect the information required by the government on an ongoing basis without an effective EMR. All GPs now know it will pay to use an EMR package and, at the end of the day, it helps with quality of care. Once they realize how easy it is to enter data for disease management, they use it more.

The emphasis on chronic disease management was the big driver for adoption. Now that we are beginning to share the records, that will become the next business driver, I am sure. Some doctors complain it is check box medicine, but most recognize the improvements in care and data quality that have resulted. One very positive effect has been that there is now much more quality data on EMRs, something we gave been able to take advantage of and have used this data for some very high quality research. That has been an incredible falling out from all this.

Are citizens interested in having access to their medical history?

Very much so. I was recently looking at some stats. We have had 250,000 hits on our patient-facing service that is based on the EMR. Sending messages to doctors and ordering prescriptions online is now very popular. There are some issues that we have overcome around that, including privacy, but it is beginning to take off here in the UK. Our health portal is restricted to one part of the UK. You can log in and see your records provided you and your doctor are happy for that to happen.

How did you come across HIStalk?

[Laugh]s I got an e-mail from a person in our Canadian install. I read and found it an interesting mix of suppliers and users essentially talking to each other. In the UK, there isn’t a forum like HIStalk where you have senior suppliers and physicians sharing their knowledge. I think I learn a lot reading the e-mail that comes through. I don’t feel I can contribute much because I come from a different space.

Do you have anything else to share?

Our problems are complex and some need addressing on a national or international level. We have to have something to shoot for. The approach we’ve had involves citizen and doctor groups, as we have found there are a lot of concerns. Frequently they are unfounded, but we don’t realize they are unfounded until we analyze them in detail. If you told me 10 years ago I could log into my bank account online, I would have been horrified, but now I do it all the time. Suppliers and clinicians need a citizen view as well as a self-interest view.

A reader suggested I interview Jim Stalder, CIO of Mercy Health Services, Baltimore, MD.  I like interviewing CIOs because it’s a great way to find out what’s really happening in hospitals out there. Jim’s got a lot of technology interests, so some of our chat involves tools, which I think is interesting (he even provided links so I wouldn’t have to look them up). Anyway, thanks to Jim for spending time with HIStalk. I enjoyed it.

Tell me about your background and about your job.

I’ve been the CIO at Mercy Health Services for the past five years. I consider myself a midwesterner, even though I live outside of Annapolis right now. I was born and raised in Ohio, Minnesota, and Illinois. I went to Duke University and majored in electrical engineering.

I’ve always been interested in computers. I started tinkering with Apple II+ computers when I was a kid and got interested in electronic bulletin board services like FidoNet World back then and never really looked back. After Duke, I found myself at Anderson Consulting, or Accenture now. I was there for a number of years, doing a lot of large-scale database design and development work for telecom clients. Like a lot of the Anderson folks, there’s only so many 24 hour, seven days a week workdays that you can tolerate. The burnout rate is pretty high, so I looked for something different.

A buddy of mine had left Anderson and went over to a company called Digex, which was an up-and-coming web hosting and early ASP business that had some venture funding. I jumped ship completely from the large, 100,000+ person organization to the small Internet startup. I did that for a couple of years. Went through the fundraising aspect of things; went through an IPO; went though a couple of subsequent sales to some telecom firms; and ended up at a similar company called USinterNetworking, which one of the first true application service providers. We managed people’s salesforce automation tools and procurement tools, HR systems, and our data center in Annapolis and on the west coast. The subscription revenue based model. We didn’t produce our own software, but we hosted other people’s software and managed the systems for our clients. Did the same rocket ride there: fundraising, IPO, went through a bankruptcy …

That’s kind of the whole era in a nutshell, isn’t it?

Yes. That whole dot-com ride, I was right in the middle of, so it was a fun, interesting time. But then, after the bankruptcy, it was time for something different. I wanted to really get on the user side of things. I’d been a provider of technology for essentially my whole career, until about 5½ years ago. I really wanted to take what I knew about technology and how it could be provided and get on the other side and be a buyer and a user of it.

So it was kind of the right time, right place to get a job at Mercy, even though I had zero healthcare experience. The only time I had set foot in a hospital was when my children were born. I have three kids. Other than that, I came in cold turkey. It’s been an interesting ride for the last five years here at Mercy.

Tell me about your responsibilities there.

Mercy is a diverse organization, an independent, non-profit healthcare provider. We’re in Baltimore and we have a traditional community hospital downtown. We also have a long-term care facility named Stella Maris that’s about 30 miles north of the city. We have probably about 35 physician practices in and around Baltimore. I sometimes say we’ve got one of everything. We’ve got a hospital, physician practices, and long-term care. So here at Mercy, the IT function is pretty much consolidated into the shop here. We provide network, telecom, and application services to those three different entities.

What surprised you about healthcare when you came in as a CIO from the outside?

I think what was surprising about it initially was the complexity. Clearly the complexity in healthcare is unlike any other organization, as I’ve come to realize. In fact, someone asked me the other day what was my learning curve coming here to Mercy. I said, “It’s been about 5½ years and I’m still learning every day.” It’s a ridiculously complex environment.

So that was the biggest surprise. I really underestimated the diversity of applications, the diversity of functions of the various departments. I’ve come to appreciate the uniqueness that everyone requires to do their job in each of the different areas here. One of the things that surprised me was the state of the applications as a whole. The software vendors as a industry in healthcare, I think, traditionally are a few years behind that of other areas. They’ve rapidly been catching up, but when I came on board five years ago, Web-based apps were nowhere to be found, where it was fully becoming the standard elsewhere.

What talents did you have to develop to become an effective CIO and how did you go about doing that?

When I was at Digex and USinternetworking, my roles were product management, strategic development, some business development, and some M&A activities. I’d always had a technology background and a technology bent to what I was working on. So the aspect of trying to come in and understand what was unique about the technology here was relatively straightforward, but a lot of the culture and the dynamics of how different groups interact was definitely one of the more challenging things I had to learn.

Anderson was huge, but you really worked on a project basis, so there might be a couple of hundred people on a project. Digex and USI were at the early stages, just a few people, but they peaked at maybe 1,000 employees or, in one case, 1,500. Coming in to Mercy was a whole different dynamic. We’ve got 3,500 employees all performing significantly different functions, so getting up to speed with what everyone was doing was definitely one of the more challenging aspect of things.

You’re a Meditech customer. A lot of CIOs seem to enjoy the complexity of running, not only complex healthcare applications, but ones that are best of breed, because that usually means you get a bigger budget and bigger staff. Are you happy where the organization is with Meditech?

Well, in general, yeah. We’ve been a Meditech Magic user for coming on 13 years now, I believe. Meditech is a very stable, reliable application for us. I say it’s the jack of all trades, master of none. Actually it’s the master of some, but it doesn’t do everything that we want do from an end-user perspective. Our users often try to look for something different.

We’ve got this hybrid model going on here now where Meditech is still our core, but we’ve got a lot of bolt-on applications around it. For labor and delivery, we’re using GE’s Centricity product that we’ve bolted on and interfaced onto Meditech. We’ve just chosen Picis for a new perioperative system that we’re beginning the implementation of. We’ve got Allscripts for an ambulatory EMR system that we’re rolling out and we’ll interface some components, probably lab and radiology results, back into Meditech. That rollout has been going particularly well.

When you came into healthcare, you said there were things that surprised you. I would think looking at an application using healthcare-focused technologies like Cache’ and MUMPS and sold by a privately held company, you might think, “‘What the heck? Somebody explain this to me.”

When I came into the organization, the changes that were being made weren’t widely advertised. So, my first day was being introduced to the rest of the IT team. As a result, I also got introduced to some of the applications. One of the guys sat me down in front of Meditech which, as you know, Magic was a character-based application, similar to a VT-100 mainframe app. I remember thinking, ‘What have I gotten myself into?’ because where I had come from, I was used to the newer, Web-based applications, whether we were hosting them for clients or whether we were implementing them for clients. Everything was about the Internet or Web-based. And fat client was some of the things we’d done, but certainly not day-to-day. So, I felt like I was thrown back in time for a little bit. That was quite surprising. The other surprising thing was that the IT offices were, as they are traditionally are in hospitals as I’ve since come to learn, in the basement next to the morgue.

So I’m thinking to myself, “What am I doing?”’, but it all quickly came that I learned to really enjoy it. These past five years have been the most fulfilling, career-wise, than any other previous roles that I’ve had.

You mentioned your Allscripts ambulatory EMR. What kind advice would you give to others who were undertaking that sort of project? 

Mercy is a little unique, I think, compared to some other organizations. Mercy employs a large number of our physicians, and so our rollout model has really been to our employed physician base. Frankly, it makes things a little bit easier. They’re all part of the same Mercy family and they’re already greatly interested in sharing information with each other, so Allscripts makes it all that bit easier for folks.

But the advice I have for the ambulatory side is, what we’ve done is basically gone practice-by-practice, versus the big bang approach. We’ve probably got about 25-30 practices under our belt, and probably have about 10-15 more to go before we consider ourselves complete for our employed physician base. What we’ve really done is put folks on-site in the practice for the first two weeks of the rollout to do some hand-holding with the staff, do some hand-holding with the physicians, and get then comfortable and have someone right there, immediately available for questions. Sometimes some of our staff may even actually go into the exam room with the physician to help answer questions and consulting, getting things done.

So that phased-in rollout, that’s been very smooth for us. We’ve spent a lot of time training the staff in the traditional training environment. We do so with the physicians when we can, but obviously that’s a little more challenging. But the nice thing about Allscripts in particular is that most of our users have found it to be very intuitive. I’ve been very impressed with them. Its one of the more intuitive applications from a healthcare standpoint that I’ve come across.

Are you on Touchworks?

Yes. Version 10, and right now, in the process of converting to Version 11.

You’ve done some work with application virtualization.

We’re past the experiment stage, but we’re still doing some trials with it. We’ve got a few folks on our team here who have used Altiris in the past. Altiris was recently purchased by Symantec. It’s fantastic. We use it for our trouble ticketing system, for our application distribution system, our PC and server imaging. We’ve got our whole biomedical medical preventative maintenance ticketing system in there, so our clinical engineers get alerts when preventative maintenances for equipment are up and coming and they use that to document what they’ve one.

One of the nice features about Altiris is that it has a software virtualization piece. There’s a lot of talk about server virtualization with things like the VMware, which another thing that we’re doing, but this client-side virtualization is particularly interesting. So, we can run applications that may have conflicts with another application, but on the same PC, in this virtualized layer.

A couple of our applications at our long-term care facility don’t play nicely with another app on the PC, and so what we’ve been able to do is virtualize it isolate this application to run in its own memory space and avoid conflicts with the other tools. It’s as simple as clicking on an icon to launch it and then, when you’re done, it disappears from memory and the PC goes on with its normal activities and its previous configuration and the other app that conflicted with that other app can run with no problem. So, one example is, just as a test, we’ve been able to run Office 2003, Office XP, and Office 2007, as an example, all on the same PC and all at the same time. That’s the power of this thing.

You license this by the desktop and basically you just install it? There’s  not a lot of configuration that has to be done?

You can download the Altiris software. I think I have this correct – individuals who want to experiment with it for their own personal use, all the tools are up on the Altiris Web site that you can  download for free and trial it. Basically, what you do is you get your machine set up in the pristine state that you want it to be, and then you run a tool that looks at how the application that you want to virtualize installs itself. It remembers all the registry changes, all the files that are installed, and creates a separate executable, a separate layer that you can turn on and off with a very small client that runs on your desktop.

Sounds pretty cool.

It’s pretty straightforward to use and it’s pretty powerful. It doesn’t work with everything, but we’ve been able to work with a lot of different applications.

What we hope to able to do is create an application self-service environment. So, ignoring licensing issues for a minute, if a person needed Microsoft Visio today, they have to call the help desk, log a ticket, and then one of the technicians will push out, through Altiris, a Visio package that we’ve done and install itself on the person’s desktop and they’re good to go. That works pretty well, but, in an ideal world, the user will be able to go to a self-service software portal and install the layer that runs Visio and really end up not installing anything on the PC. Essentially, they just download this layer and, when they need it, they activate it; and when they’re done, it turns itself off.

And so, you can imagine from an IT standpoint, we’d no longer have to deal with software installation issues. We’re really dealing with flipping a layer on and off and keeping the desktop pretty static. We’re not there yet, but that’s where we hope to get. And the nice thing is that, then let’s say somebody’s PC blows up. All we really have to do is get them a new PC with a base image on it and there’s no additional installation of software required, in theory. They can really just have these application layers on that client and turn them on and turn them off as they need them. The whole process of installing all the software is gone. We’re not going to get there for a while, but for some key application that people need quick access to, this is a fast, easy way to get it done.

Tell me what kind of IT issues you’re seeing or what kind of successes you’ve had in general.

We’ve been doing a lot over the past six months to revamp our governance process. Like everybody else, we’ve got too much going on. We’ve got a lot of demand for new applications and luckily Mercy has been, financially, doing quite well to be able to afford those applications. But as a result, there’s obviously only so much talent, time and expertise for that. The team has to get all these things done. Juggling the priorities has been a big challenge for us.

About six months ago, we bought a product that then was called E-Project, but now is called Daptive. It’s part project management and it’s part portfolio management for projects. We chose one that will do both because we’ve got some of our project managers who are really deep in Microsoft Project and use that extensively, but we wanted to keep that compatibility and we wanted to have a way to keep track of projects at a detail level.

We didn’t have a great way of doing things at the portfolio level, so we wanted some tools that we could expose to our executive sponsors to say, “Here are the ten things that we’re working on now for you, and there’s the twenty things we’ve got queued up. They’re on your wish list.” We spent a lot of time the past few months getting all of our projects and all the attributes about these projects, whether they’re ongoing, or ones that are funded but not started yet, or ones that are wish list items and someday may be items that we’ll do in to this application, now we’ve got about probably 500 different projects in there, 75 or 80 that are going on right now; and the other ones on hold or on the wish list queue, depending on funding.

We hope to get all this stuff and the rest of the attributes about these products cleaned up, and then in the New Year, begin to expose this Web-based portal out to all these executive sponsors and use that as a vehicle to better communicate with them, “Here’s what we know that you want. Here’s what we’ve got teed up and that we’ve all agreed to as the timeframes for project XYZ. Let’s make sure we communicate with each other about. Is this data accurate? Does it meet your expectations? Or is there something else that you though you wanted to do or have that’s not on this list?”

What are the most important projects?

Clearly the ambulatory EMR project with Allscripts is a big one. It’s one of our corporate priorities. Our perioperative system with Picis will be a two-year project, certainly in earnest over the next year. We’re in the process of finishing up an electronic medication administration point-of-care system with CareFusion, purchased by Cardinal recently. That’s where our nurses are at the bedside, barcoding the unit dose medication, barcoding the patient’s wristband, making sure it’s the right med and the right time. That’s in the process of finishing up. That’s been a very important patient safety initiative we undertook about a year ago.

What’s the department’s staffing and budget?

We’re about 75 people, just over 2% of our operating revenues go to IT. From the networking side, we’ve got the network team that’s also responsible for data center and telecom. We’ve got a help desk, a traditional service center. We’ve obviously got folks managing our data centre and our servers. They’re our engineering team.

Clinical engineering is part of IT here at Mercy. We integrated those guys probably about 2½ years ago. We found that IT was involved in all the bio-med projects and vice versa. Essentially, all the clinical equipment is coming out on the network now.

We’ve got a small project management office of about six folks. Now I say small, but it’s kind of funny. I was in a meeting with several other CIOs  from various hospitals in Maryland and I mentioned that fact, and I think people were very curious how I was able to get six project managers approved. I can’t imagine not having a team of dedicated PMs that can go out and herd the cats for all the complex projects we’ve got going on. And then, of course, we’ve got a team that’s the traditional business systems analysts and clinical analysts.

A big help for IT and how we relate with the clinical folks, is we actually have four nurses on the team who are part of the clinical analyst team. They’re nurses with a deep technology twist to them, and they able to not only talk technology with the rest of the team and with the vendors, but they’re able to talk to the clinical staff quite well.

If you look at the concerns you have, either for your department specifically or for the hospital, if you’re looking out, say, three years, what worries you the most?

A couple of things. One, we’re in the process of building a new patient tower, so we have an 18-story building today, it’s about fifty years old, that’s pretty much at its end of life. We just broke ground a couple of months ago on a new facility just one block to the north. So, trying to figure out how to plan and budget for 2-3 years in advance for all the technology they want to put in place in this new tower is challenging. Everybody’s got a different idea of what they want to have done. We’re not fork-lifting all the operations from the current tower to the new one. We’re going to have some clinical functions on both towers. And as a result, its going to be hard to revamp all the processes, but clearly some process re-engineering is going to be part of this move and trying to layer in some new technologies that people want to implement as part of this move are certainly things we think about quite a bit.

While we have Meditech as our core, the fact that we have added on these other systems is certainly challenging. Obviously as we add more disparate applications into the environment, how we manage those, how we attach them, how we support them, how we interface them, how vendors get access to them, how we monitor them – that just gets more and more complex. Best-of-breed is a great approach for folks who have mastered change management as an organization, but we’re not 100% there yet. So, I think if we continue to go down this best-of-breed approach, we have to get a lot better internally at managing the change that comes with all the different applications.

I saw that you’re an advisor for an open source software company. What areas within healthcare IT will be influenced by open source how long will it take?

That’s a good question. The open source software company you referred to is Zenoss. We use Zenoss for our enterprise systems management here. All of our servers and our network equipment is managed through Zenoss in a nice common dashboard front-end. Wey hope they extend that to a lot of our bio-med equipment and other areas over time.

I think open source has applicability in most areas of healthcare. Some people think of open source as, “Hey great. I’ve got the source code, I can make any modification I want to it” and other people think open source is, “Just another piece of software out there that I can hire somebody else out there to support and manage for me”. So I don’t really look at open source as fundamentally different than most of the other software that is out there. It really just depends on how deep your shop is at being able to customize the environment, customize that particular application.

We don’t have a lot of developers here at Mercy. We’re more integrating off-the-shelf stuff, but I think if there was some open source software application that could meet our needs in a particular area, we’d be certainly ready, willing and able to take a look at that. Support of that open source app, we’d have to figure out, do we hire a third party to do it, or do we staff up internally and train folks on how to do it.

You’re one of few CIOs who has a Facebook page, so I know you like cool applications. What kind of stuff have you run across that my readers should check out?

Grand Central is a great tool that I’m slowly rolling out as my main number. Once you get into the details of Grand Central, its really amazing – all the customization you can do. Most people, in this day and age, will have a home phone, a cell phone, an office phone, and sometimes a pager. You can do some interesting things with Grand Central. For instance, if I’m going on vacation somewhere, the primary way people will get a hold of me is to my cell phone, but I may have coverage problems or I may not have it with me. So with Grand Central, in about 10 seconds, I can say, any calls coming into my Grand Central number forward to the vacation house’s number. Now that phone will ring anytime someone calls me. That’s just one of many tools you can leverage Grand Central for, so it’s a great way to let people to get a hold of you when they need to.

Another tool I don’t know what I would do without is Jott. Basically, I’ve got it speed dialed on my cell phone, so when I’m driving home at night and have an idea or a thought or something I want to track … in the previous days on my Treo, I’d sit there while I’m driving and try to type in on my notes page my thought, or something might call their voice mail and leave themselves a voice mail message. With Jott, you call up a number and it recognizes your caller ID from your cell phone, so it goes to your account, and you leave yourself a message; it gets transcribed, essentially in real time, and sent back to you in the form of an e-mail. So when I get back to my desk, I’ve got my thought, my note sitting there waiting for me. I’m a great fan of David Alllen and the GTD methodology, if you’re familiar with that. One of the things about getting things done is that you need to get things off your mind, off your conscience, get it down where you know you’re going to look. So Jott drops it right in my e-mail, which is something I’m in every day, and allows me to keep myself organized.

The other big thing I don’t know what I would do without is Mind Manager from Mindjet. It’s a mind-mapping tool. So, I use that for basically everything. Outlining any kind of documentation that I’m working on or strategic planning or meetings I’m going to have with folks all get outlined in there. Also, on top of Mindjet’s Mind Manager is a tool from a company called Gyronix called Results Manager that sits on top of Mind Manager and allows you manage your to-do list, for lack of a better term. So I might have 20 or 30 different maps of all these different ideas of all these things that I want to do, whether its personal or work-related. Results Manager will comb through them all and present them to me through a simple dashboard all those things that I’ve told myself that are a priority or important that I want to get done. Mind Manager helps keep me organized, and then Results Manager really helps me get the things accomplished that I want to get done. Frankly, I used to just use Microsoft Outlook tasks for everything, but there’s only so far that takes you, because you really can’t nest things and do hierarchies. You have to have one level of items and maybe apply different categories and notes, but if you really want to organize things and move them around and reposition them, Mind Manager’s the way to go.

What kind of hobbies interest you when you’re not at work?

My wife says I’m on the computer all the time when I’m at home, which is probably true. I’ve got three kids, all in elementary school, so I help out coaching their sports teams. They’re playing basketball right, now so that’s definitely an interest. It’s more than a hobby, but something that takes a large part of my time. I used to be wannabe chef. I considered actually going to cooking school for a long time and changing careers, but IT was much more interesting to me. I don’t cook or bake as much as I used to, but I still enjoy doing it when I find the time.

I’m a big fan of music. I’ve got music playing all the time. Whether it’s at work or at home. I’m a big fan of Rhapsody, which allows me to, for one price, play an unlimited set of music, look at different styles and different artists, and pick up some new tunes. You had a post where you were talking about Love, so I listen to them. I’d not heard them before and I was like, “Wow. This is fantastic.” So, that’s a band I’m listening to now. I really enjoy the ’80s tunes for the most part. I’ve been a big fan of collecting a lot of obscure acoustic eighties music. If you need any acoustic Duran Duran or Def Leppard, I’m your guy. [laughs]

Interesting Information from Jim

Department staffing

Business/Clinical Analysts (20)
Project Management (7)
Clinical Engineering (9)
Server Engineering (8)
Logistics (4)
Service Center (17)
Telecom/Data (5)
Information Architecture (3)
Process Manager (1)
No outsourcing of any function currently.

Average tenure is 6.7 years. Half of the team has a healthcare background.

Other Projects Requiring IT Involvement

Security:  IP enabled video cameras are the new standard at Mercy. Obviously, now another device on the network that requires management and storage (a lot of storage!) Check out www.vidsys.com for an interesting vendor merging IT and security.

Point of Care Testing:  More and more POC devices are network enabled (wired and wireless). These devices need to managed, patched, secured, and replaced (frequently).

Wayfinding/Signage: Signage is moving digital. Check out http://www.cisco.com/web/solutions/dms/index.html for some interesting tools we are starting to look at as we consider signage and wayfinding for our new patient tower. Cisco’s DMS is a network-based, set-top box solution with centralized content management.

Patient Entertainment: We haven’t pursued this yet, but will probably be looking to implement hotel-like amenities in our new patient room. Movies on demand, Internet access, meal selections online, etc. are all coming to a hospital near you.

Smart Beds: The day is coming (has come for some) where even the patient bed is a device on the network. I can see a Patient Command Center running Zenoss, where bed rail up/down status, 30 degree bed elevation in the ICU status, patient location, late medication alert, etc. all monitored via a central control center. We use Zenoss for server and systems monitoring today, but why not extend it to patient centric functions – particularly since it is an open source product!

Links to tools Jim mentioned

Jott
Grand Central
Mind Manager
Gyronix
Zenoss
Daptiv
Altiris