Giving a patient medications in the ER, having them pop positive on a test, and then withholding further medications because…
Curbside Consult with Dr. Jayne 1/19/15
Several readers have sent words of encouragement after reading about my last few weeks in the CMIO trenches. I definitely appreciate all of my virtual colleagues, even those who just write to say they understand and to wish me calmer seas. It sounds like many of us are going through the same trials and tribulations even though some of ours may be a little messier than others.
Our hospital is part of a larger health system that has announced its intent to replace all the clinical systems with a single vendor platform. I’m taking a couple of days off this week to really put my thoughts around whether I want to stick around to watch it happen.
I understand the need to consolidate systems. Our IT department is larger than nearly any other except for nursing. The budget for maintaining this “ultimate best-of-breed nightmare” is exorbitant. Many of our systems feel like they’re held together with duct tape, baling wire, and bubble gum. Some of them are just plain old. And several hospitals are on a platform that is being sunset by the vendor, so their systems simply have to go.
Being part of the larger project to turn this new single-platform vision into a reality is potentially exciting. But it also looks a little bit like a bottomless pit of long hours with not enough staff to work at a pace that would allow us to deliver a quality system without burnout. It’s also difficult to know that the health system has plans for how they plan to handle legacy clinical data that will not make our ambulatory physicians very happy.
Those of us that are “in the know” about the strategy have to keep quiet until it’s formally announced. I’m not used to being told what I can and can’t say to the physicians I serve.
It’s also bittersweet to watch systems be torn out when you’ve spent the better part of your professional career building them. We’ve held our users’ hands while they learned them and while they coped with upgrades. We’ve been at the other end of plenty of angry phone calls, but we’ve also heard the appreciation when we started to provide data to help proactively manage complex patients and to identify gaps in care. Of course our new system will also do this, but it was special to see how physicians reacted the first time they realized it was possible. Now those features have become old hat.
In addition to consolidating systems, our leadership also plans some pretty radical consolidation among hospital leadership and medical executives. We’ve always functioned as a federation, but this is taking us much more towards a centralized clinical and financial model and it’s not entirely welcome. A couple of chief medical officers have already moved on and I suspect a couple of hospital-level CMIOs and CNOs are planning to move as well.
On the non-clinical side, however, mid-level administrators seem to be proliferating. The number of buzzwords in an average hour of meetings has skyrocketed. We have four different consulting companies involved and they’re stepping all over each other with contradictory advice.
I’m not sure I want to leave the provider aspect of the CMIO game. There are definitely opportunities out there, but I really don’t want to relocate unless something pops up in Hawaii, in which case all bets are off – the idea of living in a place where the difference between winter and summer is 10 degrees does have a certain appeal. I just started clinical work with a new group that has a lot of promise and an extremely low chaos factor, which is a welcome change. I also spent the fall doing a ton of work on my garden and can’t imagine walking away.
There are some interesting vendor opportunities that don’t require relocation, but I’m not sure about crossing that bridge. My friends in the vendor space seem less stressed than those of us on the provider side (except during Meaningful User certification testing, in which case I recommend either steering clear or providing copious amounts of wine and moral support). It will be interesting to see if any new opportunities arise as we get closer and closer to Meaningful Use Stage 3.
Consulting is also an option, but I’m not sure I can handle being on the road as much as most of the larger firms expect. I’ve also heard the horror stories about being on the billable hours hamster wheel. I’ve dabbled in consulting over the last several years and would consider going out on my own as long as I have some ongoing clinical work as a financial safety net. I’m not enamored of what clinical practice has become in the last decade, however, so going full-time is not an option.
Today was my day to relax and think about nothing work related, but tomorrow is my day to sit down, run the numbers, and see if I can come up with a business plan that might fly. Wednesday I’m getting together with a couple of colleagues in the same boat, where we can trade ideas and see if anyone else has come up with a better plan. Thursday I’ll be back in the office, and it will be interesting to see how that plays since I’ve pledged not to touch my email or answer my phone while I’m out. Appropriate backup resources are in place, but I know my boss isn’t used to being unable to reach me. He’ll just have to get over it.
Here’s to crunching the numbers and hopefully to some new ideas about my next career move.
If you could do anything you wanted, what would it be? Email me.
Email Dr. Jayne.
Interesting timing since I just wrote a blog post talking about the best of breed approach versus the all in one model: http://www.emrandhipaa.com/emr-and-hipaa/2015/01/19/the-value-of-an-integrated-specialty-ehr-approach/ I think you’ll appreciate this line from it:
“The real decision these organizations are making is whether they want to put the burden on the IT staff (ie. supporting multiple EHRs) or whether they want to put the burden on the doctors (ie. using an EHR that doesn’t meet their needs). In large organizations, it seems that they’re making the decision to put the burden on the doctors as opposed to the IT staff. Although, I don’t think many organizations realize that this is the choice they’re making.”
It’s definitely a challenging decision you have in front of you. I say do what seems most exciting and interesting to you. Life should be interesting.
To John’s point, the best-of-breed does put a burden on IT, but it also puts a burden on every physician that is NOT part of the specialty EHR or best-of-breed system, and can’t easily access or see that information, and if they can it’s typically not integrated with the workflow they’re used to in their EHR. I was previously at an institution that did this switch (best-of-breed to single vendor) and although the specialties could each make a compelling argument for why their own EHR was better, they all failed miserably when it came to how they would share data between their system and the single EHR. People working in the same building couldn’t access each others’ records, it was crazy. For a large multi-specialty practice group or large IDN that is trying to keep most of the referrals in-house, this is a very big deal.
Honestly… I think we’ve progressed to a ‘Best of Phylum’ approach at the very least. It is really hard to imagine a world where our ED docs were using a different system than the rest of the group.
The question of whether to participate in a large-scale system replacement is a difficult one, no question. I am thinking of similar issues. Here are some of my thoughts on the matter:
1). The organization is willing to fund and politically support the system change. That alone is interesting. If you want to be where the action is, this is the foundational piece;
2). System replacement projects have a lot of risk and the larger the project the more risk there is. Outfits like the SEI have researched this extensively. Every project wants to get these factors under control but it’s notable how many such projects either fail completely or complete with a “challenged” status;
3). Best of Breed strategies always struggle with integration and data sharing. The interfaces are always a fracture point. If something breaks the rule is that it’s most likely to break at an interface. So in spite of the homogenizing effects of Single System implementations, it’s my impression that this strategy is more popular overall. The politics of this are, “it may not be perfect but at least we can communicate internally”;
4). You can’t make everyone happy. Seriously, if that’s your goal in life then prepare for disappointment. Functionally driven folks downplay budgetary effects. Financially driven folks tend to shrug off functional compromises and limitations. You need to pick your poison and live with the consequences. Whether you feel successful or not is likely to be dictated by whether your preferred “side” is in control at the end of your career or engagement.
I suppose real enlightenment and happiness simply comes from believing that you contributed to something important.
This may seem inappropriate but I am going to dole out a little tough love.
I know this is hard. You have made huge personal investments in what you have created. And you have created good things.
But why did you create them? Was it for you? for the people you helped? for the patients? your community? for the ability to leave a legacy?
Ultimately all we leave behind us is a small ripple of activity, representing the lives we have impacted. Through your work you have left an impact.
How wonderful will it be for you to serve as a leader helping shepherd others into this new unknown, helping make it better than it might otherwise be.
Yes, you will start over. Yes, it will be hard. But you will learn new things, leverage things you already know. And help leave positive ripples in the water. And you can have yet more wisdom to impart to us.
“It’s also bittersweet to watch systems be torn out when you’ve spent the better part of your professional career building them.”
My former employer just did a rip-and-replace to move to a single-vendor platform. It’s my former employer because I was a remote employee working on the ripped-out system.
I was very suprised by how much it hurt my heart when they turned the old system off. One of my colleagues said “It feels like someone just killed my 10 year old child.”
Unexpectedly awful.
Once gave a talk that systems patched together but loved by their users feel a bit like Velveteen Rabbits to those responsible for them over the years. As Been There said, you’re impact on your organization and healthcare should speak for itself.