From Implementation to Transformation

April 10, 2013
Spectrum Health’s J. Michael Kramer, M.D. sees a world of opportunity in moving his western Michigan health system forward to fully leverage the benefits of the electronic health record to create the clinical transformation needed in today’s healthcare.

After spending nearly six years helping to lead clinical transformation efforts at the Novi, Mich.-based Trinity Health as that organization’s CMIO, J. Michael Kramer, M.D., in August 2011 joined Spectrum Health as its system CMIO. The Grand Rapids, Mich.-based Spectrum Health encompasses nine hospitals, a rapidly growing medical group with over 500 salaried physicians, ambulatory clinics, and an affiliated health plan, across western Michigan.Overall, Spectrum Health encompasses 18,000 employees, 1,500 physicians, and the Spectrum Health hospital Group, the Spectrum Health Medical Group. It is a $4.1 billion enterprise in fiscal year 2012, and is the largest employer in western Michigan.

In his role as system CMIO, Kramer is responsible for medical informatics for the entire system, including the health plan, Priority Health, and he has duties related to the health system’s formal  affiliations with Grand Valley University and the Van Andel Research Institute as well.

HCI Editor-in-Chief Mark Hagland spoke with Dr. Kramer in the late spring regarding his role and experiences at Spectrum Health. Below are excerpts from that interview.

Are all the hospitals in the Spectrum Health system live with EHRs [electronic health records]?

We have computerized physician order entry [CPOE] live in all but two of the nine hospitals. Two have yet to go live with CPOE. We’ve got about an 80-percent physician order entry rate across the hospitals. And we’re simultaneously running the hospitals, with the exception of the two that will go live this summer, and the medical group, and are in our attestation phase right now for meaningful use. We’ll be attesting for the seven hospitals and medical group, we’ll be ready to attest on June 30. And everything’s looking good, we’ve got all of our measures pretty much done, we’re just testing our health information exchange. And with our medical group, we’ll be ready to attest for a cohort of 120; and then we start another group May 1 and they’ll be done in July. So about every 30-45 days, we start another group of 100. Now, out of the 500 or so physicians, two-thirds of the practices are live on Epic today.

J. Michael Kramer, M.D.

Which solutions are you implemented on in the hospitals?

We’re one of the seven organizations in the country with Cerner on inpatient side and Epic on outpatient.

UPMC [the University of Pittsburgh Medical Center health system] has the same arrangement.

Yes, and so do Northwestern Memorial, and Our Lady of Lourdes. Aurora is moving from Cerner to Epic.

What have been the main challenges that you came into, in moving into your current position?

The biggest, and this is true of any organization that has just finished implementing its CPOE, is that there are still a lot of bumps in the road, in terms of improving processes—what you thought you were going to do, and how it was going to work, doesn’t always go as you thought it might. If you read the Institute of Medicine’s patient safety paper—one of the models I’ve seen at Spectrum and in other places, is that there’s a life cycle in terms of implementing the EHR, and there are about five phases involved. There’s planning, implementation, stabilization, optimization, and transformation—those are the five phases.

And where are you in that schema of development?

For most of the organization, we’re moving from optimization into transformation; and that’s really what I’m trying to lead as CMIO, and saying, we’re not going to do things the way we used to; we’re going to leverage this technology to move to the next level, leveraging Lean and other tools to transform care. We have more data than ever before, and we can identify waste more efficiently than we ever could. There was just an editorial last week by Don Berwick in JAMA [the Journal of the American Medical Association], and he says there’s 20 percent waste in healthcare—and that comes from redundancy in care, repeated operations and steps, extra tests, etc. And the tools for fixing that are Lean and Six Sigma and clinical decision support. And building dashboards and performance improvement tools will be needed to transform care. And as you come out of the cloud of implementation, you need to move forward into transformation. And we were doing this at Trinity and are now doing this at Spectrum Health—trying to help clinicians to learn how to leverage the tools to transform care.

Did you find any particular challenge in coming as a totally new CMIO at Spectrum Health?

I think what I faced is true in many organizations. When you think about informatics broadly, it’s change management, clinical decision support, usability, many factors. I’ve been training for this role since 1995. And people who have made this the center of their career, there are not a lot of them out there. And I did a fellowship in informatics, and had been practicing in informatics since 1999. And Spectrum got through their implementation, and really wanted someone to lead in the science of informatics. And that’s something that a part-time CMIO can’t readily accomplish.

Were you their first CMIO?

Yes, and there were a lot of comments like, ‘I’m so glad you’re here.’ They needed that level [of professional development in their first CMIO]. At the same time, coming in from the outside, at times, I have to be careful not to say, well, your gourmet dish doesn’t smell so good.

It’s all about diplomacy, right?

Yes. And I’ve actually created a progression of job titles, including physician champion, physician system architect, and associate CMIO, here. So I have a physician champion on the ambulatory side, and he practices half-time. And then I have two others in a similar role who practice 90 percent, but devote themselves a half-day a week to working with me. And I have a full-time physician solution architect, to whom I’m assigning a lot of responsibilities, including clinical decision support; and he’s doing a lot of meaningful use-related work. And we’re just starting to recruit for an associate CMIO, whose main responsibility will be for our pediatric hospital. But this role will be over both inpatient and outpatient pediatric care. So it’s really kind of neat that within eight months of being here, we’ve developed a whole physician leadership with all that you’ve described; and there’s a necessary role and responsibility for all of them.

What are your lessons learned so far about CMIO leadership and responsibility?

The biggest lesson so far as been about the magnitude of responsibility; increasingly, one can’t do anything without an understanding of the underlying technological architecture. And I’m finding that developing organizational pace is absolutely essential—to have the CMIO be able to pace the change and to explain why things should be done and in what order.

To whom do you report?

To Patrick O’Hare, the executive vice president and system CIO. He’s an excellent leader and informaticist.

What do you see as the essential elements in a strong CIO-CMIO relationship?
I think the first is that the conversations between the CIO and CMIO obviously have to be highly open and collaborative and build on ideas. The strategic vision and tactics need to be very clear between the CIO and CMIO. I’ve sat down with Patrick, and we’ve laid out a three-year plan together, and it’s very clear, with clear strategic alignment. So that sense of aligned direction is very important. I’ve said that an organization can take 12 steps in 12 directions, or 12 steps in a single direction, and the CIO and CMIO need to be walking in the same direction. Another thing is that CIOs often don’t realize how complex transformation is. Patrick already understands that it’s not about just the technology, but that it’s about managing the cultural and behavioral changes around the technology. And the CIO and CMIO have to help drive those changes together. And I’d say the same thing if I reported to the CMO.

Does it matter to whom one reports as CMIO?

That’s kind of an age-old question going back years. I think the optic that the change is being led by clinical leaders is very important. I think the CMIO is going to be most effective in the part of the organization that has the deepest resources; and if the clinical leadership is managing professional issues and credentialing and so on, but they don’t have the resources to manage change, reporting to the CMO might be difficult. You want to go where you can be most effective in leading change, and where the resources are. And not every organization is set up in the same way. In an organization like Spectrum where we are a young organization, and where the clinical leadership has not yet fully come together, it’s very comfortable for me to report to the CIO, because he has the most mature leadership in this area. Eventually, it may be more appropriate for me to report to clinical leadership.

What do you see happening in the industry in the next couple of years?

As you implement health information technology, the CMIO is leading the management of a great deal of clinical knowledge. For inpatient alone, there are 700 order sets, 300 rules, and 300 physician templates. The CMIO has to make sure that the skill sets and leadership are in the organization to manage all that. And that’s a big responsibility. The second piece is that the CMIO has to lead a culture where the curriculum and talent development around informatics and process improvement are growing, and where the CMIO increasingly is fortified by the people around him, in all departments and corners in the organization. So leading the talent and skill sets needed to be successful in an ACO [accountable care organization] world is very important; and I don’t know if that’s fully recognized yet. I feel like I’m back at the University of Michigan where I started, where I was running meetings and starting off meetings with an overview of clinical decision-making and principles. And I don’t want to be the only one standing up and speaking to that. So in terms of building the human infrastructure to build systems to be successful in the future, it’s kind of fun stuff.

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