NG: It will continue to alert people and continue to monitor for the desired outcome.
AG: I was speaking to Larry Stofko, CIO at St. Joseph’s Health System, and he talked about the fact that while you want to work with vendors that are flexible, you don’t want to work with those that have no limits to what they’ll do for each client. Does that sound right?
NG: I totally agree with him. That’s the opposite end of the spectrum where now you don’t have a product, you have a bunch of customized versions of a product and then the vendor can't roll out upgrades easily and things of that nature. So that is definitely an issue. I’d like to think as CIOs, we generally take more of a broad approach to say, ‘Listen vendor, this is something that doesn’t just impact CentraState, this impacts the industry as a whole, that’s why we want you to focus on this.’ And we’ve kind of taken that approach with Siemens, but you know, we all have selfish needs too, and we hope and lobby for our needs to be met. But I think we’re kind of working towards a realistic goal.
Siemens has set up an executive advisory council, and they constantly tweak the constituents of that group, as well as how the group functions. But it’s been an interesting feedback-providing mechanism where they're really surveying a nice diverse mix of their customer base to understand what are the needs going forward so they can prioritize their development pipeline.
AG: You went from Meditech, you hit the market, you wound up picking Siemens. Is there a reason that you didn’t go with a different vendor, such as Cerner, GE or McKesson? Those were all options for you, but you picked Siemens, tell me why.
NG: We did look at all of the above. I’ll tell you one by one a little bit. Epic didn’t want to play with us. We were too small for them. I don’t know if that’s still their model, but at the time, they were really focusing more on academic medical centers and large facilities. In terms of Cerner, we had looked at them, we looked at McKesson, we looked at Per Se, which has since sold the product to Misys. We also looked at QuadraMed.
One area we looked at was obviously functionality. We had a requirement for certain functionalities that we were going to rank. Price was another decision variable. And then we added a section criterion called relationship. Our relationship with Meditech has been one of very much this strict kind of — I don’t know what words to use — this very traditional customer/vendor relationship. ‘You bought something from me, if it’s broken, call me; otherwise do you what you need to do.’ Even when we approached them to say, ‘We’re not really that happy with some of this, can you help us?’ It wasn’t something that was part of their business model. They tried, and I want to give them credit for that. They did assign an executive who had tried to work with us, but really it wasn’t their corporate culture. Their culture was, ‘We have got this product, and people are buying it. So if you don’t like it, too bad.’ It wasn’t quite as blatant as that, but that was the overall message ultimately.
When we put this RFP out there, one of our criteria was partnership. And we kind of challenged the vendors who were bidding to say, ‘How would you partner with vendors today to make sure that our mutual needs are going to be met?’ and Siemens came to the table with the most interesting model. Frankly, Siemens also came to the table with a lot of risk. It’s a very new product versus an Eclipsys or McKesson, whose product definitely had at the time a lot more penetration and certainly a larger user base. We played those two things off each other, but really, as we scored everything out in these three categories, Siemens won heavily based on the partnership piece.
AG: What year did you sign the deal with Siemens?
NG: I want to say the end of 2003. We started implementation in 2004.
AG: Is there a date at which you ever really finish something like this, or is just always a work in progress in terms of implementing?
NG: This is always a work in progress. I think that’s the nature of workflow. I think that’s the nature of all clinical systems, as you're in there and you begin to understand the needs of your clinicians. We've got such a long way to go in terms of providing tools and automation for clinicians, perhaps saying it’s a never ending process isn't fair, but it goes out well beyond the foreseeable future.
AG: Is that type of process difficult for a CEO or CFO to understand, and do you have to do a lot of work explaining to them why it isn't done in 18 months or something more specific?
NG: I think it can be, and I’ve worked with a number of CFOs and CEOs, COOs in the past. I’m very fortunate here to have a very tech-savvy C-suite. Our CEO understands technology and is a big proponent of it, but he has high expectations of it also. That’s a big challenge for me as a CIO, because I can put technologies in, but I’m also challenged often with trying to shepherd that culture change. That’s been probably one of my greatest challenges. It is often a challenge, and what we try to do is we try to look at certain things as infrastructure. You’ve got to have infrastructure and yes, obviously, infrastructure is your network, your wireless infrastructure, etc. But there is an application infrastructure as well. So putting in a clinical system itself, we kind of viewed partially as infrastructure. We’ve got to have this system in place before we can begin to do the analytics and deliver the value then that will come from having the system in place. And so now that we’ve got the system in place, that’s where our focus is beginning to shift a little to now how do we build new workflows out, how do we prioritize those? Our nursing staff is coming to the table in our committee meetings and saying we've got an idea for a workflow to do this and to do that, and we’ve got limited resources.
So we’ve come up with a prioritization model. We didn’t come up with it on our own. We’ve worked in conjunction with some other Siemens customers who are doing this as well. Everybody has shared certain ideas, and we’ve got a model that seems to work for us right now. So based on that, we prioritize out what some of the ideas are out there and our understanding of where the pain points are in the organization. And then we hand it off to our technical folks and say, ‘Okay, here is a list of 20 things, how many of these can we do this year?’ The people who are advocating them have to have measurements in place. So they have to be able to demonstrate, for example, that we believe we’re going to reduce pressure ulcers by X percent or improve medication safety by Y percent, and here’s how we plan to measure that. And then, based on all of that, that’s presented to our executive committee here and we sign off on moving forward with those workflows. So that’s our new focus — delivering value from this infrastructure application technology that’s in place.
AG: From my other discussions with CIOs, it definitely seems like we’re at the phase where many of the applications have gone live, and now it’s time to really extract the value. How are you measuring use at CentraState?
NG: Everybody who documents inpatient clinical activity and a lot of outpatient activity is using these systems or the systems we’ve put in place, because we do have some other systems in some of our ancillary areas. We monitor compliance as much as possible. We obviously don’t have the resources or a dedicated person who kinds of sits there and runs utilization reports to monitor compliance fulltime.
I’ll give you an example. One of the things we rolled out as part of this implementation was medication administration with bar coding at the bedside. Early on, we deployed wireless cards with laptops and wireless scanners with them, so that they could roll them into the bedside and go ahead and interact directly with the patient and the meds and ensure the patient’s safety. Early on, the nurses were not happy about this at all. And in fact, they often would simply hit the override button, not go to the bedside and scan the patient. They would work in the hallway, do what they always used to do and just bypass that because there is an override capability. And we began seeing that early on and realized, ‘Uh oh, we’ve got to monitor this.’ So we started running override reports. We then, through my office, pushed those out to the nurse managers to say in your unit, ‘I see 50 overrides, and I can see who has been doing the override, and you need to come back and report to us why, because we’re reporting that to our executive committee.’
So that created transparency. That started to take away the place that these people could hide. They said, ‘Uh oh, I’m being watched on this.’ We’ve seen compliance increase dramatically. Frankly, today, there are very few overrides and those that happen, have a valid reason.
AG: You were able to learn why they were doing the overrides and possibly address those things?
NG: Yes. The override process does require them to put a reason in. So at first they would simply pick the reason, and I think ‘unreadable bar code’ might have been the first one. So we had to go out and spend a lot of time debunking those. ‘What do you mean unreadable barcode?’ Somebody would go up and say, ‘This barcode works fine, why do you call it unreadable barcode?’ And we began to hold them accountable to that. It took, I would say, the better part of the year to get the culture changed sufficiently, but we still run those reports, because I believe the moment they know you're not watching them, you will slowly start to see compliance flip. That’s become our role.
We just rolled out a function called ‘plan of care.’ It’s interdisciplinary treatment plans. So this is another thing that, historically, nurses are supposed to do, but in the paper world if they didn’t do it, the only way you’d know is through a random chart audit. That’s very resource intensive, and most people don’t really do that. Now with the system, we can say, ‘Hey, how come five of your patients don’t have a treatment plan on them?’ Now they're being held accountable. Obviously the nurses who are doing what they're supposed to do, they don’t care, it’s fine for them. But the nurses who didn’t, who would forget or miss a few, now they're a little unhappy. ‘It’s part of my job, I was supposed to do it, but now somebody is watching me.’ That’s how it starts, but ultimately what we find is that there is a six month to one year transition where they go from irritation and anger, resentment to acceptance, to actually positive feelings that this is really now streamlining their jobs. This tool is now telling them what they need to do. But that takes time, and you have to keep watching them.
AG: What we’re talking about here is really CIOs taking an active role in facilitating adoption through these different techniques. To what degree do you think CIOs should be on the hook for actual clinical clinician usage of these systems, 50 percent, 80 percent, 20 percent?
