One-on-One with Johns Hopkins CIO Stephanie Reel

Johns Hopkins Health System is in the midst of a massive $950 million redevelopment project that will produce two tower-like facilities — one focused on cardiovascular and critical care, the other a children’s center. Slated to open in 2010, planning on the towers began years ago, and required close and continual partnership with IT. Recently, HCI Editor-in-Chief Anthony Guerra talked with CIO Stephanie Reel (also an HCI Editorial Board Member) about staying on top of such a massive undertaking.

AG: Were you involved in this project from its inception?

SR: Well, I’ve been here forever.

AG: How long is that?

SR: 18 years.

AG: Okay, so it didn’t start before you (laughing). Tell me about this from the beginning, this project?

SR: I think the institution recognized, probably 20 years ago, that this campus (the hospital opened in 1889) has many facilities that are older. Many of them are not appropriate for today’s technological environment; nor are they appropriate for the expectations of our patients. Those patients want to have their family member with them; want to be able to have a quiet environment when they’re recovering and dealing with difficult diseases. So I suspect it was 20 years ago when the institutions first began to talk seriously about reinventing the campus.

It was probably in about 1995 when a physical master plan was prepared, and a lot of people participated from the university, medicine school, public health school, nursing, as well as the hospital and health system leadership in deciding what this campus of the future really needed to look like. It included, not just this new clinical building, but it included the planning for and, ultimately, the construction of a new comprehensive cancer center that opened in the fall of 2002.

It opened in September of 2002, a new comprehensive cancer center, and also included in that plan were new buildings to support additional basic science research and clinical research. So, it was truly a campus master plan that had a lot of new development and new construction in it.

One of the driving forces for that master plan was preparing for the campus 50 years from now, as well. There was an appreciation that there’s very little green space at inner city academic medical center campuses. So the plan explained the need for moving the center of the campus to the south of the existing campus, which would allow us to demolish the oldest buildings, which are to the northern edge of the campus. We would use up available green space to build the new facilities. We would then demolish the oldest buildings on the northern edge of the campus, creating new green space, imagining that 50 or 75 years from now, you would repeat that.

You would then tear down the then 50-year-old buildings so that you could create green space while building new buildings on what will then be the existing green space, giving us the ability to flip-flop or swap green space for buildings over the next 50 or 100 years.

So, that was an important component of the plan, that we would consolidate new construction on one end of the campus, so that the older end of the campus could be demolished. That, really, is what has transpired in the course of the construction of these new clinical buildings, as well as the new research buildings.

The only other thing that I would say is that, also incorporated in the 10 year plan was a plan to build a biotech park that would be adjacent to the campus, and that is also underway. It’s a separate initiative; it’s not Johns Hopkins Hospital-dollars being used. It’s state, city and private money, but it is an industry partnership and a state partnership with Hopkins to redevelop some of the community around the academic medical center.

AG: So, these clinical towers, about how many beds are planned for them?

SR: About 500. They’re replacement beds, they’re not new beds because the old facility has a lot of semi-private rooms, and the new facility will have all private rooms.

AG: So, it’s two buildings, you mentioned towers?

SR: It’s an interesting model, and I don’t know if this is typical now in new construction, but several floors will be common to both towers, so that the infrastructure can be shared. Those infrastructure components that are expensive: radiology, laboratory equipment; those things will be shared between these two new towers. Then at a certain floor, I think it’s the fourth of fifth floor, they then go up as two separate, distinct towers; one being a children’s hospital and one being an adult facility.

AG: Tell me about the CIO’s role in this process. When are you brought in, and what is the dynamic of you interacting with the CEO and the designer and the architect, etc.?

SR: A little known fact in the readership of your journal is that my husband is responsible for building the building, so I probably have an added opportunity to participate in some of the conversations early on. My husband, Howard, serves as the senior director for design and construction for the Johns Hopkins Hospital, so he is under the auspices of the vice president for Facilities; he is leading the construction projects for the Johns Hopkins Hospital. So, it’s afforded me with an interesting opportunity, I guess one would say, and then also some challenges that go along with that. But, because of that, I’ve had an opportunity to at least learn a lot about what was being planned very early on in the initiative.

But, speaking more professionally, we have a very interesting track record here at Hopkins. It goes back to, probably, before me, but in the 18 years I’ve been here, the newest building we’ve built since I arrived was the new outpatients’ center, and it was very clear that the sponsor of that building, the vice president responsible for building services, felt that the only way that building could be effectively operationalized is if we exploited all of our information technology investments as best as we possibly could. So, even going back to 1990, I remember vividly participating every Monday morning at 7 a.m. in a meeting where we were planning for how we would operationalize this new facility. So I participated very actively in deciding what the patient flow would look like, what the devices would be, what applications were necessary to promote the best patient satisfaction, patient throughput, and science and patient care. Now, with this new building, there’s really nothing different, neither was it different during the construction of the comprehensive cancer center.

IT is a welcomed partner at the table and we have been. The only difference is, I think, our focus today is much, much more on patient safety than it was 20 years ago. But we clearly are partners in the design and development of the solutions; partners with the construction leaders, but also partners with the clinicians and scientists who are going to be moving into this building. So it’s a very collaborative feeling, and I think it has very little to do with the fact that Howard’s involved; it really has been something that’s grown from our past experiences, so it’s been really terrific.

I have a member of my staff, a very senior member of my staff, who is meeting about this new building often, many times a week, and planning for both the infrastructure that needs to support the new building. To date, because these buildings aren’t opening until 2011, much of the work has been infrastructure related, but it’s becoming much more focused on applications to support safety, satisfaction, science and service.

AG: I can certainly see why a CIO would need to be at the table to discuss, at the architectural stage, server rooms and PACS deployments. So please tell me about that, and also explain your involvement with the applications in the new facility.

SR: The first half of your question, the infrastructure items and the architectural connection, is relatively straightforward, and we probably have a bit of an advantage because, over the years, we have developed standards. Obviously, they get enhanced each year as technology’s evolved, but we’ve created standards that help our facilities partners understand what a closet needs to look like, how big it needs to be, what it needs to be able to accommodate, what kind of tower requirements need to be considered, how much space and cooling, how secure it needs to be, what kind of locks, and what kinds of access is needed. All those things are reasonably well documented in a standards document that we share with our contracting colleagues, or with our facilities partners.

I think that gives us a little bit, and perhaps this is done everywhere, but it does give us a little bit of an advantage in that we don’t have to be present at every conversation because these standards exist. We participate because, as you’re building a building that’s going to be here 50 or 60 years from now, you want to make sure that it can accommodate emerging technologies and obsolescence, and all the other things that we need to be attentive to. But I think we’re not reinventing the wheel. Each time we build a new facility, we’re simply updating what already exists. So, that relationship has been a very healthy one because we’ve had those standards.

Where it gets trickier is where you’re talking about new emerging technologies like tracking technologies, bar-code solutions, or some of the much more sophisticated presentation-type systems that might be used in an ICU or in an operating room. These are areas where you might want to have five or six flat panel monitors up on the wall that a busy group of surgeons and anesthesiologists can look at to see how the patient’s doing during this procedure, or how the patients, as a whole, are doing in an ICU.

So, we’ve had to definitely update and rethink some of the infrastructure components that are required. So, lots of technology is required in the background to ensure that all of those things that are in the foreground are working appropriately.

We still have to talk about where does that control panel reside, where does that large control station get placed, what kind of power do we need in certain locations, and what kinds of supports within the wall do we need in certain locations. But I think that is such an evolutionary thing that everybody’s aware we make our best estimates. We always say the best way to predict the future is to invent it, so we’re trying to invent the future while we’re trying to predict it. I think there’s a lot of work that goes on, obviously, on a day-to-day basis, to ensure that that infrastructure is where it needs to be, and that is happening routinely, so that’s the first half of the question.

The second half of your question, what we’re trying to do is recreate this ideal patient experience. We know that technology’s going to play a very important role in that. We hope that the patient will be engaged, the patient’s family will be engaged, the patient’s referring physician will be engaged from the very beginning. They will be engaged by going to our Web site, understanding what we do, how we do it, where the centers of excellence are and how that patient or that referring physician can get access to those resources.

So, right from the very beginning, we’re assuming that some part of that connection will be electronically enhanced through the Internet. Then we also recognize that a large percentage of our patients are very sick and very worried and scared, so we recognize that there needs to be a healthy balance between the technology and the human interaction. So, from my perspective, it’s important that we create this vision for where that boundary is between appropriate use of technology and just technology for its own sake. We see this as a journey; the patient’s experience is a journey, and we want to make sure that all along the way, technology is there to augment the experience and support the experience and improve it, but not be a barrier to compassion or a barrier to communication. So, we see these things as being a permeable barrier where we need to be able to go back and forth, depending upon the readiness of the patient to deal with technology or not.

We recognize that even though there might be a kiosk right inside the front door when a patient walks in, not every patient will be comfortable using it. In our first set of slides, we had this kiosk in the front door and one of our surgeons said to me, “You didn’t show a person standing next to that kiosk who will help the patient interact it. You really need to include that because not every patient will be comfortable interacting with technology; not every patient will have a care provider with them or a family member with them or an advocate with them. So make sure, just like in the airport, when you go in and put in your credit card, if it doesn’t work, there’s an agent who magically appears and says, ‘Can I help you,’ and we need to be thinking the same thing so that we cross these boundaries.’”

AG: Can you tell me 1) how you manage the budgeting on an evolving project like this and 2) how you stay in the loop?

SR: Regarding budgeting, we have a 10-year plan, and I have to update a 10-year plan every year. We all recognize that it’s not necessarily completely accurate, but it’s a projection and a prediction. So, in my 10-year plan, probably back in 2001, I started to anticipate a need to invest in technologies that we knew were going to be important in supporting the construction of these new buildings, both the cancer center and this new facility. So we started identifying the need to invest capital in enabling technologies that would support the opening of the new buildings. Then, each year, we revisited those investments and reaffirmed the numbers and said, ‘We need to continue to invest, as an example, in clinical documentation and physician order entry because those are going to be absolutely critical to the way these new buildings are going to be operationalized.’ So, we revisited these investments to ensure that they were appropriately invested in to make sure we were positioning ourselves for the opening of the new buildings.

So, right from the get-go, we had an opportunity to identify these resources and the institution then recognized them; the President, the Dean, recognized those investments as being a part of the overall 10-year plan. The plan, of course, for the institution included many more things than just IT, but it was a package deal. It all needed to be there. The whole is greater than the sum of the parts, and it all needed to be there for there to be success from within the construction of the new building.

So, we’ve been budgeting for this for a very long time and revisiting it every year and making sure we had appropriate capital in place to do what we needed to do and, in some cases, we had to borrow from Column A to better support Column B, but it was able to be done because we were all marching to the same drummers; we knew that we were targeting, among other things, the opening of these new facilities.

From a staffing perspective, the same is probably true. When we looked at our 10-year plan, we saw that certain things would be ramping up and certain things would be ramping down, and we needed to drive that rather than be victimized by it. So we needed to drive the ramp up and the ramp down so that we would reach important milestones along the way, where we could allocate resources to doing new things and different things. Preparing for the new building was no different from anything else. We looked at it as a major project, and we knew that we needed to allocate our resources appropriately.

One of the major things that changed along the way is that new regulatory requirements seemed to surface pretty frequently. So we identified a need for more attention on core measures, as an example, that we did not anticipate seven or eight or 10 years ago. We have the ability in our capital budget process to go back to leadership and say, ‘There’s something we didn’t anticipate, and we believe this is important. It’s a little bit different from the focused attention on new buildings, but it has to be done. It’s just as important as the other work we’re doing,’ and in that particular case, we were given incremental budgets over and above what had been in our original 10-year plan. But the way our capital budget process works is, if it’s in my 10 year plan, I don’t have to compete for those dollars every year. If it’s not in my 10 year plan, I need to compete with new elevators and new roofs and new faculty recruitment and other things that are in a capital budget. So then we simply competed for those resources and were given whatever was affordable.

AG: I could imagine a situation in projects like this where the CIO is accountable but not deeply involved, or not involved early enough. What do you see as potential pitfalls that could happen to a CIO for a new construction project?

SR: I am sure that it’s happening here, to some degree, that there are meetings where groups of physicians and nurses get together, and they’re operating under an assumption that every bit of clinical documentation will be electronic and there’ll be absolutely no need for the physical paper chart; that there will be enough devices, enough locations, enough wireless connectivity, enough work stations at the bedside, and enough work stations in the nursing units that paper will no longer be needed. It is quite possible that I’m sitting back thinking that that is, indeed, the goal, but it won’t be achieved in time for the opening of the new building.

People could even be at the same table but walk away with different conclusions because they’re making certain assumptions. I think we’re as guilty of this as anyone, but we’re all making assumptions based on our perspective, and I’m sitting here thinking we’ll have this entirely paperless, wireless and filmless hospital within a couple of years of the building opening, and they’re sitting there thinking this is all going to be fully baked by the time the first patient is seen in that building.

I think if you don’t have enough people at the table in many of the routine conversations, it’s those nuanced things that get lost in the translation. In fact, I had a conversation this morning with someone who made the comment, “So you need to have fiber connectivity to every single desktop horizontally across the entire building, or can you have fiber vertically installed in the building and category 6 cabling to all the work stations?”

There a debate as to what’s in the plan; what are the assumptions based on and is the current plan going to be adequate if there suddenly is a need for huge video files to be shared among many different users in the middle of a nursing unit wirelessly. Well, somebody is out there making an assumption that we’re going to have a need for that kind of collaboration, and folks on my staff might be making an assumption that, if you’re going to have that kind of collaboration, you’re going to go to a wired workstation where there is high-speed connectivity. So we could be talking past each other, and I think that’s absolutely a risk. It’s even a risk when people are on the same meetings, because we all have our own biases and we probably listen with a bit of a biased ear to what we’re hearing. I think the more time we’re together, the more conversations we’re having, the better off we are.

The way we are trying to address that is by continually updating that slide deck that I sent to you ("Team Vision" PowerPoint document can be download below), and then taking the show on the road as much as we possibly can. Either me or my direct reports are presenting that slide deck every chance we get to revalidate our assumptions and make sure everybody in the room is hearing what we think we have heard and make sure we’re all on the same page.

AG: So, it sounds like with so many other projects, success depends on communication?

SR: Absolutely, big time, and frequently, and even more than people sometimes want to hear, just to make sure we’re all on the same page.

About the Project (source: Johns Hopkins)

Adult and Pediatric Emergency Departments
Adult and Pediatric Diagnostic Imaging/Radiology
Two 12-story towers
Two-story main entrance lobby, four-story Children’s atrium lobby
Glass-enclosed bridges between the Orleans Garage and the towers
Connecting to main hospital corridors, Weinberg and Nelson/Harvey buildings

Facts About New Towers

1.6 million square feet on a 5-acre site
lower floors are nearly 3 acres each, or 130,680 square feet per floor
12,500 tons of structural steel
44,500 cubic yards of new concrete
7,284,000 linear feet
(1379 miles) of copper wire—enough to stretch between Baltimore and Miami
1,703,364 linear feet (322 miles) of conduit—a round trip between Baltimore and Ocean City
over 4,000 plumbing fixtures
3.5 million pounds of sheet metal ductwork for HVAC systems
peak expected project workforce of 1200 workers in 2009 and 2010
244,000 square feet of glass window walls and exterior windows, including 1,423 curtain wall panels weighing up to 1,800 pounds each

33 Operating Rooms