Quantum Leap

Maimonides
MEDICAL CENTER
Brooklyn, N.Y.

120,000 patients served in 1997
33,451 inpatient

30 ambulatory centers (adding six sites per year)
704-bed hospital
Nursing home
Home health agency
Physician practices

It’s never leisurely when healthcare organizations undertake large IT implementations. Old system failures, pressures to accommodate managed competition and rapid expansion into integrated delivery systems create a climate of urgency in which millions of dollars of systems--and many more millions in staff hours--must be identified, deployed and justified. There’s no stress quite like finding your institution, let alone your career, in the middle of it.

While the experiences of other organizations can offer insight, their solutions are rarely completely transferable: If you’ve seen one healthcare organization, you’ve seen one healthcare organization. At the beginning and end of the day everybody’s on his or her own.

That’s where Brooklyn, N.Y.’s Maimonides Medical Center was in 1996 when Ann C. Sullivan came aboard as CIO. New York, famously resistant to managed care, was still migrating to a competitive, negotiated-rate healthcare environment that most of the rest of the country had already grappled with. Yet Maimonides, closely bound to its Hasidic and Orthodox Jewish community of Brooklyn’s Boro Park, was operating in the 1950s--no computers, no network, no infrastructure. And competition was headed like a wrecking ball their way.

Maimonides CEO Stanley Brezenoff and COO Pamela Brier were ready to devote more than one third of their capital budget to building an information system--buildings, staff and technologies--all at once. That entailed articulating Maimonides’ direction in the context of its competitive environment, identifing and deploying all new technology tools for which little foundation existed, and mobilizing a decidedly nontechnology-adapted staff--all while maintaining its trust and strength in the community.

Now for the most part it’s all working--which won Maimonides this year’s Computerworld Smithsonian Award for Medicine. In this interview with Sullivan and her Deputy VP/MIS Walter Fahey, CIO Sullivan credits Maimonides’ success to all those nontechnology-adapted people who were already there.

What was it like when you arrived at Maimonides?
ANN SULLIVAN: We had long-term contracts to implement clinical systems and replace legacy systems and the hospital seemed incapable of implementing what they had purchased. Physicians felt nothing was happening.

[CEO Brezenoff and COO Brier] thought there was no confidence in the MIS department to move the institution through a change process. Addressing the problem became a major priority because a lot of capital already spent was being unused. Vendors were losing interest in supporting the hospital through implementation of our systems because they felt we couldn’t organize ourselves to implement their products. We were at an impasse in being able to move the institution ahead.

Brezenoff and Brier agreed to a three-year capital plan that one-third of the capital budget over three years would be invested in systems and technology to get the hospital ready for a new competitive environment in New York.

First I tried to understand the culture of the organization--how the medical staff interacted, how the community physicians fit in to the medical staff. This hospital is highly leveraged with its community so I needed to understand that. And the only way was by walking around and trying to absorb it like a sponge.

Out of that came a sense that physicians were ready to tackle the challenge of having clinical systems and electronic records and new technologies--but the rest of the hospital wasn’t. So we had to deal one way with one group who was ready to go and another way with the 70 percent of the hospital who wasn’t ready--all while contracts were almost expiring without implementations and vendors were walking away from the place.

What did you learn from observing the culture?
To build a staff here it was important for me to hire people from within the organization and teach them technology--and particularly the clinical systems and electronic records. It would take me less time to teach them the technology than for technology people to learn this hospital.

We moved a former director of nursing (Nancy Daurio) up to be director of clinical systems, which would include PACS, radiology systems, laboratory systems, blood banking systems and the TDS order entry/results reporting system--anything clinical would be in her bailiwick. Without a doubt that was the most important move I made, because of her strong management skills and having almost her whole nursing career at Maimonides.

We increased staff rapidly in implementation of the TDS system (clinical information system bought by Alltell and then by Eclipsys). At the time, the hospital was undergoing some personnel reduction plans, and some pharmacists, lab folks and nurses had been identified for layoffs. The hospital had never had a layoff before. I proposed we become an educational center in a field that was growing--clinical systems--and I volunteered to take everyone who was being laid off and train them in clinical information systems.

We decided that education was a major part of who we were and were going to be. It worked great. Pharmacists, lab people and nurses are terrific at this. We took 16 of them on. All became IS people. Not just IS people, terrificIS people.

We put physicians on the team and hired them in MIS; the director of microbiology is half-time in MIS for us. The chairman of surgery gave us a full-time resident; the chairman of medicine gave us a graduating resident to work with us full time. We had a lot of commitment.

How did you supplement the internal staff?
We had difficulty recruiting staff--it’s not easy to get to Boro Park, and Maimonides didn’t have a track record of success to attract people in New York. We needed to come up with a whole employment strategy to help us or we’d have so many vacancies that we couldn’t manage our projects.

We were implementing the IDX radiology system the same time as upgrading the Sunquest system and the HemoCare system; implementing anatomical pathology, a PACS system, the TDS order entry/results reporting system, and the whole PeopleSoft suite of products. If we didn’t have a career path for help desk guys to go into PC support to learn LAN and then WAN; if we didn’t start to build career paths and retention plans, we would be recruiting and training all the time--we wouldn’t be implementing anything.

So we came up with a massive training program. Our PeopleSoft implementation became difficult--classes are very expensive and a week long at a time. We started employment contracts because if we were going to invest $20,000 of training into people we wanted to make sure that they’d stay here two years and not jump to Wall Street. Now, for every three people we lose, one comes back within six months.

What were the biggest obstacles?
Our hospital community had absolutely no basic computer skills so we had to create a massive training program. We built lots of classrooms--I have six nurse educators alone. Physicians don’t like to go to class so we needed classes that would teach them how to use the light pens and the mouse, but you couldn’t call it that. We called the classes "Navigating the Internet" and we had standing room only. We’ve conducted 90,000 man-hours of training just in the last two years.

The big hit for us was to show that we could get the order entry system up. We had to have it up by December 1996 to show we could do it. We brought up our first patient unit on Dec. 15, 1996; in the meantime we brought up all the PeopleSoft suite--payroll, HR, inventory, purchasing and general ledger.

How’d you get doctors on board?
There’s no big secret here--you seek out those doctors who are already interested in physician systems. Doctors can be engaged just by asking them to be involved. We had a chairman of orthopedics who develops his own software products and sells them. We had a chair of ER who is keen in technology and up to date on everything. You seek those people with an interest in systems, and it turns out there’s more than you would think.

What role did your vendors have?
We had been at war with some of our major vendors. We decided to declare a moratorium and see if we could entertain vendor partnerships with our most important vendors. We sat down with the presidents of our eight major vendors and talked about mutual goals and understandings of where we saw our relationships going. We asked them to be vendor partners and to define that partnership. That’s when we found that some of them chose not to be more than a vendor while others stepped up and are strategic partners today. Five became partners as we defined it: Unisys (which nominated Maimonides for the Smithsonian award), Cisco Systems, First Consulting Group, StorCOMM Inc. and Alicomp--a firm that runs mainframe computers out of a central site in New Jersey.

Three declined--Shared Medical Systems, American Healthware (SMS) and Eclipsys. They couldn’t clarify for themselves what the partnerships meant, or they foot-dragged, or they just didn’t step up. We’re working with them just as vendors.

What’s a ’vendor partnership’?
We defined vendor partnerships as a partnership in which the institution and the vendors would together seek the best solutions and services for the healthcare information technology market. We would be committed to helping them either by being on their advisory committees or by serving in an advisory role to come up with products that hospitals are going to need to be more businesslike in the future.

In addition, we may start to see trends in the healthcare market that they can’t yet see, and we can help by advising them in some product or services direction.

To help innovate we wanted to be a beta and have the latest information technology, which was important for us to be able to recruit the best people in IT. We wanted our partners to tell our successes and lessons learned.

We’ve agreed to help our vendor partners broaden their sales base, if necessary, and sell their products--as long as we’re a center of excellence for them on the northeast coast. In return for being a center of excellence for them, we’ll help market their products. We’ll have site visits--anything that would help them generate business.

What advice do you have now for vendors?
WALTER FAHEY: My advice is to develop better relationships with your clients. There’s a lot brought to the table when we’ve done business partnerships. When both sides are committed, the success rate is much higher.

SULLIVAN: My CEO doesn’t know why all our systems aren’t integrated. He wants to know why it’s such a problem that I need clinical people to monitor interfaces 24 hours a day, 7 days a week. I think it’s shocking that clinical systems running through interface engines are truly not integrated. Critical patient orders and information that affect patient care could fall out. I’m concerned about the whole issue of integration and how we’re ultimately going to solve it.

Problems at Maimonides

PROBLEMS FACING MAIMONIDES MEDICAL CENTER IN 1996 INCLUDED: DEREG-ulation of healthcare system in New York, no history of information technology investment; minimal staff, no infrastructure; contracts for clinical information system, billing system and PeopleSoft applications nearing expiration--implementation nowhere in sight; MIS department lacked credibility; vendors walking away.

Strategy

Lure vendors into strategic partnerships, accelerate implementation, prove credibility with deliverables, mobilize clinical staff, hire from within, invest extensively in training, emphasize staff recruitment and retention, tell the story.

Tactics

Draft nursing director as clinical information systems director, undertake 90,000 staff hours of training, build three data centers, spend $19 million over three years on technology, launch Maimonides Access Clinical System and PeopleSoft suite, American Healthware financials and other products listed below:

Hardware--IBM ES-9000; SP-2; RS-6000

Software--Eclipsys HCM 7000, interfaced through an open hub with SunQuest Laboratory, IDX Radiology, HemoCare Blood Bank, Ethicon Telemedicine, American Healthware (SMS) Patient Management, StorCOMM PACS, and the Maxsys II Data Repository.

Support--Unisys: help desk, network monitoring, break/fix services

Results

Problem medication orders decrease 58 percent, discrepancies 51 percent; medication processing time decreases 68 percent; medications arrive in patient areas in 88 minutes vs. previous 276-minute average; duplication of medical tests decreases by 20 percent; emergency department turnaround time decreases from 3 hours to 90 minutes; readmission rate decreases by 8.7 percent; vent-associated pneumonia decreases 55 percent; hospital-acquired infections decrease 32.6 percent; length-of-stay reduced by 12.8 percent--or one full day per patient admission; 2,087 additional patients served means $19.8 million revenue increase; ROI: 100 percent.

Maimonides Implementation Schedule

Terry Monahan is editorial director of Healthcare Informatics.