At Wake Forest Baptist Health, What the Mechanics of Clinical Transformation Look Like

Aug. 24, 2018
Chi Huang, M.D., executive medical director of general medicine, is helping to advance clinical transformation processes at Wake Forest Baptist Health in Winston-Salem, North Carolina

Last November, Chi Huang, M.D. came to the multi-hospital, Winston-Salem, North Carolina-based Wake Forest Baptist Health system, after previous positions at Brigham and Women’s Hospital, Boston Medical Center, and Lahey Hospital & Medical Center, all in Boston. Dr. Huang’s title is executive medical director of general medicine and hospital medicine shared services and associate professor of internal medicine He has a background of 15 years’ clinical practice as a hospitalist, along with his physician leadership

Dr. Huang will be participating in a panel discussion at the upcoming Health IT Summit in Raleigh, North Carolina, which will address the question, “Patient-Centered Care and Interoperability: What’s Next?” The Summit will take place on September 27 and 28 at the Washington Duke Inn & Golf Club in Durham. In advance of that event, Dr. Huang spoke with Healthcare Informatics Editor-in-Chief Mark Hagland about the work that he and his colleagues have been engaging in, in order to transform care delivery at the Wake Forest system, which includes four inpatient hospitals (to be five, as of September 1) in North Carolina, and whose flagship facility is Wake Forest Baptist Medical Center in Winston-Salem. Below are excerpts from that interview.

Tell me about your title and its connection to the activities you’ve been involved in and are helping to lead at Wake Forest Baptist?

To begin with, I’ve been a practicing hospitalist for the last 15 years. I started out in practice at the Brigham, and then practiced at Boston Medical Center and finally transitioned to Lahey Hospital. At those last two organizations, I either ran an inpatient unit, or multiple units at several hospital simultaneously, becoming an associate CMO at Lahey, and focusing on patient flow and throughput there. I came here to the Wake Forest Baptist Health system in November, and I’m overseeing inpatient services at most of our hospitals, ensuring that we are focused on operations, quality, teaching, and research and the wellbeing of our physicians and advanced practitioners. My clinical background is as a hospitalist in internal medicine.

Chi Huang, M.D.

What brought you to Wake Forest Baptist in particular?

I came to Wake Forest Health System in order to build on what had already been existing for inpatient care at the 1004-bed Wake Forest Baptist Medical Center in Winston-Salem. I felt that my skill set could further improve inpatient care So my work involves  enhancing our inpatient care system, and how we connect the dots between inpatient and outpatient care, and help strengthen our work in population health. I learned a lot at the Boston hospitals, and I’m applying my learnings from my Boston experiences here.

What are some of the key elements in what you’re working on?

Interoperability is a key element. Some of our institutions have different IT system and platforms.  As with many different other healthcare systems, we have converted all our facilities to Epic. On September 1, at High Point, we’re transitioning to Epic with the 2018 version; all the other facilities have already migrated. And then from a workflow standpoint, we need the physician and advanced practitioner aligned along with our nurses , ancillary caregivers, and our phlebotomists. . And one of the things we’re working on is developing standardized processes for important care delivery handoffs and communications. Let’s say for example that John Doe is an inpatient and needs a surgical consult. At one facility, there’s an automatic notification process in place; at other facilities, the office has to put in the request into an outpatient system, and then the outpatient office manager has to call the surgeon. That’s the kind of back-office cleaning-up of a process that’s needed. But it requires achieving consensus among the surgeons on how they’d like to be contacted in such instances. So a part of my job is to hold listening sessions and help  achieve consensus among the physicians.

So you’re doing process management, including around IT-facilitated processes, and change management?

Yes, and how we make chages in healthcare, as they relate to the need to shift to a population health or value-based stance, and how that all integrates into patient-centered care. I think everyone’s been trying to figure that out.. The auto industry is much farther ahead on value-based care than we are. I can’t get an appointment with my PCP without making phone calls, but I can order an oil change on my Toyota Prius with my smartphone; so we have a lot to learn from other industries.

Healthcare has tended to lag far behind other industries in terms of redesigning core processes, hasn’t it?

Yes. The two industries that have not done full industrial reengineering, are education and healthcare. I’ve become fascinated by process-improvement for decades. And statement two is, the comments that you get of, this is how we’ve always done it and how we’ve always been, reflect the insularity of healthcare. I think it’s good to have companies, such as Amazon/Berkshire Hathaway/JP Morgan Chase, disrupt us, encouraging and prodding us to do better.. There’s this naivete that we’re doing well. But when you look at the data, the number of people who die unnecessarily every year is more than 100,000 lives. If we’re serious about process reengineering, we need to look outside to other industries. When my family and I went  to Disney World, I drove my wife crazy noticing all the process stuff. There’s a reason it’s the happiest place on earth, right? And they have  hundreds of different cultures landing on their campus every day.

At Disney, they understand customer service and process improvement.. And when they say, welcome to Disney, they use their hands, but never point, because they know that pointing is culturally insensitive in many cultures. So they’ve learned customer service far better than healthcare—there’s the Disney way. They’re moving people in 90-degree weather with two kids, through lines, quickly. And that applies to HC. From a process standpoint, it is difficult to swallow  that I can be told my wait time in the hospital can take hours but that I can get a fast pass to get onto a Disney ride in less than a half-hour. There’s a reason that healthcare still has 20 to 30 percent waste in the system. What should CIOs, CMIOs, and other senior healthcare IT leaders be thinking about, in all this?

I think that CIOs should be connected at the hip to the CMIOs. Let’s say I’m a CMIO and I think that something can be implemented. There are certain things that I still don’t know  or fully appreciate that the CIO knows; and vice versa, the CIO knows things I don’t know as a CMIO. Here’s an example: I might want a particular SQL-based report from the Epic system, but the CIO might tell me, well, these are the things that actually have to happen, because it will take two months to produce that report; so you need to tell me your top priorities. Because if you’re spending 60 hours to build a SQL report and it’s only saving $10,000, that’s an issue. But if it’s preventing 100 deaths, then that’s different. So everyone needs to be in the same room, so everyone can understand the competing priorities involved.

And the other tension not yet fully recognized is the tension from the c-suite to the front line. I still spend about 25 percent of my time doing inpatient care. And I need a fellow physician to tell me, Chi, you were crazy to go through a Clarity report on SQL, when what I really need from you or from the CIO or CMIO, is to get a notification in real time of troponin levels (a cardiac enzyme). When the lab tech puts in the result on one of my patients when the troponin level is 5.5, i.e., the patient is actually having a heart attack, I want to be notified at 10:01 AM, through Epic, through a pager system, or through my smartphone, in a HIPAA-compliant way, rather than some abstract measure that’s not as timely.

My wife is a psychologist and educated me on dialectical behavioral therapy which is often employed to treat people with borderline personality disorder.. One of the concepts of DBT is, you have to be able to hold two to three to four opposing thoughts at the same time, and to be comfortable with that, and work through that tension. So from a physician leadership standpoint, I’ve been trying to apply that principle in my practice. It’s OK for the physician to be mad at me because they want X, and another physician leader to be frustrated at me because they want Y. My job is to get all the several stakeholders together in the same room and validate everyone’s emotions, but also confirm that we have only a limited amount of money, time, and workforce and we need to leave this meeting in an hour and say, this is best for the system financially and operationally, and this is what’s best for the patients. And we need to get there, and be OK with not being OK, but this is our strategy.

And some of what you do involves helping your colleagues to hold a lot of different concepts, or even tensions, at the same time, correct?

Yes. I went into healthcare because I feel passionate about patients. It becomes personal when I think about the patients we’re affecting. And I do pre-meetings in order to understand what each stakeholder person might be thinking, and so I’ll say to someone, “You know, John might not see this issue the same way…” And then in group meetings, I act as the shuttle diplomat. And I’ll say, “You know, I’m not sure if Mark is thinking the same way about this. Mark, what do you think?” Or, “Cindy, now what do you think?” And, “We’ve passed 45 minutes in this meeting, can we come to a consensus on this issue?”

And of course, there’s a burning platform, U.S. healthcare system-wide, to achieve success in clinical and operational transfomation, correct?

Absolutely. By 2021, our GDP will not be able to sustain the cost of healthcare. And either hospitals and health systems will close down, or other external organizations will be disruptive, or we’ll make the necessary changes as healthcare organizations.

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