When it comes to research, academic medical centers are second to none. But when it comes to interoperability, there is often room for improvement, and the University of Arkansas for Medical Sciences is no exception. As incoming CIO Dave Miller tries to position the organization for Meaningful Use, he is faced with a host of challenges, including EMR systems that don’t speak to each other, systems that enable clinicians only to view records, and — like many academic systems — funding that exists in silos. In this interview, Miller discusses how he plans to use his experience, both in the clinical and vendor worlds, to transition the organization from a best-of-breed shop to an enterprise system, what it will take to become an accountable care organization, and the importance of being able to put on the salesperson’s hat.
- Moving from University of Chicago Medical Center to UAMS
- Taking on a larger role, relocating
- About UAMS
- Best of breed (Eclipsys, GE, McKesson) with an eye towards an enterprise future
- “A best-of-breed shop is in trouble … do I sweep the decks and start over?”
- Making the case (and finding the funding) for a big move
I definitely have the opportunity to set my own philosophy. And it’s clearly going to be somewhat different than both my predecessor here and Eric’s. To be part of the overall strategy of the organization, especially in a time where health care has so much going on, it really is exciting.
In retrospect, I’m sure there was rationale for all the decisions that were made. But when you think about moving forward as an organization into accountable care, Meaningful Use, and ICD-10 remediation—all those types of things, a best-of-breed shop is in trouble.
I can try to find something that overlays the enterprise. But as we all know, that’s not really integration. You can’t manage enterprise-wide processes with that kind of approach.
We have a good bit of money in reserve here, and if we move in this direction, I’m going to be asking them for a large chunk of their reserves to make this thing happen… I think the organization sees that it needs to be done. But those are hard decisions. It’s a trade off—do I use it for this, or do I use it for something else?
Guerra: Good morning, Dave. Thanks for being with me today to chat about your work and your move over to University of Arkansas for Medical Sciences.
Miller: It’s great to be with you. We have some exciting things to talk about.
Guerra: Great. Let’s start of by talking about the move. You were executive director of application systems at the University of Chicago Medical Center, and you recently moved over to UAMS. Tell me about that move.
Miller: Well, it was an interesting opportunity. I had not really been looking to make a change; certainly all of us in IT leadership just about anywhere in the country have our hands full at the moment with a plethora of things. But I was contacted by a recruiting firm and I agreed to talk to them. And then I came down here and I just really came to appreciate the sort of the footprint that UAMS has across the state of Arkansas, and the leadership team here. It just seemed like a really natural fit. I’m very excited about the opportunity here and the things that we have on our plate right now.
Guerra: We assume everybody moves and makes a little more money, and let’s assume that’s part of it. But let’s talk about the other factors. You were executive director of application systems. Did you report to a CIO at University of Chicago Medical Center?
Miller: I did. I reported to Eric Yablonka.
Guerra: Right. So you’ve essentially moved up?
Miller: Moved up and out. I’m the CIO not only of a medical center, which was sort of the footprint that Eric has at University of Chicago, but I also have six schools, so I’m much heavier on the academic side here. We have schools of medicine, nursing, pharmacy, public health, allied health, and a graduate school that I also have responsibility for. In addition I have the research enterprise, which is also different from what we had at the University of Chicago.
Guerra: So there’s certainly room to expand the types of things you are doing and that’s going to be exciting.
Miller: Very much so. I love the academic side. I’ve been in healthcare for 32 years in July. And of course, I started out when I was 12. The University of Chicago is really my first foray into the academic medicine space, and it’s just a fascinating place to be. It’s very high energy and just a very fast-paced environment around academic medicine. There are a lot of really smart people who you get to interact with on a daily basis, and that really makes it something special.
Guerra: But still, everybody reports to somebody, essentially. And who do you report to—the CEO or CFO?
Miller: Here, it’s the chancellor. The chancellor sits over the entire enterprise, and I report directly to him. My official title is vice chancellor.
Guerra: That certainly sounds more imposing, when you use the word ‘chancellor.’
Miller: Well, it’s kind of funny because I get a lot of teasing over my new title and whether or not it came with a wig and a robe. But it’s really just a great organization.
Guerra: Right. Now I’m just thinking, when you move up, sometimes you get to be the one who dictates the direction and decide things that previously were set by the CIO. Is it liberating in a way that now it’s your ship, except for the fact that you do report to someone? Do you get to do it your way now to a certain extent?
Miller: Yeah, very much so. I learned a great deal under the Eric’s leadership. He taught me a lot and gave me a lot of tools from my toolbox that I hadn’t really sharpened before. But now, I definitely have the opportunity to set my own philosophy. And it’s clearly going to be somewhat different than both my predecessor here and Eric’s. To be part of the overall strategy of the organization, especially in a time where health care has so much going on, it really is exciting. I have sort of a different mindset around the service delivery and the strategic direction. So it’s really quite interesting.
One of the things that drew me to UAMS was the opportunity to really be involved at a statewide level. I’m considered now to be the top healthcare IT person for the state of Arkansas. We’re the only academic medical center here, and we’re the largest employer in the state. I already had dinner with the governor last week, so it’s definitely a different kind of a situation that I had before, and it’s very gratifying to be able to bring my own stamp to this.
Guerra: As the Vice-Chancellor, you should get to meet with the governor.
Miller: Absolutely. I’ve already had my first picture taken with him. It’s pretty funny.
Guerra: Very nice. You may have touched on this, but why do you think they chose you? Did you know if they sort of interviewed a few people or if they just singled you out and said, “Let’s try and get this guy”?
Miller: I don’t know. They interviewed a lot of people actually. I think there were about 10 candidates. They were using a recruiting firm that brought a lot of candidates to the table. I don’t know a lot about the other candidates with the exception that the interim here who’s now my CTO was a candidate as well.
It’s kind of interesting because I have a very strange IT background. I actually started out on the clinical side, as a medical technologist working in a hospital for about six years. And I’ve done everything from hospital administration—I actually ran hospital-based diabetes treatment centers—to the IT side. When I got the IT bug, I worked on the vendor side around the financial decision support piece. So I got deep into the financial piece, and then spent a number of years in consulting, most of that with Big Four. So I think I bring a lot of best practices to the table.
And I’ve been very successful in the IT leadership space. When I finally got out of consulting, I worked as head of IT for a 300-bed community hospital. Back in 2007, we were the 13th hospital in the nation to be named Stage 6 on the HIMSS EMR adoption scale. That was pretty heady company; that’s the top half-percent of all hospitals. So I’ve got a very broad background; I’ve worked with a lot of different organizations in my consulting days and had good success as an IT leader, and I think all of that from what I’ve heard, made me the clear choice.
Guerra: Was relocation any kind of issue for you? A lot of CIOs want to be consultants and consultants want to be CIOs—people want to move around. And depending on your family situation, sometimes relocation is possible; sometimes there’s a certain geographical area you look at. What are your thoughts around relocation personally, and do you have some advice for your peers who may be looking at that?
Miller: Relocation is always a consideration. I wouldn’t say I’ve relocated a lot in my career; but I spent 10 years in Nashville and 10 years in Dallas and then up to Illinois for the last seven years. We’re empty nesters, so that helps when you don’t have to worry about the kids in school and that kind of stuff. My kids are grown and out of the house, so that’s not an issue. And actually, interestingly enough, I have some pretty deep roots in the Arkansas area. My maternal grandmother is from this area. And I actually have about four or five generations who were here a long, long time ago. So that wasn’t issue.
But in relocation, you always have to kind of consider that. There are some places I probably would never go to; I’ve pretty much stayed in the middle of the country. I’m not a big fan of either one of the coasts, necessarily. So you have to look at that; you have to consider that. And certainly that was part of the consideration. I’m married to a Texas girl, so heading back to the south was not a bad thing for her either.
Guerra: So you were not looking for the congestion of the coast?
Miller: No. I actually had some people reaching out to me from the New York area and some from California area. They just aren’t areas that are interesting to me.
Guerra: Right. Let’s talk a little bit about UAMC and the situation you walked into—first in terms of the technology, and in terms of the personnel. Let’s go into technology first. Tell me about the application environment—what kind of shop it is, and where you’re going from here to move toward Meaningful Use and get advanced clinicals going, that type of thing.
Miller: Well this has been a Most Wired Hospital going back all the way to 2000. I’m sitting here looking the Most Wired awards on my shelf here in my office. But interestingly, they’ve also been a best-of-breed shop around applications which has been painful.
In retrospect, I’m sure there was rationale for all the decisions that were made. But when you think about moving forward as an organization into accountable care, Meaningful Use, and ICD-10 remediation—all those types of things, a best-of-breed shop is in trouble. And so that approach isn’t going to work. I’ve got two different EMRs, one on the inpatient side and one on the ambulatory side, that don’t really communicate well with each other. And just a lot of home-grown stuff, which is not unusual for academic health care—we’re sort of different breed in some ways. We do probably more custom development than most other organizations.
Right now, it’s a problem. It’s gotten to the point now where it’s hard to feed the research side of the house with data when you have a best-of-breed approach. And the organization is in pain, frankly, because of where they are from an application perspective.
Infrastructure wise, they’ve actually done some pretty amazing stuff. They have a statewide telemedicine program around high risk OB and a statewide telemedicine program around stroke. They’ve done some things that are kind of a well-kept secret. They’re doing things in telemedicine on a statewide basis that most states would love to have.
On the one hand, they’ve done some awesome things. On the other hand, their historic approach, based on the application side, is now a big problem for them. And I’m not second guessing my predecessors in any way, but there hasn’t been a lot of strategic deployment of technology for the organization itself—within the organization or across the organization from an enterprise perspective. And again, a lot of that is not uncommon to academic medicine, where the funding models are very different than they are for other health care organizations, because you’ve got kind of silos of funding: some in the clinical enterprise, some in the academic arena, and some in the research arena, clearly. Unfortunately, that’s the way technology had been deployed here.
My task now is to move this ship in a vastly different direction than it has gone historically. And my options are fairly few, frankly. I can try to find something that overlays the enterprise. But as we all know, that’s not really integration. You can’t manage enterprise-wide processes with that kind of approach. A second option is to pick one of my major vendors, and I’m in the process of evaluating that now in terms of what their product roadmap is, and whether that will get me to where I need to be, and in the right time frame for the things I need to get done. Or do I sweep the decks and start over? And that’s certainly on the table as well and probably as much a possibility as anything else.
So there are a lot of challenges here. But I’ve got a very good staff of very sharp people. I have a staff of about 265 here, and I think there’s going to be some sort of reshuffling of my organization. Right now I have 13 direct reports, which is just untenable, in terms of the role of the CIO. That would be a fine approach if all I had to do was run IT operations day to day, but clearly, the role of the CIO is much bigger than that now.
Guerra: Let’s talk a little bit about vendors. Who do you have on the inpatient side?
Miller: My primary clinical vendor on the inpatient side is Eclipsys—now Allscripts. My clinical vendor on the ambulatory side is GE Centricity. And then I sort of have an overlay which is my medical record, McKesson. So that’s kind of my footprint.
Guerra: I’m not familiar with that concept of ‘an overlay of McKesson.’ What does that mean?
Miller: Basically, we dump as much of the clinical information as possible so that we can give the physician a single view of the patient, so that if they want information about their medications or whatever it might be, we give them the single point to do that, and that’s the McKesson product. So it’s really a view-only EMR, for a lack of a better term. And it’s not a complete one. Both the GE and Allscripts—we use Sunrise—use a different pharmacy reference system. And it’s very difficult to marry those two into a single point even, in McKesson. So it gets very difficult.
Guerra: Everybody who follows this industry sees this going in a certain direction. What are the chances it goes in that direction? Do you know what I’m talking about?
Miller: I do.
Guerra: So everyone listening and reading this knows it too. What are the chances, if you were going to gamble on it, that we wind up there?
Miller: Well the issue with that conclusion, the big nut you got to figure out, is the funding piece. And it’s a big number. I’ve reached that conclusion; actually my last two endeavors have been with that particular vendor I’m sure we’re all referring to. And I will certainly say that I have a high regard for them. I met this week with one of my existing vendors, and it was clear that even a year post-merger, they still have no idea what they’re going to do from an integration perspective with the product line that they’ve merged with. They could not give me dates—anything, which is a little scary. You’d think that a year out they would have some idea of where they’re going with this thing. So that’s certainly on the table. We’re certainly starting to socialize that concept; whether it’s with a specific vendor or not it remains to be seen. But again, that’s around the funding. They use to say that CFOs never got fired for hiring somebody from the Big Eight. And I think there’s probably a similar sentiment around making that kind of a move.
Guerra: Let’s say you want to take things in that certain direction. Do you find yourself in a position where you have to lobby the people that are going to have to sign off on that and make them understand why you see things the way you see them?
Miller: Surprisingly, not as much as you would think. I am certainly doing that. I just had a meeting yesterday with the finance people; my friends on the revenue management cycle side, because I also have two different billing systems. We have the old Siemens Signature, which is about to go out of support, for the practice management side. And we’ve got McKesson for patient accounting, etc. on the inpatient side.
My presentation yesterday was around the benefits of having a consolidated system. And maybe I’m still on my honeymoon period here, but the audience has been very receptive. Again, I think there’s been so much pain around the best-of-breed approach that they’re very receptive to my conversations around moving this to a consolidated platform. There will certainly be some level of selling this when it comes to the funding piece. A lot of that is around the way funding and dollars are available in academic medicine; there are a lot of silos. The hospital, of course, is the economic engine of the organization, for most part. Then there’s the whole practice group side, and both of those are going to have to come to the table to help fund this. We have a good bit of money in reserve here, and if we move in this direction, I’m going to be asking them for a large chunk of their reserves to make this thing happen. And I think it’s doable. I think the organization sees that it needs to be done. But those are hard decisions. It’s a trade off—do I use it for this, or do I use it for something else? Those are tough decisions. And there will definitely be a sales tour of the institution to make that happen.
Guerra: I’ve written a column about this kind of dynamic before. And I’ve just read a book about Lyndon Johnson and his time in the senate. And I think of it that way—almost like you have to run around and round up enough votes among the Senators to get what you want passed.
Miller: That’s a very good way to look at it. I think that’s absolutely right.
Guerra: And you’re comfortable with that that process? Some people who’ve come up through IT just aren’t comfortable with those interpersonal skills of sales and harnessing support. But I know you from talking to you a number of times, and it seems like you’d be very good at that.
Miller: I’ve never seen myself as a sales kind of guy, but I’ve sat in – I’ve sat in George Halvorson’s office at Kaiser and I’ve sat in a lot of interesting places, and having those kinds of conversations is part of the deal. If you’re going to be a leader in health care IT, you’ve got to be able to talk to the points and connect what you believe needs to be done in your organization with IT, and connect that with where the organization is heading. My job as an IT leader is to enable the organization to move to where they need to be. And if you can’t connect the dots between technology and what the organization is trying to accomplish, then you’re not going to get very far. And that’s just part of what I think the role of CIO is.