To say that there is a strong focus on innovation at Vanderbilt University Medical Center would be quite an understatement. In fact, it’s more like a way of life at the academic medical center, which includes an acute care hospital, children’s hospital, clinic, and cancer center. If there is a tool that clinicians need, the IT team will determine whether it can be developed in-house before turning to a vendor. For Deputy CIO George McCulloch, this type of environment may be challenging, but it’s also deeply rewarding. In this interview, McCulloch talks about balancing the needs of different constituents, how practicing medicine is both an art and a science, the importance of working to meet the needs of specialists, and his organization’s road to Meaningful Use.
- About Vanderbilt
- The application environment: “We use a smattering of things”
- Developed Horizon Expert Orders for CPOE (bought by McKesson)
- Developed an EMR (now marketed by ICA)
- Certification and self-development
- Weighing the buy versus build decision
- Engaging the specialists
Having that flexibility on the EMR and some of the other products that we have really gives us the capability to design new things that otherwise we’d have to potentially go back to a vendor and ask for. We can pretty much control our own destiny on some of those things.
We really support research, patient care, and the academic component in trying to balance all those three things, but we really want to try to find tools and make choices for things that we need to go do that maybe somebody else isn’t doing.
It is a challenge because the depth of what they need is a little bit different. We’ve been able to, with the control that we have on the EMR, put their information in and really display things in a particular way for them that has been useful.
We can innovate fairly quickly particularly in the EMR space, and so when we get a really bright idea that we think is worth working on, we might have a little skunkworks project with that particular clinician or group of clinicians where we’ll pilot-test something in our EMR and we can restrict its use to a certain number of folks.
Guerra: Good morning, George, I look forward to chatting with you about your work at Vanderbilt University Medical Center.
McCulloch: Me too, Anthony. I look forward to talking about challenges here and in the industry.
Guerra: Yes, there’s certainly a lot going on. Let’s start with an overview of Vanderbilt; why don’t you give the readers and listeners an idea of the size and scope of the organization.
McCulloch: Sure. Vanderbilt University Medical Center is an academic medical center with about a thousand beds. Our outpatient business is over 1.5 million visits and we’re well-recognized by US News and World Report. Our other clinical quality indicators are up. We’re focused on providing great service to the community; really growing our business in new clinical areas and outreach into the community, and overall, we’re doing well. We have good margins, good clinical quality—we think we’re doing a great job for our community.
Guerra: So you’ve got a lot of residents over there?
McCulloch: Tons of residents who are starting new, so that’s always a challenge in the academic side. We get new folks coming in that we orient to the technology we have. And we’ve got a lot of it, so that’s certainly part of the challenge.
Guerra: And how many employed physicians do you have at the hospital?
McCulloch: They’re all employed. We’re a faculty model, so we have several thousand employed faculty.
Guerra: So if they’re not employed, it’s not like the independent community physicians can refer in?
McCulloch: No, they don’t. They have to come through a faculty.
Guerra: Okay, so it’s a closed system. You don’t have to deal with the independent businessman who’s coming in.
McCulloch: Not in that scope. We do have other relationship where they’re not employed. I spend most of my career in community hospitals, and that’s a little bit different pressure.
Guerra: Are there owned ambulatory sites—physician practices or clinics, things like that?
McCulloch: There are. We’ve got about 18 or 20 locations out there where we have practices; again, on a faculty model. So we’re spread out geographically in our region.
McCulloch: One of the big investments that we made is that about a year ago, we bought a dead mall and moved a lot of our clinics that were based at the main hospital there, and that’s been very successful. So we kind of decompressed our primary campus, put a large area out there and then also have one or two other practice locations throughout the surrounding counties.
Guerra: What’s your core inpatient clinical system?
McCulloch: We use a smattering of things. We have some self-developed applications and we have some McKesson applications. We used kind of a best-of-breed approach for our technologies, with some with the core components being things that we control. We sold our CPOE—Horizon Expert Orders—back to McKesson. We wrote our own EMR, which now ICA markets on our behalf. So we pick the best technologies we have surrounding those core components, and we’ve been able to kind of control and manage the growth and technology of those core pieces.
Guerra: Did you say you wrote Horizon?
McCulloch: We did, and then we sold it to McKesson.
Guerra: And I know that the ICA came out of Vanderbilt.
McCulloch: Right. StarNotes, StarForms, StarVisits—they’re now ICA.
Guerra: Okay, so we have best-of-breed shops with a lot of interfaces; some people have gone big bang with, for example, Cerner or Epic, where you can have the acute and the ambulatory sites all have the same database. Just give me a little more flavor about how that works in your environment. Do you have a lot of interfaces and is that an issue when you’re trying to get data from one place to another?
McCulloch: Well what we’ve done is, we’ve really kept the transactional systems through interfaces, but the core data really is in the EMR itself in our StarPanel so that all the clinical applications—although they might have transactional features in them—really reside in StarPanel. So we have kind of a “doing and a viewing model” of transactional things that I would do, but when I really want to know something about the patient, I go to the core EMR.
So we haven’t done a lot of clinical interfacing, if you will, and said, ‘Okay on the lab system, tell me everything in the EMR that I really need to know.’ There are certain things where we’ll say, ‘If you want to know those kinds of things in context we’ll give you some of those, but if you really want to know the big things, we need you to go to EMR.’
Guerra: And how does that leave you for certification?
McCulloch: As part of Meaningful Use, we are on the hook for certification for some of those components. And so we’re well on our way to getting those certified—certainly a step that we and others who have done some development are going to have to take. It’s something that we think is clearly doable. It’s really part of our core strategy as we try to innovate some new clinical technologies and some ways of different care delivery. Having that flexibility on the EMR and some of the other products that we have really gives us the capability to design new things that otherwise we’d have to potentially go back to a vendor and ask for. We can pretty much control our own destiny on some of those things.
Guerra: Do you have any thoughts about the intent of certifications versus what it has come out to be? I had always understood it to be something they wanted to put in place to help small physician practices going out there buying Vaporware, but now we’ve got this pretty onerous process on people like yourself and hospitals, and it’s not like you’re going out to buy a system and you’re looking for a stamp. So it kind of changed.
McCulloch: Yes it really has changed from kind of a Good Housekeeping seal of approval to something more detailed. I can understand why they would want to make it a little more detailed so that it wasn’t just a stamp and nothing more. It’s going to be some level of work for us and everybody who does it. Again, I think it’s going to be something that it’s not terribly arduous and we probably do it anyway. It’s a little bit of an effort on our part, but clearly it’s going to be worth it. Because we want to know; we want to prove it to ourselves, whether it’s somebody else’s standards or ours, that it can do what it should do.
Guerra: Right. So in the 18 to 20 ambulatory locations, you have a version of Horizon Ambulatory?
McCulloch: We do not. That’s another area where we’ve kind of gone out on our own. We’re developing our own transactional system out there with our EMR as the core, so we’re in the process of putting up an order management tool to handle that. And so we’ve gone through a lot of work in our clinics for the last couple years doing a clinic redesign that really takes a look at the people and process things that are going to occur then. Because our clinics were fairly independent of each other in terms of their processes, and a while ago, senior management really wanted to get a more standardized process in the academic environment, and had been working with us in terms of the people and process components. Now we’re partnering with them on the technology side because they’re really ready to sit down and say, ‘Okay, this is how I want these practices to run and this is the technology that I need there.’
Guerra: How do you think about the buy versus build decision? I mean, obviously there are vendors out there who are spending their lives making ambulatory products, but you have decided to do it yourself.
McCulloch: Yeah, it’s a tough one. I mean clearly it’s the resources you have available, and it’s the vision that you have for the business. And I think in the academic environment, it’s the rational to innovate and do something new. Clearly in our environment, we really want to innovate, which means new ways of practicing medicine. We really support research, patient care, and the academic component in trying to balance all those three things, but we really want to try to find tools and make choices for things that we need to go do that maybe somebody else isn’t doing.
Having been on advisory committees before, you really want to take a look at what needs to be done. And if it’s not in the best interest of the general community that their serving, the advisory committee says, ‘Well that’s interesting, but that’s just for you.’ I think that with our mission, we really wanted to have the flexibility of certain situations to say, ‘Well that’s really important to what comes next and the way in which we want to practice medicine, and we’re going to have to go do that on our own.’
So I think it’s a tough decision. I think it’s where you sit; the resources you have that makes that decision of what you have to do. I think one of the critical decisions that we saw was given the fact we had a large inpatient investment already and Horizon Expert Orders and our EMR, we really didn’t have much of a choice in terms of what we would do in the ambulatory side, given the fact that we were going to have to interface EMRs together, which would be problematic.
I think what really drove us to do it was our vision of what clinical decision support needs to be. And as we really took a look at the continuity of care, we really had a tough time figuring out how we were going to have two decision support systems—one ambulatory and one inpatient, when the patients don’t move like that. For example, if I’m an inpatient physician and I want a clinical decision support here, here are the rules, and then there’s a separate set of rules someplace else that may be integrated with the ambulatory side. We just didn’t see how we could do that. So we’re really marrying those products together functionally to get that done.
Guerra: And you’ve been able to monetize these things by selling the products you’ve developed to vendors?
McCulloch: Yes, and we have some realization components in the university as well. The real motivation was doing what we needed to do and leading and developing things that really weren’t out there, and having to do things that we couldn’t buy. We looked at bi-transactional systems. We really don’t want to reinvent the wheel on those particular things. But when it comes to how we practice medicine and the way in which we do clinical decision support and present information in the informatics component of the business, we really want to control and understand what needs to be done there.
Guerra: Right. Let’s talk a little bit about specialists. Have you seen a different level of adoption; for example, let’s say we’re talking about a general, primary care-focused EMR. Do you try to roll out that same EMR across the specialties? Have you found any specialists who say, ‘You know what, this just doesn’t work for me—I need something that’s a little more tailored?’
McCulloch: It is a challenge because the depth of what they need is a little bit different. We’ve been able to, with the control that we have on the EMR, put their information in and really display things in a particular way for them that has been useful. I think clearly the issue of what used to be a shadow chart potentially in some of those specialty areas of things that they wanted to know but the rest of the world didn’t really care about. The report was their product, and that’s a particular challenge. What we’ve been able to do with the documentation tools—and also our flexibility on that EMR—is putting that data there, and if we can get it in a discreet manner, getting it out to people who want to know that specific subset of data. So we’ve been pretty successful with that, and there’s more to be done. There’s a lot of documentation in those specialty areas that we’re still working on, but I think overall we’ve been pretty successful at getting the specialists the documentation that they need and then getting the common data out that people are interested in.
Guerra: Yeah, and some organizations are facing pressure from certain specialty groups—especially cardiology—to get something specific for them, but the CIOs don’t want to create a little pool of data that’s off to the side. So they try and get them to go with the enterprise solution if they can customize it. Does that scenario make sense?
McCulloch: Yes it does, and what we’ve done on the documentation and the imaging side is to have some specialty components in there, particularly with the way in which cardiology folks use that. I mean, that’s a particular area of ours where we’re building a cardiology information system using our tools and tools from vendors to try to do that. Because to your point, that’s probably one of the more complex diagnostic areas that uses a lot of modalities that really combine together for what we need to do for the patients. So that’s a particularly complex area that I’m sure we’ll continue to work on for a while, because I don’t know if there’s a solution for those things. But I think that goes back to our model of where can we provide tools that will do that level of integration that maybe a vendor couldn’t do because they don’t know all the components or don’t have folks in that particular area.
Guerra: I think one of the harder areas of conflict—the decision points that the IT department has to deal with, is where do we accommodate physician requests and where do we sort of hold the line so we don’t have a hodgepodge of data everywhere and we have some uniformity. Any thoughts on those types of decision points?
McCulloch: It’s tough. And really there are two points in there. How do we prioritize the request that physicians have for their particular needs and modifications to things that they want, and then how do we get common data at the same time that we do some level of specialization. We have a number of groups that we work with to focus on these things. We also have kind of like SWAT teams; it’s a component of our design. We can innovate fairly quickly particularly in the EMR space, and so when we get a really bright idea that we think is worth working on, we might have a little skunkworks project with that particular clinician or group of clinicians where we’ll pilot-test something in our EMR and we can restrict its use to a certain number of folks. And kind of it not quite hidden but not generally available, where we can pilot-test the concepts there, and then if it looks good then look to a broader rollout.
So that’s how we’re trying to balance the general release things that we give to everybody versus the things that we don’t know how it’s really going to work and try to figure out how we would go do that. One of the areas that we recently did as we’ve been trying to take a look at clinical quality is vendor-associated pneumonia or VAP. We were very concern about clinical quality in those areas, as a lot of folks are, and so that was an area focus for us.
We ended up coming back with some designs in terms of the indicators or tasks that were critical to preventing VAP. And we ended up doing a pilot of a dashboard that we use on a particular unit that said there are eight indicators of VAP and if you do oral care and had it about 30 degrees and used other kinds of indicators, that should make a difference. So we ended up using our EMR tools to do certain kinds of things and track that, and now we’re using that similar technology across a lot of other clinical problems. So we a problem and focus on it, try to use our tools to pilot test, and then see what we can do about rollout.