When it comes to major IT projects, two of the most important pillars of success include putting the right team into place and being able to guide a project through a rough patch. Allana Cummings, CIO at Northeast Georgia Health System, has addressed these key issues by embedding clinicians in the IT department and applying a different approach to right projects that seem to be veering off course. In this interview, Cummings talks about the value of a collaborative approach to problem-solving that includes the vendor, the importance of effective communication, having all the right information, and knowing when to take a time-out. She also discusses the application environment at Northeast Georgia, best practices in fostering CPOE adoption, and her organization’s iPhone and iPad empowerment strategy.
- Embedding clinicians in the IT department
- The value of taking a “Technical timeout”
- When it’s time to get everyone on the (phone) line
- Taking an ethnographic approach to workflow analysis
- iPads, iPhones and developing a BYOD strategy
We feel that by having folks in the IT department, you’re a step removed from the process. There is a difference between a nurse informaticist who had 10-15 of nursing background who steps into a full-time role in IT, and that front line individual who’s still providing care up on the unit daily.
The expertise on how to configure and build the system and maintain the system from a technology perspective is best done by the IT staff. But there is blend and crossover in what we do. We set up really collaborative processes in partnering with those individuals.
When we’ve got one of those hairy problems to solve, we’re thinking that by having someone go out and capture video of what’s going on and what the need is, and then being able to bring that back to the think tank group—that we might further be able to create efficiency in how we’re approaching things.
In looking at workflow in a unit, it’s not just where does the chart go or where does the laptop or computer-on-wheels go, but what is the actual interaction that the individual using those tools needs to have, and what things would we not capture if we were just looking at your traditional workflow diagram.
It’s not something that folks are going to stand up and cheer about, but I think they understand that to protect PHI, to protect their own practice and not be the person who allows a laptop to be stolen and PHI to be discovered, I think that folks are willing—although maybe grudgingly—to comply with those standards.
Guerra: We talked about working with the medical community, the medical staff. Do you think that going forward, we’ll see a transformation where an IT department has so many clinicians in the department that all of a sudden those lines become blurred and you have the expertise on staff?
Cummings: I think that’s a possibility. I’ll share with you something from our perspective. One thing that we’ve done is taken a look at whether we need to have all individuals working in an IT role centralized within the IT department. And our conclusion to this point has been no. It’s actually better to have individuals embedded within the work units and really feel that their primary purpose and role is serving that department and that department is their number 1 team.
We feel that by having folks in the IT department, you’re a step removed from the process. There is a difference between a nurse informaticist who had 10-15 of nursing background who steps into a full-time role in IT, and that front line individual who’s still providing care up on the unit daily and really lives these changes. One thing that our chief nursing officer and I have really worked on collaboratively over the last year is that we found that many times in implementations, we tend to lean on individuals that are at a charge nurse level or some type of leadership level in making decisions. The reality is they’re removed from the process as well. We have got to get more front line staff engaged.
Over our last two implementations, we’ve seen significant success—staff will approach me in the hall and say, ‘Best implementation we’ve ever had.’ Those were the implementations where we developed a core group of some 190 super users that went through a higher degree of training, participated in testing, got to see the framework of what we built in kind of a straw man, and offered degrees of suggestions on things that could be tweaked. And they actually served as embedded experts within their work units to help as we are implementing and transitioning to the newer versions of EMR tools in that there really was expertise to help. We realized how valuable that’s been and how we need to capitalize on that more.
We are not there yet in terms of doing it to the best degree possible, but we certainly made steps in the right direction. And we’re building this large core group with the competency and the skill set that makes it so much better for our customers and for our staff as well, because we’ve got people we can lean on when something’s not working and we’re still trying to find out exactly what we it need to do and how we can make it better. We’ve got experts right there that are guiding us and that makes all the difference.
Guerra: If I may say so, I think you’re absolutely right on with that whole idea of embedding. So theoretically, they would be the employees of IT—and I’m just thinking out loud here—and they do maybe two or three days in the IT departments and two days on the floor as clinicians doing their clinical work using the systems. They could then come back on their days in the IT department and provide feedback and help improve those systems. Is that how it works?
Cummings: That could be one approach. Ours is a little different. We actually hire people with nursing and other clinical backgrounds who want to become employees of IT and then they use their expertise and their experience to really become experts in informatics and technology delivery. We then have people that are in departments who actually are employees of the department but they are in system support and systems coordination roles.
We try to develop some lines or roles of responsibility. The way that we typically frame it is that in terms of usability and the content management, the expertise is going to be in the departments. The expertise on how to configure and build the system and maintain the system from a technology perspective is best done by the IT staff. But there is blend and crossover in what we do. We set up really collaborative processes in partnering with those individuals. I’ll give you an example. If we were to have a situation of having a system problem, whether it’s downtime or a function that’s not performing properly, we actually do what we call a ‘technical timeout.’
Guerra: I like that.
Cummings: We assemble all of our team members on a conference line. We ask our vendors—which, it took a little bit of convincing for some, but they realized the value in it now—to join in on a single line. The embedded resources within the departments—our coordinators—join in on a single line along with our technology staff. We have a manager on duty that helps coordinate the process, and we methodically go through and define what the problem is. Let’s not try to solve it until we know what it actually is. There have been many of those lessons learned that we probably all remember where we started going down the road of solving a problem only to find we really didn’t have the right information.
What’s great is we’ve got somebody actually in the work unit who can very specifically help identify what’s going on—that accuracy of information. We then work through the process in a collaborative fashion. We don’t let people go offline and do things. We make the group stay connected, because there is value in the process. A support person from a vendor may share that they’re going down a certain road, and the person who’s representing the users out in the department may say, ‘No, you’re going down the wrong track. This is what’s going on instead.’ We just find it really helps us, not only with getting the solutions quicker, but it’s a capability of being able to communicate effectively and making sure that everyone’s informed. And communication in those kinds of processes is key. What often ends in hurting us is not having an effective means of making sure everyone is informed and knows. It’s been a very good way for us to help make sure communication is effective.
Guerra: Again, I think you are absolutely right on. I love the fact that you get the vendor on the line. And you said it can be difficult but the value of having everyone who could be part of a solution and knowledgeable of the problem on the phone live together—you can’t beat that. It doesn’t compare with after the fact briefing someone on what was said. That’s a waste of time and it’s inefficient. So I think you’re absolutely right on with that process. Is there anything else you want to add on that?
Cummings: Sure. There is one other thing that we’re going to be doing and I would be curious to learn from colleagues if they’ve looked at this as well. One of the difficult things is that it’s hard for all of the staff members who are involved in creating solutions to have visibility as to what the impact is to the end user. So we’ll do things like have a nursing informatics team member or a clinical analyst who may be able to go out to the floor be the eyes and ears. And they then have to come back and be able to represent to the person who’s working with the Citrix farm, the person who is working with creating the desktop image. In trying to get everybody on the same page, we find that even with great historians and people who will come back from the units and describe in vivid detail what’s going on, it’s not the same as seeing it yourself, nor can we all get on the unit and have 20 of us standing together trying to figure out exactly what you are doing.
So we’re going to actually start using an enthronography approach of actually recording what’s going on. We’ve talked to some of our clinicians to make sure it’s not something that would unnerve them, but when we’ve got one of those hairy problems to solve, we’re thinking that by having someone go out and basically capture video of what’s going on and what the need is, and then being able to bring that back to the think tank group that can really analyze what they saw and brainstorm the solutions—that we might further be able to create efficiency in how we’re approaching things.
We just reflect back on many events that I’m sure all of us experience in our organization of going through weeks, sometimes months, of trying to fix something or improve something, only to find when we actually truly get it and understand what we were trying to accomplish, we look back and say, ‘Gosh, there was a lot of rework there or a lot of wasted effort.’ So that’s something new that we’re going to be trying, and I’m very hopeful that that’ll make a big difference.
We actually did this using that degree of looking at things not just in your typical workflow diagrams, but an enthronography study of actually what is the social interaction? What’s the whole of how the system is being used? So in looking at workflow in a unit, it’s not just where does the chart go or where does the laptop or computer-on-wheels go, but what is the actual interaction that the individual using those tools needs to have, and what things would we not capture if we were just looking at your traditional workflow diagram. We did that in actually looking at our device strategy for CPOE. We had a study where the motion and social interaction of clinicians was studied and mapped and it was used in actually determining the number of devices and where the devices were needed for CPOE deployment. And we found that it served us very well. We avoided the traditional buying of too many devices and not have devices in the right areas, even when you buy too many. We’ve done a much better job, I think, of accurately pinpointing where the needs were.
Guerra: That’s great stuff. Let’s talk about device issue with iPads and iPhones. There’s a new term out there called ‘BYOD’ or Bring Your Own Device, and CIOs are grappling with the issue of letting physicians use their own devices—Apple devices are extremely popular—versus access and security and these kinds of issues. So why don’t you talk about what you’re doing around that.
Cummings: Sure. We actually have developed a strategy of having physician public access to our network. We utilize Citrix to deliver our applications and have found that by providing a security overlay to their mobile devices, we’re able to allow them to bring their own device—with the signing of an agreement and the application of our security software such that we know that they’re getting a secure connection to our network. And it’s segmented from our core network. It also is something where having Citrix allows us to have the limit, and the data is available so long as there’s the link and the session communication. So we are trying to facilitate allowing that flexibility of device strategy. Is it something easy, getting folks to be willing to let us install software on their personal devices, and the inconvenience of having to have pin codes and additional security to get into the device? It’s not something that folks are going to stand up and cheer about, but I think they understand that to protect PHI, to protect their own practice and not be the person who allows a laptop to be stolen and PHI to be discovered, I think that folks are willing—although maybe grudgingly—to comply with those standards.