Most CIOs have experienced a major change at one point in their careers. But they’re rarely as drastic as the transition Barbara Riddell made when she went from Tenet Health, a corporation that includes 49 acute care hospitals in 11 states, to Atlantic General Hospital, a relatively small system with a patient output that fluctuates by season. And as Riddell has learned, a smaller organization does not necessarily mean less complexity. In this interview, she talks about having the right team in place to prepare for data exchange, how vendor agreements are like a marriage, and the added pressure that smaller organizations face in getting it right the first time.
- Contracting for success
- “Word of mouth is everything in this industry”
- The risks and rewards of a fast implementation
- Grappling with the HIT talent shortage
- A small hospital with all the big hospital requirements
- Managing for keeps: “If we’re doing a good job, it doesn’t have to be dreadful”
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A lot of times when it’s software, the contract is written such that we put it in, and as long as it turns on, it works. And so there was a lot of discussion about remedies. And in fact, we made them pull forward all the remedies throughout the contract into one consolidated page that is then signed, just to make it easier to manage the contract.
The truth this, the vendor needs us to be successful as much as we need to be successful. We become a referenceable site. We would become somebody who is not draining them of hours and dollars because we’re on the phone with them everyday complaining about everything. And word of mouth is everything in this industry.
We are a small hospital but we are under all the same requirements and regulations as an 800-bed hospital—only with fewer resources, both human and monetary. So this has to go in, it has to go in well, and has to go in right.
They’re getting to come to the table and learn the process of how the decisions are made and how we reevaluate the workflow. And so as we’re going toward the inpatient system, we’re already incorporating everybody in the ED design so that one, they get to weigh in, but two, they see how this new process works.
I felt very strongly that for the pharmacy informaticist position, you have to have someone who starts with the process, is part of designing the process, and stays with it and continues to run the reports and manage the tables and manage the formulary and continue to manage that process way after go-live.
Guerra: Who helps you with the contracts? Does the hospital have a chief legal officer or someone in house that you sit down with go back and forth? And they have to probably understand an IT contract to an extensive degree. They have to know all types of contracts, but you’re bringing the expertise from the IT side, and they’re bringing the expertise from the legal side. This is maybe an area that people don’t think about that CIOs have to deal with a lot, but you certainly do.
Riddell: Right. We certainly do. So, we have a legal counsel. He’s not internal to us, but he is the person we contract with exclusively. He and I have spent a lot of time on the phone. We actually met to go over the terms of the contract. Anywhere that he had concerns, in terms of the ITEs, either he and I discussed them. He also was conferring with their legal counsel, who of course was an IT legal expert. But we also made it possible for our counsel to go out and get any other legal advice and reach out to colleagues that specialize in software, so that he could be comfortable and that we were comfortable. And we spent a lot of quality time together. I can recite the contract and tell you specifically on this page, that’s where you’re going to find this.
We put a language in there that folks might be interested. And that would be to say, what are remedies? Because a lot of times when it’s software, the contract is written such that we put it in, and as long as it turns on, it works. And so there was a lot of discussion about remedies. And in fact, we made them pull forward all the remedies throughout the contract into one consolidated page that is then signed, just to make it easier to manage the contract, referencing back to where in the contract that that can be found so that we have all the remedies called out—anything that we would need to go back in terms of warranties or remedies.
We wanted everybody, including our board of directors, to clearly understand. So we vet in this contract thoroughly as a team. We met with our legal counsel, we reviewed it with our financed committee, and then we took it to our board of directors, and they reviewed it again. And so we feel very confident that we spent a lot of time on the contract. And that’s really the important piece. We have the scope detailed out. We have several addendums. We have a very good agreement that both we understood, as well as the Allscripts. We had lots of conversations where you sit down and translate to each other, what do I think I’m getting? What do you think this says?
Guerra: It’s like marriage counseling, right?
Riddell: Right—are we all on the same page? It is like marriage counseling, and it really is like a marriage. You’re going into this thing and you’re saying, ‘By the time we’re done, I want to be sure we are partners in this thing.’ And that seems silly, and I’ve been in the industry long enough to know that there will be back and forth about, should we really be partners or not? The truth this, the vendor needs us to be successful as much as we need to be successful. We become a referenceable site. We would become somebody who is not draining them of hours and dollars because we’re on the phone with them everyday complaining about everything. And word of mouth is everything in this industry.
Guerra: Yeah, sure.
Riddell: We have a small group of CIOs here in Maryland that reach out to each other. Several of us were within a year or so of getting the job, all new in the position, and we kind of reached out to each other and said, ‘Who did you go with? And what did you say? And what were you concerned about?’
Guerra: We just mentioned how we were both at the CHIME Conference speaking, and they certainly don’t want you down there unhappy.
Guerra: But you need people to talk to, right?
Riddell: You do. And it was interesting because I heard lots of folks who were in different stages of the install or the achieving Meaningful Use and the various challenges. And I honestly heard a lot of good feedback about Allscripts, which I was very, very pleased to hear. One thing you don’t want to do is go to a conference after you signed a contract and find out that you got the wrong vendor.
Guerra: It’s almost like, ‘Just don’t tell me. I don’t want hear it at this point.’
Riddell: I know, seriously. At that point it’s too late—don’t tell me how bad it is. But honestly, it’s a place where the vendors are running as fast as they can to keep up as well. This Meaningful Use thing has really put everybody to work in a good way, but also under constraints of time that are hard to achieve. And so you see everybody with that same gray cast to their skin. And we all have the same bald spots.
Guerra: One other thing that I’m hearing is that software is getting out there a little too fast and it’s not being delivered with the quality that some of the CIOs are used to. And everybody knows it’s just because of the speed and the pressure that everyone is under to make these government deadlines.
Riddell: Right. We worried a lot about drive-by install. We can’t be the victim of that, particularly because we are where we are. We are a small hospital but we are under all the same requirements and regulations as an 800-bed hospital—only with fewer resources, both human and monetary. So this has to go in, it has to go in well, and has to go in right.
I’m truly spending these winter months until the January kick-off making sure that we have the right governance place, making sure that we have the right plan in place, that the team is there, and that they have the right skills. We’re sending people to training early. We debated that with the ED product we sent them in time and much closer as would typically be prescribed. And then suddenly, because the vendor needed to hurry, they start requiring all these documents, and said, ‘We need you to pull all these data, all these tables down.’ And the team didn’t understand why they were doing what they were doing. And when the time came for them to go to training, they went to training and said, ‘Oh, now I know why I was doing all that.’
So we are sending the team to training in late November, early December. And we’re sending them altogether. And then we’re going to do a team building in December. We’ll go over the contract at that time with everybody so that everybody understands the scope and the statement of work and what our change process is going to be. And then in January, we’ll have an official kick-off. So it’s got to be fine-tuned. This is like getting called to the Thanksgiving Day Parade. We’ve got to all be on the same sheet of music, because speed to value is what we signed up for, which is a 10-month install. So it would be speed.
Guerra: I was going to ask you about that. I assumed that’s not a drive-by implementation, as you expressed. But implementations take time and patient safety is on the line because you don’t want to roll out systems where people don’t know how to use them or are using them improperly, or you don’t want to have interfaces that haven’t been tested and data coming across jumbled. So there’s a balance between speed and doing it right, and I would imagine that’s something you’re keeping a very close eye on.
Riddell: We’re doing a lot of workflow redesign right now. We have those committees already assembled. This hospital had adapted Lean years ago and they embraced that. And so we have a surgical team. We’ve already got a pharmacy team. We’ve got folks already looking at those processes.
The other thing I put in place when I got here was literally a transformation operation committee, where we bring various people from the different departments to discuss the decisions we’re making around the ED product. And we’re starting to basically rehearse with everyone else. They’re getting to come to the table and learn the process of how the decisions are made and how we reevaluate the workflow. And so as we’re going toward the inpatient system, we’re already incorporating everybody in the ED design so that one, they get to weigh in, but two, they see how this new process works. And they get used to coming to that meeting. They understand how that meeting functions and operates—that we can’t just make a decision about the blood bag tag down in ED, that that’s going to affect lab and it’s going to affect nurses on the floor. If that patient gets admitted, what’s that new process?
We’re looking at all those process decisions up front, so that we’ve got a lot of these cleaned up. I’ve got the pharmacy team cleaning up formulary right now. I hired a pharmacy informaticist a couple of months ago in anticipation of this project. We have him work on the bench some period of time in a month so that he truly learns our pharmacy and learns the process here, but also is engaged in working on those tables and the cleanup of those tables for the formulary in anticipation of building the pharmacy application. So we’re bringing up some folks right now, about six months prior to really kicking off the project, so that they really are well-versed and well-rehearsed in how the projects will go.
Guerra: How hard is to find a good pharmacy informaticist? I would imagine they’re not sitting on every corner.
Riddell: My goodness, it’s very hard. I had an outstanding team at Tenet. A lot of those folks are still there. The ideal candidate has been a director of the pharmacy before, has worked in pharmacy operations for 10 to 15 years, has put systems in just as a result of being in any pharmacy, and then moved to the vendor side and learned formal project management and those processes.
So it’s very, very hard. I started looking for this young man months ago, just right after I got here. I had three different consulting firms looking for someone and what I found was a young man who has an interest in this area. He’s got his PharmD, he’s worked in the pharmacy but not at the director level, and had worked in IT for about maybe two years, so I’m going to have to grow him.
Riddell: The ideal candidate will know the pharmacy and bar coding and how to put these applications in as well as I do or as any vendor would know. But we just couldn’t find that person with that seasoned experience already, who wants to relocate to the eastern shore of Maryland. And so we found a young man who is from here, who knows the area, and who loves it here. His family is here. And he’s got the desire and the willingness and the aptitude. And so it got to where my choice was to either keep looking to no avail, or to bring in a young man who’s eager and excited and has the education and has some background, and grow him.
Guerra: Well I would imagine the director level person would command significantly more from a salary point of view.
Riddell: Yes. That’s the other case.
Guerra: I mean, it’s a small hospital, 62 beds. This is a position that I would imagine a place like Tenet could pay triple what you could.
Guerra: It gets tricky because as you just mentioned, you need the same resources, but you may not have the scale to pay.
Riddell: You’re exactly right. We have all the same requirements, all the same requirements. We have to literally report all the same quality measures and then some. But we have fewer resources from a financial perspective. And we also have less folks living near here. It’s a lot easier to recruit to Dallas. You got a hub there, even though we traveled a lot because we had 46 hospitals.
Here, we are remote. This is a lifestyle choice. On the hand, there are wonderful things about that. There’s a beach. This part of Maryland is absolutely beautiful, and if you’re someone who loves fishing or boating, you’re all set. So it’s got to be somebody who would want to relocate to this area. I will be bringing some consulting in, and so I will rely on some consultants. But I felt very strongly that for the pharmacy informaticist position, in order to maintain bar coding of medications and maintain that patient safety, you have to have someone who starts with the process, is part of designing the process, and stays with it and continues to run the reports and manage the tables and manage the formulary and continue to manage that process way after go-live.
So we decided to invest in that person and where we can bring consultants in, we will. I will be bringing a project manager, who is PMP trained. So those kinds of resources that would come for the length of the project, then leave, I’ll use consulting. But where we wanted to really invest in the whole process, we had to invest in the people.