As a mother of six, Laishy Williams-Carlson knows a thing or two about multitasking and prioritizing — and she better, because of the 18 hospitals that are part of the $3 billion Bon Secours Health System, 14 are implementing Epic. And as Williams-Carlson has learned, dividing her time between the hospitals that are already live and those in the earlier stages is not easy, especially since the facilities are spread out across the Eastern seaboard. In this interview, Williams-Carlson talks about dealing with different cultures at different hospitals, maintaining the delicate balance between security and access needs, the benefits of having a financial background, and the importance of having go-to people on the clinical side. She also discusses the challenges in dealing with physicians who use different systems, and why conference calls can never replace face-to-face interactions.
- About BSHS
- Deploying Epic throughout the health system
- Balancing optimization versus implementation
- “I think one of the best decisions our organization ever made was going with Epic”
- Baking in benefits realization
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We’re at that most unhappy state of an implementation, where those that are live are clamoring for optimization and would like us to be focusing less on implementing in the next hospitals. And those who are anxiously awaiting the implementation want all of our focus, understandably.
For those physicians who practice in multiple settings, once they have become accustomed to the record and then they’re in a hospital where they’re back on paper, they’re like, ‘This is a nightmare.’
When it’s a small niche area that wants us to tweak and tweak and tweak, sometimes you just have to say, ‘Guys, we don’t have the bandwidth to make it perfect right now. And you’re going to have to put up with good but imperfect, so that we can get the rest of the hospitals up.’ It’s a constant trade-off.
Of all the vendors that I’ve worked with, they’re the best. They’re the most responsive. They love to sit down and talk about strategy. I think they have a bias for ‘pull the trigger and go, and perfect later’ because you’ll just die a death by a thousand cuts if you try to perfect, perfect, perfect.
We turned the system on and started using it. And now we’re stepping back and saying, ‘How can we really refine this, so that we are world-class on doing everything we need to do to keep the patient for the right amount of time and avoid readmissions.’
Guerra: Good morning, Laishy. Thanks for joining me to talk about your work at Bon Secours Health System.
Carlson: Good morning. How are you doing?
Guerra: I am doing great, and I’m looking forward to our conversation. Let’s start with a description of the health system—the parts, the size and the scope of what you’re dealing with, and we’ll go from there.
Carlson: Sure. I work for Bon Secours Health System, as you mentioned. It’s a Catholic healthcare system. It’s about a $3 billion, not-for-profit organization. We have, through either ownership management or joint venture, 18 hospitals, 14 of which we are currently implementing an EMR and are either done or about to go there. We have some long-term care facilities and assisted living and home health. So we are, I guess, an atypical healthcare delivery system.
What is unusual about us is that we’re spread out geographically. We’re up and down the East Coast, although our primary presence is in the state of Virginia, and we’re headquartered in Baltimore. So we have some challenges, I think sometimes that other health systems don’t have that are more geographically consolidated, such as a Centra or something like that. We have some additional challenges due to being geographically dispersed.
Guerra: What about physician practices—owned physician practices, clinics, and that type of thing?
Carlson: In Virginia we employ hundreds of docs and would like to employ more. We also employ some physicians in the South Carolina and in our Kentucky Hospital. Our footprint in this space hadn’t been really huge until the last few years. And we’re deploying Epic, or as we call it ConnectCare, throughout our health system. And in those employed practices, they are getting the ambulatory version of it, and so far they love it.
Guerra: Do you have a lot of independents referring into the hospitals?
Guerra: Okay, let’s go back to the beginning. There’s certainly plenty there. So you said you have 18 hospitals and you’re going on Epic, and 14 hospitals are either implemented or in the process. That leaves four—what’s going on with those four?
Carlson: Well, if we joint venture them or manage them, we’re a minority partner, so there are just might be another strategy in place for those.
Guerra: I’m sure that doesn’t make you super excited, right? You’d love to get Epic in the other four.
Carlson: Of the 14 in which we’re implementing it, we have it live in seven. And we’re at that most unhappy state of an implementation, where those that are live are clamoring for optimization and would like us to be focusing less on implementing in the next hospitals. And those who are anxiously awaiting the implementation want all of our focus, understandably.
So we’re at the height of our spend and the height of competing priorities. And there’s never a dull moment, I’ll tell you that.
Guerra: Yeah, the height of your stress, right?
Carlson: Yes, well said. Exactly.
Guerra: Do you have situations yet where you’ve got some patient data that’s on Epic in the hospitals that are up? And have you had patients that have data in there winding up at hospitals that aren’t up yet, so you sort of have a paper-electronic hybrid, or is that not coming up?
Carlson: It did for a little while in Richmond. Our four hospitals that are in the Richmond, Virginia market are all live. And they share patients between them a lot. One of the facilities is a big tertiary care facility in the market. And during that implementation, just sort of managing the MPI issues was tough—they were at this hospital and then they were electronic and now they’re at this other one on paper. So yes, that is a big challenge.
And of course for those physicians who practice in multiple settings, once they have become accustomed to the record and then they’re in a hospital where they’re back on paper, they’re like, ‘This is a nightmare.’ Fortunately we’re past that hump in the Richmond market. As we are now moving to our Hampton Roads or our Tidewater, Virginia market, we’ll have the same happy challenges again, until all three are up. But they’ll all be up within a year, so it’s not so awful, but you bring up a good point. There is that challenge during implementation.
Guerra: Well certainly, if the physicians are telling you that once they’ve experienced the electronic world they prefer it, that’s much better than hearing, ‘Oh God, this system is awful. I’m going to go send my patients to the hospital that’s still on paper.’
Carlson: Well, you always hear that during the go-live.
Guerra: You hear that too. So it goes both ways.
Carlson: I don’t want to say, ‘Gosh, I’ve never said that. We’re so lucky we do it better than everyone else.’ Certainly during the go-live and then and as you get past that learning curve, you hear that. It’s funny, I was at the Virginia HIMSS Fall Conference last week and I have the pleasure of moderating a CMIO panel discussion with five CMIOs from our state. And one of the questions I posed was, ‘What do your docs really think about your respective electronic medical records systems? Do they love them or is it more of a begrudging tolerance?’ And the CMIO from VCU, Colin Banas, had a great answer. He said, ‘You know, Laish, I find that question odd because no one ever asked us if they loved the paper. They saw it as something they had to use, a necessary tool. But they never thought about whether they loved it or not. So, I’m not sure why we’re asking if they love the electronic tool. It’s what they have to do to practice medicine.’ And I thought it was of an interesting response.
Guerra: There’s such a difference between the phases at which you learn something new. It’s just unpleasant—no matter who it is, no matter what you’re learning, a lot of times, it’s just an unpleasant process. But that can change dramatically once you get comfortable. So you mentioned the idea of wanting to give as much attention as possible to the hospitals that have gone live. They want that attention. They want to keep their momentum going. So it must be frustrating when you’re not able to nurture that excitement and you hope you don’t lose it, right?
Carlson: Absolutely. I would say at least one meeting a day I have right now, over the past few months, has involved how to strike that balance between optimization and implementation. And what you hope for is that you’re getting great ideas on the optimization side that you can incorporate into subsequent implementation so that it benefits everyone. I know that when we were in orthopedics area, we were hearing a lot of noise that it just feels kind of kludgy and we really would like some basic fundamental redesign. That’s something worth listening to because that can benefit future implementations. When it’s a small niche area that wants us to tweak and tweak and tweak, sometimes you just have to say, ‘Guys, we don’t have the bandwidth to make it perfect right now. And you’re going to have to put up with good but imperfect, so that we can get the rest of the hospitals up.’ It’s a constant trade-off.
Guerra: Epic is known for having a good methodology—at least that’s the word of mouth, that they have a good methodology and a good recipe for success. You mentioned the orthopedic pushback. Is that something maybe they warned you about, and said you’re probably going to get a little pushback in orthopedics? How pleased have you been, overall, with the guidance Epic has given you in this process?
Carlson: I think one of the best decisions our company ever made was to go with Epic. And at the time we made that decision, which is quite a few years ago now, it wasn’t perhaps the obvious choice that it is now. Our MO in IT, so to speak, was that we were pretty conservative. We were formally primarily a Siemens shop, although we had a hodge-podge of stuff because our health system had grown through purchases. So whatever that hospital had, we were running it.
So we made the decision to go with Epic, and initially we were just going to implement their clinicals. In our first two hospitals in South Carolina, we bolted Epic clinicals onto a legacy revenue cycle, and that was a nightmare. So we said, let’s never do that again. Let’s get rid of the legacy revenue cycle apps while we’re at it. So we sort of retooled, which slowed us down, but now when we go live in a hospital, the only thing that we’re not changing out basically is the lab, PACS, and the radiology system. And even in our next hospitals, we’re picking up Radiant as well. So it’s a huge footprint—OR, Stork Beacon—just about everything they have, except lab and radiology, we’re implementing.
Epic has been a delight to work with. I cannot ding them at all. Of all the vendors that I’ve worked with, they’re the best. They’re the most responsive. They love to sit down and talk about strategy. I think they have a bias for ‘pull the trigger and go, and perfect later’ because you’ll just die a death by a thousand cuts if you try to perfect, perfect, perfect. And for the most part, I agree with that methodology.
Where we’ve struggled as an organization is not because of Epic; it’s because, as I mentioned, a lot of growth was through acquisition. So we could not have been further from a standardized workflow and approach and use of third party applications. We had best-of-breed in every hospital—and I guess best implies there is one best. So we had a hodge-podge of systems in every hospital. Where we had similar applications, they didn’t look and feel the same. You probably couldn’t have gone from one hospital to the next in a different geographic area and recognize the system.
So a lot of the growing pains that we’re having is because it’s the first time we’ve had conversations that include docs from Baltimore, New York, South Carolina, Kentucky, and Virginia to say, ‘How do we want this to look.’ In the DBV sessions, folks did get together and do that but I think it’s just so theoretical at that point. And then when you’re actually using the system, you’re like, ‘Now I get that decision, and now I get why it was really bad one.’
Guerra: From what you’ve experienced so far, do you feel like it’s been a little painful but you did the best way it could have been done, or is there anything at this point that you say, ‘Maybe we should have done one hospital and then the next or maybe we did too many hospitals at one time.’ Do you have any guidance for your fellow peers who may find themselves in the same position?
Carlson: I think if I had to list a regret about our implementation, it would be that we didn’t bake the benefits realization, return on investment, whatever you want to call it, methodology in a little more firmly as were going. And what I mean by that is when you turn on an EMR, there are great things that you certainly hope and expect to happen—the obvious things like, transcription costs should decrease, paper costs should decrease, and medication errors should drop. Basically just from turning on the system. And then there are other things that you have to start to do some heavy lifting to bring into existence where you’re using data and you’re really changing behavior.
While we articulated what our expectations were in our first few implementations, we were somewhat passive about making sure we were getting those benefits. And as we went along, we said that we need to be a lot more aggressive about consolidating departments where that’s an opportunity, or more aggressive about how we’re completely overhauling the HIM function, and what it does and the resources that are required. So that’s my big regret. It’s just that we didn’t hardwire that in a more tethered way right from the beginning. Other than that, I feel like we’ve made mostly great choices that made sense for our organization.
Guerra: I’m trying to understand a little better what you just expressed. Do you mean from a budgetary point of view that you had on paper, or from an accounting finance point of view, that you had written up better ROI, or do you mean actually changing things at an operational point of view based on after the system is rolled out?
Carlson: Actually, both. Let me explain. One thing we did that I think we were the first to do at the time, and I don’t know that I would recommend this one either, actually, is that our first two hospitals to go live were in South Carolina. Our ambulatory practices to go live were in Virginia. There were a lot of reasons for that that I won’t bore you with. But we were building the system and it’s definitely a one-patient, one-record kind of system, sort of with this hope of, ‘Gosh, we sure hope these train tracks are going to meet in the middle, so that when we get to our hospitals in Richmond, the workflows that we’ve built but haven’t yet turned on because South Carolina practices weren’t using ConnectCare—that that all matches up.’
So we were doing different things in different markets. And now that they’ve all come together in Richmond, it’s working fairly well. But, for example, we have this big overarching program of clinical transformation where we’re really trying to take patient safety and patient outcomes to the next level. An obvious thing we’re focused on, as is every other hospital in the country, is readmissions. To do that well, you need to be working across a continuum and building in workflows where certain rules and things are happening both the ambulatory environment and the hospital. And we turned the system on and started using it. And now we’re stepping back and saying, ‘How can we really refine this, so that we are world-class on doing everything we need to do to keep the patient for the right amount of time and avoid readmissions.’ That’s one type of benefit that I’m talking about.
The other is sort of the dollars-and-cents thing. When I say we had more of a passive voice, it was, ‘Okay, we’ve turned it on. How much money did we save? And did we get what we hoped to in terms of financial return from it?’ And I think, to quote John Glasser, you have to manage those things into success. They don’t just happen when you turn on the system. And I wish we’d been more aggressive about that.