The relationship between CIOs and clinicians is often complicated, particularly when veteran physicians are presented with quality metrics and asked to change the way they’ve done things for decades. In this interview, CIO Lee Carmen talks about the importance of collaborating with providers and making sure they don’t feel “attacked.” He also discusses what he’s doing to eliminate departmental IT purchases that are made without his approval, the benefits of centralizing core services, how he is navigating the best-of-breed versus enterprise-system issue, and the organization’s migration to Epic in all areas but the lab.
- About University of Iowa Healthcare
- The benefits of a closed medical staff
- Centralizing core services
- Preventing the one-off departmental buy
- Warning vendors of “negative consequences”
- The pressures on employed docs
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All decisions made by any of the respective members are vetted and approved at the senior leadership level to make sure that everybody is moving in the same direction. We have a common strategic plan, and most importantly, we’ve centralized a number of core services.
There is a very small core group of individuals over the three parties that ultimately make all decisions within the enterprise. So I can go to them — or in many cases, they come to me — with issues, and we resolve the best strategy for the entire enterprise.
We make it very clear to them that what we’re trying to do is make the acquisition and implementation of these technologies as painless as possible for our customers here, but also making sure that they comply with the necessary requirements that we have.
There’s a lot of attention given to how many cases get moved through an OR in the course of a day versus how many are scheduled, and trying to leverage the fixed investment that we have in ORs as widely as possible.
It’s almost like going through the grieving process. There are several stages of it, and I think the first stage when you’re trying to change your culture to be a metrics, data-driven organization, is to question the data.
Guerra: Good morning, Lee. I’m looking forward to chatting with you about your work at University of Iowa Health Care.
Carmen: Good morning.
Guerra: All right, great. Let’s go over the organization for the folks who are reading and listening. Just give us the high points in terms of hospitals, practices — owned and non-owned, opened or closed medical staff. Just some of the high points, and we’ll go from there.
Carmen: University of Iowa Healthcare is made up of three entities. It’s the Roy J. Carver College of Medicine, the academic and research side of that enterprise; the University of Iowa Physician Group, which is a closed faculty structure of about 750 physicians; and University of Iowa Hospitals and Clinics. University of Iowa Hospitals and Clinics are three hospitals within one physical building, currently. There’s a behavioral health hospital, a children hospital, and a traditional adult hospital. It’s licensed for about 860 beds. We’re the only academic medical center here in the state of Iowa. We’re the quaternary care facility for the state. And we have and a significant offsite ambulatory practice with about 60 offsite clinic locations scattered throughout the eastern half of the state of Iowa.
Guerra: So 860 beds total, and it’s divided among the three entities within the facility?
Carmen: That’s correct.
Guerra: Is it a totally closed medical staff?
Guerra: So independents in the area cannot come in?
Carmen: They cannot practice in our facility. That’s right.
Guerra: I talk to a lot of CIOs about this. Does that make your life a lot easier, or not as much as people think?
Carmen: I actually think it makes my life pretty easy in a number of respects. The physicians are employed by the university, so we all work under the same set of rules. We’re a little bit unique, I think, compared to our peers in that historically — and when I say historically, I mean going back 40 years or more — our enterprise has really tried to function as a combined healthcare delivery organization. We have very close integration between the physician group, the medical school, and the hospital.
The senior leadership of the organization, of which I am one of the members, is governed by a vice president for medical affairs, who is a physician. All decisions made by any of the respective members are vetted and approved at the senior leadership level to make sure that everybody is moving in the same direction. We have a common strategic plan, and most importantly, we’ve centralized a number of core services. We have a single marketing and communication group that covers the three parties. We have a single finance group so we have a single budgeting process that spans the three entities. We have a single human resource group, and most importantly in my area, we have a single IT organization. So my IT shop is not only responsible for the clinical enterprise of the physicians and the hospital, but also the academic and research missions of the medical school.
This affords me, I think, a lot of benefits in terms of getting consensus and getting direction on strategic issues in that there is a very small core group of individuals over the three parties that ultimately make all decisions within the enterprise. So I can go to them — or in many cases, they come to me — with issues, and we resolve the best strategy for the entire enterprise. And then I move my organization in that direction. I’m not really prone to dealing with the concerns or issues of outlying parties who may not be within our core system.
Guerra: I spoken to one CIO recently, and we really went into the idea of centralization and the benefits, and we touched on the idea that maybe if you centralize things like purchasing and budgeting, you don’t have a lot of the one-off buys that can sort of sneak up on a CIO and you find out something’s been purchased or bought by a department and it doesn’t fit with your overall IT program. Does that make sense?
Carmen: That makes total sense. We’re at a little bit of a disadvantage in that we can’t fully execute on that strategy because we are also an entity within the University of Iowa. We are a state entity, so our purchasing, our general ledger, and our accounts payable all funnel through a University system. The University is not inclined to keep as tight controls over their IT spend, and all of those facets of operations. We struggle a little bit because we would prefer to have tighter control within our areas, but because we rely on some University systems, we can only do so much as the University is interested in doing.
Guerra: So it does happen on occasion where after the fact you find that something was purchased?
Carmen: It does happen on occasion that things slip through. It actually tends not to be so much in the domain of pure IT purchases, but more in the domain of acquiring a medical device to do something or an imaging device — some sort of diagnostic and interventional device — that has computer technology embedded in it. And so the customer who would be trying to procure that equipment won’t think of it in terms of, ‘this is a computer that has to sit on a network and has to follow certain rules.’ They just think they’re buying a device for the OR or a device for the cath lab, and so those are the things that we’ve got to tighten up a little bit more.
Guerra: We talked before we started the formal interview about the Survey Panel we have with the publication, and one of the surveys we did was about interactions with vendors. One of the questions had to do with workarounds that vendors can do to sell to a department to kind of avoid the CIO. I wonder if a lot of times when they go to the department level, they tell the department, ‘this is a stand alone and you don’t need to involve IT. Don’t bother them with this. And then of course IT does have to come in. Have you experienced that?
Carmen: We have experienced that and in response to that sort of activity, we’ve taken a little bit more aggressive approach and actually pulling in our primary vendors in these spaces. We have an extended executive session, not just with their local sales people, but I ask that some of their more senior people in the organization be involved. Prior to that meeting, I’m able to get all the information on the total annual spend we have with that organization and in what areas, so when I sit down with them, I have a pretty good indication of how much my company means to their bottom line.
We make it very clear to them that what we’re trying to do is make the acquisition and implementation of these technologies as painless as possible for our customers here, but also making sure that they comply with the necessary requirements that we have in the house. Most of the time that’s successful, and we make it clear to the regional sales staff that if they’re going to be engaging some of our physicians or other staff in the dialogue about technology, they have to let us know about it, and they understand that there are negative consequences for them if they don’t follow those rules.
Guerra: I like that — ‘negative consequences.’ That’s really good. So you sort of say, ‘here’s what we would like not to see happen. We want to make sure this kind of dynamic doesn’t occur.’
Carmen: That’s right. And in the event after such a session occurs, if that undesirable event happens, we reengage, and I remind them. They get a couple strikes, and then we get a little more aggressive with them.
Guerra: Right. Very good.
Carmen: But I have been successful at engineering the workflow such that I or a designee of mine has final review of any contract that goes out the door. So before the CEO of the hospital signs on the bottom line, I’m able to review the contract and interject where needed and make edits to the contract that are appropriate for our organization.
Guerra: Yeah, that’s a great point. The CIO I spoke to about this — I believe it was Mike Warden — talked about setting up filters such as in legal, in contracts, in purchasing, and wherever else. Different places that things could get caught and sent to him so things didn’t get though the system without him. So it sounds like you’ve got some filters out there too.
Carmen: That’s correct.
Guerra: We were talking about the closed medical staff and when I was writing about this at one point someone said, ‘don’t think that independent physicians are the only ones that have to worry about volumes.’ With employed physicians, I don’t how the formula works, but there is also a volume component in the way they’re paid. Is that accurate? And they still don’t like being slowed down. They can’t just sit there and say, ‘hey, I’m getting my pay check. I’ll take as long as they need for me to learn this EMR.’ It doesn’t quite work that way, does it?
Carmen: You’re correct. We actually have two categories of physician providers here in this organization. One category would be the traditional tenured faculty at a university, and so in our organization, those tenured faculty members are not only expected to do clinical service, but they do have expectations in the teaching and the biomedical research areas. That population is evaluated on their productivity across all three of those categories: how much research money have they brought in, and what has been their education time commitment as well as their clinical service. We also have a category of physicians that are strictly clinical track, and so they don’t have the academic or research requirements. That population is solely evaluated on their RVUs, or in some cases, proxies for RVUs — how much time they’re actually dedicating to seeing patients and providing clinical service.
You’re absolutely correct that both populations are very much aware of the metrics that drive their evaluations and their compensation. And they are equally sensitive to being as efficient as possible in the workplace. It’s probably a true statement to say that unlike a self-employed physician, it may take them a little bit longer to see the downside of not performing clinically. That is, it may not mean that next month their paycheck is lower. It may be something that they see six months out or maybe twelve months out, but they definitely see at and they’re well aware of it in their routine evaluation. So yes, they’re very sensitive. The surgical community is very sensitive to what it takes to get cases booked, what it takes to perform their cases in the OR, and how they can do that as efficiently as possible. There’s significant pressure on our organization to maximize the perioperative facility that we have.
There’s a lot of attention given to how many cases get moved through an OR in the course of a day versus how many are scheduled, and trying to leverage the fixed investment that we have in ORs as widely as possible and not leave them sitting unused during the course of a day. So not only do the surgeons have the pressure on their own personal productivity, but they also have the pressure of moving the case along so that we can turn the room and bring in the next case and maximize the use of the space. And this now, in the past year or year and a half, is manifesting itself on the ambulatory side as well, where we’re actually looking very closely at room-turns in clinics to make sure that we don’t have clinic space and clinic support staff like nurses and MAs sitting around because someone only chooses to see three patients in an afternoon. We’re trying to make sure, particularly in our high demand specialty areas like neurosurgery and ortho, that we’re leveraging all the time we have available to us in a day to get patients in and through the system.
Guerra: It’s fascinating. Part of the difficulty here in this whole dynamic is that we are still in a fee-for-service, volume-based environment. That’s how we get paid in healthcare. We’re inching very slowly toward pay-for-performance, but we’re really not there yet. We’re giving these physicians tools and telling them that this will help improve their quality, but we’re also not paying them based on quality yet. So it puts a CIO and the IT department in a tough position.
Carmen: I agree with that, and in addition, at least in my environment, many of the providers I’m working with who had been practicing for 20 years or 30 years earlier in their careers and certainly in their training, never had exposure to any quality metrics. So they assumed, perhaps rightfully so, as they were going through their course of delivering care, that they were delivering high-quality care. Now when you have dialogues and you start presenting metrics about quality, the initial inference by the provider is that they’ve been doing something wrong or they’ve been a marginal physician all these years. And so you actually start out the dialogue in a rather bad spot because the providers are concerned that you’re alleging that they have been delivering poor quality care, when that may not be the case at all.
Guerra: So they feel attacked.
Carmen: There is very much the risk of that, yes.
Guerra: I’ve heard that they immediately attack the data just as sort of a matter of course, and say it’s not valid.
Carmen: Yes, I’ve come to the realization, and I’ve seen actually some of this published in other people’s work, that it’s almost like going through the grieving process. There are several stages of it, and I think the first stage when you’re trying to change your culture to be a metrics, data-driven organization, is to question the data. Question what the source of the data is. Question the statistical relevance. Often a lot of the data that we will try and use for quality metrics has a very low end. You may be trying to look at quality on a month by month slice, and for a particular case for, say, a particular neurosurgeon, they may only do three cases of that nature in a month. So their initial reaction is, ‘statistically the data you’re presenting to me is irrelevant or inconclusive.’
It takes a fair amount of work and a fair amount of collaboration with the providers to get past that issue and get to the point where they either agree upon some true quantitative metrics to evaluate performance, or they agree that we have to rely on proxy data in some cases and just look at the proxy and accept the inherent challenges of using the proxy data for that metric. So when you get beyond that and then they start looking at that data, then I think you get into a really exciting period where the physicians start evaluating their own performance — and particularly when they can look at their performance — their metrics versus a peer’s metrics. Then it gets pretty exciting and you start to see real change.