Earlier this year, Ed Martinez received the 2012 Innovator of the Year Award from CHIME for his efforts in leading the mHealth program that is transforming the way care is practiced at Miami Children’s Hospital. But Martinez’s innovation goes beyond that. In this interview, he talks about his unconventional methods for winning over naysayers, the enormous role that process improvement and change management play in a successful implementation, why his organization chose Cerner over Epic, the importance of taking risks, and what all CIOs need to keep in mind during a sales pitch.
- About MCH
- Now live on 15 Cerner modules since April
- Secrets to selecting a system – the importance of not focusing on the front-end look and feel
- Focusing on lean methodologies and process improvement
- The art of process redesign
- “The mandate from the top was to ensure process redesign occurred”
- Bringing in GE to help with change management
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We were very cautious knowing that the look and feel will ultimately change overtime as the developer learns what their mistakes are, but the functionality of being able to hit an Oracle database and being able to extend your environment using an Oracle backend environment — those were critical IT and strategic decisions.
Sales people will tell you one thing, but reality is another thing. And don’t get me wrong; whether you buy an Epic system, a Cerner system, or whatever system, the install is as hard as you allow it to be. It’s going to be a very difficult process either way.
If we hadn’t spent the time in the process redesign and in improving the way people work before we implemented the technology, we probably wouldn’t have had such a successful go-live.
While it was difficult and you had to walk a little bit slower in certain areas and then get a little bit stricter in other areas, the mandate from the top — and this is what made the difference — from the board of directors, from the CEO, and on down, was to ensure that our process realignment occurred.
That’s the way IT people think. We think, ‘hey we’re just going to implemented it. It’s cool, it works, let’s just go with it,’ and the reality is, life doesn’t work like that. You have to get buy-in.
Guerra: Good morning Ed, looking forward to chatting with you about your work at Miami Children’s Hospital.
Martinez: Thank you, looking forward to doing the same.
Guerra: All right, great. Let’s get the overview, if you would, about the organization. I believe you have some owned practices, but give people the lay of the land so they have some context for our conversation.
Martinez: Sure. We’re roughly a 300-bed pediatric subspecialty hospital in South Florida. We’re one of two standalone hospitals in the state. We’re the only ones presently in the South Florida area. We take care of about a million lives or so, something like that. We have an extensive amount of outpatient centers. We have centers all the way up to Jupiter, Fla., and across to Naples. We’re currently going to open one up there. We do international business — we have facilities both in the Caribbean and in the US Virgin Islands and other Islands. We go as far to Europe into the Vatican. We actually have Vatican presence as well. So we’re international as much as it can allow us to be.
Guerra: You use the word standalone, but then we talk about outpatient centers and things like that. So when you say standalone, what do you mean by that?
Martinez: Standalone means we’re not affiliated with another adult care facility where they do other things. The only thing we do here is children’s care. So we are a standalone facility not affiliated with any other hospital system or anything like that. Our patients are 100 percent from the ages of birth to 21 years old.
Guerra: Let’s talk a little bit about your application environment. What’s your core clinical system?
Martinez: Our core clinical system was just installed in April of this year. It’s Cerner. We call it PEDS for our internal name — Pediatric Electronic Data System — and we went live with 15 solutions.
Guerra: Were you coming off of another vendor system?
Martinez: We were. We had McKesson Series for the last 31 years here, and so it was a long time coming. We spent about a year and a half in the planning stages and preparation and developing processes, and we took about 24- to 48-hour cutover, and we went totally paperless in basically one evening.
Guerra: So you did that in April. You’ve been at the organization for about three years and you said you started the planning a year and a half before, so you were pretty much heading up the whole transition.
Martinez: Absolutely, yeah. I’m going on my fourth year now — actually it will be four years next April. So I’m here about three and half years, and the intent the moment I walked through the doors was to refurbish the infrastructure, put in a state-of-the-art infrastructure environment, both wireless and wired, put in an EMR, and focus on the data warehouse. Since that time, my goals have changed a little bit. We’ve added to this telemedicine initiatives, e-mobility, and e-health, and all the stuff that comes with that. It’s broadened a little bit in terms of what we’re trying to reach.
As I mentioned, we have patients that come from all over the world. So one of the things we wanted to achieve is how do we get these subspecialists in front of these kids that can’t actually just walk in here and see one of them. We’re moving forward and at a very fast pace, investing a lot of money and a lot of resources into telehealth and what its promises to bring to the table.
Guerra: Yeah, I certainly noticed that, and we’ll get into that quite a bit. Anything interesting you wanted to talk about in your EMR selection journey from walking in the door to the process of finally selecting Cerner. Anything you picked up there — any best practices you want to share?
Martinez: I think that one needs to not get fooled or wowed by the sales people, and some sales people do a really good job. Our finalists were Epic and Cerner, which is typical in this day and age. We think both systems were very good. In fact, we were probably somewhat divided in our decision making approach, but we did realize that based on our acuity levels and stuff that we were going to bring to the table and our clinical processes, we felt Cerner can actually deliver the better outcome for us. We felt it was important to focus on the patient and not necessarily on the frontend look and feel, which is hard to believe, because most people look at a system and the look and feel, and make a decision based on that.
We were very cautious knowing that the look and feel will ultimately change overtime as the developer learns what their mistakes are, but the functionality of being able to hit an Oracle database and being able to extend your environment using an Oracle backend environment — those were critical IT and strategic decisions that we could not forego. Our reasoning was the frontend look and feel may be a little clumsier in the Cerner world than in an Epic world, but the functionality far outweighs that, and so we went in that direction.
Guerra: Is it fair to say that your vision of collaboration, openness to telemedicine, and these kinds of things, could be better realized with Cerner than with Epic?
Martinez: I think it’s very fair to say that. I have experience in both Epic and McKesson now and Eclipsys and Siemens Soarian, and SMS (the old Shared Medical Services). I’ve been around the block a little bit, and I can tell you that the one thing that Cerner brings to the table is the backend Oracle infrastructure allowing us to really do a lot of things that we wouldn’t be able to do with a MUMPS-type of environment. So everything from our genetic personalized medicine initiatives that we’re undertaking right now for Latin or Hispanic origin kids, to the telemedicine and telehealth initiatives, to our ability to extend into the Latin American countries where now the product has to be in a different language and the functionality has to be the same. All these things are extensions of that.
You asked me what to be afraid of — again, sales people will tell you one thing, but reality is another thing. And don’t get me wrong; whether you buy an Epic system, whether you buy a Cerner system, or whether you buy whatever system, the install is as hard as you allow it to be. It’s going to be a very difficult process either way.
One of the things we did this time that I haven’t done in my career is we focused on lean methodologies upfront. We looked at process improvement. We looked at every area of the hospital in terms of functionally, area by area. We basically looked at their processes, current state, future state, and looked at where we can cut fat and where we can improve processes, and then we orchestrated the EMR to the future state processes — not trying to recreate the current state, because that’s always a hard thing to do. That allowed us to basically do 15 systems all live in one night and go paperless over a 24- or 48-hour period. That was the key. If we hadn’t spent the time in the process redesign and in improving the way people work before we implemented the technology, we probably wouldn’t have had such a successful go-live.
Guerra: Regarding process redesign, I don’t know if you ever saw the movie, Office Space, but it’s a comedy, and there’s this scene where efficiency experts come in and they’re going through people’s jobs with them and getting to describe their jobs, and it becomes clear how ridiculous some people’s jobs can be or maybe the way they do them. What I want to ask you is, when you start to go in and review processes and suggest improvements, that’s very delicate because you may come to say, ‘why do you do it that way? Why don’t you cut that step out, that’s totally irrelevant?’ So there’s a delicacy I would imagine about initiating process redesign. Maybe you can talk about that.
Martinez: You’re absolutely right. We experienced it in some areas. Some areas were very open to working with us and looking at improvement. The nursing staff was fantastic, and oddly enough, in most places I’ve been, nursing staff has always been the most difficult. However, here we’ve had a great team of nurses and they’ve had the open-mindedness to really understand that there’s got to be something better out there.
Now, understand that a lot of these areas were paper, except for nursing. Nursing was always on some type of computer system, but more importantly, they’d been on this old antiquated order entry system for 31 years. So they were very hungry for a change. They were open to that dialogue. Oddly enough, the physician community was a little bit more resistant to it. We found a lot of areas where the physicians didn’t quite grasp the idea of CPOE and what it was about and why we had to do things in certain ways. And we’re still challenged a little bit, even six months after go-live.
However, I can safely tell you that you’re right. While it was difficult and you had to walk a little bit slower in certain areas and then get a little bit stricter in other areas, the mandate from the top — and this is what made the difference — from the board of directors, from the CEO, and on down, was to ensure that our process realignment occurred. This wasn’t just something on the side. We spent millions of dollars on the process redesign. We looked at area by area and one of the things we did which was differently as well in process redesign was we looked at change management. When we were doing process redesign, we looked at what were the things that create a change? What were the things that were going to create pushback?
That allowed us to bring in GE, for example, and they came in with their change management methodologies. We trained key folks, change leaders that would actually help people basically adapt to these new processes and allow for the change to occur. While the resistance was there, we also had people who were trying to break down those resistance levels. So we thought about every possible possibility, and even then — even when we felt we had it all — there was always some area. For example, anesthesia was a hold out well into maybe three months ago. It took them a long time to basically adapt to the workflow. However, for the most part, for the hospital, taking the process redesign and bringing the change management folks to the table really did pan out and worked very well for us.
Guerra: Talk about the idea of change management being as much science as art. I think people sometimes make the mistake of assuming it’s an art and it’s just change management, but there is a science and there are methodologies out there that can really work, and maybe make CIOs more comfortable embarking on some of these projects. Does that make sense?
Martinez: Yeah, I have to tell you, if you have the budget and you’re looking for a major enterprise implementation of this magnitude, process redesign and lean methodologies are very, very critical. But those are processes that we can draw on a paper, put it on a chart somewhere, and say, ‘here’s what you’re going to do.’ The behavioral science of this, the change management piece of this is really incredible. The biggest successes in the country in EMR implementations — or any implementations of this magnitude — are because people have the right mindset, even though of course there’s a lot of behind-the-scenes work with logistics and technology and everything else. But if the people don’t want to accept it, the implementation won’t work.
So we felt that with the change management process — and this is the recommendation I have — if you have the money and the budget, spend the time in both of those areas: process redesign and change management. Make sure people have a sense of what we’re you’re trying to achieve. Make sure people can help with that process. And it also helps you understand who are the folks that are going to become the bottlenecks. Who are the folks that are going to become the folks you’re going to have to spend more time with ultimately, or perhaps decide whether this person needs to be in the organization or not. It could lead to that decision. But definitely, it allows you to have that vehicle, that information that’s very important.
A lot of times you get blindsided by things. I can tell you, one thing we weren’t was blindsided. We knew exactly where our hot points were going to be. We didn’t know to the level they were going to be, but we absolutely where the hot points were. And I owe that all to change management, because we were able to look at the behavioral part of this — who was going to be the resistance, and break them out accordingly. So I would say yes, spend some time on this. It’s very, very important.
Guerra: You talked about someone possibly having to go. And I’m thinking, it could be one thing if someone’s being difficult about adopting a system, but it could be another thing if you find out through the grapevine that they’re really voicing that at every opportunity they get and being a negative of influence. I don’t talk about that with a lot of CIOs, but I would imagine that could be a real challenge if not only is someone being difficult, but they’re bringing everyone else down.
Martinez: We took different tacts. Again, it depends on the personality. It’s a behavioral thing. I’ll give you an example. We had one physician who was openly saying, ‘This is going to be a disaster. It’s not going to work.’ I happened to be in the physician lounge one day and he started to talk to me about it, and I said, ‘Okay, tell me what’s going to change your mind.’ We wound up having a bet. If we would actually go live and implement correctly, he’d buy me dinner at the best restaurant in Miami. And so for him, it was a challenge. ‘Hey, let’s see if they can pull this off.’ Oddly enough, after go-live, when he realized, he came back and said, ‘Where do you want to have dinner?’ He was one of the ones that became a very big advocate for us and he’s now one of the ones pushing for this stuff, because he himself got himself in the middle of the decision-making process.
Then other individuals were not vocal but they were vocal via email. So those folks took a little bit more time. I think it was more frustration and venting. With the ED docs, think about the volume of patients coming through a facility like ours, and then trying to learn a system real-time in an evening where you have 200 patients outside of the waiting room. These things are behavioral, because the doc is thinking to himself, ‘I have to take care of these kids. I don’t have time to be able to enter an order.’ Because for 31 years before that, they would just say, ‘Give him 5 mg of this and 10 mg of that,’ and they’d write it down on a piece of paper and give it to a nurse, and the nurse would take care of the rest. Now they’re being asked to do more while providing the same level of care.
So understanding that basically allowed us to have a different perspective on things and attack this individual naysayers or roadblocks from different perspectives. When I saw that I wasn’t making headway, I would introduce my administrative director of clinical operations. She’s a nurse, so she had the ability to talk to them from a nurse perspective. Or I’d bring in the chief medical officer. Together, we took down a couple areas by understanding what their dilemmas were. Mostly, it was always about give and take. It was never, ‘Hey, this is what you’re going to do.’ It came down to that maybe in one place but mostly it was, ‘What do we need to do to help you understand the value here?’ And this went back and forth for weeks after the go-live. Ultimately, like I said when I was telling you about the doctor who made a bet with me, it’s all about trying to understand what makes them tick; what makes them look for the next best great thing, and why this is important to them as well as to us.
I’ll give you another example. We have a great, great cardiothoracic surgeon here, one of the best in the world. And he developed 10 years ago the first EMR for cardiac care. He had it implement here, and we said to him, ‘We’re going to turn this off and we’re going to implement this new Cerner System.’ Well, can you imagine how he would that something he developed himself; that he brought to life, is now going to be shut down? The resistance there was just natural.
So how do you get him to come to the table? You work with him, and understand the functionality he had, and show him a bigger picture where now that we have this, if we can do the same thing you were doing, but do this globally and do this using telehealth and using other environments, wouldn’t that be cool for the kids?
When we started talking about what would be cool for the kids, great for the kids, and better for the kids, you start breaking down those resistance layers in many of the areas. So again, it was just trying to figure what was the right angle of approach but not ignoring them. Because part of the change management methodologies that you learn when you study the GE change management process, is that they’re voicing their concerns, whether physically or verbally or other, because there’s something that’s bothering them. If you ignore them, it’s just going to get worse. And you can’t plow over them because that’s going to create basically a guaranteed failure on your implementation. So you have to spend the time to take apart the areas of resistance and understand where they are. And when you get there, you ultimately wind up having a better relationship with this individual, and in the end you have a better outcome.
Guerra: Yeah. When you’re frazzled with so many things on your plate, you think, ‘Listen, we just have to put this out and they’re going to have to do it’ but that doesn’t work.
Martinez: It doesn’t work. That’s an IT blunder. That’s the way IT people think. We think, ‘hey we’re just going to implemented it. It’s cool, it works, let’s just go with it,’ and the reality is, life doesn’t work like that. You have to get buy-in.You see everything from politics to a kid’s baseball game, right? There is a give-and-take in this world for everything we do. And IT individuals need to understand that while we are bringing great value to healthcare and to the technology that drives this business now more than ever before, we still have to understand the way people think and their perception of things and help them understand how we see the world while we understand how they see the world at the same time.
Guerra: It’s interesting because of the level of the caliber of folks you’re dealing with and what they mean to the organization. You talk about that cardiothoracic surgeon you mentioned — it’s quite possible the board might say, ‘Hey Ed, you’re going to have to go before he does.’
Martinez: That could happen; not in this case, but that could happen. You’re absolutely right. You have a guy that operates on hearts the size of peas. So you’re exactly right. You have to accommodate him, but the idea is never turn your back on them. Even though we have the right strategy and we have the blessing from the board, the last thing you want to do is have this blow-up and take it to a board-level discussion. It doesn’t look good for you. It doesn’t look good for them. Ultimately, it looks bad on the whole project, and it shows you weren’t able to control the resistance or the problem. That never works out well. Thankfully, we didn’t have that issue.
Chapter 2 Coming Soon…