Perhaps the biggest benefit in taking on a new CIO role is the grace period that comes in those early days. Jamie Nelson took full advantage of this window by tearing down the old governance structure at HSS and establishing a culture where IT is viewed as a strategic focus, along with creating steering committees to improve processes and increase transparency. In this interview, Nelson discusses the challenges in getting private practitioners on the same system, why academic medical centers are moving away from best-of-breed strategies, and the line CIOs must walk in fully leveraging IT solutions without impeding clinician workflow. She also talks about the guiding principles she learned as a consultant, the times when CIOs can’t just say “no,” and when she knew she chose the right industry.
- About HSS
- Allscripts in inpatient, Optum in ambulatory
- Getting private practitioners on the same EHR
- A new governance structure
- IT as a strategic priority
- Building relationships with docs — “You really have to listen.”
- Breaking away from best-of-breed — “We need a single vendor solution.”
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Sometimes you just have to let people come to their own conclusions. You provide the tools, and then they see how important it is to start doing things like share information.
When you have those relationships, it makes it much easier. If you go to these physician’s offices and you listen to what they want — really listen — I think it makes getting these systems implemented much easier.
One of the important pieces in the strategic plan is the governance piece. How do we listen to all the constituents? How do we take various opinions across the board and channel them up and have the requests come through committees that prioritize within their silos?
When you come in as a new leader, you have a certain amount of latitude. I was able to be use that timeframe of being a new leader to say, ‘Look, these are some of the changes I want to make,’
You no longer have to trade off with a single patient record and suboptimal departmental systems, or best-of-breed departmental systems and a non-integrated record. I think now the bar has risen and the vendors have much better solutions that clinicians would be happier to accept into their departments.
Gamble: Hi Jamie, thank you so much for taking the time to speak with us today.
Nelson: My pleasure, Kate.
Gamble: To get started, why don’t you tell us a little bit about the Hospital for Special Surgery?
Nelson: The Hospital for Special Surgery is located in New York City on the Upper East Side of Manhattan. We are strictly an orthopedic surgery hospital. We actually do rheumatology as well, but really orthopedics is our primary mission. We have about 4,000 staff members, 300 active medical staff, and 200 beds. But we have 35 ORs, and those 35 ORs have the volume of a hospital with 1,200 beds, so it’s a very busy place. We do about 29,000 surgeries a year and about 370 non-surgical outpatient visits a year. Just to give you an idea of size, we have 11 MRIs that run seven days a week, so we are pretty busy here.
Gamble: Right. I know from living in the area that it’s a pretty high profile hospital too.
Nelson: We have very high profile patients. We have athletes. We have dignitaries. We have celebrities. People come here because we do excellent work. And we also have people from around the world, from around the country, and from the tri-state area here who really need to have their mobility given back to them. That’s what we specialize in.
Gamble: From the clinical application environment standpoint, tell us about the systems you have in place.
Nelson: For our inpatient electronic medical record, we have Allscripts, which is the old Eclipsys System. Then on the outpatient side for our ambulatory private physician practices, we have Optum. We’ve got that in about 30 practices right now. We have about 100 orthopedic surgeons and we are trying to get them as close to being on a single ambulatory practice system and EMR as possible. It’s an interesting environment because they are private practitioners although they are here on our campus. They rent space from us. They don’t operate on other hospitals. Their patients strictly come here for surgery. And so although it looks like an academic setting, which it is, and a faculty practice plan, it isn’t. Each of these doctors is an individual solo practitioner. So we have unique challenges in encouraging them to use the same electronic medical records as their colleagues and showing the benefits of sharing information.
Gamble: Yeah, I can imagine that that’s pretty challenging. How does that work? Is it something where you have committees with physicians where you address this?
Nelson: We have a very good governance structure that we recently put into a place with an executive committee at the top, and then steering committees for clinical systems, research systems, education systems, and corporate systems, and we have a committee around the ambulatory electronic medical record. We do have those lower level committees where we work through certain issues and then bring it up to an executive committee for final approval or negotiation.
What I think we’re finding is that once you start to implement, physicians realize very quickly that sharing clinical information is to everyone’s benefit. I think everybody is starting to see that this is not a clinician’s medical record; it’s a patient’s medical record, and sharing that information is very important. When we first brought up the Optum system, we had strict separation of financial and clinical information for each physician. Now they’re saying, ‘We’d like to share more clinical information.’ Sometimes you just have to let people come to their own conclusions. You provide the tools, and then they see how important it is to start doing things like share information.
Gamble: That can’t be easy. You’re dealing with what really are all these separate entities almost and trying to get everybody on board with one system. Logistically, that can’t be easy.
Nelson: No it’s not, and we have a good team that’s managing them. A lot of it is that relationship. Luckily for us the surgeons are all right here, so if they have a concern or if they have a question, it’s not like you have to drive in your car and go out a half an hour to the community to go find them. It’s a five-minute walk to somebody’s office. The geographic co-location makes it much easier to address concerns and build relationships, and I think that when you have those relationships, it makes it much easier. If you go to these physician’s offices and you listen to what they want — really listen — I think it makes getting these systems implemented much easier.
Gamble: You brought up some of the changes in governance. You’ve been there about a year or so or a little more than that, right?
Nelson: Yes, a year.
Gamble: Can you talk a little bit about some of the changes that have been made since you got there just as far as the governance process and all the committees?
Nelson: The first thing I had to do is reorganize internally. We needed to elevate the internal leadership team in IT, because when I got here, the hospital really had come to the realization that IT is a strategic focus of the hospital. In fact, this year for our hospital strategic plan, we have seven different initiatives around strategy, and one of them is to invest in IT as an enabling strategy. It was recognized that we really had to elevate IT within the organization.
So first of all, I went ahead and I put in some leadership roles that were missing, like a chief medical information officer. We didn’t have a CMIO here. The first thing I did is get a director of planning. There are certain positions that were unfilled that we really needed, so I’ve gotten those in place. And then we developed an IT strategic plan, and one of the important pieces in the strategic plan is the governance piece. How do we listen to all the constituents? How do we take various opinions across the board and channel them up and have the requests come through committees that prioritize within their silos? For instance, it’s really important that all of the various clinical systems are looked at by the clinical steering committee and vetted there before being brought up to a senior governance committee. Research has a number of system priorities — we need to look at them together. Let them prioritize within that silo and then bring it up to the executive committee.
That’s the new structure we’ve put into place, and I think that’s working very well. My goal is that by next year’s capital request, which in hospitals is basically how projects get approved going forward to the next year, all those requests come through one of those committees. Nothing comes to my desk that hasn’t been vetted through one of those committees — that’s my goal.
Gamble: When you got there, I’m sure part of you wanted to kind of blow it all up and just start from the beginning when you’re talking about all these different committees and making sure that the right processes are in place.
Nelson: That’s exactly what we did. We blew up the original structure when I got here and put this new one in place.
Gamble: And was it received fairly well from the people who were there?
Nelson: It was received extremely well. People were frustrated. IT looked like a black box. They would go to the committee that had been put together before, which was effective many years ago, but as things got more sophisticated it became less effective. So they had had this committee where they’d go in and make requests and then never hear back. This is a much more transparent process.
For instance, we have our corporate systems, which is all of our non-clinicals. So the heads of human resources and different finance divisions get together and they look at the portfolio of projects that they all have together and make a decision amongst themselves as to what the priorities are. It’s not IT making these decisions; it’s leaders of business units making the decisions. That is, I think, a much better process. People were very excited about having a new governance process because they really did feel like they put in requests and they were really uncertain what happened in the middle and how requests got prioritized and improved. It’s a little more work for them, but they get a lot of benefit out of it.
Gamble: I’m sure. Now from your standpoint, were you were really open to this challenge? It’s not the easiest way to start a new job, I’m sure.
Nelson: No, but I saw that people really needed to have some structure around the IT process, and again, transparency. Since we were developing a new strategic plan for the IT department, and since we were listed as one of the seven strategic priorities for the coming years, it was something that people were open to. When you come in as a new leader, you have a certain amount of latitude. I was able to be use that timeframe of being a new leader to say, ‘Look, these are some of the changes I want to make,’ and so I think people were receptive to change.
Gamble: I’m sure it’s been a pretty interesting first year for you.
Nelson: It has, and one of my other challenges is that I walked into a best-of-breed environment, which is very common in the New York City academic medical center environment. I had worked at Memorial Sloan‑Kettering in my past and I worked at New York Presbyterian, so I’m very familiar with how these organizations were very much around best of breed. But one of my other challenges was that I saw that with the complexity of clinical systems these days, that’s no longer, I think, a viable solution for long-term. So one of my immediate challenges is to say okay, we need to go to a single vendor.
What’s that single vendor going to be? Are we going to be an Allscripts shop and everything we buy is Allscripts and that becomes our single vendor? So when I go for a patient accounting system, when I go for radiology system, and when I go for a scheduling system, will I only put in Allscripts and that becomes my single vendor? Or do I look toward an Epic or a Cerner and put in a whole new environment? That’s an analysis we’re going through right now.
Gamble: What’s the timeline on that?
Nelson: I think by the summertime we should have a decision made as to which direction we’d like to go in. But my guiding principle is I need a single vendor solution. So whether it’s Allscripts or a different company, I need to have really a single family of solutions so that we have less interfaces and a lot more integration that is supplied by the vendor, versus us cobbling it together with our interface engine.
Gamble: It’s interesting that the New York Academic Medical Centers tend to do have a best-of-breed strategy. Why do you think that is?
Nelson: Because I think that you have clinical departments that are very strong, and they traditionally were looking at systems that optimize their clinical workflows. That’s starting to change, because first of all, I think these integrated systems are a lot better now than they were five or six years ago. Cerner has a much stronger integrated platform. Epic has a much stronger integrated platform. The departmental systems have come up to speed, so their OR systems or their radiology systems or their lab systems are much stronger. I think it’s an easier sell to these academics now to say, ‘You wanted this lab system because it was so strong. Well guess what? These integrated systems have actually brought the functionality of those systems up.’ So you no longer have to trade off with a single patient record and suboptimal departmental systems, or best-of-breed departmental systems and a non-integrated record. I think now the bar has risen and the vendors have much better solutions that clinicians would be happier to accept into their departments.
Chapter 2 Coming Soon…