It’s hard to say which is more challenging — implementing an EHR system or the optimization phase. Although there are many moving parts during a rollout (particularly when it involves five hospitals), “it’s a fairly finite set of work” with a hard deadline, whereas optimization never really stops. But to succeed with either task, a CIO needs “an exceptional team,” something Mark Zirkelbach is lucky enough to have. In this interview, he talks about what his team learning by going big bang with Epic — and what he might have done differently, the fine line between fixing a system and optimizing it, the challenge of prioritizing when there is so much to be done, and why today’s IT leaders “need to be a little more entrepreneurial.”
- About Loma Linda
- Vision 2020 & the focus on wellness
- IT planning for new hospitals
- Post-implementation optimization
- Going live with 5 hospitals in 1 day — “It was a lot of moving parts.”
- “We knew it would be more difficult… but we decided it was the best thing.”
- The slippery slope of configuration changes
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I’ve reached out to a lot of my colleagues that have gone through construction here recently to try to understand how do you plan for something that’s not even going to be here for four or five years?
We knew it would be more difficult, more challenging, many more moving parts, but we decided that was the best thing. I think I’d probably stick with that. I wouldn’t want to do it again, but if I was in that situation, I would give that pretty strong consideration.
I think I’d be more intentional about that, getting the organization ready to use the system on a day in and day out basis and get some of those processes in place sooner.
I would want us to make sure that we’re focused more on what changes are needed to the workflow first, and have those discussions and make sure the labor that goes into that workflow and the quality you’re trying to get out of it are the drivers.
Gamble: Hi Mark, thank you so much for taking the time to speak with us today.
Zirkelbach: Hi Kate, it’s my pleasure.
Gamble: To give our readers and listeners some background, can you just talk a little bit about Loma Linda University Medical Center — what you have in terms of hospital bed size and other care facilities?
Zirkelbach: Loma Linda University Medical Center is part of Loma Linda University Health. We’re an academic center. We have eight schools as part of our organization, and six hospitals. The hospitals are mostly focused on different disciplines such as adult, children’s, and rehab. We have a behavioral health hospital, a spine specialty hospital, and a cardiac hospital. In total, we have just around a thousand beds. There are also about 850 faculty members that practice and teach here at Loma Linda, and they’re primarily multi-specialists. There’s some primary care, but they’re specialists and subspecialists, which is probably typical for an academic medical center.
Gamble: Do you have physicians that are affiliated with the system as well as employed by it?
Zirkelbach: In California, that’s an interesting question because of the corporate practice of medicine. Really, we see all physicians affiliated in some way, some are employed by the School of Medicine. In terms of affiliates in the context of what you’re asking, we are starting to work with different community physicians and create partnerships that help build out our integrated delivery system and help with care coordination.
Gamble: It’s definitely a trend we’re starting to see in areas all over the country. Now, I had seen on the site that there is expansion going on or being planned for the organization. Can you talk a little bit about that?
Zirkelbach: Sure. We had a very exciting announcement in July called Vision 2020, where we announced some expansion, but also talked about our view and vision for the future of health care which has a very strong wholeness-wellness aspect to it as well as the traditional acute care settings that academic medical centers are known for. We’re going to be developing a wholeness institute, which creates an environment for research around how we can help keep people healthy, not just focus on those that are having some sort of a situation in their lives.
We also are caught up in a construction situation where our seismic retrofit created some challenges for us and we ultimately decided that it was best for us to build some new hospitals as opposed to trying to make the ones that we have meet the California code for earthquakes. There’s some new construction going on for our children’s hospital and adult hospital, and we’ll repurpose the buildings that we have. And then we have some expansion on the academic side, as I said, for the wholeness institute. Very exciting times.
Gamble: Yeah. As far as the new buildings, are you playing a role as far as design and things like that to incorporate certain technologies?
Zirkelbach: Yes. Even though it’s going to be three or four years before the buildings actually start to take shape, we’ve already started on design for the rooms, and it’s one of those challenging things. I’ve reached out to a lot of my colleagues that have gone through construction here recently to try to understand how do you plan for something that’s not even going to be here for four or five years? And it is challenging, but we are in the process of that. We’re finalizing our budget, going though our design right now, and hopefully that won’t have to go under much change as we move forward.
Gamble: That’s interesting because technology is advancing so quickly that you can’t say right now all the things that you’re going to want to utilize.
Zirkelbach: It is very hard, especially trying to imagine what it would be like if, on any kind of scale, people were bringing their own devices to work. One of the traditional things that IT has done is the infrastructure for cabling and connectivity and making sure that there’s equipment in the right places. We know that won’t go away totally, but trying to create a space that anticipates some form of that is really challenging.
Gamble: Yeah, I can imagine. As far as the clinical application environment, you have Epic in place at the hospitals?
Zirkelbach: Yes, at the hospitals and in all of our clinics with the faculty. That was a huge project that started several years ago. We’ve been live on all parts of our organization as of February of last year. We’ve been in optimization and trying to get back to a steady state since all the changes with swapping out many systems and many processes and lots of new capabilities. It’s been a pretty exciting time as you might imagine.
Gamble: Sure. You talked about swapping out different systems. Were there multiple EHR systems in place in the hospital?
Zirkelbach: Yes. We had different systems in our OR than we had in the rest of the hospitals. It was a big challenge to just move patient information around, particularly as patients left their med-surg setting and went into the OR, where there are significant documentation requirements, and then trying to return back to postop or to the med surgeon and making sure that everything that happened was well-documented. A lot of those issues went away with implementation of one platform for our documentation.
Gamble: Was it implemented first in the hospitals or in the ambulatory setting?
Zirkelbach: We started in the ambulatory setting. We had a different practice management system and so, we replaced the practice management system within about six months of signing the contract. When we went live there, we also went live with about six of our family practice clinics, and then about every six weeks or so, we would roll out another set of clinics until we were finished. The timing of that was just about perfect with the go-live of our hospitals. We went live with five of our hospitals for both patient accounting and clinical systems all in the same day.
Gamble: There were probably a little bit of nerves leading up to that day.
Zirkelbach: Yes, it was. The last couple of months are very intense with trying to pull everything together, trying to make sure everyone is trained and all the interfaces are working and all the testing is completed and validation and file changes, getting ready to bring in a number of people just to be at the elbow to help people around the clock, getting a call center and a command center in place that’s manned by 100 people or so around the clock. So it was a lot of moving parts. We were fortunate we were able to pull it off fairly well.
Gamble: If you had to do it again, would you do it the same way having all those five go live on the same day?
Zirkelbach: I think so. I’ve talked to others that have taken on similar projects and did it over time. In fact, we did a little bit of analysis on breaking it up in a couple of different ways. One was just financials versus clinical systems to see if we would reduce the risk, and also just doing it maybe by location or by site. Both of those proved to be more expensive and actually create scenarios and workflows that would be confusing because as you would roll out a deployment, it would be difficult for people to understand which way we are doing it today.
Ultimately, we knew it would be more difficult, more challenging, many more moving parts, but we decided that was the best thing. I think I’d probably stick with that. I wouldn’t want to do it again, but if I was in that situation, I think I would give that pretty strong consideration based on what we learned.
Gamble: Were there any major hurdles along the way or is there anything that you would do differently? Maybe you can share some of the things you learned.
Zirkelbach: We learned quite a bit. Maybe just to highlight a couple of things, when you take on a project like this, there’s a lot of energy in getting reading to go live and just getting the system built and all that. I would start sooner developing what the ongoing support model would look like and get things in place much sooner, maybe as much as three or four months in advance. Start working on that in a more earnest way. We knew it was going to be an area that we needed to focus and spend time, but really just the urgency of the project drove out much time to do that well. I think I’d be more intentional about that, getting the organization ready to use the system on a day in and day out basis and get some of those processes in place sooner.
Another area is that even though there was a lot of focus on workflow and a fair amount of documentation, I’d want to make sure that we captured that with the intention that we would use that in any go-forward discussions about changes in the system. We found ourselves getting a lot of request to make changes — I’ll call them configuration changes to the system. In reality, when we started looking at it, a lot of it was things that would be convenient for people and make it possibly more appealing to the eye or just less cluttered. I would want us to make sure that we’re focused more on what changes are needed to the workflow first, and have those discussions and make sure the labor that goes into that workflow and the quality you’re trying to get out of it are the drivers, and help make sure that we’re focused on the right things.
It took us a bit to pull back and stop fixing the system and really get focused on optimizing the system. Those would be probably the two biggest things that I would highlight that I would definitely try some different approaches in another project.