Most CIOs deal with a great deal of complexity, but what Kathryn took on when she started with Kings County Hospital nearly a year ago takes it to another level. The hospital is part of NYC Health & Hospitals, which recently began an organization-wide conversion to Epic, while at the same time going through a major governance transition. Adding to it is the fact that NYC H+H is a public system, meaning all leaders report to the mayor’s office. In this interview, Crous talks about what it’s like to lead through change, the advantage she had in having to “test drive” the organization as a consultant first, and her thoughts on the evolution of patient engagement. She also discusses her leadership mantra — “listen twice as much as you speak,” her interest in EMR forensics, and why healthcare shouldn’t be compared to other industries.
- About Kings County & NYC H+H
- Governance in transition — “We’re in that middle valley right now.”
- Reporting to a corporate office
- Transition away from QuadraMed — “Support was diminishing.”
- Complex interfaces for billing
- “We have a lot of moving targets.”
- Working with Ed Marx on Epic conversion — “We’re taking those lessons learned and building a template.”
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It’s a little confusing at the moment because the actual table of organization hasn’t been released and titles are changing and chairs are changing. And so we’re kind of in that middle valley right now where things are not clear as to how we’re going to proceed.
We’re changing from one business model to another in the midst of an EMR implementation, in the midst of moving from Unity to Soarian, and in the midst of many other projects. We have a lot of moving targets right now.
Some of our billing comes out of QuadraMed, some of it comes out of Unity, so the analytics is complicated, but not withstanding the fact that we have a lot of integration, the analytics are actually pretty good for such an old system, and the amount of effort it takes to get the data into a data mart.
The conversion was very calm, and probably one of the calmest I’ve ever been on. And so, Ed and I were looking at each other and saying this is a little frightening. But nonetheless, we went through the usual trajectory of lots of incidents, and then it trailed off over time.
We’ve hired those senior vice presidents and then IT will be reporting up to those senior vice presidents that are going to be determining the strategy. And so, some of that complexity is also how do you build the governance structure so that you include all the facility leadership and the clinical leadership and the IT leadership appropriately to make sure that you’re making the best decisions.
Gamble: Thank you, Kathryn, for taking some time to join healthsystemCIO.com today. To get things started, can you give maybe like a general overview of Kings County Hospital, what you have in terms of bed size, ambulatory offerings, things like that?
Crous: Kings County Hospital is part of New York City Health and Hospitals. It’s the largest public healthcare system in the country. Kings County itself has over 800 beds and ambulatory clinics that cover almost every specialty and subspecialty you can think of. We serve the greater Central Brooklyn area and we have a very diverse population here. We have had to translate into 95 different languages our discharge instructions.
Gamble: Oh wow. How does it work as far as NYC Health and Hospitals? Do you operate somewhat independently or how does that work?
Crous: It’s in a great deal of transition at the moment. We’ve gone from having regional networks which is why the ‘N’ is in front of the CIO for network CIO, to being more of a consulting type of organization where a central office has a shared service line leadership role. So it’s a little confusing at the moment because the actual table of organization hasn’t been released and titles are changing and chairs are changing. And so we’re kind of in that middle valley right now where things are not clear as to how we’re going to proceed, and we’re still having to function in some of the old network type of function.
Gamble: So that brings some unique challenges for you and the staff as you’re kind of straddling two different boats?
Crous: It is right now. It’s kind of interesting because technically, none of the staff reports to me. We all report up to a service line at the central office, and so for most people that’s not a problem because we have kind of a matrixed reporting structure. Unfortunately, a few individuals take that to a different level, and so there are some communication challenges that come with that.
Gamble: What’s the approximate size of the IT staff?
Crous: We have about 1,300 people over all of the healthcare system. How many are physically located here depends on any given day. We probably have about 50 people on-site on any given day, but some people straddle between being at the corporate headquarters and being on site, and that again varies day by day.
Gamble: I guess this is the big question, but do you know really when things are going to start to be a little bit more clarified as far as what’s happening with the relationship?
Crous: We’re working on it day by day. We’ve had a huge leadership transition last year, and just very recently our corporate CIO was given the title. He had been interim because of the leadership exit that happened last year and so now that he’s been finally defined as a permanent senior vice president and CIO, the rest of it will trickle down once they get things a little more clearly defined.
Gamble: And who is that CIO?
Crous: His name is Sal Guido.
Gamble: Now, so at Kings County Hospital, what type of EHR system do you have right now?
Crous: Currently we’re on QuadraMed. My understanding is it’s 15 to 20 years since we’ve been on QuadraMed here, and this gets back to my original point about the networks really having their own functional roles in IT. With all the different hospitals, each has a separate instance of QuadraMed. We are moving to Epic in single instance, so we’ll have a consolidated database for our clinical EMR. We converted two of our 11 hospitals in April of this year and are working to accelerate that, but it’s a complex organization and we have many challenges. We were supposed to take a couple of hospitals up in December; we’ve shifted gears and we’ll be bringing up another hospital probably February or March timeline.
Gamble: And where does Kings County fit in that?
Crous: Unfortunately, Kings County is likely to be at the end of the list, because it’s such a big organization and because we’re in the midst of a lot of leadership change and reporting structure change, and we’re an academic center associated with SUNY Downstate. We’d like to get through some of our less complex organizations and make sure we have the template for the Epic deployment a lot more stable than it is right now.
Gamble: Right, that makes sense. So QuadraMed is being used, and it’s obviously been in place for a really long time. That’s pretty rare to have that kind of time with any system.
Crous: Agreed. When it was deployed here originally, it was really a physician system rather than an EMR, and so it’s taken several years for the nursing documentation and the ancillary staff documentation to get up to speed. As we all know, QuadraMed is not a market leader and the support is diminishing, and so one of the more compelling reasons to get off of it and on to Epic.
Gamble: As far as being able to do things like analytics, where does the organization stand? I imagine that that’s a tough one.
Crous: It is difficult. We have a complex environment. Our ADT system is Unity, which is an old Siemens product. We’re moving to the Soarian component of it, so we have interfaces from Unity into QuadraMed, and then it goes back to Unity for patient billing and that kind of thing. Some of our billing comes out of QuadraMed, some of it comes out of Unity, so the analytics is complicated, but not withstanding the fact that we have a lot of integration, the analytics are actually pretty good for such an old system, and the amount of effort it takes to get the data into a data mart.
Gamble: What are some of the ways that the organization’s been able to leverage analytics?
Crous: We’ve been working with Meaningful Use and meeting that both on the hospital side and on the physician side. As we know, those targets are also kind of squishy and whether we’re going to be moving into another phase of that is not clear.
We also have DSRIP (Delivery System Reform Incentive Payment), which is a statewide program that focuses mainly on the Medicaid-type population. There are many programs associated with the funding that comes to a public hospital system through meeting certain metrics. And so that adds a layer of complexity to where we’re going, because New York City Health and Hospitals is funded a lot through the actual mayor’s office in New York City. And then we have kind of a partnership with OneCity Health and then the DISRP-run programs that are necessary to keep the funding for the public facilities.
But they’re coming in with different technologies, so interfacing those technologies is also complicated. Again, we’re changing from one business model to another business model in the midst of an EMR implementation, in the midst of moving from Unity to Soarian, and in the midst of many other projects. We have a lot of moving targets right now.
Gamble: Yeah, definitely. You mentioned the plans to go onto a single system and as far as the hospitals that have started with it, is there a process in place for having different people involved to share some of the lessons learned or give feedback as to how things might change for the next hospital? I imagine this isn’t an easy thing with such a big organization.
Crous: Sure. It is complex. I was part of the conversion at our Queens and Elmhurst facilities and I worked with Ed Marx — he’s the consultant CIO that’s helping us through this Epic conversion. And I remember on day 1 or day 2 of the conversion, we were walking around and we were chatting about how it was eerily quiet. Because I’ve done a lot of conversions, most of mine have been in the Cerner arena over the years with consulting, and you know how you’re always waiting for that catastrophic thing that happens when you go from one system to the other? Well, it was day 2 or day 3 and we were like, okay, we’re really nervous because it’s not happening.
There were the usual printer and user access and education issues that came — not to say that there weren’t some issues, but they were addressed very quickly. It was just very calm; the conversion was very calm, and probably one of the calmest I’ve ever been on. And so, Ed and I were looking at each other and saying this is a little frightening. But nonetheless, we went through the usual trajectory of lots of incidents, and then it trailed off over time. So we are taking those lessons learned and we are building the template and then doing the localization at each of the facilities as we move forward.
Gamble: And is this something where there are specific dates for meetings? I imaging there’s more action when there is a go-live.
Crous: Sure. With our governance strategy, the clinicians have made the decisions about the original design and everything. We’ve recently hired a corporate CMIO, and putting together that governance structure is another one of those moving targets at the moment, but we’ve also had changes in senior leadership, not just on the IT side, but at the corporate level. We’ve hired senior vice presidents in service line methodology where we’re going to have acute care, long-term care, ambulatory care, HR, and finance.
So we’ve hired those senior vice presidents and then IT will be reporting up to those senior vice presidents that are going to be determining the strategy. And so, some of that complexity is also how do you build the governance structure so that you include all the facility leadership and the clinical leadership and the IT leadership appropriately to make sure that you’re making the best decisions.