When University of Vermont Medical Center brought Adam Buckley on board in 2012, it was because they believed his focus wouldn’t be on what technology could do, but rather, how it could improve patient care. They were right. Two years later, he was named CIO of the medical center (and eventually the health network, when it was formed), and Buckley’s attention is still on how IS can be leveraged to provide better care.
In this interview, he talks about how being a rural organization affects his strategy, what it took to sell Epic to the board (and get through the state’s red tape), and his team’s plans for becoming an integrated system. Buckley also discusses the need to leverage the experience of others, why he refuses to believe that a CIO needs to be “a CISO and CTO rolled into one,” and what it was like to go from the hustle and bustle of NYC to cow country.
- Selling the board on integration: “It’s the how, not the why.”
- Being a “careful steward of resources.”
- From 80 licenses to 1
- Taking on the CMIO role: “My approach wasn’t from an IS perspective.”
- Experience in clinical & quality: “I understand those concepts. I’ve lived them.”
- CIO: It’s not CISO & CTO rolled into one
- “You always need expertise”
You could not have tried to invent a more complex, convoluted system that requires more human factor engineering to manage it if you tried. When I looked at the risks that are associated with that, both from a patient care and financial perspective, I saw an opportunity to engineer that complexity out.
We’ve seen a lot of wonderful quality work done across the health network. But I still think that to reduce variations in care across a large system, you need to be able to drive a standard order set across the organization. At the end of the day, you need a single EHR to do that effectively and efficiently.
I’ve spoken to people who say, ‘our CIO needs to be a chief information security officer and a CTO all rolled into one,’ and my response is, five-billion dollar companies have CISOs or chief security officers, because you can’t be an expert in all things.
We’ve reached the point where you need to find expertise regardless of what your foundation is in, because it’s very unlikely someone’s going to have a foundation that spans all the realms you need to understand in the IS space.
Gamble: In terms of the integrated EHR, I imagine one of the biggest challenges in taking on this type of initiative is in selling it, because it is such a large undertaking.
Buckley: The price tag was certainly the price tag. I’m originally from New England—although I hadn’t lived here for a while — and Yankee frugality is definitely something that is a streak throughout the region. ‘You want to spend how much?’ is always the first reaction.
Meanwhile, coming from the New York market, I had a colleague who’s doing an EMR implementation at one of their affiliates for $300 million; we’re spending half that much. We sometimes joke that we spend money that’s the equivalent of the big systems’ rounding errors, and we take pains to do it. But I think that’s appropriate. You want to be a careful steward of the resources you create in a mission-driven, not-for-profit environment. And we are; we don’t take spending lightly. In this case, the critical mass was the ‘how much’ — the ‘why’ was an easier sell. We have 20 clinical systems between all of our affiliates now. And we have one affiliate where it’s not uncommon for a patient to be seen in the clinic, get sent to the ED, then get admitted to the floor or go to an OR, and along the way, hit four different systems, very little of which have information traveling between them.
My background is patient safety and quality; it’s not IS. And so the first thing that occurred to me when I looked at the system was you could not have tried to invent a more complex, convoluted system that requires more human factor engineering to manage it if you tried. When I looked at the risks that are associated with that, both from a patient care perspective and the financial standpoint, I saw an opportunity to engineer that complexity out. At UVM Medical Center alone, we could collapse 80 different licenses to one license and do away with a million and a half dollars of the interface expense, which from my perspective would be better spent on clinical care, direct clinical care. So the ‘why’ wasn’t a hard sell, but there was some pushback on the ‘how.’
I think I was able to sell it credibly because I have a clinical background and a quality background, and didn’t necessarily come to the table with an IS perspective. Even though I understand and can speak to the IS risks of having so many different systems, the way I framed it was patient care first, system complexity and the associated risks second.
So yes, it was a hard sell. And we’ve haven’t completely aligned our governance yet. I needed 13 board approvals, and so that’s a year spent doing deep dives with boards, board members, and clinical leadership, and that’s before the Certificate of Need (CON) that’s required. And there are multiple levels of stakeholders. First there are stakeholders within UVM Medical Center and its affiliates, then at the board level, and then we had to engage business leaders, government leaders, and legislative leaders. It’s interesting; you might not necessarily have to engage with them in other cases, but with the CON being a gate for us, it was critical that we talked to those stakeholders. That probably added another six months, and so it changed the way in which we approached approval.
And so I’d say in the order of issues to overcome, it was finances first, and ‘how’ second. People didn’t really ask ‘why.’ At this point, enough people across the country have lived in systems where their records don’t flow, and they’ll say, ‘my bank can do it, but my hospital can’t.’ They understand the negative risks of having all these different systems.
Gamble: Was that the case, even with legislative leaders?
Buckley: Yes, definitely. In fact, when we had to do an initial testimony in front of the Green Mountain Care Board — which was done for informational purposes and was a public forum — the people there didn’t really have anything negative to say about it. If anything, they were concerned with the lack of transparency around drug prices. I had to point out that our system can’t manage that, unfortunately.
But it was interesting that even in that audience, no one questioned the ‘why.’ It was immediately, ‘You need to have more information moving seamlessly like you’re planning on doing for this project.’ Even in a public forum, it was supported — at least in the initial discussions we had in the state setting.
Gamble: Very interesting. You mentioned your background as a clinician; when you stepped into the CMIO role at the University of Vermont Medical Center, was that your first foray into IT leadership?
Buckley: Yes. I was hired as a CMIO, so it was certainly my first formal IT leadership role. When I was with Mount Sinai Beth Israel, we implemented an obstetrical EHR that was rich in analytics. I did rapid cycle clinical redesign through the EHR to get to better outcomes.
What I took from that experience was the potential power of an EHR, not only to redesign care through standardization, but also the ability to extract data and use it meaningfully. UVM Medical Center liked the fact that my approach to the CMIO role wouldn’t be from an IS perspective; it would be more the practical application of current technology and the furtherance of improved patient care and improved outcomes.
And that’s been the perspective I’ve had, both as a CMIO and now as a CIO — that ultimately, we’re not quite there yet. We do need a single EHR to do things like reduce CHF readmissions. We certainly can do it in the current setting, and we have. We’ve seen a lot of wonderful quality work done across the health network. But I still think that to reduce variations in care across a large system — especially from a geographical perspective — you need to be able to drive a standard order set across the organization. At the end of the day, you need a single EHR to do that effectively and efficiently, unless you have a staff of 1,500 people — and no one does. I still think we’ve got a lot to do to lay the foundation, but I have no doubt that once the foundation is there, we can continue to achieve a lot of the gains that we’ve already seen, and even achieve greater gains on clinical outcomes.
That’s been my perspective. And it’s not just a clinical perspective, because my career up until now has been focused primarily on patient safety and quality. Not only do I have clinical perspective, but I have a systems perspective. I understand those concepts. I’ve lived them. I’ve applied them. I’ve had success with them and failed with them, and I believe it lends itself to having a unique perspective.
Gamble: Right. On the flipside, are there people you rely on for the areas in which you might not be as strong because of your background?
Buckley: Absolutely. One of the things I quickly learned, particularly in the safety world, is that no one can succeed in all the domains in which they have control over. You always need expertise. I needed expertise in patient safety when I was diving in on quality and statistical analysis. And I needed help on the EHR when we did the implementation. I needed it when we renovated structures or built buildings because I was involved in big construction projects. I’ve never had a problem finding an expert who can inform our view.
I’ve spoken to people who say, ‘our CIO needs to be a chief information security officer and a CTO all rolled into one,’ and my response is, five-billion dollar companies have CISOs or chief security officers, because you can’t be an expert in all things. And so yes, I absolutely rely on expertise. Part of what I’ve done in this role is cultivate and find the best, smartest possible people I can to support and augment those areas in which I might be conversant or fluent, but I shouldn’t be the one making all the decisions.
That being said, I’ve found that a tremendous amount of my systems-based and quality thinking and background does carry me forward. You need system simplicity, you need scalability, and you need flexibility. With the things our CTO makes decisions on from an architecture perspective, I can speak to what the end state needs to be. I can speak to what our goal needs to be. I can speak to supportability and scalability. And so while you might not want me doing anything other than looking around in your data center, I understand what they do there. I value what they do, and I think finding the expertise to manage that side of the business is critical. If I was on the technical side, I’d need help understanding the clinical operation. And if I was on the operational side, I’d need help with the clinical and technical.
I think we’ve reached the point where you need to find expertise regardless of what your foundation is in, because it’s very unlikely someone’s going to have a foundation that spans all the realms you need to understand in the IS space. And I say that because in the 21st century, there’s literally nothing we don’t touch in the delivery of care. If we have a network outage, we can’t send stat orders from the ED. But as a physician, I understand the stat order piece in a way that maybe other CIOs don’t.
It’s very hard to be all things to all people, regardless of what realm or span of control you might have. And so finding expertise and leveraging it for all its worth has to be a critical core competency for any leader running a very large complex organization. I have no problem pulling in my CISO. In fact, I often put her front and center in front of our board. And I’m thrilled I found a CTO that’s smarter than me. I think that’s a part of the success — being willing and able to round out your areas of expertise with strong people.
That’s my perspective on that.