Most CIOs can identify what they believe to be their defining moment; for Dan Nash, that moment came before he was actually named CIO. Rob Curry, President and CEO of Citrus Valley Health Partners, had called him in for a one-on-one meeting to ask for feedback on whether the organization should move forward with its current EHR platform – Meditech Magic, which had been in place since 1987 – or go in another direction. Nash, who was corporate director of EHR optimization at the time, saw it as an opportunity to make a case for starting fresh, telling Curry, “I’m a change agent. I want to affect change and make a positive impact.”
Fortunately, the CEO and board were on the same page, and Nash was eventually named CIO and tasked with leading the selection process for a new EHR system. But the road hasn’t been without its share of bumps, according to Nash, who recently spoke with healthsystemCIO.com about what it has taken to help set the stage for a new EHR system at Citrus Valley, the importance of setting (and managing) realistic expectations, and the mantra he always tells his team. He also discusses CVHP’s dramatic financial turnaround, and breaks down how they eventually selected Meditech 6.1.6.
- About Citrus Valley
- CVHP’s turnaround: “We’re not just stable; we’re investing in our future.”
- Building a business case – “When we ask for funding, it’s not just the CIO asking.”
- IS as a tool
- Changing the culture without disrupting it
- Project management basics: “Every project should have a start and an end.”
- The power of root cause analyses
Initially, it was about getting the organization to a state of financial stability; now it’s become, how do we make it better? What’s the best thing we can do for the areas we serve?
My goal is to help my team understand that we are all caregivers, because if we don’t do our job well, then those that are directly touching the patients can’t do their job well.
‘This is a family. People come here and stay here. How can I understand the culture and do my best to make improvements where necessary?’
When people have been at organizations for a long time and have grown through the ranks, they don’t necessarily see other ways of doing things. There’s a lot of history and the mentality of ‘we tried that 15 years ago and it failed, so we’re not going to do it again.’
I needed to help my boss understand why project management is so important. It’s about leading the team through a process — how do you scope it, how do you budget for it, and how do you resource it. A lot of education had to happen upfront.
Gamble: Can you provide a brief overview of Citrus Valley Health Partners — what you have in terms of hospitals and some of the ambulatory offerings?
Nash: Sure. Citrus Valley is made up of three acute care hospitals totaling about 634 beds, and we also have a Hospice and Home Health program. We have been growing significantly in the last few years, acquiring a variety of ambulatory services, including a surgery center and an imaging center, along with physician practices.
We are located in the East San Gabriel Valley, which is about 35 miles east of Los Angeles, and we serve a population of over a million lives. Citrus Valley itself has around 40 percent of market share in this area, so we’re one of the bigger players in what is a fairly competitive market.
Gamble: How would you characterize the patient population?
Nash: Our organization primarily serves the underserved as our patient population is about 85 percent government funded through Medicare/Medicaid, and we expect to see a 20 percent increase in our senior population within the next five years.
Gamble: You mentioned growing some ambulatory practices out there — is that focused on a particular area or demographic?
Nash: We’re trying to grow the entire umbrella as we look at population health and risk-sharing. The organization has gone through a transformation during the last nine years under our President and CEO, Rob Curry. About eight years ago, we were close to having to close the doors — we were doing poor financially and we weren’t well-managed, but we have had a tremendous turnaround.
Our EVP/CFO, Roger Sharma, was named as one of Becker’s Top 150 CFO’s for two consecutive years; he has done a fantastic job in terms of trimming costs and bringing the hospitals back in line to the point where the organization has had its seventh upgrade from Standard & Poor, which is phenomenal considering where we were. Because of the investment that’s been made, we’ve been able to take what we’re earning and reinvest it to keep growing. Initially, it was about getting the organization to a state of financial stability; now it’s become, how do we make it better? What’s the best thing we can do for the areas we serve? It’s a good team here that’s made some great decisions and brought us to the point where we’re not just stable, we’re investing in our future.
Gamble: Now that the organization is in a better place financially, I’m sure there’s even more motivation to demonstrate how every project will benefit the bottom line.
Nash: Absolutely. When I first discussed the idea to my CFO about switching our EHR system, I ran into a lot of scrutiny before we were able to approach the board in terms of the business case to support the decision, and that’s a good thing. I’ve been here three years now — two as CIO, and one as director of the EMR (which is really a project manager role), and in that time I’ve learned to do the work upfront so that when we approach the board for funding, it wasn’t just me, the CIO, asking, it was the entire team bringing the recommendation forward. We brought representation from operational areas and had them speak with the board, tell their story, and we got very positive feedback, because they were hearing from caregivers as to why they needed something different.
Gamble: That seems like a wise approach having it come not just from IS, but by all of those who are going to use the system.
Nash: The EHR is a tool; IS supports that tool. But the whole reason we’re here is to care for our patients. My goal is to help my team understand that we are all caregivers, because if we don’t do our job well, then those that are directly touching the patients can’t do their job well, and that means a lot. And, how we have communicated this EHR change is that it’s not at IS project—it’s an ‘everyone’ project.
One example is when we recently put a telemedicine device in one of our ERs as part of a stroke initiative. The same day that the desktop team installed it, it was used for a patient to communicate with a physician at another hospital. The physician was able to order the medication that was needed and deliver it before the patient was transported, which helped minimize the damage from the stroke. And that’s a tribute to the team. Showing the team how their effort affects care helps to show how these tools can make a difference. We didn’t just put a technology in place; we changed someone’s life.
Gamble: I’m sure stories like that can have a big impact.
Nash: They do. When I arrived here, I was a bit of an outsider at a place where tenures were really long. The VP of technology and the VP of applications had each been here for 40 years, so that paints a picture of what it was like. My original engagement was to the EHR platform, which was Meditech Magic — how it was being used, whether or not we should do an upgrade to it or optimize it, or if we should replace it. I remember in one of the first sessions, I sat with the imaging team and asked everyone what they did and how long they’d been with the organization. There wasn’t one imaging director with less than 40 years of service. And I thought, ‘this is a family. People come here and stay here. How can I understand the culture and do my best to make improvements where necessary?’
Gamble: Can you talk a little bit about what your experience was like assessing the EHR? How did you approach it?
Nash: A lot of it is understanding the current state. On my first day, I made a list of what improvements needed to be made, and what was missing — and there were a lot. When people have been at organizations for a long time and have grown through the ranks, they don’t necessarily see other ways of doing things. There’s a lot of history and the mentality of ‘we tried that 15 years ago and it failed, so we’re not going to do it again.’ It was really ingrained in the organization, so it was a very tough culture to change. I had to make a case for everything.
To me, it was, ‘how do I approach this without disrupting everything?’ And remember, when I came here, I was a director that reported to the CIO/CMO.
Gamble: That’s a tough spot to be in.
Nash: It was. My predecessor was a physician who had been CMO, but then was asked to take on the CIO role when his predecessor left. He’s a very smart person, but doing both of those jobs is just too much for anyone. And so he hired me — I’ve spend my entire career in health IT, and I was able to bring that experience to the table.
Gamble: Right. So when you faced this EHR assessment, I’m sure you had to really build a case based on what the users told you, and not just pitching them on what you think is needed.
Nash: Exactly. When I first came here, the organization had just implemented Kronos a year and a half earlier, and there was a lot of negativity surrounding the implementation of that system. They ended up spending a lot of resources to bring in experts to get it done right. What they didn’t realize is that as part of the initial deal, leadership tried to cut costs, not realizing they were cutting the support that’s vital with an install. If you try to cut implementation costs by going with a team that’s understaffed or inexperienced, it’s not going to work.
And so I needed to help my boss understand why project management is so important. It’s about leading the team through a process — how do you scope it, how do you budget for it, and how do you resource it. A lot of education had to happen upfront. It’s also about prioritization.
Citrus Valley didn’t have an IT governance structure; basically the VP of applications made the decisions and recommendations. Operational folks weren’t being brought to the table. There were silos everywhere, including in IS to the point where we had our technology team, then our informatics team, and also our applications analyst team, and operations. And even within those groups, people didn’t really speak to each other.
I knew this going in, and I saw it as an opportunity to make things better. One of the things I’ve learned over the years is that there’s a reason behind everything we do. For example, documentation — we’re not doing it to create extra work. I’m always telling my technical team we have to make the time to document. We live in California. If we get a 7.5 earthquake, how are we going to restore that data center if you don’t know what’s even in there? Providing them with the reasoning behind decisions was key to getting them on board. My initial focus was with project management. I was talking to someone on the team who was doing an install that never ended. I said, ‘if you don’t have a defined scope, the project isn’t going to end. Every time the director asks for something, she would add it to the project deliverables. How are you going to celebrate your success if you never know when it’s finished?’ She told me that she kept getting requests for changes, and I said, ‘okay, open it up as a new phase or a new project.’
It’s teaching people that a project should have a start and an end. Let’s celebrate our success, but let’s also look at what we learned, what went well and what didn’t, and let’s document it. Ultimately, you want to be able to refer back to lessons learned from previous projects so the same mistakes aren’t made again.
When I explained the concept of root cause analyses, it helped people understand that it wasn’t just another step thrown in to make extra work, but that there’s a reasoning behind everything.
Gamble: And that, of course, requires a cultural change.
Nash: It does, and it’s a long road. It’s taken me two years to get the team ready, and then another year of getting the board ready to approve it, and then ultimately get on the path to making it happen.
But we’re in a good place now because of all the steps we put in place, and that comes from my experience in PMO — understanding the governance structure in terms of decision-making, making strategic decisions, educating the team, scoping projects, running a successful project, and celebrating the successes. It’s also about the team.
When I came here there was an analyst who had been with Citrus Valley for 20 years, and in that time, her job description had never changed. This particular application analyst was very good — and in fact, she was the only analyst over our entire rev cycle, but she had never been recognized for the considerable knowledge base she had acquired over the years. And there wasn’t a true opportunity for growth — no career ladder. As leaders, it’s our job to make sure we’re developing our staff.