Dennis Sato took over as interim CIO at Hawaii Health Systems Corporation with one goal in mind: to select and implement an enterprise EMR system that meets everyone’s needs. But with a health system that includes 13 hospitals on five islands—each of which has its own board of directors, a task like that is easier said than done. For some, the idea of dealing with five separate entities that each has its own IT strategy may seem like a nightmare, but Sato is determined to make it work, even if it means making unpopular decisions, and finding victories in the smallest places.
Chapter 1
- About HHSC
- Selecting a consultant to help select a system
- Beacon Partners gets the gig
- The second time around for Sato
- Navigating a bevy of boards, the governance challenge
- The application environment — “It’s almost a paper system”
- Finding a system that spans acute, LTC, critical access and ambulatory
- Appreciating the cultural nuances of working in Hawaii
- “How do we get everyone on the same page with a common goal?”
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Bold Statements
The number one challenge we have—because of our disparity and everything that we’re doing in terms of the islands and the many facilities—is trying to come up with a strategy to meet all the health care initiatives; reform, HITECH, meaningful use, and everything that goes with it.
It’s a public benefit corporation and we have five regions of board of directors, so you can imagine the challenges of having that many boards in addition to the corporate board. You need a little negotiating to get everybody on the same page.
Some of the decisions that are made are not the most popular, but we have to have something that we can actually support, and implement, and continue to sustain in order to be a viable organization.
When people come to Hawaii they think, ‘Well, it’s an island, they’re laid back.’ But that’s not necessary true. Each island, and this is the thing that I’ve tried to educate people about, is almost like a separate country.
It’s a tough job, but I have to say that this EMR selection has brought everybody closer. This is the first time in many years that we’re doing something enterprise-wide, and so in that way, we see it as a success.
Guerra: Good morning, Dennis. Thanks so much for being with me today. I’m looking forward to chatting with you about your work at Hawaii Health Systems Corporation.
Sato: Thank you, Anthony. It’s nice to join you today.
Guerra: Alright, let’s start out with an overview. Why don’t you give the readers and listeners an idea of Hawaii Health Systems Corporation; what you’re all about—your facilities, both the acute and ambulatory side, clinics, that type of thing, and we’ll go from there.
Sato: The Hawaii Health Systems Corporation is comprised of 13 hospitals on five Hawaiian Islands, and our facility is made up of acute facilities; for instance the Maui, Hilo and Kona, and many critical access hospitals throughout the islands. On the big island of Hawaii, we have five hospitals located there, three of which are critical access hospitals in rural communities. In Maui, we have two hospitals—the acute Maui Memorial Medical Center, and we also have one in Kula, which is more of a long-term care facility. We also have a critical access facility on Lanai and two hospitals on the Island of Kauai and two long-term care facilities located in Honolulu, the Island of Oahu, and then another critical access that we manage up in the North Shore of Oahu called Kahuku.
And so we are a safety net organization. We’re funded a lot by the State of Hawaii so we take a lot from the general funds. And of course we many of the same challenges of other health care organizations, but the number one challenge we have—because of our disparity and everything that we’re doing in terms of the islands and the many facilities—is trying to come up with a strategy to meet all the health care initiatives; reform, HITECH, meaningful use, and everything that goes with it.
Guerra: It’s all order?
Sato: Well it is, and they brought me in here again. I have over 30 years experience in having to implement EMRs in three states, and so I’ve been here since May of this year to help them first select the consultant to help us, and now to select a system. And so I’m leading as the executive sponsor of all the islands. Actually we’re representatives; we have about 15 people representing all of the different regions, from COO to CFO to nurses to doctors. I actually put in the government structure in order to meet what are the requirements given everything we want to do to improve the quality of care.
So you know they brought me again in after having worked in Oregon, California. I was actually the CIO here from 1997 to 2002 when they first established this corporation. It’s a public benefit corporation and we have five regions of board of directors, so you can imagine the challenges of having that many boards in addition to the corporate board. You need a little negotiating to get everybody on the same page. We have a new CEO, Bruce Anderson, who was previously the Director of Health for the State of Hawaii, the Public Department, but that was long time ago. We now have a leader that just started recently. And so most of the initiatives we face is just like every other health care organization—how can we improve our quality and reduce our cost, but at the same time do it in an efficient way and provide the services to all of our rural communities. That’s what we are, a safety net. We don’t have a lot of money, so we’ve got to be very creative and innovative with what we do in terms of technology and actually meeting the goals and objectives of all the regions. And so that’s where I am. That’s why they brought me in here.
Guerra: Let’s start with when you come back to organization in May. What do you find from an applications point of view? Is there one system at all 13 hospitals or are some of them on paper, some of them have the system, and some of them have different systems. Give me an idea of the application landscape from an EHR point of view that you walked back in to.
Sato: Sure, our legacy system is McKesson. It’s done its job, but it’s 25-year-old system and I basically helped implement that when I was first here and also did the consolidation of the data center. But of course, that’s the old technology, and many things are happening on the vendor’s side that are kind of sunsetting some of the older products. And so coming back here looking at the landscape, we saw that in order to continue to be competitive out here, and also meet the needs of our clinicals, mainly physicians and nurses and the community, with trying to link up to the health exchange—the regional centers and all of that, we needed a more of a robust system in order to actually make things more efficient within our organization. So that’s why the landscape is almost a paper system, with very little in terms of clinical applications. Yes we have PACS systems, we have you know radiology systems, and we have lab systems—more of a best-of-breed at that point. We also some quality systems but still not really integrated, and everything that they asking for meaningful use, we cannot do with the old technology and software applications. So that’s what they brought me in; to do just that. They made the decision here that we would do an enterprise—all of the systems, to move forward and see if we could get a system that will meet everybody’s requirements. And this is a very difficult challenge because what we’re talking about is the acute side of business long term care facilities—and these are strictly long-term care facilities, critical access, and some of the ambulatory needs of some of our clinics. How do you get one system that’s going to do all of that, in addition to getting on the financial side—the revenue side all the way down to general financials.
It’s a big task that we’re trying to do, and so that’s the landscape. And a lot of our dollars we have to get from the State of Hawaii, and as you know, like most states, they have deficits. So we’ve been working with the legislature—and we’re still doing this today—to really help them see how important is this when there’s a million dollar, billion dollar shortfall today. So we’ve been meeting with our legislator to educate them. They need to have an electronic system out there in order do everything we want to do to improve the quality with these medical errors and everything that’s out there for accountable care organizations that we need to be more efficient. So when I came, it was how do I get that all together and a lot of it had to do with setting up a whole governance structure. The governance structure was not in place. When I left I chaired the steering committee, but now we’re reestablishing that, and there are different players out there—different CEOs, different CFOs and the boards. I think the big challenges to satisfy the boards that are driving each of these regions.
Guerra: You have five boards and then a corporate board?
Sato: Yeah and you can imagine what that’s like. The boards feel like they can run everything within their hospitals, and that’s true, but when you look at IT, that’s not a long range plan of how this will affect other parts, since we are still a system. That’s the difficulty, and that’s what I’ve been trying to negotiate through. And some of the decisions that are made are not the most popular, but we have to have something that we can actually support, and implement, and continue to sustain in order to be a viable organization.
Guerra: I mean, obviously your vision is if that a patient winds up in one of your 13 hospitals and then they wind up later in a different one as far away geographically as is possible between two of your hospitals, that their record should be able to come up instantly, and you need to be on the same system in all the hospitals for that to happen, right?
Sato: Well that’s our goal, because we also have to link up with the other acutes in, for example, Honolulu. We have the trauma center, some of the ones that do specially care, and children’s hospitals, and so it’s not only our hospitals, but we do a lot of transporting over to Honolulu for additional care or specialty services so that’s also a part of it too.
In 1999, I actually implemented a whole telemedicine system for all the islands which we still utilize today. But we’re looking at the continuum of care, which is true not only within our hospitals. We don’t always transfer to another island; we try to work within our own region, but there are times when we can’t. For instance, Maui Memorial is really is our heart hospital, so a lot of a patients would probably go there versus trying to go to another Honolulu hospital. So that’s what we’re working on, and it takes a lot of transformation to accomplish this; transformation and a lot of change within the organization. And the real challenge out here in Hawaii, and I’ve worked in other states, is the cultural differences. When people come to Hawaii they think, ‘Well, it’s an island, they’re laid back.’ But that’s not necessary true. Each island, and this is the thing that I’ve tried to educate people about, is almost like a separate country. It’s like the old King Kamehameha days; there’s a long history of that here where physicians want to set their own region. So that’s the tough part, about even the system selection that we’re going through; how do we get everybody on the same page to look at the common goal of improving the care for all our communities.
Guerra: Have you found the right sales pitch to convince them?
Sato: Yeah, I think I have because everyone looks at it differently. The state legislature looks at how much money you are going to get for meaningful use and how you can do that. The message that we’re sending out there is the message of quality and improving rural health care. I think that’s the number one thing that we need to do, and without the adequate systems to do this, we cannot treat our patients right now, because we do not have a completely automated system from ambulatory all the way out to the long term care facility. It’s a lot of manual work; records are lost, and we can’t find charts. All of the benefits of an electronic system would definitely help this organization. So we’re trying to put a spin on it that yes, we are going to reduce our costs. We are going to be more efficient. But you have to look at the community; the patients that do not even have health care in the rural areas. A lot of these rural areas are far from the hospitals and we are the safety net out here. So that’s the message that we’re trying to get across, that for communities of Hawaii, health care should be for everyone.
Guerra: What about getting even more specific than convincing them of the need for an electronic system. So there are five boards in the five regions—how do you go about convincing each of those boards that acts very autonomously, and for cultural reasons, just wants to do what they want to do? It’s almost like the different departments you have in a single hospital. Oftentimes they want the system that works best for that ancillary department, so the CIOs have to convince them by saying, ‘Hey, we want to get an enterprise system so that data can be shared.’ So you also have to make that pitch to each of the five regions that they’ll need to somehow get on the same page and pick one system. Does that make sense?
Sato: That’s exactly true, and that’s the challenge that we’ve been having. So what I’ve been trying to do, along with the chair of our corporate board, is to bring the chairs in from all of these other boards. I’ve made the point to go out to the board meetings and pitch to them and talk about what we are trying to do at the system versus what they’re trying to do as a region. For instance, one of the regions has the two long-term care facilities here in Honolulu. They want to go on their own in terms of just getting a nursing home software, but I am trying to explain the benefits of system and system reporting; everything you have to do to report outcomes, plus the whole support issue.
I’ve been pretty successful up to this point because they already had approval; the board gave the regions approval to go out and buy their own system, and so I went to the board. I’m very familiar with long-term care, so I got them to participate in the process. So far they’re in the process, but if we don’t happen to find the right system for them, they may go in a different direction.
Guerra: To me that sounds a big governance problem. If they can go out and buy something without your signature, that could be really problematic for you.
Sato: Yeah and we’ve looked at the governance. They had a consulting firm that came in here and did a very good job and made recommendations. When I was here from 1997 to 2002, we only had one board that represented everybody, and we made those decisions. We had a CEO that all CEOs reported to; it was more of a centralized model on the governance and we know that was the only way to be successful. The corporate board, because of the fiduciary responsibilities, had to make certain decisions and everybody had input. But you listen to the board, and the challenge is to come up with the strategy for the whole organizations instead of this strategy for the regions only, and we’re still struggling with that. And you’re right, it’s all about governance and that’s the part that we have difficulty with, because these regional boards were established by the legislature. Each community is represented by Senators, and they push for what they think is the best for their regions.
So it’s very complicated, like you said. I mean, most people struggle within the hospital, but we’re struggling within islands; we’re silos. And what I’m trying to do is to get everybody on the same page. For instance I reported at all the corporate board meetings, and we have representative from many of the islands.
So it’s a tough job, but I have to say that this EMR selection has brought everybody closer. This is the first time in many years that we’re doing something enterprise-wide, and so in that way, we see it as a success. Hopefully the outcome will get everybody on the same page, but we know that’s going to be a challenge too.
Guerra: So, every day that you don’t receive an e-mail from a board member that says, ‘Hey, we’ve decided we’re just going to go ahead and buy this system; a salesperson just showed up here and they sounded great. So we went ahead and bought it.’ Every day you don’t get an e-mail like that is a good day.
Sato: Yeah, what I’ve done is I now have the IT governance committee I renewed here, and now any request from the regions—any request that is even a $10,000 purchase—has to go through this committee for approval. We have that under control now. So now they can’t go out there and purchase, because that’s what our policies states; that they have to go through that. Nobody was following that, and so when I came here in May, I said, ‘This is the first thing we have to do. We can’t have people go out there and purchase things,’ and that’s what happened. That’s why Corporate IT gets a bad reputation. We can’t support everything out there.
Guerra: Right, right. They go and buy products that don’t meet the real strategy.
Sato: Yeah, but I think we’re on the right page now, because I attend the CEO meeting, the CFO meetings, the CFO regional meetings, and the board meeting. You have to continue to communicate to all these committees because somehow, not everybody hears the same message.
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