With nearly two dozen years of CIO experience under her belt, Michele Zeigler knows full well that when it comes to physicians, no two are alike. The needs and preferences of a specialist can differ drastically from those of a primary care physician, and affiliated physicians and employed doctors often present with a completely different set of concerns. So how does Zeigler handle this delicate situation? By steering clear of the cookie cutter approach when deploying new systems, and by getting physicians involved in the selection process. In this interview, she talks about the importance of being flexible, the challenges of dealing with many interfaces at once, what she looks for in a vendor, and what her organization is doing around wireless device management.
- The ambulatory integration challenge: “You can have three people on NextGen but they can be on different versions”
- “You can’t just slap in new code”
- The main challenge: “Getting all the clinical data together in a similar format”
- Making the physicians understand: “It’s not plug and play”
- The interface maintenance nightmare: “You’ve got a moving environment”
- Reading the healthcare IT tea leaves
- Requirement overload: “When you add them all together, it’s just too much”
That’s something that we’ve been trying to strategize—how, from a resource perspective, we’re going to maintain that. Because it’s one thing to do the initial feed, but you have to think about how you’re going to keep that going. And it’s an awareness that you can’t just slap in a new code. You have to test it.
I think they have the same challenges—they just don’t have it times five or times six. I know that, for example, when we made the decision for our employed practices not to go with the Meditech LSS solution, there were a whole lot of organizational strategies as that broke.
You would think something as simple as today’s date would be similarly captured and collected in all tools. But I can tell you that amongst our three hemodynamic vendors, it is captured differently. And so we have to go through a process to translate that field into a common so that we can share that and interface that with our electronic documentation tools.
So you have a moving environment that now you’re going to have to commit a lot of resources to. And while it may look like, ‘This is easier on the front end and we can get physicians to use it,’ there’s a whole lot of other commitment that has to be made from an organizational resource perspective.
I think it would have been a whole lot easier if we had started out with standards first. We might not have gotten a lot of data sharing early in the process, but I think it could have been easier.
Guerra: You mentioned a few ambulatory EMRs that are in your environment in one way or another. You mentioned Sage, NextGen, Medent, and LSS. Among those 150 independents, are there any other ambulatory EHRs that are have a significant presence that you’re going to have to deal with; for example, Allscripts, or any other EHRs in clusters?
Zeigler: Actually, I have been keeping a list of physician offices that haven’t done anything yet; haven’t even selected an EHR. So at this point, I’m not sure if we won’t have somebody else in the mix. You can have three people that have NextGen, but they can be on different versions. So you get that kind of cluster as well, so that if you’re doing an extract, you may have to have an extract for version two, version three, and version four. And sometimes datasets, layouts, and things like that change. So I think that’s going to be another struggle for us. Because even if we get a swell of people that are using NextGen or using Sage, they may not all be on the same versions.
So that’s something that we’ve been trying to strategize—how, from a resource perspective, we’re going to maintain that. Because it’s one thing to do the initial feed, but you have to think about how you’re going to keep that going. And it’s an awareness for these offices too that you can’t just slap in a new code. You have to test it. At one practice we found that they didn’t have a test system. What they were doing was loading new code in their live system and then creating fake accounts, and unfortunately, that’s how their vendor guided them. And when I sat down and talked to them, I said, ‘You really have to be careful. This is your legal medical record. In the paper world, would you create false entries?’ And then there was just an awareness that they have to treat this system differently.
I think it’s unfortunate that sometimes vendors don’t lead these small practices down the right path initially. But really, to have an EHR and to go paperless, which is the goal of many practices, you really need to treat that live production environment like your legal medical record, and you have to have disaster recovery and downtime plan. And that’s where we come in and help some of those folks; even if they’re not using our tools, we can go in and help them with some of that type of planning and infrastructure. And that’s helpful for them.
Guerra: You can almost break it down to your environment which is a typical environment with a number of vendors and the ambulatory solutions, all these types of things, and then you have the shops that have thrown out everything and gone with one vendor for the whole health system. Do you look at those shops and think they have it easy or better, because those CIOs over there have one database? Maybe they’ve got a few ancillaries on the side, but essentially they’re functioning off one system.
Zeigler: I think it’s easier. I think they have the same challenges—they just don’t have it times five or times six. I know that, for example, when we made the decision for our employed practices not to go with the Meditech LSS solution, there were a whole lot of organizational strategies as that broke. For example our EMPI strategy—it broke that. Our patient portal strategy—it broke that. Our clinical data repository strategy—it broke that. So we had to lay out the priorities and select tools in the MPI. We’re almost done selecting our EMPI vendor.
For our patient portal, we’re putting together the strategy. The challenge won’t necessarily be working through the process and the functionality, although that will be a challenge for us. The bigger challenge for us, because we have a diverse set of clinical tools, will be getting all that data together in a similar format. And I know that we’re gravitating to standards with Meaningful Use, but quite frankly, we just don’t have enough of them now really to be helpful.
Guerra: Right. When the selection was taking place for ambulatory for the owned practice, were you in the position of advocating for LSS, or were you merely laying it out on the table and saying, ‘Okay, but here are the consequences of making this decision.’
Zeigler: I really wanted them to take ownership and select a tool. I was trying to educate them about the complexities of going in a different direction and still wanting to maintain the goals of an integrated platform. Because it’s not integrated, it’s interfaced; it’s points of failure. I described for the group of folks that were doing the selection that you would think something as simple as today’s date would be similarly captured and collected in all tools. But I can tell you that amongst our three hemodynamic vendors, it is all captured differently. And so we have to go through a process to translate that field into a common so that we can share that and interface that with our electronic documentation tools. And I said, ‘that’s just the date. I’m not talking about medications. I’m not talking about allergies.’
And so we’re going to have to go through a process where we very carefully build these tools. And where there aren’t standards, we’re going to have to develop that, and that takes discipline. That may be a reason why we can’t do certain things within the tool. So I don’t mean to be a naysayer, I just wanted to point out the realities of doing this. And unfortunately, I think some of that education and lessons learned from when we’ve tried to do this with other tools—as positive as I tried to make it—was probably interpreted a little negatively, or it may have seemed like I was in favor of our current tools. What I told people is that at the end of the day, you have to use the tools; you have to select what works best for you. Just understand that these are still the goals and vision, and that it may not be easy. It may take a lot of time to get this integration.
Guerra: Do you find it that if you’re speaking to physicians you have to be careful about how you articulate your point of view? Because they may say, ‘Just make it work. I like this application. This is the one we want. You’re telling me about interface—just make it work.’ And so it’s not resonating; they’re not getting it.
Zeigler: And then they look at IS as a barrier, when we’re trying to make you aware that it isn’t that easy; it’s not plug and play. Here’s a good salient example. One of the goals is that physicians want to place their orders for labs in their office, in their ambulatory EHR, have it seamlessly come across to the hospital system, have the orders be placed. The patient shows up, they get their test results back automatically. If after a period of time they haven’t got whatever they ordered, they get a list so that they can do follow-up. Well that sounds great, but the current ambulatory EHR vendor has never done that before, so that’s a huge risk right there. And if we don’t build systems in sync—if something is called SMAC 12 panel and on the hospital side it’s Chem-8, we’ve got to go through a translation table, and that takes time. And that has to be maintained and it has to be tested, and in describing some of these things, I got some like eyeball rolling. But you have to understand what it takes; you’re going to have pony up the resources, and somebody’s going to have to take accountability to validate some of these things. And I do have a lot of clinical folks within the IS team, but we have to partner with the clinical folks who are involved in the operations and get some ownership, and it’s a collaboration. So if people aren’t willing to really cough up some of the resources to do this, then it’s not going to get done. Or it’s not going to get done well.
Guerra: Right. You used the word ‘maintained,’ and I think maybe that’s the biggest part they don’t understand. These applications aren’t static; we’re talking about service packs and upgrades. So if we’ve got an interface, once it’s established it may work well, but we’re talking about dozens of applications, dozens of interfaces where both sides are continually moving with upgrades and service packs, and you need retesting and maintenance. Am I describing that correctly?
Zeigler: Right. And a lot of the articles about EMR implementations talk about change management from a process perspective. And I get it, because that’s huge. But what I find we do with the service is, we don’t share and educate people about system change management. I described to the board when we were talking about Meaningful Use because they thought, ‘Oh, we’re Meditech certified. We’re certified for Stage 1.’ Guess what? When Stage 2 comes out, we’re going to have to do another whole upgrade to be compliant with Stage 2 and Stage 3. And every other tool that we have; every other EHR is going to have to do the same thing. And if we don’t do them in some sort of a sequence, we’re going to be touching those interfaces all the time to do this.
So you have a moving environment that now you’re going to have to commit a lot of resources to. And while it may look like, ‘This is easier on the front end and we can get physicians to use it,’ there’s a whole lot of other commitment that has to be made from an organizational resource perspective. If you’ll look at the total equation, sometimes it’s just a challenge.
Guerra: I listen to the HIT policy committee meetings all the time, and they’re starting to understand the idea of downstream effect. So they say, ‘Okay, if we recommend that we want this kind of functionality, the vendors are going to have to write the software and be recertified. And then the users will have to take delivery and implement.’ But it stops there for them. I don’t think they understand that there are far more downstream consequences like we’ve been talking about. The user could take delivery, but then you’ve got dozens of interfaces that also need to be adjusted and maintained.
Zeigler: Right, dozens of things that hang off the tool to make it more effective—forms applications, automatic appointment reminder systems, all those things you have to validate so that you don’t disrupt that process or that functionality. So it’s mind boggling. And all the while you’re trying to implement new applications and lead the organization through change. You’re doing these advanced clinical applications and you still have to do this thing called patient care. And hopefully you’re not disrupting that process. I mean, you’re trying your hardest not to, but hopefully you’ve got good clinical leadership and good management leadership. But sometimes that doesn’t always happen. People don’t understand what it means what it takes operational ownership of a tool.
Guerra: I just had an epiphany. I think that everyone on the policy committee who needs it—and certainly some of them don’t need it because they’re intimately involved., but everybody on the policy committee, everybody at ONC, and everybody at CMS needs to take a boot camp to understand exactly what are the ramifications of these changes they want. And I think we’d see a whole different set and a whole different program coming out.
Zeigler: Well actually, I think it would have been a whole lot easier if we had started out with standards first. We might not have gotten a lot of data sharing early in the process, but I think it could have been easier. Because in my mind, as I think about how this evolves, all of a sudden we’re going to have people using these tools in a meaningful way; we’re going to have more clinical information collected in real-time, more real-time clinical decision support, more patient portals, more ways to engage the patient differently, and then in Stage 3, we’re going to come out with the standards. And we’re going to gravitate to more of the standards, so then you’re going to have to change your data capture, because your datasets may change and your layout may change. And I just think it’s going to be challenging. It’s going to be challenging for the folks rolling it out, and it’s going to be challenging for the folks using the tools, because they’re just going to settle, and then we’re going to reorganize.
Guerra: Yeah, it’s definitely like they did things in a strange order and there’s going to be a lot of rework to fix that down the road.
Zeigler: Right. Because we’re doing some things locally here with information exchange just because it’s good for patient care. But our state isn’t going to be ready for a year to do some things, and I’m just trying to figure out what format they’re using so hopefully we don’t have to create yet another format to do the exchange with them. I mean, if we have to, we have to. You try to get as much economy of scale as you can, but it’s challenging. Even within the CCD, different vendors have different definitions through the CCD, which is the standard. So it’s just going to be challenging.
Guerra: Is one of the main things you’re trying to do to prevent doing work that’s going to have to be undone or redone? You need to move forward on certain things, even Meaningful Use issues where the clarifications are a little fuzzy, so you’re kind of wading through and figuring out all your colleagues are doing, and you can’t wait, but you’re not sure you’re going in the right direction. Do you have a lot of that going on in everything you’re trying to do today, including the HIE piece?
Zeigler: Yes, for some those things that are new, like some of the interchange. And we are sending some of our syndromic information; we do an extract of real-time disease surveillance, and we’ve been doing that for years. So I went to validate that that met our Meaningful Use and they said, ‘Oh, it has to be in one of two HL7 Standards that you’re doing the feed.’
So I checked with the state, and they don’t accept the one. And thankfully we were doing our feed in the one HL7 standard that was accepted. And trying to do immunizations has been a challenge because our state has added more requirements than what the Meaningful Use does. And we so we’ve been lobbying that we understand that it’s great and it’s important and we should gravitate to that, but don’t make that the minimum, because we’ve got all this other stuff that we have to step up to. Some people are just taking as an opportunity to fix everything, and when you add them all together, it’s just too much.