After years of taking on responsibility after responsibility, John Halamka, M.D., CIO, Beth Israel Deaconess Medical Center, found the increasing demands of his many roles meant one would have to go. Considering he’s a doctor fascinated by the challenges of accountable care, it’s not surprising the CIO role of Harvard Medical School wound up on the chopping block. In this interview with healthsystemCIO.com — during which Halamka begins to caution government organizations that the industry is being asked to change too much too fast — he discusses Meaningful Use, ACOs, ICD-10, CIO leadership, and much more.
- Thoughts on the HIT Policy Committee
- Why the HIT Standards Committee is “Camelot”
- Advice for furthering CPOE and electronic documentation
- Hospital/physician practice integration
- Tackling quality measures
- Dealing with the onslaught of Apple devices — “There is no question that doctors are moving to the iPhone and iPad faster than any other platform I have ever seen, so it’s the CIO’s role to enable them to use the device they want.”
- Finding the right vendor for the right job
- Dealing with the HIT workforce shortage
- How to stay innovative
… we have to have simpler quality measures, all based on data capture that’s a side effect of care processes, and make any complexity optional.
There’s no question that doctors are moving to the iPad and the iPhone faster than any other platform I have ever seen. So, it’s the CIO’s role to enable them to use the device they want to bring.
Start looking at raising the wages of your existing key staff, and take some positions that you consider critical to the existence of the operation and instead of setting them at 50% of market wage, set them to 75% of market wage.
Is the future of computing: desktops running Office suites or mobile devices running cloud-based productivity apps that are less functional but highly available and collaborative. So, I would argue that not many people I know are buying that brand new desktop.
Guerra: You’ve written that all regulations have consequences, both in time and dollars. I’ve written before about the makeup of the HIT Policy Committee and some of the more consumer-oriented privacy advocates who really haven’t worked in the trenches. Many of them seem to be creating a wish list based on the desires of their constituencies. What do you think of the makeup of the HIT Policy Committee in terms of churning out workable recommendations?
Halamka: Well, I have great respect for the folks that are on the Policy Committee. I mean, they’re very, very thoughtful people. And what has happened in the past is that the Policy Committee is aspirational. And then the aspirations are tempered by standards and technology reality, by implementation complexity, and by the comments from stakeholders as part of the regulatory process. So, in that respect, I think the process works pretty well because I wouldn’t want the policy committee to just say, “Oh, here are the three things we know we can do.” I would rather have them say, “Here are the 10 things we’d like to do.” The industry then says, “Three we will do and two we will try.” And that’s the right balance — be aspirational and be realistic in the process. It tends to be self-correcting.
Guerra: What can you tell the listeners and the readers about your Standards Committee? I believe you co-chair with Jonathan Perlin, M.D. You always seem to be very upbeat when describing the meetings in your blog. Does that generally reflect your feelings about it?
Halamka: So, in many ways, it’s sort of an odd analogy, but the Standards Committee is Camelot. We have all the right people who are extraordinarily smart and work together with checks and balances as a seamless team. There are people to the left and people to the right. There were people who are big and people who are small, but they have such great respect for each other that we come up with recommendations that are never controversial. They’re always collaborative. It’s probably the most functional group I have ever had the pleasure of co-chairing.
Guerra: Let’s talk about a couple of issues that every CIO is facing, most are Meaningful Use related. We really have CPOE, electronic documentation. As a physician, is there any insight you can give, especially to those working in community hospitals where most of the doctors are independent, as to how they can get physicians to buy into the systems?
Halamka: Well, sure. So, there are only three ways to influence a doctor: pay them more, give them more free time, or public humiliation. And you don’t want to use the third very often. But what you need to say is, “Hey, CPOE will actually reduce malpractice assertions and will save you time as you do order sets. And when you use it for eprescribing, for discharge of medications, you’re going to have fewer callbacks, you’re going to have better care coordination. So, if you do this, you will actually save time and earn more money. And, by the way, we can put in care paths and plans so that when they institute pay for performance requirements, you actually look good. So, your reports won’t be two standard deviations from the mean. In fact, you will be one of those low-cost high-value docs. So, hey, it saves time, earns more money and makes you look good, what’s not to like?”
Guerra: What is the CIO’s responsibility for making a system user friendly? I’m thinking that you could have the same vendor product in two different organizations. In one place, the CIO has spent a lot of time with the medical staff and the CMO helps create those customized order sets and tweaks the system to whatever degree it can be to make it attractive to the physicians. And then in the other one, maybe they didn’t do that. So, is it true that you can have the same system and have a completely different experience?
Halamka: So, many vendor systems are user configurable. And so, let me give you an example of user configuration. There are fine vendors out there in the world for drug dictionaries. Drug dictionaries have many drug/drug interaction settings. One would be what I call FDA black box. If you give nitroglycerin and Viagra together, the patient will die, right? These are serious. You better pay attention to these kinds of interactions.
As well, there are interactions that say, “You know, if you have this medication with grape fruit juice, it might be slightly ineffective.” Or, “Oh, if you had two martinis last night with Tylenol, your liver enzymes could bump.” These are things that are true, but are unlikely to change medical decision making and will create unbelievable alert fatigue. And so, imagine that every time I wrote for a Tylenol, I got an alert that said, “Have you asked the martini history?” You would go insane. So configuring the system to have the right level of interaction with the docs is absolutely key to acceptance.
Guerra: And that takes a lot of interaction with the physician community.
Halamka: It does. And that’s why, you know, I’m an MD/CIO and I recognize that’s a somewhat esoteric combination. But the idea of having either a CMIO as a partner or having a designated physician champion is absolutely key.
We just went live about six months ago in a community hospital, the 21-bed community hospital, with full CPOE. And the way we did it was that a physician champion greatly respected by the medical staff helped with the configuration and design. So IT was really the project manager and the enabler in partnership with physicians.
Guerra: Do you think of electronic documentation as a completely different, much more difficult, step than CPOE?
Halamka: Right. So, electronic documentation can mean many things. Here is the way I would love electronic documentation to work. So, you’ve been in the hospital. You’ve gone to the paper chart. You’ve seen that you have 17 progress notes written by the intern, the resident, the consultant, it’s all indecipherable. What if nurses, doctors, pharmacist, social workers and case managers opened a Wiki page on every patient everyday and the whole team wrote a Wiki one-time, of all of the events of the day. And at the end of the 24-hour period, the attending in-charge would lock that Wiki page. So, it’s one team effort representing everything from all disciplines. Wouldn’t that be great?
So, that’s we’re going to begin experimenting with, that kind of concept, because clinical documentation today is a lot of cutting and pasting, a lot of free text, and it’s pretty challenging to read.
Guerra: I read somewhere that the cutting and pasting can create a dumping in of too much data and not being discrete enough. Does that make sense?
Halamka: Oh, absolutely right. And so, you can imagine the intern says, you know, the patient is allergic to cashews and then the resident and the attending and the consultant all copy that. And it turns out to be totally untrue, or you get the same lab results copied 17 times in the chart. Cutting and pasting can be a real problem with not only quantity but also poor quality of the resulting documentation.
Guerra: Maybe the second main issue, when I’m speaking to CIOs, is that they’re working on integrating the hospital and physician practice worlds. You’ve got your physician organization. You’ve got eClinicalWorks out there. Inside, you’ve got your homegrown application, right?
Guerra: So you’re integrating those, and you’re very pro-cloud. So, what would your advice be to the typical CIO who’s just looking to shore up and connect his or her world with the outside world?
Halamka: Sure. Well, I’ve written about the cloud as a blessing and a curse. And we use a private cloud, recognizing that to support 1,758 physicians, it’s just not possible to put servers in every doctor’s office. But the public cloud at the moment isn’t going to provide you necessarily with the business associate agreement, HIPPA compliance, HITECH compliance you need. So, operating a small data center with the private cloud has worked very, very well for us. And the integration touch points are that eClinicalWorks has the capacity to send and receive data through our health information exchange. So, similarly, our homegrown systems do the same. So, we push data at discharge to and from, from PCP to specialist, specialist to PCP, hospital to PCP. So, that’s one way — push data.
Another way is pull data. So we have modified our internal built systems and eClinicalWorks to enable name, gender, and date of birth queries so that our authorized individuals — although they’re not inside eClinicalWorks — can be in their EHR and do a “magic button,” we call it, a query by pushing a button, and then you get a Web page summarizing all the data from the EHR. And that works pretty well. And then there’s the quality data center I described where we’re aggregating all the data for population health into one location.
So, if you just ask yourself what’s the workflow, what are the requirements for Meaningful Use or for operations? Is it pull? Is it push? Is it aggregation? Working with vendors and building systems that are private cloud and self-hosted, it works pretty well.
Guerra: And you mentioned quality measure there, and that’s certainly another issue that people are grappling with. What are your thoughts around all the different programs the government is coming out with that require quality measures.
Halamka: Right. So, Jim Walker who chairs our clinical quality workgroup for the Standards Committee is working on simplification of the quality measures and standards around the quality measures. Because right now, here’s a problem, doctors do not like to be measured. They don’t like report cards. So, when you have a consensus developed quality measure, it tends to have so many exclusionary criteria that it becomes so complicated to compute a numerator and denominator. It just – it’s impossible. And so for the data capture that’s necessary, the CIO needs to build a database and that’s very, very hard. So, one of Jim’s contentions is all exclusionary criteria should be optional. And so, that means we write a numerator or denominator and there may be 15 different things you could potentially exclude. If they choose to exclude something, fine. It probably won’t make your quality measure different, maybe a 1% variance, but, boy, does it make the quality measure much easier to compute. So, to me, we have to have simpler quality measures, all based on data capture that’s a side effect of care processes, and make any complexity optional.
Guerra: Another issue would be, let’s call it the Apple takeover of healthcare, and you’ve written about this as well. A typical scenario would be a doctor walking into the CIO’s office with their iPad or their iPhone and saying, “I want to see the clinical application and the results on my device.” So, you know, Bill Spooner from Sharp has written about this too — everybody is writing about this and grappling with this. What are your thoughts?
Halamka: So, I have, as of this morning, 1,600 iPhones and 1,000 iPads on the network. All of our applications are Web-based. We have created server-side protection using a Web application firewall from a company called Imperva that allows us to deliver all of our clinical information securely over the Web. And so, in that respect, if you’re bringing an Android device, if you’re bringing in an iPad, we are doing everything we can to ensure that there’s a sufficient level of protection, regardless of the consumer device you may be using. There’s no question that doctors are moving to the iPad and the iPhone faster than any other platform I have ever seen. So, it’s the CIO’s role to enable them to use the device they want to bring.
Guerra: You have mentioned a few different vendors that I haven’t heard of before. What is your strategy when you’ve got an issue for finding that specialty vendor out there who’s going to be able to help you? You’re not running a small shop, so how do you find someone who can handle what you’re bringing to the table?
Halamka: So, I get about 100 vendor calls every day and my assistant’s chief role is fending off vendors calls. I am a voracious reader. And so, as you know based on the times I post my blogs, I have quiet time from 3 to 6 AM. During that time, I’ll say to myself: “New technology is emerging. Here are the requirements. Let’s take a look at the vendor space,” and I will simply use the Web to do a deep dive reading articles and specifications on the Web. And then, based on requirements, I’ll figure out the two to three vendors that seem to be able to meet our needs, and then we will call them and bring them in for demonstrations and sometimes to do pilots. So my vendor selection process is driven by me and not driven by sales guys.
Guerra: So, don’t call us, we’ll call you?
Halamka: That’s it. You got it.
Guerra: Let’s talk about workforce issues. A lot of people are having some difficulties finding the talent they want. I interviewed one CIO who was dubious about the value of HITECH-related workforce education programs. He said, “Well, you know, I really need people that understand and have experience in the clinical environment. I can teach them some technology, but I really need people who have that experience.” How appealing are those people that are coming out of those programs to you? And would you have any suggestions for ONC on tweaking those programs?
Halamka: Hospitals now are grappling with cost-reduction imperatives, so it’s challenging to simply get new talent but, at the same time, you want to retain your existing staff. We have almost what I’ll call a mini .com bubble in that people with depths of experience in healthcare IT are being snapped up at premium wages by private companies because hospitals don’t have stock options that are appealing. So, our strategy? Start looking at raising the wages of your existing key staff, and take some positions that you consider critical to the existence of the operation and instead of setting them at 50% of market wage, set them to 75% of market wage.
I also believe strongly in co-ops. So, I do like bringing in young people and training and developing those young people, because the hard thing right now, given the competitive marketplace, is bringing in that person with three-to-five years of healthcare IT experience at a wage you can afford. So, retain your existent people and hire young people and train them yourself.
Guerra: I’m sure every CIO can name the three to five people on staff that make their lives worth living (laughing).
Halamka: Yes. That’s it. So, I look at what I call my single points of human failure. So, if one of those people got hit by a bus, what is it going to cost in terms of real problems?
Guerra: Right, right. When they get hit by the bus, it almost hurts you as much as them.
Halamka: Yeah, that’s true. (laughing)
Guerra: One of your posts about inspecting piping to look for glycol leaks using ultrasound made me say, “My God, how many things is a CIO is responsible for”?
Halamka: You got it. Think about my role. So, at Harvard Medical School, I have 4,000 servers. I have 2 petabytes of data. I have 14,000 desktops for the hospitals. I have networks of over 450 square miles with 17,000 network connections, two data centers, 146 mission critical applications. So, it’s a tough job.
Guerra: So, a lot on your plate. You’ve also written about innovation. You wrote about different vendors in one of your posts and talked about three or four different large companies and how they’ve miss a step and been overtaken by niche players. And you seem, not overly concerned, but it’s on your mind that you want to make sure it doesn’t happen to your shop. You mentioned taking your key people out to dinner in the near future to talk and just stay on the cutting edge. This is top of mind for you right now, isn’t it?
Halamka: Oh, it is. And so, here’s a question. Is the future of computing: desktops running Office suites or mobile devices running cloud-based productivity apps that are less functional but highly available and collaborative. So, I would argue that not many people I know are buying that brand new desktop. Not many people care about the next version of Office having 100 more cool features. They would much rather say, “You know, I’m a mobile person and I’ve got an iPad, an iPhone, an Android and I want to be able to share documents with five collaborators around the world, do edit tracking. And, you know, I don’t care whether it’s pretty. I just want it to be functional.”
And so we need to be there when the demand changes and not get stuck with, “Oh, sorry, we’re two years away for being able to help you.”