When it comes to major IT projects, two of the most important pillars of success include putting the right team into place and being able to guide a project through a rough patch. Allana Cummings, CIO at Northeast Georgia Health System, has addressed these key issues by embedding clinicians in the IT department and applying a different approach to right projects that seem to be veering off course. In this interview, Cummings talks about the value of a collaborative approach to problem-solving that includes the vendor, the importance of effective communication, having all the right information, and knowing when to take a time-out. She also discusses the application environment at Northeast Georgia, best practices in fostering CPOE adoption, and her organization’s iPhone and iPad empowerment strategy.
- About NGHS
- McKesson Horizon 10.1 inpatient, GE Healthcare (mother/baby, NICU, L&D)
- Allscripts for ambulatory
- McKesson/GE integration
- Single-sign on for improved workflow (Imprivata)
- Upgrading to 10.3
- The importance of “Elbow support”
- Going live with CPOE, looking towards e-documentation
- ICD-10 decision points (CAC, NLP)
- Maintaining the narrative while optimizing documentation/coding
- Partnering with the docs
We’ve taken a staggered approach in the implementation by providing what we call elbow support where staff are literally at the elbow of the physicians during those early days of go-live to help make sure that we’re giving the tools and the tips and the knowledge for them to become as efficient as possible in their entry.
There are some components of documentation where if you create a template and can pull forward information that’s already stored in your EMR and allow a quick and easy workflow for clinicians to be able to document in that structured manner, there is still value in those templates.
As an organization, we’re looking at it from a leadership perspective. How do we connect with the ‘why’? It’s so important. Too many times, people will define the outcome or solution that they need and we run off and deliver on that, and it falls short. And the reality is we probably never investigated the ‘why’ in what we were trying to accomplish early
Your chief nursing officer is a very key leader to help ensure that there is that connectivity of the ‘why’ and the needs of the clinical staff and making sure that there is an understanding that technology cannot be delivered in a vacuum by IT. It truly has to be a partnership where it really is operationally or clinically-led.
There are days where it never seems to be enough. Because just about at every point in our day, whether it’s troubleshooting something that’s requiring a break-fix solution, or trying to advance a new technology that’s being implemented, or going back and trying to optimize what you have in place, there is just that need for clinical expertise at every step of the process.
Guerra: Good morning, Allana. Thanks for joining me to talk about your work at Northeast Georgia Health System.
Cummings: Good morning.
Guerra: All right. If you would, tell us a little bit about the health system. I see you have a number of elements here so a lot of things going on under that umbrella, but why don’t you give the readers and the listeners a little bit of an overview.
Cummings: Sure. Northeast Georgia Health System has a medical center that is 570 beds. We also have a physicians’ practice, a multispecialty practice of just over 100 physicians, and we have a skilled nursing facility, a behavioral health facility, and a number of rehab facilities as well. So we’re a fairly complex system, and we’re growing. We are actually adding a 100-bed hospital in the Braselton community here in Georgia, so we’ll become a multi-hospital facility soon.
Guerra: Wow. That’s a lot going on.
Cummings: It is.
Guerra: You have 100 physicians in the owned multispecialty practice, and approximately how many referring in from the community?
Cummings: We have a referral base of probably 700 physicians.
Guerra: Okay, first let’s talk about the application environment, and then we’ll go into some of the other issues. Tell me what you have for inpatient on the acute side and what you have in the owned practice, and then some of what’s going on with the community physicians, if you’re doing anything with Stark—that type of thing.
Cummings: Sure. In the acute setting, we have McKesson as our core inpatient EMR. We also have GE involved in our mother and baby area with a tool that’s used for our NICU and labor and delivery as well. So there is some complexity in having two EMRs to be integrated on the acute side, and then in the ambulatory environment, we have the Allscripts product.
Guerra: That’s in the owned practice?
Cummings: That is, yes.
Guerra: All right, let’s talk about that integration between GE and McKesson. Do you have much going on there or not yet?
Cummings: We do. We have a strategy of utilizing a document imaging system to create that snapshot of the legal medical records. So in that environment, there is a combining of both of those elements, and then we also have interfaces where information crosses between the two systems. Obviously, not integration to the degree of a single system, but all of the core components that you would expect are fed between the systems. Another toolset that we use to help with that integration from more of the usability standpoint, the end-user workflow, is the use of single sign-on technology.
Guerra: Who do you use for that?
Guerra: So the thinking there is that before the mother is pregnant, if she is in your inpatient facility, when she does wind up in mother-baby you want that data, and then down the road if she should wind up in the inpatient facility, you want to know what happened with her pregnancy, right?
Guerra: We want all that data flowing back and forth—that’s important.
Cummings: That’s correct. And again, we have the capability to exchange the information that’s particularly critical—to not create duplication of data that’s very important to make sure that it’s really a single source of truth, even though it may be shared between systems. The other strategy is that from a legal medical record standpoint, you really have that comprehensive view of all of the care.
Guerra: What version of McKesson Horizon are you on?
Cummings: We’re on Horizon 10.1, and have just started our 10.3 upgrade process.
Guerra: What’s that been like? What is that going to entail?
Cummings: It has just started in terms of 10.3. We were actively and are actually still actively in the deployment of our computerized provider order entry. We have gone live in our Laurelwood facility, we have been able to implement in our ICU very successfully, and we are in the midst of rolling out to all of our hospitalists. So we will be house-wide with the hospitalist implementation, and then we’ll have some of the specialty physician groups. We’ve taken a staggered approach in the implementation by providing what we call elbow support where staff are literally at the elbow of the physicians during those early days of go-live to help make sure that we’re giving the tools and the tips and the knowledge for them to become as efficient as possible in their entry. And we’re seeing that well-served. We’re seeing high degrees of user adoption out of the gate, which I think is very important if we’re going to really help impact patient safety by being able to get physicians at the computer so that they see things such as the clinical decision support alert and have access to the evidenced-based order sets. Those are all very important to help with our quality initiatives and get that high user adoption that we think is paramount to those initiatives.
Guerra: You mentioned CPOE. Are you doing electronic documentation at the same time, or is that going to be down the road?
Guerra: I’ve spoken to some CIOs who are looking at ICD-10 and they’re looking at maybe using some computer-assisted coding natural language processing technologies to extract information for coding purposes. I had one CIO—and I think it was a McKesson customer too—tell me, ‘We’re looking at the templated screens. I’m looking at these other technologies, and if the natural language is good enough, we might not need the templates. But if it’s not, we will need the templates.’ Does that make any sense to you—that kind of decision point or looking at it that way?
Cummings: I can certainly understand their point of view. I guess we’re in a little bit of an interesting situation in that we have already been utilizing computer-assisted coding. And on top of that, we’ve actually been using natural language processing for some time. We’ve had a really significant initiative over the last couple of years around the quality of our documentation to support not only accuracy in coding, but also just the clinical richness of data so that we’re able to really help impact our quality and safety initiative.
So we have been working with J.A. Thomas on the natural language processing components. Our coders are actually presented with a list of terms that are extracted from the transcribed documents that suggest that these might be viable key terms to search for when assigning appropriate codes. We’re actually looking at the potential of doing some piloting with J.A. Thomas and McKesson to perhaps use the same extraction of key terms to possibly even populate the problem list as a way of helping physicians with that data entry component. And then on the computer-assisted coding pieces, we have been utilizing 3M’s product. That is an initiative that went live this year and has been going very well.
I think from our perspective, we’re really thinking that they’re all complementary strategies. No one strategy alone will exclusively meet our needs. There are some components of documentation where if you create a template and can pull forward information that’s already stored in your EMR and allow a quick and easy workflow for clinicians to be able to document in that structured manner, there is still value in those templates. Do the templates need to be exclusive? I think that’s where folks run into challenges in trying to make everything template-driven. There are certain elements that are better dictated or spoken to create the clarity that’s needed, and we think that having a flexible strategy is going to be very satisfying to the physicians overall. And we’ve got those more important elements already under way and we know where we’ve had success and we know where we can add the templating to help further the documentation quality.
Guerra: So the main issue is that the narrative is still important as an element of the medical record, so how do we not overly burden physicians with everything having to be checkboxes and templates? We do need that to be able to get the data on the backend for CMS and these kinds of programs and quality improvement programs, but how do we extract the gold that lies in the narrative to further document what’s happening with the patient, right? That’s where the art comes in, pulling that data out of the narrative?
Cummings: It does. I think physicians will tell you it’s just as important that they collect data as it is that they relay the story of what’s going on with that patient, and it’s hard to tell a story in a template. So I think offering them the tools that accomplish those goals—their need for data to be able to be extracted and do analysis looking at treating their patients over the continuum of care, and having data that can be combined with the inpatient EMR data, is very important, but it’s lacking in that ability to tell the story. So combining the two strategies, we think, is going to be the best approach.
Guerra: I would imagine it’s important for you, as the CIO, to let the physicians know that you are doing everything possible, using every technology that you can, to make their lives easier. But when you ask them to do something that they maybe still don’t want to do, you have to say, ‘This is the way it has got to be done. We’ve done everything else to help you, so you have to help us a little.’ Is that kind of a dynamic that has to happen with the physicians?
Cummings: I think it does, but it really needs to be in partnership. You can’t go through all of the investigation—the looking for solution sets, and then come up with a conclusion and only bring in the physicians at the end of that process. I think they have to be brought along with you, so we try to have a process of really having a core group of physicians who have indicated, ‘We really understand that technology is going to be an important part of our daily lives and we want to help be a part of shaping it.’
We have a physician advisory council of 12 physicians. One of those individuals is actually a mid-level provider, and they come together and work with us on a very regular basis doing what I call the ‘deep dives’ into researching what their specific needs are, and helping us understand how to walk in their shoes so that when we go out and find a tool, we haven’t just found something that looks cool from a technology perspective—we’ve really found something that’s going to deliver based on their specific needs.
As an organization, we’re looking at it from a leadership perspective. How do we connect with the ‘why’? It’s so important. Too many times, people will define the outcome or solution that they need and we run off and deliver on that, and it falls short. And the reality is we probably never investigated the ‘why’ in what we were trying to accomplish early enough to make sure that we really had a meeting of the minds.
Guerra: We always talk about how important it is to involve physicians and physician champions and advisory boards and councils and these types of things. What is the CIO’s role in recruiting physicians for these types of tasks and finding physicians? I don’t know if you ever want to say no to someone who volunteers, but you may not have all the people you need just from those who volunteer. What are your thoughts around selecting the right physicians that have some degree of influence or the respect from their colleagues so that what you ultimately decide upon leveraging that council has some weight?
Cummings: We’ve been very blessed here in that we have leadership from an administrative standpoint and a medical staff that is highly involved in wanting to partner with IT and what we’re delivering. So in many instances, it’s the medical staff themselves suggesting who the right representatives are. People like our chief of staff actually being able to share feedback and say, ‘These are key physician leaders who I know can help make a difference in how they’re impacting their peers. We’d like to support you and make sure that you know these individuals are available and willing to participate.’
The other thing is just a very transparent and open relationship with the medical staff as a whole way. In terms of ways that I think we’re being successful in accomplishing that, we have a chief medical informatics officer, Dr. James Bailey, who is a highly respected physician leader within the organization. Just his credibility alone in not only helping lead IT change but change within the organization has been very critical to that success. We have actually seen Dr. Bailey’s role evolve with our use of business intelligence tools, and we’re seeing ways in which there really can be a blend between what IT is teeing up and delivering to the organization with his expertise and quality. He is now in a combined CMIO/CQO role, being our Chief Quality Officer as well. What’s really nice about that is it’s integrating what IT does into the actual strategy. It’s no longer IT separate and apart. He is really being able to capitalize on the data, our direction from a data services standpoint, and being able to translate that into outcomes and wins for the organization and our patients as it relates to quality improvements.
Guerra: For those who don’t have a CMIO, who would you think would be their key point of contact? Would it be the CMO? Who would be the key person they would need to partner with?
Cummings: That’s another key physician leadership role in our organization where our CMO, Dr. Sam Johnson, is very tied to helping drive our quality initiatives and our technology initiatives. He has been a significant champion for our various IT projects, and I think even in the situations of having a CMIO, there still needs to be a close relationship with the CMO as well. And that transcends over into the nursing side also, so your chief nursing officer is a very key leader to help ensure that there is that connectivity of the ‘why’ and the needs of the clinical staff and making sure that there is an understanding that technology cannot be delivered in a vacuum by IT. It truly has to be a partnership where it really is operationally or clinically-led.
Guerra: I always interview CIOs who are doing interesting things, otherwise they wouldn’t come to my attention. I wonder if this is one of the points that CIOs are having trouble—where they are getting pressure from the top to get these systems in, but they just don’t have the key people on the medical side that are supportive or are really moving forward with this. Do you think that could be one of the problems that people have out there when they’re having trouble?
Cummings: I’m sure that it is. And even when you have representation and really have a connectivity to your medical staff, there are days where it never seems to be enough. Because just about at every point in our day, whether it’s troubleshooting something that’s requiring a break-fix solution, or trying to advance a new technology that’s being implemented, or going back and trying to optimize what you have in place, there is just that need for clinical expertise at every step of the process. Those individuals often are busy taking care of patients and have other priorities, and so anything that you can do to create a situation where people see value in their participation—that’s the one thing that I would share with my colleagues. There is just such an importance around making sure that you demonstrate that value of the time spent working with your group in IT. If you do that, you’ll be surprised at how many people are willing to help and participate.