Stephen Stewart is one of many CIOs who believe that Meaningful Use is happening too quickly. In fact, he believes that delaying Stage 2 isn’t just a smart idea; it’s a necessary step to avoid the perfect storm of requirements that would inevitably cause undue stress. In this interview, the CIO of Henry County Health Center — a southwest Iowa-based system that includes a 25-bed critical access hospital, a long-term care facility, and physician offices — talks about the process of attesting to Stage 1, his organization’s EMR journey, and the benefits and drawbacks of being a small facility. He also provides insights on why it’s better to lead than to manage, how to handle pushback from physicians, and what it takes to cultivate an environment that enables the staff to thrive.
- Addressing physician concerns
- Order set creation
- “The lesson was we should have had more of their input before we started”
- Getting physician participation up-front
- Software bugs and the pace of change
- Staff retention — “It’s got to be a very, very high priority because the effort, energy and cost to replace those resources are extremely high”
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Their comment was, ‘We dictate all of that in the H&P. We dictate all of that in the discharge instructions, and now you want us to do it a third time to enter it into the computer and a fourth time to update it at discharge. That seems like a waste of effort.’ And they had a really good point.
We had to rebuild some of the items to get it in a more user-friendly fashion. But that difference drove about an 18 to 20 percent difference in the usage rate on CPOE. So it was well worth the redesign. The lesson there was we should have had more of their input before we started.
The rules for certification weren’t even finalized until approximately June or July of 2010, and from the vendor’s perspective, if you don’t know what the standards of certification are for sure, you’ve got to make sure that your product can comply with those once they become final. They had a lot to do in a very short period of time.
We have our moments and they can be tense and they can be heated at times, and the frustration level can get very high. That’s when I think you just have to take a deep breath and say, ‘Okay, let’s tackle this one issue at a time and move forward.’
Even in a small community, you need to make sure that you are treating those people right. Retention has got to be a very high priority for you, because the effort, energy, and cost to replace those resources are extremely high.
Guerra: I want to go back to talking about working with the physicians. You mentioned the idea of pushback and you said you’re usually able to work through it and work around it. How would you describe the type of issues that you usually see pushback with?
Stewart: The physicians are concerned about their workflow. They really look at this stuff. They want it to be a tool that enhances what they do and improves patient safety. At the end of the day, we all have those objectives and believe and that it will also contribute to reduced cost, but they want it to be a tool. They want it to fit their workflow, or at least be as close to time-neutral in their workflow as possible.
Let me give you a classic example. When we initially were going to implement the problem list, that was probably the thing the physicians pushed back on most—even harder than CPOE. I have a point to make on CPOE too, but let’s stick with the problem list. Their comment was, ‘We dictate all of that in the H&P. We dictate all of that in the discharge instructions, and now you want us to do it a third time to enter it into the computer and a fourth time to update it at discharge. That seems like a waste of effort.’ And they had a really good point. The workflow that we worked out was to get intake involved in nursing to record some of the things and have the physicians do the validation and the status at discharge—which didn’t completely solve the problem of being more work for them, but it drastically reduced the impact that it had on them. And that compromise setting was really a great thing and worked out really well for us.
Another example is in the CPOE implementation. One of the keys about CPOE is to build the order sets and physician preference lists and that sort of stuff, but before you do all that, you’ve got to have the items defined so they can be ordered in a way that the physician can find them and pull them into an order. We did some of that almost in a vacuum without physician input, and they were designed in ways that might make sense to a nurse when they were looking up things for nursing orders, or might make sense to a radiologist when they were looking at procedures—and radiology in particular was designed in a billing perspective—and our physicians came back and said, ‘This isn’t the way we look at it. We look at it differently.’ And from sitting down with them and saying, ‘Help us understand how you really see it, and what you believe this should look like.’ And to be honest with you, we had to rebuild some of the items to get it in a more user-friendly fashion. But that difference drove about an 18 to 20 percent difference in the usage rate on CPOE. So it was well worth the redesign. The lesson there was we should have had more of their input before we started.
Guerra: Was it a matter of just trying to do it the fast and easy way? Because getting them involved is a lot of work, right?
Stewart: It is a lot of work. As I’ve talked with my medical staff, I’ve said, ‘Getting your time is a very difficult thing to do, and what we’re really talking about is to do these things right the first time, I need more of your time upfront.’ Finding that delicate balance is really the biggest challenge that we all face. I will say that there are several members of the medical staff that are really willing to go the extra mile. They’re all great and they all will take time. What we as the implementers of these sorts of things and the project managers need to do is make ourselves available when it’s convenient for the physicians. If that means early in the morning, it means early in the morning. If it means in the evening, it means in the evening. If it means meeting with them on a Sunday afternoon, then meet with them on a Sunday afternoon and get their input and build what you need to build.
Guerra: But if you have to be available early, late, and on the weekends, that’s tough for your IT staff.
Stewart: Yes it is, but the physicians have to be available early, late, and on weekends too, so it comes with the turf. It doesn’t have to be a constant thing but particularly with major physician-facing applications where you need to get their input, we need to make ourselves available when it’s convenient for them. What we found over time, though, is that when they begin to see the results that accrue to them—for example, sitting down with one of our informatics nurses and building their custom order sets—and when they see what that gains them in the long run, they become much more willing to make that time available and to make it available at more pleasant times. Lunch is a hot time. We have an IT training room and we’ll often have a lunch brought into the training room and sit down with the physicians for an hour over lunch and work on some of the stuff collectively with them and that works out great. So it’s getting better all the time.
Guerra: They’ve got to eat, right?
Stewart: They’ve got to eat.
Guerra: So you’re working through that pushback. You mention when you talked about CPSI that some of the stuff was a little buggy. I’m hearing that a lot from CIOs with the pace of change. It’s as much on the vendors as it is on the CIOs in the hospitals and the vendors are having to get stuff out there faster than they might like. I guess you’ve seen that also as an issue.
Stewart: Sure, yes.
Guerra: What can you tell me about the effect that has on the users? I spoke to one CIO and he said, ‘We get software over here and then a week later or a few days later, the vendor sends another version because they’ve fixed a few bugs, and then a week later, another version. We’re having a lot of downtime of doing upgrades and the end-users are not happy.’ Does that make sense to you, that kind of dynamic?
Stewart: Yeah, I think that’s a fair comment. But I think the order of magnitude of the change that we’re all being asked to make, and the timeline that that change is on, makes this a fairly understandable scenario. If you think about it, the rules for certification weren’t even finalized until approximately June or July of 2010, and from the vendor’s perspective, if you don’t know what the standards of certification are for sure, you’ve got to make sure that your product can comply with those once they become final. They had a lot to do in a very short period of time.
And it wasn’t just CPSI. Our ambulatory society had the same issues and the dialysis center that is on a separate software system had some of the same. But yes it was a difficult period of time, and our mantra to the users, even though they were frustrated and disenchanted was that we are living in some very extraordinary times. And we are doing this because we believe it’s the right thing for the patient and we need to tough it out, if you will, and work our way through this. But yes, the pace of change and updates from our vendor is pretty substantial—and from all of them. Most of the time those aren’t catastrophic things, but it is change for the user and it is frustration when there are bugs and you have to use workarounds for a while, particularly in clinical areas where that arises.
As a CIO, I’m really blessed with some really dedicated and great clinicians and a really dedicated and great medical staff. It’s not that we don’t have our moments and our stress points, but at the end of the day, everybody keeps their eye on what’s right and what’s good for the patient. And we seem to be able to work our way through it, but we have our moments and they can be tense and they can be heated at times, and the frustration level can get very high. That’s when I think you just have to take a deep breath and say, ‘Okay, let’s tackle this one issue at a time and move forward.’
When I think about one issue that we had in July, we needed to go to the newest version of CPSI’s software. So we were a beta site for that and then we’re the first site to implement their physician documentation system, and we had to get to this newest version to implement the physician documentation. One of the side effects that we had in the first few weeks was that the reference lab interfaces broke, to put it mildly. We were sending thousands of reference labs per week to the ambulatory system for our family medicine group and a good percentage of those had problems with them. There wasn’t anything about a data integrity problem. It was all about the way the data got presented and what flowed and what didn’t flow.
That was a very difficult couple of weeks, for both my staff, for myself and for our vendor partner, because when we discovered what the problem was, it was significant, and I will give CPSI very high marks for the effort they put forth to resolve it. I would give my team very high marks for the work that we did to get through that process, and our clinicians for what they had to put up with. Those things create a lot of stress when you have moments like that, but you have to step back. And I think one of the most gratifying things was that at the independent practices board meeting, they said, ‘It’s frustrating but we know that you guys are working very hard. You didn’t cause it on purpose and you’re working very hard to resolve it. And that’s all we can really ask.’ It doesn’t mean that they weren’t frustrated; I could walk down the hallway and some of my physicians would make some comments—they were mostly good-natured, but just to make sure I hadn’t forgotten the fact that problem was still there. They’d remind me.
Guerra: Right. You talk about the stress on the staff. Everybody’s got a lot of stress. There’s a workforce shortage, and you’re in a rural area. I would imagine there are a few people on your staff that if you lost them, you’d be in really big trouble in terms of replacing them, being in the type of area that you’re in. There are less places for them to go, but if they want to relocate, they can go anywhere in the country if they’ve got a certain level of experience. How have you found the whole issue of managing your staff and making sure you have the people you need?
Stewart: My staff has been very stable over the last four years and you are absolutely right. I have a very, very good staff—small but good, and if we lost some of them, it would be a difficult thing to replace, but not impossible. Our area happens to have some fairly good availability of talent and I participate actively in two internship programs with the local schools that have the potential to be a great pipeline to people. I’ve gotten to know a lot of the folks that way. But I’d hate to lose any of the people on my staff, because it would be a big challenge and a setback to us. Any time you bring somebody new, there is going to be a learning curve. It’s going to take some time to get to where you need to be.
We chose the path of going to some technically-inclined clinicians to fill the clinical informatics positions, and that was a brilliant move, because clinicians like to talk to clinicians, and they see the world through a different set of lenses than technical people do. And I can train the technical skills a lot easier than I can train the clinical skills. I’m not a nurse or a pharmacist or a lab technician, and I’m certainly not a physician. It’s very unlikely at my age that I’m ever going to be any of those, but with all of those, I can teach the technical skills a lot easier than they can teach me what it is they do. So we chose that focus in the informatics world, and it’s worked out very well for us.
For the technical IT staff, we’ve been very blessed with being able to find people from the area who are pretty committed to the area, but I will tell you that even in a small community, you need to make sure that you are treating those people right. Retention has got to be a very high priority for you, because the effort, energy, and cost to replace those resources are extremely high.
Guerra: Tell me a little bit more about what you think it means to treat them right. What does it mean to be a good manager when there’s so much in play?
Stewart: I think you need to lead rather than manage, first of all, but I think the most important thing is to start with the basics. Are they getting paid fairly? Is the ‘what’s-in-it-for-me’ piece a fair and reasonable deal? It should be above average for your geographic area—not be way above, but above.
Then it’s the environment. What is the leadership environment, and what is the environment and the culture of the workforce? I think IT people generally love to continue to learn and grow, and you need to provide that opportunity. They love to be heard and to express what their thoughts are, and you need to be willing to do that. And I think you need to treat them with fairness and respect. My strategy is to treat them as peers and not as subordinates, and it’s a collaborative effort. We each have our little areas of specialty, and we collaborate with each other and do the very best that we can.
IT people and good technical people don’t need to be managed—they need to be lead. They want to buy into a good set of mission, vision, and values. I think people are in health care because they generally want to help people. They want to serve and there is a vicarious reward from doing what we do that, if you’re in a manufacturing plant, is probably not the same.
What are we doing here—are we implementing health IT or are we saving lives? If you look at it like we’re saving lives, some of the things aren’t as hard as they would be if you say, ‘I’m implementing health IT.’ If your vision is making people better, saving lives, and improving the quality of life for people, and you can find a way to take some vicarious reward in that. And I think everybody in health care should, from the guy mowing the lawn to the ophthalmologist doing cataract replacements to the cardiologist and everybody else. We’re all involved in making people’s lives better and that’s why we’re in health care.