The regulatory requirements that CIOs are grappling with are overwhelming enough—throw in a major leadership change, and it can feel like being caught in a whirlwind. It’s how Kim Ligon felt when DCH Health System had a new CFO take the helm just as Meaningful Use was coming down the pike. But rather than panic, Ligon, who serves as CIO for the West Alabama-based system, reached out to her colleagues for help. What she found is that there is no better source than CIOs for issues like dealing with steering committees, prioritizing projects, and balancing the budget. In this interview, Ligon also talks about having to interface with physician offices that use different EMR systems, her role in developing a statewide HIE, when a project needs to be delayed, and why she believes nurses bear the biggest brunt of CPOE.
- Ligon’s CHIME survey on IT steering committees
- New boss, new priorities
- Prioritization and governance
- Acceptable rates of change — “There’s only so many things that people can absorb”
- The role of nursing in HIT transformation
- Mastering the pharmacy
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With the old CFO, the steering committee’s attitude was if we can make Meaningful Use in time to not be penalized, that’s adequate. With new CFO, the focus was that’s money on the table. And in uncertain political times, do we really want to wait an extra year before we attest?
It became very apparent that if we’re going to make Meaningful Use and do the things we need to do, there’s an awful lot that has to happen. People need to realize we can’t also do all the other laundry list of things that are out there that various areas would like to have done.
They sent me sample agendas and they talked about how they prioritize projects, and I’ve had some conversations with CIOs where I’ve said, ‘I see what your agenda is, but walk me through how that kind of happens—how much work happens outside the steering committee and who are the people at the table.’
There are 90 projects on the list—36 of them are the directly related to Meaningful Use. So if you say it’s given that those are all going to be done by July, then you have very little resource to do the rest. And I think it’s not even just IT resources, I think there is a limit to what an organization can absorb for change.
The biggest challenge in the CPOE front, apart from just physicians adjusting to it, has been having all of the resources in the pharmacy informatics area to do all of the strings and to do dose checking and to really tweak the pharmacy dictionaries and things so that they are physician-friendly.
Guerra: This sort of dovetails into your CHIME survey. There’s a lot going on—ICD-10, Meaningful Use, your Meditech upgrade, ambulatory integration, so you really need strong governance and processes in place and project prioritization, and I want you to just go through the genesis of the survey. Tell me about some of the challenges you were facing and what prompted you need to reach out and ping your colleagues to see how they were handling things, and in particular, your survey was on steering committees. So why don’t you go through that?
Ligon: One of the geneses was the fact that I got a new boss in August. The CFO that I had been reporting to for the last 13 years retired and I got a brand new CFO. Prior to my new boss coming in, the steering committee had been coming together very irregularly and it was kind of a situation where IS presents what’s going on and they say, ‘Okay.’ Even with our strategic planning, I wouldn’t have said that it was a real interactive or participatory type event, and with the old CFO, the steering committee’s attitude was if we can make Meaningful Use in time to not be penalized, that’s adequate. With new CFO, the focus was that’s money on the table. And in uncertain political times, and so do we really want to wait with the time value of money an extra year before we attest? And do we really want to get down to the 11th hour? What happens if something goes wrong? We have no wiggle room to be able to still attest and not be penalized in any way to get our full payment.
So the focus started shifting. And when that focus started shifting, it became very apparent that if we’re going to make Meaningful Use and do the things we need to do, there’s an awful lot that has to happen. People need to realize we can’t also do all the other laundry list of things that are out there that various areas would like to have done.
Ligon: And so it became very important, and the CFO believes that her counterpart should be stepping up and doing some internal prioritization in their divisions as well to talk about what realistically has to happen, and be able to look at what are the true resources that it’s going to take to do everything that we have on the table. So it’s been kind of a mixed bag for me personally. It has been an opportunity to really step back and look at what we’re doing, but it’s been a question of how do we get that engagement from that executive level. And so all of the project prioritization in the past has been kind of ‘bring your project to IS and we’ll look at what we have for resources and figure out when we can do it.’ And sometimes the wait list has been very long to be able to get something done. And there hasn’t really been criteria other than are people available.
Ligon: And now, the new CFO would like to have it where there needs to be some criteria around it, like what are other people doing? Are they looking at only things that are on the strategic plan? We would like to get to an environment where we can actually plan the projects before the budget process. Historically what’s happened here is that the budget has happened and then we get notified by some department or division that they put in their budget for this year to do install X, Y, Z. And we may or may not know about it, and so we’d like to be able to shift that to having the discussion ahead of time about how it fits in with the strategic initiatives or what’s the return on investment we’re going to get from that, or how does that help us meet the regulatory things that are coming up. And so that was what precipitated the need for the survey because there are lots of great ideas about how to do things, and probably for as many CIOs there are, there are approaches and ideas about how to look at what you need to do. I was really pleased with the survey because we got 132 responses.
Guerra: That’s very good.
Ligon: I thought that was excellent. And out of those 132, about 70 percent of them had some kind of formal steering process, and it has actually caused me to get in contact with some individuals directly to just talk about, okay, I know the basics now of what your steering committee goes through. They sent me sample agendas and they talked about how they prioritize projects, and I’ve had some conversations with CIOs where I’ve said, ‘I see what your agenda is, but walk me through how that kind of happens—how much work happens outside the steering committee and who are the people at the table.’ Those types of things.
Because part of our other issue is questioning whether we have the right people at the table. We have the CEO of the organization and the administrators and the chief nursing officers and the vice president of Medical Affairs, the outpatient division vice president, the human resources vice present—all of those people at that level. But there were some question about do you really need the CEO of the organization in that prioritization meeting, or do they need to actually get the Reader’s Digest version of how that all fits together. And what I’m finding from the survey is a lot of people really have what I would call operational vice presidents—nursing and outpatient and Medical Affairs-type vice presidents, and then the directors who have a particular project that is up for review. The directors are coming in to present their case of a project of what they want to do.
The other pretty major change for me that precipitated part of this is that historically, if we haven’t had the budget or there haven’t been enough resources to do something, the answer has been, ‘No, we cannot do that.’ My boss now would like the answer to be ‘yes with criteria, meaning that if somebody needs something, you need to be able to say, ‘Yes, we can do that, but this is what has to be in place for us to do that.’ We either need an additional resource or we’re going to have to purchase a piece of software or we’re going to have to do something like that. And then they can make a decision about are we willing to meet the criteria to go forward with the project.
Guerra: Well, you could make the criteria so obviously impossible that it’s essentially a no.
Ligon: I’m not sure that that would fly.
Guerra: Yeah. I’m just making myself laugh. But you could say, ‘Sure, I guess we can do it if…”
Ligon: Correct. It’s as much about communication as it is anything else.
Guerra: It’s fascinating. The situation you described is fascinating to me. And one of the first things I thought was that the whole game changed for you with the new CFO saying it used to be just make sure we don’t get penalized, now it’s about get the money. So your whole world changed, your whole schedule, your whole prioritization—everything changed for you. Does that make sense?
Ligon: It absolutely changed, in a big way. That’s part of the reason honestly. I’ve been enjoying reading some of your messages that are about how we’re in the middle of the whirlwind. And I’m one little piece of it. I know I’m not alone in what’s happening. The regulatory changes and the other things without having leadership changes are pretty mind-boggling, and then when you add leadership changes on top of it, it makes for even more whirlwind.
Guerra: It’s interesting—we talk about prioritization, and prioritization has to happen under an overarching message from the CEO or CFO, whoever the top person seems to be, about what are the values we’re operating under or what is the agenda, and then under that, as a committee, we can prioritize. But that changed too because now you’re operating under a sort of mandate of qualify for Meaningful Use and that frames all the decisions you make. Does that make sense?
Ligon: It frames a lot of them. When we started listing of all the projects that needed to go for further review, when I grouped all of the things that are on the list that are related to Meaningful Use. There are 90 projects on the list—36 of them are the directly related to Meaningful Use. So if you say it’s given that those are all going to be done by July, then you have very little resource to do the rest. And I think it’s not even just IT resources, I think there is a limit to what an organization can absorb for change.
So you can’t be going out and changing all of the ways that you’re doing some particular nursing process and be changing all of the assessments and things to capture additional clinical data for the e-measures and do those things. There are only so many things that people can absorb. And I think nursing is taking a bigger brunt even sometimes than we are in IT, just because they are the ones who are going to have to be the front runners to learn what’s going to happen with CPOE. Historically, they’ve been the ones who’ve been hand-holding the doctors to get them over the next hump of whatever it is has to happen. There’s nothing different about going to CPOE. They are still going to be the first line of defense that a physician is going to go when they’re in a stuck place, regardless of what you have for a support mechanism out of your IT area.
Guerra: Sure, they’re right there.
Ligon: And so, those people have to be intimately involved in this prioritization process because they also have major initiatives going on for patient satisfaction and the HCAP scores and all the things that are happening from that front. So I see them as being probably the most squeezed entity for what we have to do in the timeframes that we have to do it.
Guerra: So you report the CFO and you have a new boss come in and he gives you a new mandate. In my head I’m thinking that you might have responded to him, ‘Well, that can’t work now. If someone would have given me these marching orders a year ago, maybe I could have done this, but I can’t do this now. There’s not enough time to do it safely.’ Did any of that conversation take place?
Ligon: When we talked about changing the deadline for when things were going to happen, my response is that technically, we have the pieces in place to do it; that the bigger question was, culturally can we make it. And so my response was, ‘Yes, we can technically have all the pieces in place, but we’re going to have to have the support of those other areas to be able to go forward.’ So I think everyone is in a place of saying that that’s a stretch goal, that they want to be in that place to begin data collection by July, but if we don’t make July, then we need to make it as quickly after that as possible.
Ligon: It hasn’t been done completely in the vacuum, and I don’t want you to think that somebody new came in and said, ‘You have to do all these things.’ It wasn’t really that. It kind of evolved like, ‘Okay, we’ve already bought all of the software. We already have all the pieces and parts in place. We’ve done the Meditech upgrade. What else do you need to be able to do this?’ What I need is the support of the clinical areas so that we can get the rest of these things done. And the chief nursing officer and the vice president of Medical Affairs are on board with doing what we need to do to keep going forward. It was a major relief to everyone that the ED physicians basically temporarily solved the CPOE issue because we’re at 57 percent on the medication ordering just because so many patients come to your emergency room.
Guerra: So for Stage 2, you’ll definitely need in-patient CPOE?
Ligon: We definitely will need in-patient CPOE, but the next groups that are after our pilot on rehab—the next groups who have expressed an interest are our hospitalists at the two larger facilities. And they will put us past the Stage 2 limit. I was extremely glad to see that Stage 2 backed off a little bit about how soon we have to be ready for that, because that gives us a little more wiggle room to get things set up.
But honestly the biggest challenge in the CPOE front, apart from just physicians adjusting to it, has been having all of the resources in the pharmacy informatics area to do all of the strings and to do dose checking and to really tweak the pharmacy dictionaries and things so that they are physician-friendly. That has been a huge job just to get all of the medication strings loaded so that they were appropriate for dosing for the different kinds of things. It took our pharmacist about 700 hours of time to do that.
So I think a lot of people underestimate that you can’t just take the first data bank strings and load them out there, because then you’re just giving the doctors overwhelming options that may or may not be appropriate in your environment. You may not carry that dose form. You really have to have some review of it and some fairly major cleanup, and unfortunately, it has to be done by a pharmacist.
Guerra: Did the pharmacist do that working closely with Meditech?
Ligon: Our pharmacists have worked really closely with Meditech on what has to happen for the strings. We did get strings from first data bank, but going through and applying them and figuring out what’s really the appropriate dosing for what we do here, our pharmacist didn’t want to just take those blindly and apply them. They wanted to actually do a review and make sure that things were set up correctly. And they had such good success in really streamlining what had to happen in the emergency room. It seemed like a very logical step to take to have them do the same thing for the inpatient arena.