Every hospital CIO is undoubtedly feeling the burden of Meaningful Use, but for some, the weight is greater. As Tom Ciccarelli, CIO of East Orange General Hospital, leads the 211-bed, community hospital through EMR implementations and other major projects, he is finding that organizations that are on a tight budget — and can’t afford consulting help — really are at a disadvantage. In this interview, Ciccarelli speaks candidly about how the combination of ICD-10 and Stage 2 of Meaningful Use will overwhelm hospitals, how vendor flexibility can be a double-edged sword, and the effect that changing workflows and an increased data entry burden has on clinicians. He also talks about the similarities between EMR implementations and having young children, and the critical attributes needed for today’s CIOs.
- A year of implementation in review
- Flexibility and customization — a double-edged sword
- “An EHR install is an extremely painful situation”
- Why consulting help could be key
- The financial strain of meeting Meaningful Use
- Contemplating Stage 2
LISTEN NOW USING THE PLAYER BELOW OR CLICK HERE TO DOWNLOAD THIS PODCAST AND SUBSCRIBE TO OUR FEED AT iTUNES
GE is extremely flexible in developing the software product and customizing it to fit the needs of the individual departments and their workflows. And that’s a two-edged sword. That’s very good and that’s very bad.
Think about going to somebody and saying, ‘How do you want it to look? How do you want your ED steps to fit and how do you want your screens to look?’ I think you need to be careful, because some folks might not know what to do or how to do it.
This is an incredibly underfunded mandate. There’s no way that what the federal government will give these hospitals will cover the cost of this thing. There’s just no way.
When we did this, we tried to stay as budget-neutral as we could, but that meant pulling people out of pharmacy and pulling people out of ED and saying, ‘You have to attend classes and go through all this development stuff.’ And that was perhaps our most difficult thing.
I think the challenges in the first phase are design and technology. I think the challenges in the next phase are going to be physicians and process changes. And I expect that to be very difficult. But I think we’ve learned a lot from the earlier experiences and I think we’re in a much better place to deal with it.
Guerra: Good morning, Tom. Thanks for joining me to talk about your work at East Orange General Hospital.
Ciccarelli: How are you doing, Anthony? How is everything?
Guerra: I’m doing great. It’s nice to catch up. We spoke maybe a year ago, and we talked about your plans or your process of implementing GE Centricity inpatient. It was really great interview; I actually wrote a column about it; about trusting your clinicians and how they had come back to you with the selection of GE. And you were a little cautious because of some of the KLAS scores and things like that.
Guerra: So we’re going to review the past year and how things have gone, and that should be pretty interesting. So why don’t we just go from there. Why don’t you update everyone, if you would, on the basic outline of what you’ve been doing, maybe the organization and the process, and then how it’s been going over the past year?
Ciccarelli: Sure. If you recall in the initial discussion, we talked a little bit about the selection process and how this was a bottom-up selection methodology. This was not a product that was selected by administration, but selected through a whole series of committees and teams who picked GE overwhelmingly. They actually picked GE. And it was really interesting because it was a very new product. There were not a lot of them around, and to a certain extent, we were one of the first. I think we would be a development site in some ways.
But one of the things that it’s kind of good and bad that we certainly became aware of during the install was the fact that the GE product offered a matrix user-driven methodology. Unlike some vendors who go in and say, ‘This is what you’re going to do and you have to customize your workflows and your procedures around the software that we could view,’ GE is extremely flexible in developing the software product and customizing it to fit the needs of the individual departments and their workflows. And that’s a two-edged sword. That’s very good and that’s very bad. It’s very good for some folks because obviously they can build the software around the uniqueness of their institutions. It’s very bad in some ways because they might not know how to do that. And that’s been some of our challenges. We made an assumption that our folks had that type of expertise, and in some cases they did not, which resulted in some challenges.
Guerra: You mean that at a departmental level in this scenario, the vendor is coming in and saying to the department, ‘You tell us how you want us to design this workflow.’ And you’re saying some of those departments don’t know how they want it to look.
Ciccarelli: Well, I mean think about it for a second. And East Orange happens to be very progressive and very much ahead, but think about going to somebody and saying, ‘How do you want it to look? How do you want your ED steps to fit and how do you want your screens to look?’ I think you need to be careful, because some folks might not know what to do or how to do it.
First of all, let’s go back and say that we have successfully installed the GE Centricity product, and we attested for Meaningful Use a couple of weeks ago. So we went live around July. And we could’ve attested in the fiscal 2011 year, but we wanted to wait a few months to kind of stabilize things and get the data quality that we were comfortable with. We began the first day of 2012, which was October 1. So our 90-day period was October, November, December, and then we attested — relatively easily, I might say — in January.
Now if you recall, when we started this whole process, we made a decision that we bought the full GE product line, ranging from order entry in the frontend, right on to the backend to the AR. But we decided that we would do it in a phased approach. We felt that for a little organization such as us with limited resources, we wanted just to install the components of the product that, in essence, would allow us to meet Meaningful Use. So that was our goal. We did ED, and we did we did some nursing stuff on the floors. And that is what we attested to. GE has an excellent attestation process. They give you a whole series of reports, which are required under the law, of course. And we have to say, that was a relatively easy task, the attestation. The reports were right there. You just had to fill in the screens. And we’re going to get about three man hours, no more than that for the first period.
Guerra: Okay, all right
Ciccarelli: I’m going to hesitate between thoughts and then you tell me if you want me to continue or change the topic.
Guerra: Oh, no. That’s no problem. I can hear in your voice, and you tell me if I’m reading too much into this, but I can almost hear you saying, ‘You know what, we did enough to attest, but I’m not feeling great about this whole thing.’
Ciccarelli: No, I don’t think so. First of all, an EHR install is an extremely vendor-neutral and extremely painful situation. Personally, and I’ve been doing this a long time, I never imagined it would be as difficult as it is. And it’s really around processes and change and people having to do things differently. You go into the average ED and I think any experienced ED installer will tell you — they have paper systems down there. How many complaints do you get from the medical record folks about how they can’t read doctor’s handwriting? Most guys will scribble something on a piece of paper. Now all of a sudden you say to these guys, not only do you have to stop what you’re doing and use technology you’re not familiar with; you have to get it right. You got to put in a whole bunch of discreet data. You have to put in maybe 50 or 60 percent more data, whereas before that was just a matter of scribbling down on a piece of paper.
So you know you really change, and I think you need to be sensitive of the fact that you really change people’s lives unbelievably. I think when I write my book or when I become a consultant, I would say there are a couple of things here. First of all, this is an incredibly underfunded mandate. There’s no way that what the federal government will give these hospitals will cover the cost of this thing. There’s just no way. We tried to do it as economically as possible, so we tried to stay away from external consulting help. But I think if I had to do it over again, I think I might have brought in some external help to help out with process reviews in certain areas where people had difficulty and I would say that was the single biggest problem that we’re having. I think GE did a good job. I think they customized the product based on what they were told. That decision — going back to what you’re hearing in my voice — was made because we felt that this would be a very difficult process and I’m glad we did it. Had we done more? I don’t think we could have done it.
Ciccarelli: One of GE’s major clients is Montefiore. They’ve got all sorts resources there and people. And in my department, I have two analysts. I have to pull people off the floors and make them super users and they have other things to do. So when we did this, we tried to stay as budget-neutral as we could, but that meant pulling people out of pharmacy and pulling people out of ED and saying, ‘You have to attend classes and go through all this development stuff.’ And that was perhaps our most difficult thing. They just didn’t have the time. It was a very time-consuming, difficult thing to do.
Guerra: So if you brought in external consultants, do you think that would have helped quite a bit?
Ciccarelli: Oh yeah.
Guerra: Eventually they’d leave though.
Ciccarelli: Well, I think it’s just a matter of the design. It’s just a matter doing the work. The problem is, can you afford it? I mean, I don’t know. Our dilemma is we’ve been profitable for the past five years. I mean, in healthcare, breaking even is profitable. So we’ve been doing well. But I don’t know where we would have gotten that money from. So that’s the dilemma. If you asked me as a technician what should we have done, I’d say, ‘Well, we should have spent three or four hundred thousand dollars on consultant’s fee.’ But could we afford it? And the answer is no. So you have to go to your people that already have a full day, and say to them, ‘Now you got to come in and spend all this time in development.’ And that was an enormous amount of time. It was a lot of time and a lot of commitment on behalf of people. They did it. They did it and they did it well, which is a credit to this organization. All in all, it worked out very well, I think, in terms of where we are. We’re in a good shape. We still have a lot of work to do; it’s far from over.
Guerra: Having gone through what you’ve been gone through, is the next phase of this — however you want to define that, maybe Stage 2 of Meaningful Use — scarier than you thought was going to be, having gone through the first phase?
Ciccarelli: Oh yeah, absolutely. I think the challenges in the first phase are design and technology. I think the challenges in the next phase are going to be physicians and process changes. And I expect that to be very difficult. But I think we’ve learned a lot from the earlier experiences and I think we’re in a much better place to deal with it. You have to do it. They pushed back Meaningful Use a year, so we have a little bit more time, so we’ll see.