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.
- Thoughts on ED scribes
- The ICD-10 factor
- Living on a razor-thin margin — “This is where the small guys are going to have big problems”
- Giving users what they want versus what they need
- Clinician dissatisfaction with the data entry burden
- The benefit of bringing in outside eyes
- GE’s performance — “You can’t go wrong”
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The bottom line is you’re putting a lot more data in. It has to be discreet. It has to be exact. You have to put it in and follow the technology rules. That takes more time.
If you have hospitals that are on the razor’s edge of margin in terms of profit, where are you going to get the money from? You have these arbitrary decisions that are sometimes made by the government, like ‘we’re going to cut Medicare by 10 percent.’ Well, how are we going to operate on 10 percent less money?
These are the challenges that CIOs have to face going in. If you give people what they want, it might not be the right thing. I have people coming to me complaining about the design that they created. I’ll say, ‘but you designed it.’
That level of, ‘I hate you, you’re killing patients,’ really has not occurred here. But there has been a lot of unhappiness. And we’ve tried to be aggressive with that and confront them and go there and talk with them, and try to resolve it as best as we can.
What I would do, if I had to do it over, is perhaps sit with that user and say, ‘is this really what you want?’ If these consultants are familiar with process flow in a hospital, they might say to the users, ‘listen, this is not going to work. Why don’t you try to do it that way?’
Guerra: I was in the ED recently — not for myself, for someone else. And I saw a scribe. Actually he had the shirt with his company’s name on it, and he was following around an ED doc when the ED doc went to the different little areas or booths or beds. And the scribe would follow him with his laptop in his hand, and would obviously be taking notes and whatever. And then they would sit back at the station together. But basically that was his scribe to follow him around. What do you think about that?
Ciccarelli: Well, for who — the ED or the organization?
Guerra: Are you in favor of that? Do you think that’s reasonable?
Ciccarelli: No. I think the criticality of this is that administration has to hang tough. I think this has to come from the top. I mean, you get this ground swell of ‘I don’t have the time,’ and ‘the thing doesn’t work right’ and ‘it’s too slow.’ As they say, if you have an ED doc that can see 20 people in an hour, you just screwed up in life. In all fairness to this guy, you just said, ‘you can’t see 20 people now. You can only see 15.’ What would you do with the other five people?
So I could see some organizations reaching that and putting more resources into it. And maybe that’s what it’s going to be. That’s why I said this is a terribly underfunded endeavor. I read things in physician offices that you could be looking at 30 percent loss in productivity. And some of the more intuitive physicians are saying, ‘I’ve got to hire more people to do this thing.’ Look, the bottom line is you’re putting a lot more data in. It has to be discreet. It has to be exact. You have to put it in and follow the technology rules. That takes more time. It’s not about the vendor; it’s not about whether it’s working right or anything like that.
Guerra: This whole thing is exacerbated when we go to ICD-10?
Guerra: And you need much more granular data on the frontend, correct?
Ciccarelli: Yeah. ICD-10 and Meaningful Use stage 2 come at the same time — October 1. It’s astounding because if you have got to wonder whether these guys in Washington understand what they’re doing. It’s astounding.
Guerra: Well, let me play the government here. And say to you, ‘Hey Tom, the Meaningful Use incentive money was never meant to cover the cost.’
Ciccarelli: That’s right.
Guerra: And what do you say to that?
Ciccarelli: I would say, ‘but if you have hospitals that are on the razor’s edge of margin in terms of profit, where are you going to get the money from?’ You have these arbitrary decisions that are sometimes made by the government, like ‘we’re going to cut Medicare by 10 percent.’ Well, how are we going to operate on 10 percent less money? So when you say, ‘Okay, we’re only going to pay 50 percent of the cost or 60 percent of the cost’, the argument is, where is the other 40 percent is going to come from? And this is where the 4,000 and the less hospitals, the small guys, are going to have a big problem. Not the big guys — they have big IT staffs and all sorts of budgets. It’s the little guys. And unless something’s done, and I think we need to wait and see what the election looks like, but unless something is done in terms of increasing some of this funding or changing some of the rules, it’s just not going to happen.
Guerra: You can’t imagine there’s an appetite on the national level for increasing funds going to the Meaningful Use program.
Ciccarelli: I think it all depends on how the Congress comes out, personally. I think if the republicans win, I have dire predictions because they’re going to look to cut money. You have this ground swell of opposition and criticism coming up. If the democrats win, you have a different situation. I think that nobody realized how hard this would be. And now that they do, the question is, what do you do about it? We either have the vision and hang in there and get it done right, or you have to bail.
Guerra: ONC is in a position of cheerleading this whole thing, right? So they’re not sitting there wringing their hands over what guys like you are going through. They’re going with the ‘rah, rah’ press releases about ‘look how great we’ve done. Look at all the people attesting, and everything is great.’
Ciccarelli: It’s like the glass half full-half empty thing. And they’re right. And they’re getting a lot of this stuff from vendors, and they’re getting this stuff from consultants. I sat at the table once at the HIMSS convention with a bunch of consultants telling me how wonderful it is. Well, that because they made $200,000 on it. Yeah, of course it’s wonderful.
Guerra: They are the ones you were talking about getting more money to bring in.
Ciccarelli: Yeah, they love it. They say, ‘it’s all great. We did a great job; come and hire us.’ But where do you get the money from? So it depends on who do you talk to.
Guerra: As you were saying, you’re representative of a huge contingent of hospitals out there — the community hospital — that is breaking even; maybe making a little money, maybe not. But on the other end, we have these mega health systems that are spending $100 million on a new system and bringing in everybody they need. So there really has a huge divide in healthcare, isn’t there?
Ciccarelli: Absolutely. And the vast majority of them are under 200 beds. I think they are the ones that have been having the most difficulty doing that. And I think that’s what GE’s goal is. GE’s goal is to try to develop a product that can be installed easily with a great deal of flexibility. You would have to talk to them. It’s going to be their 6.9 version. That’s their target — that under 200-bed hospital business. And to some extent, what they are doing here is they’re trying to learn how to do that and make it easy and cost effective. But we’ll see.
Guerra: It’s fascinating. You just said, ‘installed easily with a large degree of flexibility.’ And I think you made the point that those maybe don’t go together.
Ciccarelli: I know. They are contradictory terms.
Ciccarelli: Yeah, but you’re making an assumption. If you’re going to go to particular department and ask what they want, do they know?
Guerra: Or maybe what they want isn’t what’s good for them.
Ciccarelli: Yeah. These are the challenges that CIOs have to face going in. If you give people what they want, it might not be the right thing. I have people coming to me complaining about the design that they created. I’ll say, ‘but you designed it.’ It’s unbelievable. They say, ‘it has too many screens,’ and I’ll say, ‘but you designed it. I mean, we could have given you less.’
And that’s part of our phase 2 as we’re going in and cleaning up stuff. We’re going in and saying, ‘Okay, this is what we needed to do to get in there for meaningful use.’ Now let’s re-look at some of this stuff.
Guerra: Here’s the thing. It’s really fascinating—when we talked the first time, I wrote a column about the interview. And I said, ‘This is how you do it. Everyone says the users have to pick the system. So Tom went out and he let his users pick the system. He wasn’t crazy about it, but he stood by them.’ And I said, ‘You go, Tom.’ But now we’re in a different phase. And tell me if you’re thinking has changed on the way you handled the initial buy or if you’re still happy with that, but now we’re in a phase where you said, ‘go ahead, pick your screens.’ But that didn’t work out. So how much do we empower the users? How much do we trust the users? Everyone says, ‘let the users make the decisions,’ versus now we’re in a new phase where maybe the users can’t make all the decisions.
Ciccarelli: And that’s kind of one of the reasons why I kept postponing this conversation, because we’re a little more than six months into the process. I think if you ask me that question in a year, I might have a whole different answer for you. And all in all, I think it has worked very well. But there are criticisms. There are a lot issues that have really nothing to do with the vendor — they just have to do with the EHR. But I think to really do an evaluation of the success of an EHR you need at least a year or more. And then at that point, you can look back at what you did.
I mean, it was their stuff. And the modifications worked very well in nursing. What we did in nursing is we hired people. We hired two informatics people. That’s an example. And nursing is beautiful. They’ve had some software issues that we’ve had to resolve with GE.
The question you need to ask is ‘what’s good?’ It’s never going to be good to put in 60 percent more data. And the people that are doing that on the frontend don’t see the advantage of that. All they see is a big pain. They say, ‘I’m not getting anything out of this. I might down the road.’ We all read about the theory and the vision of the universal record and all that stuff, so everybody buys into that. But for that clinician at that moment in time, all they know is before they had to do X, and now they have to do Y.
Guerra: I think I’m starting to understand. So it’s not so much the consternation over anything specific that you’ve done with product or picking the product; it’s more just the overwhelming process change, and you said that’s the hardest part. And that’s the dame for everybody with any product.
Ciccarelli: That’s right, and that is clearly where I see the single biggest problem. And that results in finger pointing and blame and people saying, ‘it takes too long and it’s too slow.’ You start getting into all that stuff, when the real issue is you just made their life very hard. You just changed the very essence of how they do things. And then you gave them a whole bunch of extra work to do it. What do you expect them to say? ‘Oh, I love it, thank you. You just doubled my work. Please give me more.’
Guerra: Yeah, these are very busy people. These are very intelligent people.
Ciccarelli: And very committed people.
Guerra: They’re very committed, and they don’t enjoy it being trifled with.
Ciccarelli: I think everyone understands the goal. But like anything else, you have to work at getting to that goal. And some people are more open to that. We have a very positive administration here. They’re very supportive of it. We talk to people. We work with them. We listen to them. GE has been very receptive. If they have a problem, we get right on it right away. We turn it around. We help.
This vendor has been extremely responsive. Some of these other stories I hear about other vendors, and it would be a disaster if that happened — where they just say, ‘this is it. Forget it. Don’t call me anymore.’ These guys will come in and redesign it, and God bless them for their patience. And I’ve had to redesign systems two or three times in some cases in certain areas because we just couldn’t get it right. So I don’t know how much more you can do. I can’t make it go away, other than hiring a scribe and follow the guy around, which is what some people might do. Or, ‘I don’t want to go to the computer figure out how to get my lists, so I’ll just hire somebody to be there to give it to me.’ It’s what they want and you could do that.
Guerra: When you think of your most difficult conversation and moments, is it a physician marching into your office and saying, ‘you’re ruining my life?’ Just give me an example of when it gets toughest, what happens?
Ciccarelli: Relatively speaking, there it has been very little of that. The physicians have been actually reasonable. There are complaints; they usually funnel it though our CMO. We’re very upfront with it. We put meetings out there. We go out there and talk to them. We’ll call the ED and let them yell at us. We’re not afraid to do that. So that level of, ‘I hate you, you’re killing patients,’ really has not occurred here, to be honest with you. But there has been a lot of unhappiness. And we’ve tried to be aggressive with that unhappiness and confront them and go there and talk with them, and try to resolve it as best as we can.
Guerra: Is there any advice that you can give — you talked about bringing people in to help study the workflows and redesign workflows, maybe being a little bit more in charge of the processes as opposed to letting the departments work on it. And maybe I’m using words that you don’t want to use, so please clarify. But I’m picturing that you want to be a little more involved or have GE be little more involved or giving direction on creating these workflows and screens as opposed to giving the departments carte blanche.
Ciccarelli: Well, we really did that. IT was actively involved in that process, and GE was actively involved in that process. They just had difficulty doing their own workflows in some cases. Again, I think it’s too soon. I have to write my book and get on a lecture tour, but I think one of the things I would suggest is that I would not assume that somebody has the situation under control no matter how confident they seem to be. And I think perhaps where outside resources would come in would be to just kind of do a smell check. Because that’s what they’re saying—they don’t want to be accused of not understanding it. So they say it’s okay, and then when it doesn’t work, they get mad.
So I think I would pay a little more to the process, and I think perhaps I would bring in some resources to just check it out and make sure everything is in order. But I think back and I say that maybe there’s nothing that can be done. Maybe we just have to tough it out. Maybe we just have to live with it, and not bail every time something gets heated.
Guerra: And in terms of the engagement with the clinicians, let’s say you bring in consultants to define the workflows and the process change and help with that. Will those consultants also actually work with the users and help in terms of the change management?
Ciccarelli: Yeah. That’s what I would do. I would have the consultants sit in on the design sessions. What I would do, if I had to do it over, is perhaps sit with that user and say, ‘is this really what you want?’ If these consultants are familiar with process flow in a hospital, they might say to the users, ‘listen, this is not going to work. Why don’t you try to do it that way?’ And you shouldn’t expect that from the vendor or expect that from IT. So I think in certain areas, I might have done that. And I might now. I’m talking to some consultant folks; I have certain areas where I think they might need a little help. And I’m looking at maybe sending in somebody there for a week or two. GE has put a lot of resources into that, including in the contract, I might add. They’ve come in and actually given us some reports and bits of analysis. We did a current state analysis beforehand.
I guess I don’t know if there’s any other way of doing it better, other than just toughing it out and doing it. And then you just have to get used to it. It takes time to get experience. The technology has to stabilize. In the beginning, you have all sorts of bugs and errors and stuff, and that doesn’t help.
Guerra: So GE has been very supportive and very flexible.
Ciccarelli: Extremely so. You can’t go wrong with them. I cannot say enough about them. Senior management has been very much involved. We have calls with the senior management of GE and our CEO. So I think that’s very critical that all levels of management be involved. And we talk with them all the time. We have calls every day — literally every day.
Guerra: So it’s just hard and it’s just expensive?
Ciccarelli: It’s just hard and it’s just expensive, yeah.
Guerra: And that expense, is it perhaps an unmanageable burden on a community hospital?
Ciccarelli: It could be. And I think we need to look at it. If I were to give ONC any advice, I think I’d take a look at some of those numbers and see what can be done. I think if they threw another million at a hospital, it would make all the difference in the world. There’s just not enough money. What I’m reading is most hospitals would be lucky if the cost covers 60 percent. We’re talking millions of dollars here. To go to your CFO and say, ‘I need $3 million more’ is tough. Now I think when we talk again in six months, I might even have a much more optimistic point of view. I think we’re just coming out of six months of a very difficult install.