Lee Carmen, CIO, University of Iowa Health Care
The relationship between CIOs and clinicians is often complicated, particularly when veteran physicians are presented with quality metrics and asked to change the way they’ve done things for decades. In this interview, CIO Lee Carmen talks about the importance of collaborating with providers and making sure they don’t feel “attacked.” He also discusses what he’s doing to eliminate departmental IT purchases that are made without his approval, the benefits of centralizing core services, how he is navigating the best-of-breed versus enterprise-system issue, and the organization’s migration to Epic in all areas but the lab.
Chapter 2
- An early Epic customer (still running Cerner in lab)
- Running a transplant center
- Being a model for device integration
- Working through the best-of-breed versus enterprise-system question with departments
- Thinking creatively, outside the box
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Bold Statements
IDX came to us and said, ‘we have a lot of academic customers who are signaling that your organizational model is their desired destination, and we would like to work with you to develop that system.’ And so we commenced the development partnership with them.
When you look at the continuum of care that a patient will experience here, from ambulatory to inpatient and across all the services and all the interactions, we feel very strongly that the advantages of a highly integrated system outweigh the potential functional shortcomings.
I think the key is having good, positive communication. I don’t come into it saying, ‘here’s a list of 10 things that you’re going to do, and like it or not, this is what you’re going to do.’ I sit down and have a very constructive dialogue with them.
You really have to get out of the box on how you approach some of the problems. One of the greatest challenges and one of the greatest benefits of the CIO role is that you can never predict what’s going to hit you. Every day brings a new learning opportunity and a new challenge in trying to leverage the assets at your disposal.
Initially, when we ran the numbers, it looked like there was a way to make this work, but it wasn’t something we wanted to do as a service line for revenue generation. That wasn’t our motivation. We were trying to see how this would help us at a grander scale.
Guerra: Now, I believe you’re an Epic shop. Is that correct?
Carmen: We’re Epic across the clinical side of things. We’re running GE — the former IDX software for revenue cycle — on both the hospital and physician side, and we’re Cerner on the laboratory side. We are, in fact, just now commencing to kick off a project to replace our GE revenue cycle system with Epic’s revenue cycle system.
Guerra: And what about ambulatory?
Carmen: We are Epic across the house with inpatient, outpatient, ED, and OR. We’re running their patient portal. We’re running their specialty modules in transplant, in oncology, in ophthalmology, in cardiology, and in labor and delivery. We’re working with them. We’re actually, I think, very fortunate in that by our geographic location, we’re less than three hours drive from Epic’s headquarters in Verona. For example, I was up there yesterday, and it was pretty easy to get in the car, run up there, and get five or six hours’ worth of work done and be back down here in a single day. Epic also leverages that geographic proximity, because they will frequently send their developers down here to meet with our providers to either discuss current system issues or future system functionality.
We signed with them in 2006. We went live, big-bang, inpatient/outpatient with the physicians on documentation and CPOE in May of 2009, and we’ve been able to engineer, I think, a very constructive working relationship with them.
Guerra: When did you become CIO there?
Carmen: In 2001.
Guerra: But you’ve been there in other positions before that in a different capacity?
Carmen: That’s right. I started out in the cardiovascular research domain and sort of drifted up into the medical school where I was working with the physicians. And then it just coincidentally was the time when the senior leadership decided to bring together IT from the medical school, the physicians, and the hospital, and they asked me to lead all of that. So that took place in 2001.
Guerra: So you were fully on board obviously for a number of years and were involved heavily in the decision to go with Epic?
Carmen: That’s right.
Guerra: Were you coming off a clinical vendor in the hospital?
Carmen: No. We had a history since the 70s of writing our own clinical software. In the 70s, they developed some software for some clinical documentation, some order entry, and results reporting that was mainframe-based. In the 90s, they put a lot of effort into transitioning that from a traditional green-screen, character kind of model to a Web-based solution and that was in place. Actually, we were using, at the time, internally developed software for clinical, for financials and for patient access. Leadership made a decision in 1999 to transition to commercial, off-the-shelf software for patient access and revenue cycle for both hospital and physicians. At that time, there really wasn’t a vendor system in place that recognized the highly integrated structure of our physician-hospital unit.
We have a single financial services group that works both hospital and physician charges. We generate a single patient statement that has both H&P charges. We’ve been doing that for a number of years, and at that time, as we were looking at the vendor market, the only vendor who was intrigued by that model was IDX. IDX came to us and said, ‘we have a lot of academic customers who are signaling that your organizational model is their desired destination, and we would like to work with you to develop that system.’ And so we commenced the development partnership with them, and although I was not CIO at the time, I was asked by leadership to be the technical director of that initiative. We went live in 2003 with IDXs combined business office, revenue cycle, and patient access system.
We stabilized that environment and then turned our attention to clinicals and really had made a decision that an off-the- shelf solution was the best solution for our organization. We commenced almost a year-long evaluation in 2005, made a decision in August of 2006, and signed a contract with Epic in October of 2006, and then formally kicked off the implementation in January of 2007.
Guerra: So you were really ahead of this whole thing where the whole industry has come now — you were years ahead of it.
Carmen: We’ve been very fortunate that our leadership has directed the organization, both operationally and strategically, into a space that secured us well for what ultimately ended up happening in healthcare.
Guerra: It’s interesting. When I go to the gym you have a membership number, and you could tell how long someone has been a member by how low the number is, so you must have a pretty low number when you get together with the other Epic customers.
Carmen: Yes, it’s interesting particularly with the tremendous flurry about 18 months ago of everybody singing up. The other advantage that we have, again because of our geographic proximity, is that Epic will frequently rely on us to hold site visits. We’ve got a potential sales group that I’m obviously not at liberty to divulge that’s going to be here on Thursday of this week, and we’ve had some of their customers from Europe who are just starting implementation.
As part of our Epic project, we’ve placed a lot of focus on medical device integration. We have over 225 ICU beds between our adult and our children’s hospital, and all of the bedside devices are interfaced directly into Epic. That’s brought a pretty significant positive return for us, and that seems to be an area that a lot of Epic’s customers are very interested in. So we actually host a number of site visits for people just interested in seeing how we do device integration.
Guerra: Very interesting. I also noticed that you’ve got a transplant center, and we haven’t touched on that yet. I’ve come across a vendor that specializes in transplant software. Is that, in your opinion, something extremely unique, or have you found you need special tools or software to handle that?
Carmen: Well, that’s actually a wonderful story from our organization. We are a transplant center, and we went through a period in the early part from 2001 to 2006 where we didn’t have permanent leadership of our transplant program. We were under a number of interim leads while we were trying to recruit someone. At that time, the transplant program was actually more focused on some of the other aspects of their operation than their clinical systems. We successfully recruited a gentlemen — a wonderful transplant director from another center. In his previous role, and in fact, not only at his previous role but all of his training locations prior to his professional position, he was using one particular Best in KLAS transplant system.
He was so enamored with it that he was actually on their formal advisory board and so it was a very, very close relationship. When he was being recruited, we had already started our Epic journey, and he sat down with me. I have nothing but praise for the guy, because he kept a very open mind and he said, ‘Look, I’ve used this system. I know it works. This is what I want to do. I want to partner with you to go and acquire this.’ And I said, ‘I appreciate your perspective,’ and at the time, Epic’s transplant module wasn’t really ready for primetime, according to our clinicians. I said, ‘we work on a premise that we think there’s great value in integration of the data.’ And when you look at the continuum of care that a patient will experience here, from ambulatory to inpatient and across all the services and through the perioperative environment and all the interactions and issues with medication management, we feel very strongly that the advantages of a highly integrated system outweigh the potential functional shortcomings.
So I bargained with him and said what I’d like to do is have you work with us and work with Epic to implement their transplant module. We basically agreed to put a large chunk of money effectively in escrow for a couple of years, and that chunk of money was how much it would cost to go buy the Best in KLAS transplant software. My deal with him was he would give us two years to get Epic’s transplant module in and running to his satisfaction, and if at the end of two years, it wasn’t meeting his objectives, then we would go take this money out of escrow and I would agree to wholeheartedly support and prioritize getting his transplant module in, and we actually find a little MOU (memorandum of understanding) between the two of us.
I, again, have nothing but high praise for this guy, because you can imagine in that kind of scenario the potential that the individual would not be terribly committed to making it successful and might drag their heels, and that was absolutely not the case. This individual came in with guns blazing saying, ‘this is what I want the tool to do,’ and he sat down with the development staff of Epic’s transplant module and said, ‘This is what it needs to do.’
At that time, Epic was very interested in having some more transplant partners to work closely with so they jumped on the opportunity, and well before the two-year mark he came to me and said, ‘I’m incredibly satisfied with what we have. We’re on the right path. We’re going to be able to do so much more that we would have been able to do with a stand-alone system.’ And he said we can eliminate the escrow account. Our direction was set, and he was happy with that. That’s been a really positive success story for us. Again, it’s a great partnership, largely driven by a physician being open-minded and really engaged to try and bring the best possible solution to the institution.
Guerra: I think that’s a fantastic story and shows a lot of creativity. What I was thinking when you were saying it is I can imagine you getting a call from a higher up, whoever hired this highly sought-after and prized gentleman, to run this transplant center and said, ‘Lee, just give this guy what he wants. Do you know what we went through to get him and you’re giving him a hard time? If he wants his system, get him his system.’ Did anything like that happen?
Carmen: I’m incredibly fortunate that I have senior leaders here that have been very engaged with decision making in terms of what we want for our information architecture and our information strategy. They’ve been very engaged. They’ve embrace the strategy of a single integrated system across all of our service lines, and certainly if my insistence had pushed it to the point where the individual may not have come, we might have had a different discussion. But again, because of how great this guy was, it worked, and actually that set a precedent for future recruits that I’ve been involved with very closely. I get involved very early in the recruitment stage, and as you can imagine in the market now, there’s a lot of interest in data analytics and big data and genomics and that’s certainly an emphasis for our biomedical research enterprise. And so I’m very fortunate that I’m at the table very early and can have discussions with initial candidates as to what are their interests and what are their directions.
I’ve been lucky through past partnerships to have some really good, compelling stories to share, and I think I’ve been able to establish a pretty good degree of trust with our clinical leaders that they can also articulate to the candidates to say, ‘If this guy says he’s going to do something, he’s going to do it.’ We have a new chairman of our pathology department, who will be coming on board soon, and we followed the same model where I sat down with the candidates early and once an individual was identified as the leading candidate, we got very aggressively into the discussions about IT and systems.
I think the key is having good, positive communication. I don’t come into it saying, ‘here’s a list of 10 things that you’re going to do, and like it or not, this is what you’re going to do, and so lump it.’ I sit down and have a very constructive dialogue with them and there are things that I give on that perhaps in the ideal world I would prefer not to be that situation, but I understand it from a clinical perspective, and we can make allowances for those so that it’s a win for everybody.
Guerra: Like I said, I really like the creativity that went into making it work. I think when people hear this story it’s going to get their creative juices flowing. I don’t know if they’ll get the leeway that you got in terms that MOU and escrow account. It’s great that you were given the freedom to actually structure this and someone signed off and said, ‘yeah, go ahead and do that.’
Carmen: Yeah, again, I have an incredible senior management team here that really works together.
Guerra: So in terms of creativity, any other thoughts for your colleagues around being creative? You’ve got an idea in your head of what you want to do. It’s not going to go smooth when you pitch it, but the idea of bringing some creativity to the table to make it work.
Carmen: I find that in my enterprise, often you really have to get out of the box on how you approach some of the problems. One of the greatest challenges about the CIO role, and I think one of the greatest benefits of the CIO role, is that you can never predict what’s going to hit you. Every day brings a new learning opportunity and a new challenge in trying to leverage the assets at your disposal. And in my case, I have a lot of assets. I have a phenomenal workforce working for me. We didn’t mention this, but I also have the advantage that I am administratively responsible for bioengineering. So I’m able to leverage those parties as well to achieve the goals of the organization. We’ve been able to demonstrate success on past projects, and sometimes the proposals have been kind of crazy. But we’ve been able to execute them to everybody’s satisfaction, and because of that, that’s built up a trust factor that the organization has for us going forward.
One of the initiatives that we started about two years ago is we have 12 critical access hospitals that are associated with our organization, and as the whole Meaningful Use program started to ramp up, many of the critical access hospitals in a state like ours, where there’s significantly rural populations that are very underserved, it’s very tough to get clinical staff to work there. It’s certainly tough to get IT staff there. They just didn’t have the resources to do advanced IT systems. So one of our critical access hospital CEOs came to me and said, ‘We’ve been looking at clinical systems and the only one that really appeals to us is Epic. But Epic won’t sell to us because we’re not in the market demographic that Epic sells to. Can we work out a deal where you guys run Epic for us?’
Initially, when we ran the numbers, it looked like there was a way to make this work, but it wasn’t something we wanted to do as a service line for revenue generation. That wasn’t our motivation just to bring in an additional revenue stream. We were trying to see how this would help us at a grander scale. We started looking at the referral patterns from this particular hospital and we saw that we happen to get a lot of stroke referrals. We happen to get a lot of neonatal or high risk maternal patients sent to us from this group. And we started to think about how integration of data might really help our providers and provide better care to that part of the state.
Initially, our leadership team was like, ‘are you crazy? Why would we do that, particularly when there are so many other IT projects that we want your team prioritized against?’ It took us about 18 months of modeling, pitching, going back to the drawing board, and working with the CEO at the critical access hospital. All at the same time, the federal government is kind of adjusting their program, so we’re trying to compensate for that.
We ended up coming up with a model that we thought would work for us and for the critical access hospital. It’s revenue-neutral, but it affords us the ability to build on the existing referral pattern and to help the patient population that comes through that critical access hospital.We went live at the end of September with that hospital, and even in the month or six week since it’s been live, we’ve had a number of cases of trauma patients coming to their ED that got transferred up here, neonates, stroke patients, those kinds of populations that have come through, as well as patients of ours like transplant patients who live down in that region and can get their follow-up care down there.
And so the tighter data integration — we’re really seeing the benefits of that now. We’re now starting to explore with that hospital expanding our clinical trials out to that patient population. That’s good for us, because that expands the size of our pool and the diversity of our pool for clinical trials. That’s great for that patient population, because they’re getting the earlier access for consideration for some of these clinical trials for which before they would not have been considered. Again, these kinds of things they take a lot of work to set up and they take a lot of trust and collaboration amongst disparate groups, but once you get them working, they yield other benefits downstream.
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