Carolyn Byerly, CIO, Stanford Hospital & Clinics, Chapter 1

Carolyn Byerly believes vendor relationships don’t have to be so complicated. During her 11-year tenure as CIO at Stanford Hospital & Clinics, she made it a point to take the high road by being as transparent and honest as possible. The strategy served her well; she helped transform a best-of-breed shop into a Stage 7 Epic enterprise environment. In this interview, the recently “semi-retired” Byerly talks about partnering with Perot to successfully implement Epic, the criteria for selecting the right vendor, and her organization’s five-year data warehouse journey. She also discusses Stanford’s sizeable investment in securing patient data, the creation of an Innovation Council, and the attributes all CIOs should have.

Chapter 1

• About Stanford Hospitals & Clinics
• Reflecting on the Perot outsourcing
• Reflecting on the Epic rollout, and the Epic Way
• Best practices in vendor selection processes
• “They want to make money, and we want them to make money”

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Bold Statements

Cost was not really the deciding factor. It was important, but for us it was how quickly can we remediate and refresh and build the type of foundation you need in order to look at an EMR. And it was very clear that the fastest way to do it was to outsource.

I’ve been doing this for almost 40 years, and I can tell you that they are industry best practice principles which every organization should be thinking about when they’re embarking on such a large complex project as implementing an EMR.

When I come to the table and go through an evaluation, I make sure that there’s very clear decision criteria that is agreed upon before we make a decision on what solution we should purchase for Stanford.

You have to have transparency. You have to be able to have honest conversations. It’s not a test. It’s not a gain. You have to believe that you can trust them.

It’s tough to call companies and say you’ve been eliminated. I always follow up with, ‘Come talk to me. I’ll tell you why,’ and I’ll share the data with them. From my perspective, it just really works better. Everybody’s on the same page.

Guerra:  Good afternoon, Carolyn. Thanks for joining me to talk about your work at Stanford Hospital and Clinics.

Byerly:  I’m happy to talk with you, Anthony.

Guerra:  Let’s start out by giving the readers and the listeners an overview of the organization — some of the major high points to set the stage, and we’ll go from there.

Byerly:  Stanford Hospital and Clinics is part of a larger family called Stanford University and the Stanford University Medical Center. It’s been around for over 100 years. We have a large hospital and close to 43 clinics mostly on campus. Part of our growth strategy has been to build new services beyond the campus, which is part of our continuing network of care strategy for the Bay Area. We’ve got about 8,000 physicians, and about 10,000 employees. We have a HIMSS Analytics Stage 7 EMR Certification, which is the highest level that you can achieve for EMR adoption and EMR use, and we’re very proud of that. We’ve been acknowledged over the last three years as one of the most wired hospitals in the state of California and across the nation.

Guerra:  Congratulations on that. I did see that. The main hospital has over 600 beds, you said?

Byerly:  It’s probably close to 450 or 455. We are building a new hospital that we’ll open in 2018, and it’ll be close to 600 beds.

Guerra:  You were named CIO in 2002. Is that correct?

Byerly:  That’s correct.

Guerra:  Okay. And where are you with the Epic rollout? Is that finished or is it just getting started? Where is it?

Byerly:  It’s completely finished. We started it in 2006 and we finished in the fall of 2009. We implemented Epic everywhere that we could both in the inpatient and the outpatient setting and in all of our specialty clinics. We are what is called an Epic enterprise EMR environment.

Guerra:  You became CIO in 2002 and the Epic rollout started 2006. When did the Perot outsourcing happen? Was that before the Epic rollout started?

Byerly:  We signed the agreement in 2004 actually, and we did that because for us at Stanford, it was a risk mitigation strategy at the time. When I came onboard and when our CEO Martha Marsh came onboard in 2002, we realized that coming out of the merger with UCSF in the late 90s put us in what I would call a very weak position from an IT perspective to even begin to think about implementing an EMR. We were best-of-breed, loosely interfaced. We had very obsolete solutions in place, and our network was not at all robust. The infrastructure was very decentralized and had been neglected for several years.

So we looked at how quickly we could remediate all of those issues and chose to look at an outsourcing solution with remediation happening in the first 18 months of the agreement with Perot. It was not a cost savings — I want to make that clear. It was not a cost savings endeavor on the part of Stanford. We actually doubled our cost for IT as a result of it.

Guerra:  Now I imagine that you would have doubled your cost any which way to get where you needed to be, whether you outsourced or built up in-house.

Byerly:  That is absolutely right. It would have been more costly to do it ourselves, but the cost was not really the deciding factor. It was important, but for us, it was how quickly can we remediate and refresh and build the type of foundation you need in order to look at an EMR. And it was very clear that the fastest way to do it was to outsource and have the remediation and all the necessary work that needed to be done get done in the first 18 months of the agreement. Once we did that, we initiated our vendor selection process to find an enterprise EMR, because we wanted to do that as quickly as we could.

Guerra:  Epic is known for being particular about the way they do business and the customers they pick and the setup that they want the hospitals and health systems to have, and that’s all with an eye towards making sure they’re successful and ready to handle the program. I’m wondering, did they have any issue with the fact that this was an outsourced job to Perot? Did that give them pause?

Byerly:  It took them a while to understand that the outsourcing decision was a strategic partnership for Stanford, and that they were our arms and legs maintaining and supporting our IT environment and would be instrumental in implementing Epic.They have their own definition about who’s the consultant and who isn’t, and all the individuals who worked on the project had Stanford Hospital and Clinic badges — not Perot badges.

So it took them a while to realize ‘okay, this is a different relationship. They’re here for seven years. They could go another seven years.’ I think it took them a while to realize we were going to make this happen. And we did make it happen, by the way. It was the most successful project ever taken on by Stanford Hospital and Clinics, and we brought it in on time and we brought it in on budget. Our doctors adopted it, and today I think it demonstrates the highest use of an EMR possible, and that’s why we got the Stage 7 award.

Guerra:  Right. So you had to get them comfortable with your setup?

Byerly:  Yes. I do want to say that what I consider to be Epic’s guiding principles are very appropriate and very worthwhile agreeing to, and I would say they’re not just Epic’s. I’ve been doing this for almost 40 years, and I can tell you that they are industry best practice principles which every organization should be thinking about when they’re embarking on such a large complex project as implementing an EMR.

Guerra:  I guess we could even take it beyond the industry and talk about the principle that underlies their method, which is don’t take on customers if they’re not going to be successful or if you can’t make them successful. If it’s not going to work, don’t just take the check.

Byerly:  That is a guiding principle that’s almost as high on the list as never going public.

Guerra:  Right.

Byerly:  I think ‘never go public’ is number one, and that’s number two.

Guerra:  That’s number two, right. Let’s talk a little bit about the concept of values. I read some stuff about when you got together with Perot and you discussed the idea of making sure the values lined up between Stanford and Perot, and I would imagine it’s also been important to make sure the values lined up between Stanford and Epic. Talk to me about the importance of values in selecting these long-term partners.

Byerly:  It’s an important element of a decision process. I think what’s most important is the time you spend with the vendors in the decision process. I’ve always taken the approach that I stay on the high road. What I mean by the high road is I don’t have any secrets, and when I come to the table and go through an evaluation, I make sure that there’s very clear decision criteria that is agreed upon before we make a decision on what solution we should purchase for Stanford.

The reason why I believe that you get the decision criteria clear and defined and weighted is that it helps with the selection and the downscoping of the solutions that might meet your needs. When you do that and you share that criteria with the companies you’re considering to do business with and it’s all above board, they understand the definitions. They understand how they’re being evaluated and what value we’re looking for, and in many cases, the decision criteria describes the value.

One of the criteria obviously is functionality and features and other things like strategic alignment which are very important. Are they strategically aligned with the strategy that an organization is looking for going forward? Value from a decision perspective is very important. You define that first. Everybody who is part of the group that will make the decision understands the definition and they understand that we’re going to weigh this, and yes, we’re going to have different opinions, but at some point in time, if we’ve structured the definition and the process clearly, a decision can be made and will be made and it can be done in a shorter period of time. Our decision when we went with Epic was about four months. Academic medical centers are known to take years and years. So that’s one piece of it.

Then the second is how you work with an Epic or how you work with Perot. You have to have transparency. You have to be able to have honest conversations. It’s not a test. It’s not a gain. You have to believe that you can trust them. Now they want to make money. We want them to make money. I’ll be honest with you, any vendor we do business with, we want them to make money because if they’re not making money, they’re not going to be aligned with what we need and they’re not going to take us to the next level. So I always seem to treat them with mutual respect, mutual transparency, and very clear decision criteria which will help us define the value they bring to Stanford.

Guerra:  You talked about the decision criteria and putting that out there. I would imagine the side benefit is that you take the human element out of the sales process and it doesn’t become a popularity contest about which sales team was the most dynamic or these types of things. You take that out of it and make it more quantitative.

Byerly:  That’s right. There are few qualifying points in decision criteria, but yes, you have to. The worst thing — and we don’t have that here — is vendors thinking they have to call someone because they’re not getting a fair chance.  A fair chance and an honest chance is really important because, like I said, I’ve been doing this for a while, and it’s tough to call companies and say you’ve been eliminated. I always follow up with, ‘Come talk to me. I’ll tell you why,’ and I’ll share the data with them. From my perspective, it just really works better. Everybody’s on the same page, and I think you come out feeling good about it.

Guerra:  Have you had a situation where a company took you up on the offer to learn why they didn’t win the bid, and they didn’t quite take the constructive criticism the right way but tried to argue you into picking them?

Byerly:  Yes. I think back to my days at Mayo, where we just had that situation. I’m not going to name the vendor, but we had just that situation and we granted dinner. John Camoriano, MD, who was my partner and the CMIO there, we sat through a very long dinner and listened to the CEO telling us how wrong we were and that we would fail and we would regret it. But we sat there, had a nice dinner and a bottle of wine and thanked them for flying in. The next day we looked at each other and went, ‘Wow, what was that?’

Guerra:  It’s a missed opportunity for them to learn about how to maybe win the next deal.

Byerly:  Yeah.

Chapter 2