Bill Rieger, CIO, Flagler Hospital, Chapter 1

When he started as CIO at Flagler in 2010, Bill Rieger found himself in an interesting situation. Not only was it his first CIO role, but it was the first time the hospital had named a CIO. Instead of having big shoes to fill, Rieger had “a blank slate,” and he has leveraged that opportunity to help strengthen Flagler’s IT presence. In this interview, he talks about the challenges in migrating from one major system to another, what it was like to take over a department that was lacking in governance, the importance of having a strong CMIO in place, and why communication is absolutely critical. He also discusses his ACO plans, why he’s avoiding HIEs — for now, his social media strategy, and what he’s doing to keep his staff engaged.

Chapter 1

• About Flagler
• Migrating from Meditech to Allscripts
• Different strategies to get buy-in from physicians and nurses
• Access to inpatient records for affiliated docs
• Dealing with the fallout of Allscripts’ MyWay being pulled —“It was a little confusing.”
• Town hall meetings led by docs — not administrative leaders
• “If I can get out of the way & coach in the back ground, it’s much more effective.”

LISTEN NOW USING THE PLAYER BELOW OR CLICK HERE TO SUBSCRIBE TO OUR iTUNES PODCAST FEED

Podcast: Play in new window | Download (Duration: 13:43 — 12.6MB)

Subscribe: Apple Podcasts | Spotify | Android | Pandora | iHeartRadio | Podchaser | Podcast Index | Email | TuneIn | RSS

Bold Statements

There’s tons of documentation about people going from paper to electronic, but not too much about going from electronic to electronic. So we’ve been documenting our way through this and hopefully it will help somebody at some point down the road.

It’s a lot easier than it was 10 or 15 years ago to convince a physician to go to CPOE. I mean, what are they going to do? If they go somewhere else, they’re going to have to do the same thing, so there’s no ‘grass is greener’ with regards to their documentation and their mindset of staying on paper.

That’s probably the biggest reasoning we used — better tools at the point of care, and a better way to monitor progress while the patient is still here, and not having to wait after they leave and get some reports back from a third party.

They made it very difficult for us to communicate to our physicians. We were getting pricing directly from Allscripts and they were challenging us with pricing from Costco. We worked through all that; we finally got good messages, and then they pulled MyWay. So it has not necessarily been easy to get all those physicians on board.

It’s not been administration standing up in front of them. It’s been physician leaders standing up in front of them explaining what’s going on. I’ve been helping and coaching in the background, but it’s really been an interesting experience to watch these physicians grow leaders among themselves.

We have great conversations back and forth. But if I can get out of the way and just help and coach in the background, it’s much more effective. It’s actually been quite a leadership growing experience for me personally.

Gamble:  Hi Bill, thanks so much for joining us. Why don’t you start by giving us an overview of Flagler Hospital — bed size, affiliated physicians, things like that.

Rieger:  Sure. Flagler Hospital is located in St. Augustine, Fla. in the northeast area of the state. It’s a 335-bed stand-alone hospital. We actually do not own any of our physician offices. We have about 250 community physicians here and they are all affiliated with us and credentialed to practice medicine here at Flagler. We do own one office, but it has not been our strategy, nor is it our long-term strategy to purchase physician offices. So we’re just affiliated with all of them. But we are a full community hospital as designated by CMS, which means we have no other hospital within a 35-mile radius. There are some that come very close, but none within that radius.

Gamble:  So you’re in St. Augustine. I know that’s somewhat of a vacation destination. Are you in a situation where you have a lot of changes in patient volume by season, or is it fairly steady?

Rieger:  No, we do have seasonal volume. Over the winter months it’s a little bit heavier. I think probably one of the bigger challenges, besides just fluctuations in volume, is the workers that are here. There are a lot of seasonal workers, and then there are a lot of workers in the resort industry that are part-time/PRN, and so there a lot of uninsured workers here. We certainly have large employers in town. The county is our largest employer in town here and they’re obviously insured, but there are a large number of service industry folks that are uninsured. That actually is a problem we have here, and I imagine most vacation communities have a similar problem where they have a workforce that is largely under insured.

Gamble:  Yeah, that’s an interesting take. That’s not something I had asked about before, but it’s a really good point. I’m sure some of the facilities we have here in New Jersey — especially toward the shore area — deal with some of the same issues.

Rieger:  Yeah, we monitor bad debt in charity cases a lot. In our management meetings on a monthly basis, it’s something that we  are constantly looking at and playing budget games, if you will, with that number trying to figure out how best to manage that. We work with the county here to provide some kind of primary care for the community for the underinsured or the indigent, where there’s obviously no or minimal charge for that, but it is an issue and I imagine it is in most towns like this. It’s something we keep an eye on for sure.

Gamble:  You said that you have affiliated physician practices. Now in the hospital, as far as the clinical application environment, you’re on Allscripts, correct?

Rieger:  We’re moving to Allscripts. We’re currently on Meditech actually, and we contracted with Allscripts in August of 2011 and have been working on putting Allscripts in here. We should go live with them on July 1of this year.

Gamble:  Obviously that’s a process migrating to a different system.

Rieger:  Yeah, it’s different. There’s tons of literature out there about going from paperless to paper and the culture changes and all of that. There’s not a lot of literature and research that’s been done and resources for going from a computer system to a computer system. It’s a little bit of a different dynamic in some ways. In some ways it’s better, but in some ways it’s a little more complicated.

I’ve been in environments where you go from paper to computer and you work with the people in the change management process and say, ‘I know that’s the way we did it on paper. I know it’s what you’ve been doing for the last 20 years, but we’re going to do it more efficiently.’ You can say some things to sell them on the idea. But when you’re going from a computer to computer, it’s a little bit harder to sell efficiency as a good reason to do this or something else that makes a lot of sense going from paper to electronic. Going from electronic to electronic is a little bit different, so buy-in was a challenge, actually, in a different way than it is when you’re going from paper to electronic.

It will be interesting over the next 10 years in the industry to see what happens if more people jump systems to go from one to the other. I know it’s happening increasingly, but there’s just not a lot of historic documentation over the last 15 or 20 years of people moving. There’s tons of documentation obviously about people going from paper to electronic, but not too much about going from electronic to electronic. So we’ve been documenting our way through this and hopefully it will help somebody at some point down the road.

Gamble:  Yeah, that’s a really good point. I do imagine that’s a tough sell because you can’t use the old fallback of ‘this is going to make things easier for you.’ So what are some of the things that you can say to the clinician leaders?

Rieger:  In terms of what we have been saying to them, as far as the physicians are concerned right now, the only place we’re doing CPOE is in ED. We have Medhost in ED and it interfaces with Meditech. They’re fairly up to speed down there with regards to the physicians, but the rest of the hospital is not. The physicians are documenting on paper. The nursing documentation is all done on the computer. So with the physicians, we talk a lot about CPOE. It’s a lot easier than it was 10 years ago or 15 years ago to convince a physician to go to CPOE. I mean, what are they going to do? If they go somewhere else, they’re going to have to do the same thing, so there’s no ‘grass is greener’ with regards to their documentation and their mindset of staying on paper. It’s a little bit easier to convince them that we need to do this. There’s Meaningful Use. There are all kinds of things to help us communicate that.

But with the nurses, it was a little difficult. We’re already doing barcode and medication administration and things like that. So one of the things we talked to them about really was analytics and being able to see some things in real-time — how they’re doing and how they’re performing some quality measures in more real-time. We’re struggling, honestly, to get that out of our current system. We’ve had to put a lot of workarounds in place and the clinicians really don’t have the tools that they need at the point of care. We made a choice not to invest in that product anymore. Could we get there? I believe it’s possible, but we made a decision to go in a different direction and part of what we told them was that we would have better tools in place at the point of care and the demos and everything that they saw supported that message and that’s kind of where we have them right now.

I think that’s probably the biggest reasoning we used — better tools at the point of care, and a better way to monitor progress while the patient is still here, and not having to wait after they leave and get some reports back from a third party. More real-time monitoring about our performance. I think that’s one of the biggest reasons and one of the biggest things we use to communicate to clinicians about why we would make a change like this.

Gamble:  That is definitely an interesting component of it.

Rieger:  Yeah, it sure is.

Gamble:  Now as far as the affiliated physicians, are they going to be offered some kind of access to Allscripts?

Rieger:  They will. They’re certainly going to have access from wherever they are to the inpatient side of Allscripts. They’ll be able to do remote monitoring, ordering, and things like that through Citrix. There is a Mobile MD app Allscripts has which has some limited functionality — mostly viewing at this point, until we get into optimization, then we’ll open the door to ordering different things like that. They will have remote monitoring.

The biggest challenge with the affiliated offices was helping them get to a place where they can make a decision about what system they want in their office. We’re trying to get them to use the same system, if possible, and our discussions have been around getting them to use Allscripts. We feel that they would have the best chance for tighter integration if we had Allscripts on the inpatient side and Allscripts on the outpatient side, and I believe that’s true. We are offering a subsidy to the physicians for those who choose Allscripts. We started off with several of them going up on MyWay, and then of course in the last couple of months, they kind of pulled the plug on MyWay, and the few of them that did go from MyWay are now on a waiting list to convert over to Professional. For those who did not go up on MyWay, we’re not going to have them go up on MyWay. We’re going to wait until we can get them up on Professional, and the rest of them are going to be coming up on Professional as well.

It was a little confusing for them at first to hear that message, and a little challenging with the way that Allscripts was selling that through direct sales, and then they had the third-party partners. It wasn’t a very good sales process or channel of partners that they had. They made it very difficult for us to communicate to our physicians. We were getting pricing directly from Allscripts and they were challenging us with pricing from Costco, and it was challenging. We worked through all that; we finally got good messages and good understanding and good buy-in, and then they pulled MyWay. So it has not necessarily been easy to get all those physicians on board, but I think we have them on board now. They understand why they’re not promoting MyWay anymore and moving to Professional, so I think we’re on pretty stable ground now, but it has been a little challenging.

Gamble:  Do you have town hall-type meetings with some of the physicians? How do you usually conduct these communications with them?

Rieger:  I will tell you, I’ve heard a lot of horror stories about physicians and communications and the challenges, and I just think that we’re really blessed here in our community with a great group of physicians, because these guys take it upon themselves to communicate. They are the ones calling, organizing these town hall meetings, bringing me along, and helping. I’m providing a lot of communications, but there’s a lot of great leadership in our physician group here. They’re doing some of the leg work. They’re taking some of this responsibility upon themselves which is really, really good. That, combined with the fact that I’m sure we have the country’s best CMIO here — he’s a phenomenal guy and a great physician. He’s been in this community for 25 years, and just recently took a position as CMIO.

I think the fact that they take responsibility and that we have a great CMIO — both those things have really helped with regard to this communication, with regard to those town hall meetings and the effectiveness of them. So yeah, we have had them, but they’ve mostly been physician-led. It’s not been administration standing up in front of them. It’s been physician leaders standing up in front of them explaining what’s going on. I’ve been helping and coaching in the background, but it’s really been an interesting experience to watch these physicians grow leaders among themselves to help through this. It’s been very, very good to watch.

Gamble:  Not to lessen your role, but maybe it is better coming from physicians because obviously they relate better and maybe they can be a little more candid, a little more honest, and just talk about the day-to-day things that they deal with.

Rieger:  Yeah, no question. I don’t feel like I’m disrespected in any way or that I don’t have credibility with those guys, because I feel like I do. They listen. We have great conversations back and forth. But if I can get out of the way and just help and coach in the background, it’s much more effective. It’s actually been quite a leadership growing experience for me personally. I’ve really enjoyed working with these guys.

Chapter 2