Jamie Nelson, CIO, Hospital for Special Surgery, Chapter 2

Perhaps the biggest benefit in taking on a new CIO role is the grace period that comes in those early days. Jamie Nelson took full advantage of this window by tearing down the old governance structure at HSS and establishing a culture where IT is viewed as a strategic focus, along with creating steering committees to improve processes and increase transparency. In this interview, Nelson discusses the challenges in getting private practitioners on the same system, why academic medical centers are moving away from best-of-breed strategies, and the line CIOs must walk in fully leveraging IT solutions without impeding clinician workflow. She also talks about the guiding principles she learned as a consultant, the times when CIOs can’t just say “no,” and when she knew she chose the right industry.

Chapter 1

Chapter 2

• Upgrading without slowing down docs
• Technical infrastructure — “The frosting on a layer cake”
• Allscripts on the iPad
• Mobile device requests — “You can’t just say no.”
• HSS’ 5-tier strategic roadmap
• Big data plans
• Prioritizing projects in and out of silos

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One of the key challenges I have is how we use the tools that these software vendors provide us, but not let them get in the way of getting clinical practice done. We don’t want to slow people down; we want them to be able to get through their work effectively.

Like anything else, with experience it becomes much easier and faster — but you don’t even want to slow them down for a month or two. So really understanding the clinician’s workflow and how to get these systems in to optimize that workflow is important.

We’re constantly trying to make that much easier for our users. We have a lot of research that goes on and the research analysts all seem to want to dump the information using iPads, so we had to make sure that we’ve got that optimized.

The problem is that often the applications are not optimized for the smart devices yet, so the users can’t understand why they can’t bring up a system on their iPad. It’s not hospital IT’s fault; it’s because the vendors are still writing apps to match the devices.

You have to have enough discreet data to put into these tools, and also have the institutional wherewithal and ownership to use them, and that tends to be an issue. Who will own these clinical analytics projects?

Gamble:  Are there unique challenges when you are dealing with surgeons especially surgeons at the top of their field, in terms of finding ways to consider their input and their preferences when making decisions?

Nelson:  We know what their preferences are — they are about optimization and efficiency. We have a high demand here for services. We have very high quality services and we want to make our clinicians as efficient as possible. Also, I’ve done a lot of work in my prior organizations in Lean, and I’ve found that quality and efficiency are hand in hand, because when you have high quality, you don’t have a lot of mistakes and you don’t have a lot of rework, so you can get a lot more through a system. These are very high quality clinicians here with very high quality practices, so enabling them to do their work in an expedient manner is very important.

I was actually thinking about this interview before as I was driving in, and I think one of the key challenges I have is how we use the tools that these software vendors provide us, but not let them get in the way of getting clinical practice done in an effective manner. We don’t want to slow people down; we want them to be able to get through their work effectively. So balancing what the systems have to offer and what the clinicians need to get done in the work day is a challenge.

We’ll have a clinician who can see, in their outpatient practice 60 or 70 patients, and those are patients that will then come for surgery. If you add two minutes to each patient because you’re putting an electronic medical record, that’s two hours a day. That’s not tenable. So you need to figure out how to use what those electronic records are offering but not slow down or add work to a caregiver’s schedule. There’s my challenge.

Gamble:  Right. The goal is always to provide the clinicians with all the information they need at the point of care, but getting to that point is the tough part.

Nelson:  Sometimes in the beginning it’s hard, but like anything else, with experience it becomes much easier and faster — but you don’t even want to slow them down for a month or two. So really understanding the clinician’s workflow and how to get these systems in to optimize that workflow is important. I’m very lucky because many of my analysts in the IT department have professional degrees or professional experience. I have surgical PAs that are working for me. I have nurses that are working for me. I have pharmacists that are working for me in the IT department. They understand clinical processes, and it’s easier for them to go in and say, you know what, I understand what they’re trying to do here. If we could reformat this screen or move these fields, it would help. So having people with that type of background is really important.

Gamble:  Sure, it makes a big difference. Okay, obviously you have something pretty huge on your plate with deciding whether to go with an integrated system or what to do going forward. In the meantime, what are some of the other key priorities you have?

Nelson:  Well, as with every other CIO, ICD-10 and Meaningful Use are very important. We are a little bit behind the eight ball on nursing documentation so I really like to get nursing documentation in. In terms of the technical infrastructure, we want to do single sign-on. We want to build out our wireless network. Mobility is a constant challenge for us — meeting the needs of clinicians with smart phones, iPads, tablets, etc. Having the proper infrastructure in place for that is very important, so I have a lot of technical upgrades I’d like to do while we’re working on the application portfolio.

I was likening our technical infrastructure to being the frosting on a layer cake. It holds the layers together for the applications. But also, that icing on the top just makes the applications better. So if you can put in a really nice proximity badge and have single sign-on so clinicians can go from place to place and just pick up where they were in their systems and recreate their desktop and have virtual desktops behind it, that takes all the work we did on the application side and makes it even better. It really enhances it. The technical infrastructure not only builds the foundation and holds things together, but also enhances the experience. We’ve got a lot of technical projects that we’re working on as well.

Gamble:  Now because you have physicians who are not employed by the hospital, is it something where they bring in their device of choice and then you just have to work to accommodate that?

Nelson:  Yeah, it’s called an iPhone and an iPad. We already know the device of choice. 

Gamble:  Right, that’s true.

Nelson:  It really is. We’re working with our vendors right now. We’re testing with Allscripts. They have an iPad for early adopters of their iPad for their inpatient clinical system. We’ve worked very hard on making a much easier VPN connection from staff homes so it’s easier to get into their systems. We recently swapped out Good for BoxTone so it’s much easier get our email on any of these smart devices. We’re constantly trying to make that much easier for our users. We have a lot of research that goes on while patients are here and the research analysts all seem to want to dump the information using iPads, so we had to make sure that we’ve got that optimized. We know what their device of choice is.

Gamble:  I don’t know when exactly that happened, but it’s not really a contest anymore.

Nelson:  What’s happening is that consumer devices become organizational devices. The question is, if I can use this at home why can’t I use this here? So we’re playing catch-up. One of the problems is that the iPad is really a personal device. It’s not a business grade device at this point. The vendors are catching up, but the problem is that often the applications are not optimized for the smart devices yet, so the users can’t understand why they can’t bring up a system on their iPad. It’s not hospital IT’s fault; it’s because the vendors are still writing apps to match the devices. So a little bit of catch-up, but we’re getting there.

Gamble:  When this first started to happen where the iPads really started to gain a lot of traction and clinicians first started to say, ‘This is what I use at home — I want to use this for work too,’ I can imagine that your first reaction was to cringe at the idea of having all that mixed information on there with the security concerns and everything like that.

Nelson:  I think cringe is a great description, but you can’t say no. You have to figure out how can we do this. That has been our challenge. I beefed up my staff to have more experience with these tools. We’re bringing in different types of software that can make it easier and make it more secure. But also it goes back to communication. If you sit down with a clinician and say, look, I know you’d really like to use this research application on this device, but until your research company optimizes it for a tablet, it’s not really going to be effective. You can’t go through 10 web pages and hit enter and expect all that information to be there on a wireless tablet device. It’s got to be optimized for data entry on that device. Once you explain it to them, they get it.

Gamble:  The good thing is that like you said, the vendors are catching up with it so that helps.

Nelson:  Yes, they are.

Gamble:  As a specialty hospital, what type of work are you doing with data analytics and business intelligence, things like that?

Nelson:  That’s a big project for us because we don’t really have a tool. I think many hospitals are behind on that. I think once we make a final decision on our ultimate vendor solution, then we’ll start looking at analytics. My guess is that these vendors all have tools and it’s probably best to use your single vendor’s analytic tool as a basis versus starting another third party tool in.

We’re looking to really improve our analytics capacity. Right now we can show why something happened. What I really want to be able to get to is ‘what if,’ and that’s what these analytical tools will help us with. But we really need to make sure we have enough data that’s no longer text, but real data. You have to have enough discreet data to put into these tools, and also have the institutional wherewithal and ownership to use them. I think that tends to be an issue. Who will own these clinical analytics projects? It’s not IT. Is it the CMIO? Is it CMIO and nursing? Does finance get involved? Who really owns these tools in the end? Who’s the business process owner? And that’s often a hard decision.

Gamble:  When you talk about securing the funding that’s needed for IT projects, I imagine that that gets a little sticky when you are talking about something like data analytics, but it’s not just an IT project. It really touches a lot of different areas.

Nelson:  It is, but I also think that this is another thing where the use case here is tremendous, especially with the amount of research that we do. It would be very, very helpful to a lot of people. So I think for us, if we could define what the value proposition is and what benefit will come out of analytics, I don’t think it would be too hard to get the approval for funding. We have put together a 5-year strategic road map, and analytics is certainly in that road map. We’ve also been able to demonstrate when the appropriate time would be to put one of these solutions in. Again, having enough data to feed it is important, so because we have it in a logical place within our plan, I think we will get approval to go ahead with it when the time is correct.

Gamble:  Right. So one of the big challenges we hear about a lot is prioritization. It seems like something that can be a bit daunting, especially when it there are so many projects that big priorities and that kind of hinge on each other.

Nelson:  That’s one of the reasons that we have these steering committees, so they can prioritize within their areas, and then the executive committee gets a prioritized list from research, from education, from technology, and from clinical systems. We’ve prioritized within each of those silos, and the executive committee at the top that looks across silos can understand those dependencies, and then can look at all the priorities across the various silos and come up with a list that makes sense. Again, we’ve got a lot of this defined in our strategic plan. At this point we’re just trying to refine and make sure that as the years go by those priorities we set out now continue to make sense.

Gamble:  And then of course there’s the cost issue — for most organizations, the goal is to try to cut cost or at least go within a certain budget and I’m sure that that’s where it can get challenging, just in terms of trying to secure enough funds for IT or clinical projects.

Nelson:  We’ve secured the funds. The hospital understands what’s important. However, it seems that no matter how well you plan, there’s always something up that’s going to pop up. So what we have to sometimes do is say, okay, although we said that these 10 things were priority for this area for this year, now number 11 has popped up. So the question is can you look at something else and say, okay, we thought it was a priority, but we’ll move it out a little bit? Do we secure additional funding for it? But often, you have a finite set of people to do the work. So if you have 10 projects and an eleventh pops up, just by definition, because you have the same resources that are going to do it, something else will get pushed. It’s just deciding what you have to push in the end. It’s a constant juggling act, but it’s something we become very good at, I think.

Chapter 3 Coming Soon…