There are very few CIOs who call themselves “useless,” but that’s precisely the term used by Shafiq Rab of Hackensack University Medical Center, who says his top priority as CIO is “to make sure everybody else becomes useful.” In this interview, Rab talks about his eventful first year in the new role, during which he has focused on optimizing the Epic EMR, enhancing the infrastructure, getting predictive analytics into place, and most importantly, building relationships. He also discusses the work he’s done to obtain clinician buy-in — which involves creating “hoopla,” and talks about his plans for genomics, the technologies that are game-changers, the organization’s ACO work, and how he thinks the CIO role will evolve.
- What keeps me awake at night is cyber-security
- ACO and Team of Care
- On HIEs — the funding and competition problems
- “Patients are mobile; they don’t stay in one place.”
- The costs of it all; the keys to coming in on time and on budget
LISTEN NOW USING THE PLAYER BELOW OR CLICK HERE TO SUBSCRIBE TO OUR iTUNES PODCAST FEED
I think we are too comfortable. We are not paranoid yet. Someone once said, ‘Only the paranoid survive.’ How do I bring paranoia about security? I have not succeeded in that. We are very comfortable, because nothing has gone wrong.
Somebody has to figure out how to fund it. If nobody funds it, then how are HIEs really going to work? To be honest with you, it worries me. If nothing happens, people who are in a larger healthcare institution will be able to buy their own. But that is not sustainable.
We have to be honest with ourselves as CIOs. Can we do it or not? First we have to figure that out. Do I have the knowhow? Do I understand infrastructure? Do I understand teambuilding? Do I really understand the software? Did I ever go for training? Do I have the right people?
The first thing I do when I get a budget is decrease it by 10 or 15 percent, and that is my budget. Everybody has a contingency when you build a building, but somehow for IT, they never have a contingency.
Go to the vendors and hold them accountable. Listen to what they have to say. I fight with Epic on a daily basis. I tell them, ‘This is the way I want it. I don’t care what you do. This is the way I want it. This is the way my operation people want it.
Guerra: You talk about security; certainly that’s huge. A lot of CIOs have that as probably their number one concern, or one of their top concerns. You said you’re trying to educate yourself as much as possible, and that it’s one of your weaknesses. So there are a couple of interesting things there. One, that security is so critical because of cyber threats, and number two, I don’t know if it’s an issue of staffing, in terms of making sure you have a great security officer or educating yourself, but talk about those things a little bit.
Rab: The first thing is to understand that we have a threat. I think that for me and my institution, we all know it’s a threat. We have an information security officer. We have those things in place, but what it needs is the following. I’ll start with how this started. Again, my cloud will be ready next month so I have a private cloud now. So I have a cloud — it’s a private one, and now I want to hook up with another cloud somewhere else. Well, some of them would not even sign a BAA, thinking, ‘Oh my God, something’s going to happen.’ And then there are breaches over the public cloud, so that throws you off. That means you always have to have something onsite. And everybody’s becoming mobile, so you bring Androids and smartphones, and even though you control them — even though you can wipe them, even though you have data loss prevention so that people don’t download things, you still have internal threats.
I think we are too comfortable. That’s the word. We are not paranoid yet. Someone once said, ‘Only the paranoid survive.’ I want to bring paranoia. How do I bring paranoia about security? I have not succeeded in that. We are very comfortable, because nothing has gone wrong — not to the extent that our life is dependent on it. And also with technology like Intel Chipset, you don’t have security. I have spent millions of dollars buying different equipment and different software to protect myself, and at the same time, I have a whole security team with the compliance officer who’s teaching the entire community how to keep yourself safe. I just started enforcing that you cannot use a thumb drive to copy things.
Of course there was an outcry from our people who want to go speak at other places who asked, ‘How are we going to take the thumb drive from here to there?’ It’s hard for people to understand how to protect themselves if they lose things, or how to protect their confidentialities. What I’m saying, in a roundabout way, is that I am not sure how to bring that cultural change. Everybody loves Bruce Springsteen, so everybody would like to go to a Bruce Springsteen concert, but nobody wants to go to a cyber-security concert. You know what I’m saying?
Guerra: Yeah. Well, at least it’s a mission that you’re on, so you’ll keep working on that. One piece of news that came out of your organization was you’re doing some ACO work, working with a company called Team of Care Solutions and we both know a couple of the folks over there. Talk about your ACO work and then talk about how that may differ from HIE work that I suppose could be larger in a sense than your ACO work. But just give me some information around that stuff.
Rab: I call it connecting the dots. In healthcare, as I said before, you have catastrophic care, acute care, and preventative care, and I talked about wellness and all those things. These are different dots. With accountable care organizations, we have about 11,000 lives from Medicare that we are involved within. We saved about $11 million. Somehow the 11 number comes up all the time. TEAM of Care is helping us a lot. What it did was it brought the primary care physicians front and center. The government does not have to help. If I tell you how much they pay a primary care physician to do a physical in New York State, you’ll be laughing. Medicare does not even pay $15. You might as well become a taxi driver or a barber and you’ll make more money than being a doctor. The government talks a lot, but it’s a whole shift on healthcare change, man. Really we are pushing it and I hope it does happen and I hope more doctors go to choose primary care as their main specialty, but they are not, so it’s a big deal.
But having said that, what it did was bring the primary care physicians front and center, and it also brought the specialists to align with them. Because with specialists, let’s say a cardiac surgeons, you get a letter from a primary care doctor. So that’s one thing that happens. The second thing that happens is that the care coordination with patients becomes a little better. We have an app that tells you if a patient has come for readmission. In about 30 seconds, the PCP knows it, the case manager knows it, the doctor knows it — everybody knows it and then we try to make sure that the patient is taken care of and all the things that happens. So that also brought the care coordination the front and center. On top of that, it also brought it to our attention that it would be nice if we had doctor offices open in the evenings. Then it brought in front of us that it would be nice if we had doctor offices open on the weekends, because patients need care at different times. Those things came front and center and helped us to better serve the constituency and the patients.
On top of that, it also helped us to forge a relationship with other counties like Rockland County, which is far away from us. People who are associated with the accountable care organization and the patients that are associated with that in Hackensack are better served, and the relationship between the doctors and the patients also improves. That’s a big deal. It’s a big deal because one day I will become old — not today, but one day I will. When I become old I want everybody to take care of me nicely. I wish teleporting will be available at that time so nobody has to drive me. Those are a couple of things that have helped with our Accountable Care Organization.
Guerra: In regard to HIEs, we certainly hear it in New Jersey that the whole situation is kind of a mess; that there are multiple competing HIEs. I think one has become prominent, Jersey Health Connect, but in general, we hear that the process by which these things have been funded has not been very efficient. I’ve certainly also heard this in other states. What are your thoughts on how the government has handled the HIE money they doled out — whether or not it made any sense, and how you decide where your organization is going to make its bets when you go outside your ACO and talk about connecting up with HIEs or these type of things.
Rab: First of all, I’m a very good Monday night quarterback. I can criticize everybody, but I really have to thank President Clinton, President Bush and President Obama. All those three presidents supported the electronic healthcare. And Ted Kennedy, God bless him, he’s dead, but at least he started something and people are trying to get to it. What everybody’s forgetting is that before all of this, President Obama funded it and Tommy Thompson talked about it. All this electronic health would have never happened if people did not enforce it and funded it. So first of all, we have to give credit to the government for supporting it. We can criticize it. We can get mad about how it was handled and those other things.
As far as health information exchange is concerned, it worries me a lot, and I’ll tell you why. Even though there are NHIN protocols and we try to make it right and connect with each other, this is the lynchpin that will connect everybody together. Even though we have protocols for it, the problem is that you have to have a standardized way of connecting. Hackensack is part of Jersey Health Connect. We were the founding members, so I have a seat on the board. We had to do that because we had to qualify for Meaningful Use, so we did all that. Statewide, somehow or the other, we have to get to one way of doing it, and we have to start making sure it’s funded.
What is killing me is the following. Presently, the way Jersey Health Connect is working is that we all pay money. The hospitals are funding it. Up the road in New York, some of them have bought their own. Other CIOs who are my friends they have their own. They have Axolotl or other companies. When I was in New York, I partnered with Taconic Healthcare HIE. So there is no standardization. Some have their own, and some are going with the state HIE. So in two to three years when we really need a robust connecting thing, somebody has to figure out how to fund it. If nobody funds it, then how are HIEs really going to work? To be honest with you, it worries me. If nothing happens, people who are in a larger healthcare institution will be able to buy their own. But that is not sustainable, because as we are engulfing other hospitals and we’re trying to become larger and larger, ultimately there will be four or five bubbles. That means four or five big health systems, but they do have to connect with each other. Patients are mobile — they don’t stay in one place. They move. And that’s why we have this Portability and Accountability Act.
So in my humble opinion, I think somehow state and private entities need to sit down together one day and be open about it and say, ‘Hey guys, what is it really going to cost us? Who’s going to pay for it and who’s going to benefit it?’ Some of us still know deep in our hearts that hospitals will have to pay for it, and that’s how it will work. Until somebody funds it, there is no perpetual government funding. But it is what it is. It’s like the DMV. We can’t give DMV to Shafiq. DMV has to be done by somebody who people respect and honor.
Guerra: I respect and honor you, come on.
Rab: You know what I’m saying, brother. What I mean is that at some places, you have to have a neutral governing body. This is too much of a risk in which private entities are trying to run it and then here’s a consent form and there is a legal thing. Legal things have not started yet. Those things will happen, and then all of the sudden we’ll kill a good thing.
Guerra: You mentioned a few times about investments and spending money. We touched on it earlier in the interview that you came in under budget on your Epic implementation. Maybe you can be more specific, if you want, about what you meant. In your LinkedIn profile, it talked about implementing technology in a fiscally responsible manner. We have seen health systems that are going way over budget and having a lot of problems, and the bonds are being downgraded and they’re stopping their implementations and running out of money. What do you see happening? These systems are quite expensive. All these investments are significant. Some hospitals are operating on extremely thin margins. It doesn’t seem to make sense when you think of the books of these facilities. Where do you see all this going?
Rab: Anthony, here’s the secret sauce. You and I are friends, so I’ll be honest with you. Number one, we have to be honest with ourselves as CIOs. Can we do it or not? First we have to figure that out. Do I have the knowhow? Do I understand infrastructure? Do I understand teambuilding? Do I really understand the software? Did I ever go for training? Do I have the right people with me or not? It’s not because I have a job; I’m cruising, I’m going to retire, and I can hire three consultants I can do it. It starts with me. I have to know what it is. I’ll tell you what I did. Maybe that will help other people if you do this podcast or other people will have their own idea. Some people may know more than I do, and they will add to it.
So the way I did it is the following. We have to understand as an institution what our budget is and what we can spend. We have to do that. And so the first thing I do when I get a budget is decrease it by 10 or 15 percent, and that is my budget. Everybody has a contingency when you build a building, but somehow for IT, they never have a contingency. So you have to build your own contingency by saying in your own head, ‘I’m going to decrease my budget by 15 percent,’ and then go from there. That’s the first thing you need in the secret sauce, and it’s not that difficult.
Number one, get yourself knowledgeable about it — what are you trying to implement? Talk to 20 other people about why they have failed and what went wrong. Be totally honest about it. Talk to your friends, talk to the company, talk to an industry. Say, ‘hey, what did you do that went wrong?’ That’s what I did.
The next thing I did is build a strong team. You have to have great people. You have to have smarter people than you — smart and happy people. Without happy workers, you will never succeed. You have to have happy people, because happy people do happy things. Then, you have to have the institution behind you. It cannot be an IT project ever. Ever. It has to be an institutional project. Then, go to the vendors and hold them accountable. Listen to what they have to say. I fight with Epic on a daily basis. I tell them, ‘This is the way I want it. I don’t care what you do. This is the way I want it. This is the way my operation people want it. I don’t care what you have done; what everybody else implemented. I just want it the way I want it, and this is the way I want it.’
And deadlines are supposed to be met. Don’t come up with a fake deadline, because everybody puts on pressure. So that’s when the backbone of the CIO has to come up and stand up and say, ‘It will only go live on that day,’ and stick to it. Don’t make up fake deadlines. When those things happen, somehow things gel together, because this is what happens during implementation or building. First, you didn’t know the real costs. Oh, I forgot to buy $350,000 worth of storage. Well, how can you forget? Sometimes what happens is three people left because they were not very happy here, so now we have to hire 60 other consultants. Or, I have no clue as a CIO what Epic actually is. I’ve done it two and a half times. So I know all the hindsight and back site.
And then on top of it, if your institution is not behind you, from the janitor to the CNO to the CFO to the CIO — if it’s not their project, don’t do it, because it’s not going to happen. It’s just not going to happen. The last thing is to test it. Test it one million times before you go live, because if it doesn’t work in the test, it’s not really going to work.