[Below is the latest in a blog series in which Dale Sanders explores the “combination of fate, luck, planning and preparation that rolls together and creates a career.” Click to read Part 1 and Part 2]
My search for the leading healthcare organizations in computer-aided decision-making that met the time-critical and life-critical requirements didn’t last very long. There was only one clear leader in the published literature at that time — Intermountain Healthcare in Salt Lake City.
In 1993, I reached out to Intermountain for a meeting, starting with Al Pryor, who was the de facto CMIO. I couldn’t discuss the details of SEDA — not even its name — because the project was classified, but I could share that I was working on decision support tools for the Pentagon and was hoping to learn from Intermountain’s work in healthcare. Two other informatics leaders from Intermountain were in the discussions: Reed Gardner and Peter Haug, who demonstrated several decision support applications, including the ARDS ventilator weaning protocol and the antibiotic assistant. Later, with Peter’s assistance, we dug into the deepest pockets of the software code that was running the decision support tools on Intermountain’s HELP EMR.
Intermountain’s tools were complex, highly effective, and very useful. But they were also a sad reflection of the industry; they weren’t widely used and were inaccessible beyond the walls of Intermountain’s flagship hospital and region. I began to think that if Intermountain was the best in the industry, then rest of the industry must be in a poorer state of computerized maturity than I realized. Further research quickly confirmed that healthcare was, in fact, abysmally behind in its exploitation of computers to improve care.
I borrowed some ideas and concepts from Intermountain’s tools and took them back to the SEDA drawing table, but the poor state of healthcare computerization and decision support kept gnawing at me. I went back to my bosses at TRW and explained healthcare’s state of computerization affairs and suggested that we investigate it as a potential line of business, although it fell outside of TRW’s typical space and defense technology focus. We ended up creating a very successful line of business, doing work for clients such as Kaiser Permanente, The Cleveland Clinic, Veteran’s Affairs, the National Institute for Health, Loma Linda Hospital, and the Centers for Disease Control. Eventually we sold the business to a company called BDM, who in turn sold it to SAIC, and I left TRW to start a small software development and consulting business called Information Technology International (ITI).
We grew ITI into a 50-employee company, doing software development and data warehousing for a number of clients including Intel, Motorola, Britain’s National Health System, and the New Mexico Women, Infant and Children’s Program. But despite the success of this business, I didn’t believe I understood healthcare well enough to be a great vendor and consultant. I decided that the best way to deeply learn and understand healthcare was to become embedded in it — as an employee, not a vendor.
After two years I divested my portion of ITI and in 1997, applied for a position as a data architect at Intermountain Healthcare, willingly taking a 40 percent pay cut that I perceived as an investment in my career — like an expensive, real-world MBA. My goal was to stay in healthcare for three years, learn from the experience, and then return to the vendor and consulting space.
But after three years, I still couldn’t wrap my head around the details of the healthcare industry. I still didn’t understand it well enough to consult or build software. It was the most complicated, nonsensical practice-filled industry I’d ever been exposed to, and that was saying quite a lot given that I had worked in the US military industrial complex. My three-year commitment had now turned into 17 years, and I still don’t understand all the details of the industry.
At Intermountain, I applied the general lessons of software engineering, data management, decision support, and data warehousing that I had learned in the military as best I could to the specifics of healthcare. Eventually I succeeded, leading the design and development of Intermountain’s enterprise data warehouse, working closely with Brent James and David Burton on their visionary and transformative approach to optimizing healthcare delivery. The Intermountain EDW is still operating and has adapted quick nicely 16 years after it was initially deployed, having won at least five national awards along the way. It is a role model technology asset in a role model culture of care — a perfect combination for success. I also served as the Regional Director of Medical Informatics for their flagship and largest region, which gave me an invaluable opportunity to work closely with physicians and nurses in care delivery while learning the details of Intermountain’s homegrown EMR — the HELP system.
The transition into Intermountain and healthcare was not easy for me, culturally. In fact — and some will be surprised to hear this — my eight years at Intermountain were the most stressful years of my professional career. In part it was my fault because my insistent and impatient personality couldn’t tolerate the nonsense that existed in the industry. Both the processes and the technology were poor, and there seemed to be no great urgency to change that situation. The notion that you could deliver a poor quality product and achieve financial success as a result made no sense to me.
Generally speaking, Intermountain’s executive leaders, as well as the physicians and nurses, appreciated my style and commitment to making their jobs better through the IT resources that I controlled, notably the EDW and HELP. The employees who worked directly for me were consistently among the most satisfied in the company. But despite success in these areas, I ruffled a lot of feathers in Intermountain’s medical informatics culture by constantly criticizing our techniques and strategies for developing internal software. Looking back, I realize I could have been more diplomatic and patient, and yet I’m also somewhat vindicated by the accuracy of those criticisms.
Overall, my experience and association with Intermountain was invaluable, to say the least. I’ve been around the industry long enough now to understand just how far ahead Intermountain was in its approach to healthcare — at least 25 years ahead at one time. The gap is now smaller, as more organizations have finally realized that Intermountain was delivering “accountable care” decades before the federal government defined it. It is the best healthcare system in the US, and I am very hopeful that their recent decision to partner with Cerner will lead to the development of a true next generation EMR — one that delivers personalized medicine and the Triple Aim at the point of care.
And so concludes this chapter in the odd twists of fate that led my career to the healthcare industry.