The word “innovation” is tossed around a lot these days, but when your organization is located at “the nexus of IT” — a neighborhood in Boston that houses some of the most cutting-edge IT shops in the country — it’s not just a term; it’s a way of life. It means having a long history of development while also being willing to utilize (and customize) commercial products; it means developing an innovation program to help bring ideas to life; and it means partnering with other organizations when the right tools aren’t available. In this interview, Dan Nigrin talks about what it’s like to be a Cerner-Epic shop, his organization’s data warehousing and analytics strategy, the other “CIO” at Children’s, and the unique collaboration among children’s hospital leaders.
- About Boston Children’s
- Collaboration in Boston’s “Nexus of IT”
- Being a Cerner/Epic shop — “We have a pretty nice flow of data back and forth”
- From a self-developed system to commercial platform — “The expense was just not going to be sustainable”
- Room for customization
- Leveraging Cerner’s experience with pediatrics
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When you think about things like regional healthcare and data exchange, in many instances you’ll find Massachusetts tends to be out in front, and I think that’s in large measure due to this environment of cooperation.
I’d be lying if I said that at times there are not instances where it does create a little bit more work for us, but all in all, I think the environment we’ve got is working well.
There are still little pockets where we find that the off-the-shelf offerings are not sufficient for our needs, and in those cases we have no reluctance at all to custom develop.
We span from 25-week, preterm newborns all the way to 18-year-old, 250-pound football players, and dosing of medications for those two extremes is not necessarily straightforward. And so we wanted to be sure that the systems that we were implementing were going to be able to accommodate that degree of complexity.
Gamble: Hi Dan, thank you so much for taking the time to speak with us today.
Nigrin: Hi Kate, how are you?
Gamble: Good, thanks. To give us the lay of the land, can you tell the readers and listeners a little bit about Boston Children’s Hospital?
Nigrin: Boston Children’s Hospital is a longstanding pediatric-only organization in Boston. We’ve been around for quite some time. The organization was founded in 1869. It’s the primary pediatric teaching hospital for Harvard Medical School. We do a lot of patient care. We’re about 400-bed institution. We also have a very large research component here at Boston Children’s. We’re one of the largest pediatric research enterprises in the country. I think that’s about it, in a nutshell.
Gamble: What do you have in terms of bed size?
Nigrin: It’s about 400 beds. We have roughly 30,000 discharges a year, and around 600,000 outpatient visits in a year, on the order of about 75,000 emergency room visits.
Gamble: I imagine you’re doing a good bit of referrals with other organizations.
Nigrin: Absolutely. We’re not part of a larger IDN. We’re fiercely independent, so we’re not part of a system or anything like that, but we do obviously get referrals from all of our surrounding systems and institutions in the general area here in New England. We obviously also do get referrals national and internationally. It comprises a large portion of our business because we do have many of the leading pediatric experts here at the institution who do things that are just not done in other places and care for some unique and rare disorders that are not covered by many other institutions.
Gamble: Are you actually located within the city?
Nigrin: Yeah, we’re in downtown Boston in a place called the Longwood Medical Area, which is a medical community here in Boston. Harvard Medical School is right next door, Beth Israel Hospital is across the street, and we have Dana Farber Cancer Institute and Joslin Diabetes Center. We’re all located within a three or four block radius, which is neat because there’s such a large concentration of high-end medical care and medical care professionals. It makes for an exciting environment. It also makes it a little bit challenging just because of space constraints. Other than IT resources, space is generally the biggest commodity in all of these institutions. So if you’re looking to expand the size of your staff or get a new office or anything like that, you’re pretty much out of luck. It’s a big challenge.
Gamble: That’s got to be an interesting neighborhood to work in.
Nigrin: It’s definitely exciting. I don’t want to taint the excitement by talking about the challenges around space. It’s a neat place to work just because you’ve got some of the world’s experts — not just in pediatrics, but in adult medicine as well, and especially in IT. The Boston area has long been a nexus for folks who have been thinking about healthcare IT, and many of the leading research organizations that think about medical informatics are based right here in the Longwood area and the greater Boston area.
Gamble: That’s very cool. It’s not just coincidence that we’ve talked to a good number of people from Massachusetts and from Boston in particular.
Nigrin: Absolutely. What’s great about the community is that despite the fact that we all work for different organizations — and in some instances, competing organizations where we vie for the same patients — in the IT community, there’s generally a lot of cooperation and collegiality and a spirit of working together to solve common problems. That’s been present really for as long as I can remember and it continues through to this day. When you think about things like regional healthcare, data exchange, and things like that, in many instances you’ll find Massachusetts tends to be out in front, and I think that’s in large measure due to this environment of cooperation that we’ve got, which is nice.
Gamble: Definitely. Let’s talk a little bit about the clinical application environment. What type of systems are you using?
Nigrin: We’ve got a little bit of a unique situation at Boston Children’s. We have essentially two major vendor-based systems in place, both Cerner and Epic. It’s not common that you’ll find both of those present in the same organization, but we do have that. The way I like to describe it is that Cerner comprises most of the applications that are clinician-facing; so the docs, the nurses, the pharmacists, the respiratory therapists, etc. are primarily interacting with Cerner applications on a daily basis. The Epic applications are clinical in nature but tend to comprise what are considered more the back-office functions. Some of the more administrative things so ADT, registration, hospital and professional billing, scheduling, HIM — all of those things are on our Epic platform. We’ve had both of those systems in place now for quite some time. And although we do have the challenges of interfacing them, we wrestled with them in the distant past, and we now have a pretty nice seamless flow of data back and forth between them.
Gamble: Is it something where you’re looking to eventually transition to one, or does it seems to work having the two systems?
Nigrin: Right now for most of our needs it’s definitely stable and working well, and I don’t see any reason in the near term that we would consider swapping one out for another. I’d be lying if I said that at times there are not instances where it does create a little bit more work for us, but all in all, I think the environment we’ve got is working well.
What I should probably say is that historically — maybe up until the late 90s — we were an organization that was predominantly best of breed, and/or where we developed things in‑house. That’s the other thing about Boston; it’s got this long history of custom development. Obviously, down the road at Mass General things like MUMPS were developed. And in fact, across the street at CareGroup at Beth Israel, they are still using their in-house developed systems predominantly.
We also grew up in that environment and have plenty of our own self-developed stuff. But around the late 90s/early 2000s, we made a decision that we wanted to start to think about a transition to a commercial platform simply because, a) we felt that the commercial offerings had improved to the degree that we were more comfortable in being able to use them and have most of the pediatric functionality that we needed, and b) we started to realize that the expense both in people and other resources in maintaining those custom developed systems was just not going to be sustainable in the long term. So that prompted the decision to move toward a commercial set of systems.
That said, there are still little pockets where we find that the off-the-shelf offerings are not sufficient for our needs, and in those cases we have no reluctance at all to custom develop. And actually, the tools are quite nice now with respect to the vendor offerings in that they allow you to incorporate some of that custom development within the framework of the commercial offering that the end user may not even detect if they’re in the middle of some custom development within the application. So it’s a nice end user experience, but it also allows us to custom develop where we need to.
Gamble: Was it a deliberate strategy or did you just end up with the two and then things kind of evolved that way as far as having two major vendors?
Nigrin: The way I usually answer this question — and I do get it a lot — is it’s a lot about timing. We had already implemented Epic’s solution for scheduling, and we followed that soon after with the conversion of the registration and hospital billing functions. And we were very satisfied with them. We felt the company was strong and the products were working well. We love them. So clearly when we were thinking about implementation of the more clinically facing systems, Epic was a consideration.
But at the time — and again, this was in the early 2000s — Epic had not had nearly the penetration that they have today within the inpatient space. They were predominantly focused on the ambulatory setting, so we had a concern about whether or not they would be able to capture the degree of complexity that we had in a tertiary care, pediatric organization like ours, especially around things like medication safety and the complexity therein. That was one reason that we were a little bit reluctant. Again, this was pre-Kaiser, before all of the big deals that Epic subsequently was able to gain.
The other is just a specific focus on pediatrics. When we were evaluating Cerner, they had a stated and explicit emphasis on trying to improve their offerings around pediatrics, specifically in medication safety, which we were quite focused on. Any pediatrician knows that dosing is more complex when you’re considering pediatric patients. Obviously, we span from 25-week, preterm newborns all the way to 18-year-old, 250-pound football players, and dosing of medications for those two extremes is not necessarily straightforward. And so we wanted to be sure that the systems that we were implementing were going to be able to accommodate that degree of complexity. Cerner really did have that stated goal as well and were explicit with it, and so those were the primary two reasons behind our decision.