Gene Thomas can tell you the precise date and time his team ‘flipped the switch,’ going from three EHR systems to one. It was a big move, one that Thomas believes has placed the organization on the right track. But it’s also a move that required a great deal of planning and discipline, and came with challenges no one could anticipate. In this interview, he shares some of the lessons learned in leading a big-bang implementation, what it will take to go from stabilization mode to optimization mode, and the many hats CIOs must wear. Thomas also talks about the his team’s big plans for analytics (and what they’re doing to set the stage), his thoughts on patient engagement, and how he has benefited from his previous career experience.
- About Memorial Hospital Gulfport
- Going big bang with Cerner Millenium — “It requires a lot of discipline.”
- Change management & avoiding knee-jerk reactions
- Cross-section representation
- Defining optimization — “We wanted the most integrated system possible”
- Robust analytics with Health Catalyst
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You quickly have to kind of dissect is this a want or need; is it just that someone doesn’t like the new workflow and therefore they put in a request to have it changed? You’ve got to be careful you don’t make too many of those, because it may not be the right change long-term.
You’ll have a group of physicians say, ‘I would like for the look or the feel or the workflow to be this way,’ but you’ve got to have a governing body. Somebody has to make decisions on behalf of the entire medical staff.
Optimization is really how do I wind up getting the return on investment and better patient experience — how do I tweak everything in every area as finely as you possible can tweak it? So we define ourselves right now probably at the tail end of our stabilization.
I don’t want to say analytics is more strategic than your EMR, but it’s obviously very strategic. Without a robust EMR, you don’t get the analytics you need.
Gamble: Hi Gene, thank you so much for taking the time to speak with us today.
Thomas: You’re welcome.
Gamble: Can you just give our readers and listeners a little bit of information about Memorial Hospital Gulfport?
Thomas: Memorial Hospital Gulfport is a not-for-profit, community-based hospital founded in 1946. We’re a 445 bed licensed facility. We have somewhere close to 90 clinics that we own and operate. We have about 3,000 employees and about 450 medical staff members, half of which are employed. We do somewhere around 400,000 ambulatory visits a year. We probably do 180,000 to 200,000 outpatient procedures, 17,000 discharges, and somewhere near 80,000 to 85,000 emergency department visits at our current volumes.
Gamble: Okay. And tell us a little bit about the area geographically.
Thomas: The main campus facility — we do have clinics in the community — but the main campus is a little less than a mile from the Gulf of Mexico where hurricanes like to hangout oddly enough. We’re about 65 miles to the east of New Orleans, right on the coast, and so we’re kind of wedged in between New Orleans and the Florida Panhandle.
Gamble: So now in terms of the clinical application environment, what do you have in place at the hospital?
Thomas: We have recently — and that means June 14, 2014 — converted and did a very large, big bang, house-wide EMR replacement. We replaced three existing systems, and the three systems are between our ED, our inpatient venue, and our clinic footprint, and went completely house-wide with Cerner Millennium installation for electronic medical record in almost all venues of care.
Gamble: How did that work as far as going big bang? Was that something that presented challenges and maybe benefits as well?
Thomas: Yes, I would say both. And this is agnostic to Cerner to some extent, but just the nature of when you do these things. Big bang has its benefits in that you’re not building multiple interfaces to Legacy systems in a more staged rollout. Big bang gives you the benefit of not having this long-term staged rollout that has pain points along the way as you bring individual venues and individual procedural areas up. So we believe that was the right decision long-term.
But certainly going big bang all at once has its challenges because you’re changing workflow holistically in almost every venue of care — except for one in our case, cardiology. It just requires more planning in advance in terms of your workflow, your build, the horizontal view between various departments and venues of care and clinics and emergency department, procedural areas, etc. So it requires some of that planning. It also requires a lot of discipline on go-live for the unanticipated consequences and unanticipated workflows that are very difficult to model and anticipate completely upfront.
Gamble: Right. How were you able to try to anticipate those things or try to work out ahead of time some of the problems you might run into?
Thomas: You do it as best as you can, but specifically what we did is we went through some pretty detailed workflow sessions to say, here’s current state, what is future state going to be? We still had to learn what I call the nuances — and I’ll rephrase that as say the benefits — of an integrated system, because we didn’t have an integrated system before. So we did a lot of workflow modeling. Here’s current state, here’s what the future state is going to look like. We relied on Cerner quite a bit. They’ve got a lot of experience doing this, so they were a good partner in helping us understand those things. We tried to pay a lot of attention to the inevitable workarounds that happen upon go-live when things or people just function differently than you anticipated. And although we still had some workarounds, we quickly tried to say, what was our modeling of workflows beforehand, and what do we need to change to either make a workaround change to our model of ideal workflow, or change the workflow we thought we needed to now what we actually need based on reality?
Gamble: As far as that change management piece, was there anything that you can offer as a takeaway is terms of handling what can be a pretty big change in the way that people do their jobs?
Thomas: Yeah, I can offer some specific comments there. The caution is, be careful of what I call the kneejerk reactions upon go-live, which is, ‘I want to change something.’ Something goes into the change management queue and you quickly have to kind of dissect is this a want or need; is it just that someone — whoever that someone may be — doesn’t like the new workflow and therefore they put in a request to have it changed? You’ve got to be careful you don’t make too many of those, because it may not be the right change long-term.
The second is you’ve got to have a pretty disciplined change management process. I would suggest that even though it’s not obvious upfront, if you’re going with integrated system, I’ll qualify it as such, make sure you’ve got a good cross-functional group that’s reviewing the changes. From time to time, we would have a change come through that made perfect sense for a particular area, but we didn’t fully understand the upstream or downstream consequences of that change. And so while you go through that investigative and, therefore, resulting approval process, you need to have a good cross functional group that understands how it may or may not impact an area, upstream or downstream. That’s a really important point if I was advising someone doing a big bang implementation.
Gamble: Right. That is a really good point and I’m sure there’s that temptation to want to make everybody happy, but there’s never going to be a scenario where everybody has the exact situation they want as far as workflow.
Thomas: That is correct. You really need to make sure that the medical staff understands the new workflow — a lot of care of course is predicated on the medical staff and the orders that they place. And rightfully so, you’ll have a group of physicians say, ‘I would like for the look or the feel or the workflow to be this way,’ but you’ve got to have a governing body. Somebody has to make decisions on behalf of the entire medical staff. Because you will have a group of physicians, either in a specialty area or high-volume physicians say ‘I really would like these lab results to be this color.’ Well, those are global changes in many cases. So you’ve got to then have this body of physicians say, ‘I’m making this decision on behalf of everyone.’ That’s an important thing from a governance and change management and change control process.
Gamble: I take it that you had kind of representation from different areas.
Thomas: Medical staff or otherwise, or both?
Thomas: With the medical staff, what we did — and I started this early in the selection phase before we selected Cerner as our vendor — was create a physician advisory committee. Basically, what we did is we took the medical executive committee (MEC) and I dovetailed into their existing meetings — and they actually met once a month, so we went to twice a month. And that body, meaning the MEC, doubled as our physician advisory committee. We would meet with them literally every two weeks up until about two months ago. We’ve moved back to monthly now. So that was how it worked on the physician side.
On the procedural areas, we had a cross functional team in information systems and informatics people that would work for the departments. If I were doing it over again, I would probably have more horizontal people that were making sure as decisions were made in those particular procedural areas, or even registration, that somebody had a view of the horizontal impact. But yeah, we have multiple groups; we called them solution teams that worked on different solutions including radiology, cardiology, and lab, etc. I think we had 17 solution teams across 17 different areas.
Gamble: That’s certainly a pretty wide-scale representation there.
Thomas: Oh yeah.
Gamble: Okay, so June was when the big bang happened. At this point, are you pretty focused on optimization, or is there still some of those post go-live issues being taken care of?
Thomas: Oftentimes I answer this little tongue-in-cheek, it depends on who you ask. It was actually June 14 at 7 a.m. when we flipped the switch. It’s interesting; this industry — and this is my personal take — is definition-dependent. We call ourselves right now in the stabilization mode, probably at the tail end of that, and then that will lead into optimization. Optimization, depending how you define it, can take a long time. You want to get to the point where you’re stable and you’re operating in all of your areas and there’s smooth workflow and there’s good patient experience. Safety and quality are always there from day one. You want those there.
But then optimization is really how do I wind up getting the return on investment and better patient experience — how do I tweak everything in every area as finely as you possible can tweak it? So we define ourselves right now probably at the tail end of our stabilization, meaning we’re still changing some workflows, we’re still saying let’s redefine how this is going to work in this area, or let’s do some maintenance or configuration changes. Once we do most of that, we will then call ourselves probably in the optimization phase. But now that we’ve got a number of encounters under our belt, should we change something that might make it more efficient?
Gamble: That’s probably a far more accurate description to talk about stabilization mode. Nobody’s flipping a switch and going right from go-live to optimization.
Thomas: No. I would say — and this is tongue-in-cheek — you first go through trauma, denial, and acceptance, and then you work on stabilization.
Gamble: And then all the while, I’m sure that you’re also looking ahead to optimization and what are we going to be able to do at some point soon.
Thomas: Absolutely, and ‘some point soon’ is relative on the definition of ‘soon.’ I’ll tell you, in our case we’re pretty laser focused in that we knew we wanted to go an integrated system; with best of breed and disparate systems, it was easy to make a decision to get way from that. We knew we wanted the most integrated system possible, so we took the approach of, if Cerner had a solution, we were taking it. If they didn’t have a solution but had a partner they’d integrated with, we would take that partner’s solution as if it were theirs (theirs being Cerner’s), unless that decision could cause potential patient harm or have a negative quantifiable financial impact. So we wanted the most integrated system possible.
When you talk about optimization, we wanted that for a number of reasons. I think a lot of them are obvious, but in our case, since more than half of the medical staff is employed and we’ve got a clinic footprint of close to 85 or 90 now and growing, when you talk of population health management and continuum of care, in our market, we can actually care for most patients underneath our umbrella. And so when we talk about optimization, in our clinic footprint, it’s more than just primary care and family practice; we have specialties as well. We’ve got almost all specialties. There’s only a few that we don’t have. So when a patient enters our system through primary care and has to have specialty procedures or an inpatient procedure or they enter the system through the ED, we actually have a good view of that patient because we’ve got all the services that most patients are going to need. So our optimization really includes, how do we prepare for population management and changing payment models? How are we going to use analytics to first and foremost improve quality and outcomes — not that we have poor quality in outcomes today, but you always want to focus on that. How do we want to prepare for the changing payment models that are going to come?
There are a lot of people that will speculate on what those models will be, but I would say — and this is a personal opinion, somewhat of the institution’s opinion — we just know that it’s going to be different in the future than it is today. Optimization includes everything on the patient side and everything on the operational side to prepare for the future.
Gamble: You brought up is analytics and looking at what you’ll be able to do now that you have this information and this unified view of the patient. I wanted to talk about some of the things that you’re looking at as far as analytics.
Thomas: When we scoped the project, we strategically said not only do we need an EMR, one chart, one unified database where all clinical information goes on that patient, but we also want a robust analytics. Cerner’s got robust analytics. I would say their analytics is more robust now than it was two years ago when we were in the selection process. And so we, in addition to contracting with Cerner, we strategically planned budget-wise to go contract for robust analytics. We round up through a selection process landing on a company called Health Catalyst. I would assume at this point that a lot of people know who they are. They’re a really good company out of Salt Lake City. We were very impressed with their enterprise data warehouse and analytics. So we were able to do what at least Gartner has commented on in the past, which is a stack vendor — they’re an EW and an analytics vendor that does analytics tools and applications.
So I would say my two most important vendors as CIO right now are Cerner and Health Catalyst. Both are important for what we want to do and what we think we need to prepare for down the road. I don’t want to say analytics is more strategic than your EMR, but it’s obviously very strategic. Without a robust EMR, you don’t get the analytics you need.