James Wellman, CIO, Comanche County Memorial Hospital, Chapter 1

When James Wellman arrived at Comanche County, he was met with a thorough to-do list. The data center and network needed an overhaul, the current EHR system was fading into the sunset, and the hospital had “lost faith” in the IT department. But instead of running away, Wellman rolled up his sleeves and got to work. His first priority was to move IT away from “bandaid patching mode” and provide some much-needed stability, and then it was time to make some changes, which included transitioning to McKesson Paragon, and introducing a new approach to vendor partnerships. In this interview, he talks about selling to vendors like EMC and Brocade (instead of the other way around), what he learned from the job he didn’t get, why it’s wise to line up with large health systems rather than try to compete, and how to make changes without changing everything.

 Chapter 1

• About Comanche County
• McKesson in acute, eClinicalWorks in ambulatory
• Transition from Horizon to Paragon — “It was quite an interesting challenge.”
• Outsourced IT & the “added layer of complexity.”
• Attesting to MU — “It wasn’t ‘we barely made it.’
• Continued optimization with Paragon 13 — “It’s another opportunity to tackle.”

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Bold Statements

I inherited a little bit of an opportunity there. There had been a significant amount of turnover with some of my predecessors over that period of time, so continuity was an issue.

It is a bit of a confidence shaker, because that meant the decisions you’d made years ago — were they still the right decision?

Our question came in as, how many other hospitals are going to do this, and did they have the support staff and the expertise to provide to us to make that transition.

The physicians are much happier — I don’t know if they’re ever going to be totally happy, but they’re happier because we’ve reduced clicks and improved workflow, and so there’s a continuation there.

The change is a good change. We’ll do the next best thing, and that’s what’s best for our patients and our families. So from our perspective, it’s a good thing and we look at it as a positive thing.

Gamble:  Hi James, thank you so much for taking the time to speak with us today.

Wellman:  Hi Kate, it’s nice to hear from you.

Gamble:  You too. To give a little bit of information for our readers and listeners, can you just talk a little bit about Comanche County Memorial Hospital in terms of bed size, ambulatory care, things like that.

Wellman:  Comanche County is a 61-year-old hospital that was formed by private donations for the betterment of the community, and they set that up quite a while ago. It is now a full service, 283-bed hospital. We’re the largest hospital in Western Oklahoma, west of Oklahoma City, and we’re one of the larger hospitals in the state, when you get outside of Tulsa and Oklahoma City.

We are a full service standalone hospital. We operate on authority with a board and we have some management over another hospital that is nearby. We run a nursing home and a durable medical equipment business. We take care of all the ambulance services for this county and parts of the surrounding counties as well. As the years have gone by and a lot of hospitals in smaller areas — I’m sure you see this nationwide — have closed, you’ll see some that have grown and picked up some of those extras, and that’s the mission that we have right now at Comanche County.

Gamble:  Is it a fairly rural area where you’re located?

Wellman:  We’re actually in Fort Sill/Lawton, Oklahoma.  It’s the third largest city, if you count metropolitan areas from around Oklahoma City as all part of that area.

We’re not considered rural; there’s no special compensation we get from the government for being in a rural area. We have rural clinics, but our area itself because of our proximity to Fort Sill and some large manufacturing plants, specifically Goodyear, we have a little over 100,000 people in the city and a demographic area of about 300,000 that we serve. So it’s in between growing city and a small-town feel because in 10 minutes and you can be out in the country.

Gamble:  Okay. And we’ll get into this more in a little while, but how long have you been there?

Wellman:  I’ve been at the Comanche County a little over four years.

Gamble:  So let’s talk about the clinical application environment. At this point, are you on McKesson Paragon?

Wellman:  Yes, we are McKesson Paragon for our inpatient, and we use pretty much everything McKesson from that standpoint, from our pharmacy to our lab. We are using the McKesson lab products and Accenture for our automation as McKesson sold that area.

In ambulatory we have eClinicalWorks and we’ve merged those two. So we have actually two instances of Paragon that we support both here and at a hospital that we manage in Frederick, Oklahoma, and then we have two instances of eCW. We have it for our full clinic here and then we also have a federally qualified healthcare center, Lawton Community Health Center, and they run a different instance of ECW. So those present some different challenges as well because even though we’re all under one umbrella, I have four disparate systems there.

Gamble:  Is that just the way things are going to be, or is it something you’re hoping to change down the line?

Wellman:  I would like to change it down the line. It’s not, from my perspective, a very efficient component. Being a standalone hospital and running a full EMR all by yourself can be an expensive endeavor. So for a hospital like us it’s manageable, but when we look at this much smaller hospital that we help manage, that’s quite a burden on them financially. So we’ve been investigating making that an add-on facility, and that would co-mingle our clinical data and keep the financial data separate. Even though we do have a management clause with them, we have to have that ability should the need ever arise to make sure it’s a clean separation and break.

It’s the same with eCW. That was a matter of timing. When those came in, before I arrived, Lawton Community Health Center (LCHC) had already started up with eCW and the hospital was in the decision component at that time between going at that time with Horizon Ambulatory Care or another product, and they ended up opting for eCW. So we ended up with those two separate instances and we’re investigating that as well right now to merge them. That way our physicians aren’t working on multiple systems, I’m not having to do multiple upgrades, and you’ve got continuity no matter where you go.

Gamble:  Yeah, that’s certainly not ideal. Let’s talk a little bit about Paragon. When was that selected?

Wellman:  So the hospital, before I ever arrived, signed a contract with McKesson to go full Horizon around 2007, and they were on that path when I showed up at the end of 2010. We went live with our CPOE less than 90 days after I arrived. I inherited a little bit of an opportunity there. There had been a significant amount of turnover with some of my predecessors over that period of time, so continuity was an issue. And then we were just stabilizing the system, getting everything set up, and we were running that for a year.

During that year (2011), McKesson started making some inroads and talking about their future, and they launched an initiative called Better Health 2020. At that point, they were seeking out transition sites that would make the switch from Horizon to Paragon. We were at a fairly good point in the road from their perspective. We had a solid foundation, but we were not so fully committed and implemented at that point that it would be like turning an aircraft carrier. We were actually more nimble and able to do that. They approached us at the beginning of 2012 to talk about this. We went back and talked to all of our clinical staff, which also involved the medical staff, and at that point they came back and agreed that the Paragon was the best selection, and that switching out completely wholesale would not be a very cost-effective means for us.

Within 13 months of that, we went live, on March 25, 2013, with Paragon 11. It was a big-bang, wholesale switch, and that meant we had to bring up an entirely new physical infrastructure to port all those systems, build it, and meanwhile maintain everything that we already had in place. So we essentially had two systems running for about a year at that point. It was quite an interesting challenge.

Gamble:  Yeah, I can imagine. What were the initial thoughts when you were approached by McKesson? I know that you said that you were in a reasonable spot as far as this goes, but still.

Wellman:  Honestly, it kind of shakes you. For McKesson, being such a large player in the industry, that’s quite an endeavor for them to come back and say, ‘we’re going to take essentially our largest base with our largest hospitals and start ultimately migrating away from it.’ While they never came out at that time and said that they were going to sunset the Horizon product, I think in the user community when all of this started, we all said that was the shot over the bow, and in the near future they will be sunsetting Horizon. Now in 2015, it’s much more formalized that it’s happening and we’re seeing in those products sunsetting. They had to do that in regards to competition in the market.

So when you’re with that vendor, that shakes your confidence a little bit. It makes you nervous. The Paragon product had a good reputation; it had been primarily sold as a smaller hospital solution even though it had more than enough capability and there were hospitals larger than ours using the product.

But still, it is a bit of a confidence shaker, because that meant the decisions you’d made years ago — were they still the right decision? Financially it’s very concerning as well, because again, we don’t have a lot of options in who we could switch to and what we could do, and they had invested quite heavily into the McKesson product.

Gamble:  That’s a really interesting curveball to be thrown, and then you had to deal also with having those two systems running for quite a while.

Wellman:  For a year we maintained two systems. Now the upside was for the McKesson product, the legal medical record is now McKesson Patient Folder, previously Horizon Patient Folder. The upside is we did not have to take all that data and migrate it, and that is quite a substantial time saver and headache saver, because unlike switching wholesale from, let’s say, Cerner to Epic, you’re not having to pull all that data and migrate those databases and put everything in. They used the exact same legal medical record. So that part of it made the transition much easier.

Gamble:  Being one of these transition sites, it’s not something where Paragon wasn’t being used. Like you said, it was certainly being used in a lot of hospitals at that point. But to be one of the transition sites, I could imagine there may have been some hesitation there.

Wellman:  There was concern, and unfortunately, it played out to some degree. While we were approached, a lot of hospitals were looking at Meaningful Use and getting on the tail end so you could just make Meaningful Use stage 1. That’s what we were looking at; we were right at that point where we had to make a decision on what we wanted to go with. We could have stayed with the Horizon product and met Meaningful Use, or we have to decide right then to make that transition.

So that was a bit scary, and then our question came in as, how many other hospitals are going to do this, and did they have the support staff and the expertise to provide to us to make that transition. They admittedly came back after our implementation and a few other hospitals and said, no, they did not. They were a little thin and they acknowledged that, and they’ve been working with a lot of us since then. But you had a lot of really good solid people and they had been working on a much more controlled implementation. Now suddenly 50 hospitals are switching. That’s quite an endeavor for them, and so supporting that spread their ranks a little bit thin. And while they could hire the people, they can’t hire that direct expertise to do it. That was a little tougher. So those brought some challenges to us, and the continuity was not quite as what we would want it to be.

Gamble:  Right. So now at this point are you kind of optimization mode?

Wellman:  Yes. You put the product in, you’ve done all of your training, and at that time, just to further complicate matters, we were a fully outsourced IT shop with McKesson. And that contract was actually coming to an end a year after the implementation of Paragon.

So during that first rollout, the hospital itself had a staff that was overseeing a large portion of the build for Paragon and putting all that together, and they didn’t have a lot of experience doing that. They hired several outside companies to come in and help with that and some third-party groups, and then the IT shop was kind of sitting there in the middle. They were caught in a very gray area on what to do. They saw the challenges, but also, those were the people they were reporting to, and so it’s a really tough message. It just further added a layer of complexity to everything in our optimization. So it went in, we had some initial problems.

And at that point, the hospital administration came in and moved all of that under the IT department, and so the IT department then rallied around that and started working with the hospital group and broke down any type barriers or walls, and really started on the optimization. It’s been doing that ever since. They met stage 1 Meaningful Use successfully, passed the audit, went into stage 1, year 2, and successfully tested there as well, and with large numbers. It wasn’t ‘we barely made it.’ We had 95 percent of the physicians using the system as expected, and most of the numbers there are just part of it because of our either turnover or locums or some of our contracted physicians who weren’t quite ready to use the system. Training that quickly is another tough endeavor, but we’ve overcome that as well.

There’s been a continued optimization of the system. We made the transition to Paragon 12 from 11, and that was a very big change. They’ve done a continual improvement, and that’s what they’ve been doing ever since. We’ve upgraded to 12.1 recently. The physicians are much happier — I don’t know if they’re ever going to be totally happy, but they’re happier because we’ve reduced clicks and improved workflow, and so there’s a continuation there. We have a pretty good plan, and we’re watching McKesson is going to do, because they have, in their eyes, a game-changer product in Paragon 13, and it is essentially a complete rewrite of the program.

Gamble:  That’s got to be a little daunting to hear that.

Wellman:  Yeah, because that means essentially I’m going to be right back where I started three years ago. We’ll have to build and put in a whole other infrastructure system in the data centers, new servers — everything set up just to implement this system. And as we know in IT, that doesn’t mean just one system. I’m going to be putting in multiple systems. Right now I have three instances of Paragon running. I have a full development, a test and then our production, and I will have to do the same thing on the other system; granted I don’t have to put all three right from the get-go, but within close proximity as soon as we go live, and shut down one and turn on the other one. I still have three systems running. I’m landlocked in my facility, so that presents different challenges in our data centers, so we’ve had to do a lot of work and transition there. And so we’ll put in another system, meanwhile running the full system that we have and doing day-to-day support on that and running the hospital. But at this point, we feel like we’re fairly experienced in that regard. So we look at this one as just another opportunity to go and tackle.

Gamble:  Yeah, a very positive way of looking at it.

Wellman:  That’s something we actually changed in this organization from the morale perspective. I can lead and complain and say, woe is me, and that in turn will migrate into the staff and they’ll feel that, and it’s not. It’s a continual change. In IT, while we have a challenge, the change is a good change. We’ll do the next best thing, and that’s what’s best for our patients and our families. So from our perspective, it’s a good thing and we look at it as a positive thing.

Chapter 2