When Walnut Hill Medical Center opened its doors in April of 2014, Forbes magazine called it “The hospital Steve Jobs would have built” — not because it was built from the ground-up to support cutting-edge technology, but because Walnut Hill is “founded on the premise that the patient is first,” a mantra that is evident in everything from the “15-5” rule to the design of the rooms. For Aaron Miri, the opportunity to serve as an enabler in improving patient care was too good to pass up. In this interview, he talks about what he’s learned from his mentors, his strategy to incorporate wearable technologies into everyday practice, and the challenge Walnut Hill faces of how to grow meaningfully without losing its core values.
- Attesting to MU as a new org
- Prioritization challenges — “It’s keeping up with the demand.”
- Focus on population health & HIEs
- Information blocking — “It’s cost-prohibitive”
- Pros and cons of being new – “There’s something to be said for tried and true practices.”
- Solving the process improvement Rubik’s cube
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We’re expanding bricks and mortar as well as internally by continuing to add staff and add physicians on staff as well. So how do you accommodate for that? How do you quickly grow meaningfully without losing the most important aspect of Walnut Hill, which is the culture?
We’re really looking at that data in aggregate and saying, okay, the population of folks coming in with diabetes — here’s what the number one indicators are. What can we do to get ahead of this and deal with this in a very programmatic way so we’re not just being reactive, but we’re being proactive?
When I see the marketplace big players that don’t want to talk to each other, I have to ask myself the very fundamental question, ‘Are the people making those decisions really in it for the right reasons?’ Because if you came into healthcare for anything beyond the fact that you want to take care of somebody else, you’re in the wrong industry.
Technology is a wrapper. Technology wraps good process and good people and good clinical care. You don’t look at technology to solve a process gap, and so a lot of times as we’re white-boarding out a problem to solve, it’s asking, ‘what’s the process?
When you want to start a new organization or something brand new, to make sure that you are truly comfortable with the fact that there is no road. You have to build the road.
Gamble: What are some of the other really big priorities on your plate? I’m sure you have a lot, but just what’s really pressing for you right now?
Miri: Really pressing for us is a lot of the industry mandated items — ICD-10, Meaningful Use. We are getting ready to do our stage 2 modified rule attestation come January 1. What’s interesting to Walnut Hill — and I give credit to CMS and the ONC for working with us to try to figure this out — is we are a brand new institution, and if you look at the Meaningful Use rules and regulations, it’s a little vague on how a brand new institution that opened its doors in April of 2014 is supposed to navigate all the changes that are coming. You have the proposed rules and you have all these things now with MU3 and, oh wait, modified rules for MU2 — all of those. So we had to quickly figure out what it is we need to do to be accurate, to be succinct, to be in line, and then make sure that the data is there and make sure that our clinicians are properly trained. It’s been a lot of caveats and nuances where I didn’t have the runway to quickly get to speed, and it was again, those partnerships and those quick actions of working with the ONC and so forth to get to goal. A lot of the priorities in the industry side are built around just that — what we have to do.
From an organizational perspective, it’s keeping up with the demand. We’re growing by leaps and bounds. Our service lines are getting busier, and so it’s making sure that the workflow internally is matching. As an organization, we’re expanding bricks and mortar as well as internally by continuing to add staff and add physicians on staff as well. So how do you accommodate for that? How do you quickly grow meaningfully without losing the most important aspect of Walnut Hill, which is the culture?
So a lot of what I’ve been focused on over the past six months has been 1) the technology and making sure that it’s truly integrated, (2) meeting the regulations and mandates of the industry, which are there and are very much are very real fact, and (3) making sure that the technology is not in any which way a detractor from our core competency, which is our culture, and making sure that the buy-in, the leadership, the galvanizing parts of the technology continue to play into the culture and continue to grow it, which is why you’re seeing our patients and our patient stat and our HCAP scores some of the highest in the nation.
To give you some perspective, we just won an award from HealthStream last week where we are the number one hospital in the country for medium-sized hospitals for our ED satisfaction scores. And I’ll tell you, at other facilities I’d been at that do an exception job, to have some of the types of patient experience scores that we’re receiving, I think it would’ve been just a dream, but here we’re actually doing it and we’re getting recognized in the industry for it. Again, those are the kinds of things we’re continuing to push for — what makes a difference to the patient.
Last but not the least, I have to speak about some of the population health and community health things that we’re doing. We have a lot of integration points right now as we really get our HIE into full swing. We have a private HIE we stood up. We’re integrated with multiple EMRs, multiple PCPs and physician practices. We’re really looking at that data in aggregate and saying, okay, the population of folks coming in with diabetes — here’s what the number one indicators are. What can we do to get ahead of this and deal with this in a very programmatic way so we’re not just being reactive, but we’re being proactive?
Gamble: That’s really interesting. To me it’s so fascinating, this giant step that’s being taken toward population health. It’s something where the groundwork has been being laid for so long, and now to see those steps is really cool, for lack of a better word.
Miri: It is absolutely cool. And again, it goes back to what pulled me to Walnut Hill, which was, ‘Aaron, there is no red tape. Make it happen. Let’s work it, let’s make it happen.’ That’s beautiful. If you give a CIO worth their salt an opportunity like that and say, ‘the world is your oyster, make it happen.’ We want that. We want to be different. We want to make sure that patient is first. That makes it fun; then it becomes an engineering problem, which I’ll take that any step of the way.
Gamble: Right. And you said the private HIE is working with physician practices. Those are affiliates, right?
Gamble: And then what about outside of the organizations as far data exchange with other facilities, other hospitals?
Miri: We are. What we have found is that a lot of the private smaller organizations are very eager to share data because it benefits them as much as it benefits us. The larger organizations we have to work through legalese and some of the aspects that are there. There’s a lot of momentum in the industry right now about information blocking between EMRs. And I will agree that it’s cost-prohibitive depending on the EMRs that are talking and so forth, but it’s not so much that as much as the gray space when it comes to the legalese; the potential competitive advantages that exists within a marketplace. With those sorts of things, it does take a lot of cycles to work out. But what you find commonly in healthcare — and I wouldn’t say this exists universally — very commonly is that everybody is in this industry for the right reasons. Folks want to take care of people that are coming to us in their time of need, so it’s working through the red tape with the hurdles to get to goal. So when I see in the marketplace big players that don’t want to talk to each other, I have to ask myself the very fundamental question, ‘Are the people making those decisions really in it for the right reasons?’ Because if you came into healthcare for anything beyond the fact that you want to take care of somebody else, you’re in the wrong industry. This is not about my private needs, this is about the patients.
Gamble: Absolutely. It’s really an interesting time with so much of that going on, and you just hope that the people start to see the greater good and take that into account above other factors.
Miri: I agree. I think you’re seeing a really good galvanization in the marketplace with folks on the FHIR group for HL7 and other initiatives that are grassroots-led where people that are all in it for the right reasons are saying, you know what? Enough’s enough. We’re going to do it ourselves. We’re going to figure out standards. We’re going to figure out ways. We’re going to get through the rhetoric and make this happen because again the patient will benefit. I truly believe in that, and I truly believe that as a vertical, as an industry, and as a country, you’re seeing people come together with awareness with that understanding, and it’s just a matter of time and we’ll get there. And you’re seeing also Congress now paying a lot more attention to this because of the advocacy efforts by groups like HIMSS or CHIME and others speaking up going ‘Enough’s enough, guys. Help enable us to make this happen. Let’s get through some of the rhetoric and let’s make this happen.’
Gamble: You mentioned a little bit about the lack of red tape or there being less tape at a new organization, and I wanted to talk about some of the maybe benefits and challenges of being so new. It’s not something that we see a lot, so when you talk about via attesting the Meaningful Use at a new facility, I don’t even know if there’s that many other organizations you could talk to, because it’s such a unique thing. Maybe just talk about some of the benefits and challenges of being brand new.
Miri: Sure. It is absolutely a unique challenge to be a new organization, because I think while on one hand you could say that organizations that have done something for 50 years or 60 years, that’s old hat and they don’t want to change their ways, there’s also something to be said for tried and true practices. At Walnut Hill, you take the people and you take the technology and you take all those items and you put it on one side of the table. On the other side of the table is the process that integrates all of it together. The beauty of it is we’re bringing people from across the country together to say, what is best practice, how can we do it better, faster, cheaper, meaner, leaner for the patient on their behalf. But coming up with those processes, and figuring out, and realizing, ‘oh, we need to do this better on discharge or this better on a transition or a hand-off between the floors, or this checklist needs to be developed.’ Those types of process improvement initiatives take time. And so that has been the biggest eye opener for myself, which is technology is a wrapper. Technology wraps good process and good people and good clinical care. You don’t look at technology to solve a process gap, and so a lot of times as we’re white-boarding out a problem to solve, it’s asking, ‘what’s the process? Oh, we haven’t thought about that process yet. Let’s talk about that first.’
So I’ve found myself now leading a number of PI initiatives, which I love to do. I love to solve a Rubik’s cube and coming up with, ‘how do we handle a clean discharge and follow up process? How do we make sure that our order sets are clean and succinct and very clean for the physician to be able to follow those kinds of things?’ Those are very real challenges that if you get them wrong, you can truly debilitate an organization, and so we spend a lot time on making sure that our processes and the way we integrate things make sense and it benefits that patient.
Gamble: Right. It’s a really interesting spot to be in. One of the things that comes to mind almost automatically is that you probably don’t have the mentality of ‘this is how we did things before.’ I would think that’s refreshing to not have to go through that.
Miri: It is, but it’s also a challenge. There are individuals — and it’s a wonderful thing and you want that — who don’t like to step outside of a box. They like to know that, ‘hey, I’ve done this this certain way every single time for so long.’ And so I would encourage folks to really think; when you want to start a new organization or something brand new, to make sure that you are truly comfortable with the fact that there is no road. You have to build the road to begin with. You have to clear the land. You have to put the dirt and gravel down. You have to asphalt on top of it and the rebar and all those sorts of things. That sometimes is discomforting for people and that’s okay. That’s an okay thing.
So what we have found, especially at Walnut Hill, is a group of leaders and physicians that love to say, ‘There is no road. Let’s build a road. Let’s build a better road.’ And you drive it forward. It’s very comforting, but it’s also fun and I think that for me is the overriding principle. Another mentor of mine used to always tell me, ‘If your job isn’t fun, what are do you doing?’ And so for me, I come to work every day with ‘hey, I get to build a new road.’ For me that’s what brings passion and joy.