When Bill Spooner stepped down as CIO at Sharp Healthcare in 2014 after spending 35 years with the organization, he had mixed feelings. Although he was ready for a change from the frenzied pace of the CIO role, he hesitated to leave because “there were so many exciting things going in healthcare.”
Fortunately, Spooner found a way to remain involved in the industry — and pass on some of the wisdom he gained from his tenure — through his work as an advisor with Next Wave Health Advisors, and as an active participant with CHIME’s advocacy initiatives. In this interview, he offers insights on a number of pertinent issues, including why workflow is still a significant challenge for many organizations, the factor that most slows down the optimization process, and the surprising area in which healthcare is still far behind. Spooner also reflects on his own career, where we stand in terms of interoperability, and why perspective can be the best gift for leaders.
- 35 years with Sharp Healthcare
- Value-based care’s origins
- “It was a lot of experimentation. We knew the next step in the evolution was an EHR.”
- Investing little by little to build a “robust environment”
- HITECH – “We saw the money as a bonus; a recovery of investments we already made.”
- Workflow challenges that remain
- Working as an advisor – “It’s interesting and rewarding.”
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Reimbursements were getting cut. Managed care was coming into California, and all of a sudden, we were receiving a capitated payment and having to figure out how to provide the services for it. That pushed us into doing a lot of innovative things in the financial management area.
We had to make smart investments. And as we made an investment, we really looked carefully. We didn’t buy anything that we didn’t need. We tended to negotiate very thoroughly. We were looking to get the best results with the investments we were making.
Meaningful Use was the gotcha that we didn’t really appreciate when the monies first started coming in. It’s one of those things that lives forever, and today I question whether it was the right idea at the time.
You’re trying to adapt this system that the vendors produce for you with some flexibility, with the workflows you’ve developed over the years that have a lot flexibility, and bring the two of them together into a way that allows you to collect the data efficiently and to practice the kind of care you want to practice — that’s a challenge.
Gamble: Hi Bill, thanks so much for taking the time to speak with us.
Spooner: Thank you, Kate. I’m glad to be here.
Gamble: I’m looking forward to getting your thoughts on where the industry is today, and where it’s going. But first, I’d like to talk about your career. You were with Sharp Healthcare for more than 30 years, correct?
Spooner: Yes. I was with Sharp for 32 years, but I actually have 35 years tenure because I was with a related organization before coming to San Diego.
Gamble: I’m sure you know how rare it is to have spent pretty much all of your career with one organization.
Spooner: It is rare. But interestingly, when you look at health systems, you see long-time employees of 40 and 50 years — it makes my tenure look short. I think that’s part of the nature of health systems and hospitals.
Gamble: During that time, I imagine there were several different periods of transition. Looking back, was there a time period that stood out as being one of dramatic change?
Spooner: It’s really hard to pick one. But when I was at Sharp, the 1990s were really pivotal for us because we were merging into an integrated delivery network, having started from a single, successful, high-quality hospital then deciding we wanted to grow across the county. The financial situation in was really tough during the 1990s, because reimbursements were getting cut. Managed care was coming into California, and all of a sudden, we were receiving a capitated payment and having to figure out how to provide the services for it. That pushed us into doing a lot of innovative things in the financial management area. It was pretty neat to be able to participate in terms of providing some innovative IT solutions to support them.
Gamble: I’m sure that was pretty cutting edge at the time.
Spooner: It was cutting edge at the time, yes. We had close to half of a million capitated lives that we were responsible for and interestingly, the organization learned how to provide high quality care and be profitable doing so.
Gamble: I’m sure it has served the organization well having that experience.
Spooner: It’s interesting because as I look at the value-based purchasing models that we see emerging, there are various twists of the same ideas, and I’ll say, ‘we did that 25 years ago.’ But it’s fun to see how it is starting to grow around the country, and how organizations are really seriously looking at how to provide better care within a budget.
Gamble: In terms of digitization, was Sharp somewhat ahead of the curve?
Bill: We went in leaps and bounds. We really spent a lot of effort during the 1990s trying to make our financial management systems more effective and really learn how to manage care, but we also were having to generate outcomes indicators — which basically mean developing clinical outcomes without an electronic health record. So we learned how to develop our own data warehouse, which started out as a server under one person’s desk, and began pulling claims data and getting the clinical elements out of it. So it was a lot of experimentation at that time. But at the same time, we knew that the next step in the evolution was in electronic health record.
At one point around 1995, we did a study to determine what it would take to get us to an electronic medical record, as we called it at the time. Essentially, the outcome of the study was, keep doing what you’re doing for right now; the product isn’t mature. You’re doing a lot of good things, wait a few years. And that’s what we did. As we approached the new century, we started making investments that took us a little at a time to what has turned into a pretty robust environment.
Gamble: It seems like that study had some very good learnings as far as making sure the technology is mature enough or the organization is ready for something like implementing an EHR.
Spooner: It was good for us. We weren’t a wealthy organization. Throughout the 90s, finances were tight. We had to make smart investments. And as we made an investment, we really looked carefully. We didn’t buy anything that we didn’t need. We tended to negotiate very thoroughly. We were looking to get the best results with the investments we were making.
Gamble: And with HITECH, do you think that for organizations, it was more difficult to have that mindset because now there were timelines and penalties being faced?
Spooner: I think it became difficult, because we all ran to the troughs. I was really proud that our organization, like many others, had begun implementing our medical record systems well before HITECH came around, both in the hospitals and our medical groups. We saw the money that was coming in as a bonus — a recovery of the investments that we had already made. I think that the real value out of HITECH was in helping to outfit the small physician practices and perhaps the small hospitals with EHRs, because many large practices and most hospitals and health systems were already moving down that path.
Clearly HITECH increased the utilization of electronic health records, but at the same time, many of us were ahead of the game. We can debate it, but overall, I think Meaningful Use was the gotcha that we didn’t really appreciate when the monies first started coming in. It’s one of those things that lives forever, and today I question whether it was the right idea at the time.
Gamble: Years later, we’re still talking about workflow challenges. Does it surprise you that it’s still an issue, even though most organizations have been in the EHR world for a while now?
Spooner: It surprises me from one perspective and then it doesn’t for another. Some of the Meaningful Use requirements required a lot of change in a short period of time. You can argue that 18 months or a year is not a long time, but when you’re talking about altering the way an organization practices medicine and patient care, it is a long time. And so many of the requirements around Meaningful Use were not necessarily done in the most optimal way. It was a way to somehow collect the data, often a way that was not part of the normal workflow.
On the other hand, there’s a lot of variation in healthcare workflow, and typically we all believe that our method is best. So you’re trying to adapt this system that the vendors produce for you with some flexibility, with the workflows you’ve developed over the years that have a lot flexibility, and bring the two of them together into a way that allows you to collect the data efficiently and to practice the kind of care you want to practice — that’s a challenge. So I guess it shouldn’t surprise me.
Gamble: It seems like workflow is something that has to be addressed continuously, because there are always being changes made. Do you think this is enough of a priority, or do CIOs and organizations need to do more to make sure workflow is being assessed continuously and not just during an implementation?
Spooner: I think most organizations have learned over the years that optimization is an ongoing process. When you purchase a system, the vendor wants to implement it, they want to collect their money, and they want you to be effective in using the system. But there are compromises to meet the timetable, and one of the compromises is that some features are left out in terms of implementation. You overlook some workflow challenges going in, and you recognize that you have to go back and do it later.
At the same time there’s still the mindset, despite years of learning, that when you bring in a team of people to implement the system and it’s implemented, you’re going to be able to cut back some of that staffing, without recognizing that the work is not complete. And so that slows down the optimization process.
Gamble: Looking at the some of the work you’re doing now as a consultant, I imagine there’s a variety of issues that you’re dealing with, but is there a specific area where you’re focusing a lot of your energies?
Spooner: I’ve been fairly flexible in terms of the things I’ve been doing. I like to call myself an advisor rather than a consultant. A colleague back at Sharp told me that an advisor doesn’t write reports and a consultant has to. So I try to call myself an advisor and avoid writing reports.
I’ve done some work around strategy with a team of people. We like to go in and do quick and dirty IT assessments. In one case, a CIO was retiring and they wanted to have a quick look at the organization to determine what they need in a new CIO. A couple of organizations were having problems in their IT shop and they needed some help — both to coach the internal staff to help bring some of the vendors in line, and to make some overall improvements. Some of these have been a couple of weeks long; one was six or seven months long. So it’s been different types of projects like that. I’ve done an interim CIO gig. I’ve done an interim executive VP level assignment in another organization. I’ve done a couple of projects helping a vendor understand what problems his customers have had. So not a specific area.
I will say honestly that when I left Sharp, I had the idea that given all of our experience in value-based purchasing, there was probably some demand in that area. That really hasn’t turned out to be the case. I think most organizations are inventing their own, such as we did, and other organizations are hiring the big shops to help them. There hasn’t really been a demand for independent firms to do that.
Gamble: That’s surprising.
Spooner: It was surprising to me. Outside of consulting, I spend a lot of time doing voluntary work. I continue on the fringes of the CHIME policy committee; I’ve been on that from the beginning. It’s interesting work and it needs to be done in terms of trying to influence regulation and legislation.
I have spent the past six months actively participating in CHIME’s Opioid Task Force. That’s become a big interest. I’m spending time locally with the various providers trying to learn what’s going on in northeast Tennessee, because this is a real problem area in terms of opioid addiction. It’s never-ending and frustrating, but rewarding at the same time. I helped the local health system create a board IT committee back in the fall, which finally just launched a couple of weeks ago. I’m a member of that IT committee. I also joined a board committee around risk and compliance for another large health system. All of that’s really interesting and rewarding. It keeps my fingers in the game, and keeps me fresh.