Michael Marino, CMIO, Providence St. Joseph Health, Chapter 2

One of the biggest crises facing healthcare leaders is burnout. Physicians and nurses have had an enormous burden put on their shoulders, and they’re tired of carrying it. Organizations have realized this, and racking their brains to try to find the answer.

But perhaps brain-racking isn’t the right approach. As the ancient law of parsimony (also known as Occam’s razor) suggests, perhaps the simplest solution is the correct one. It’s this philosophy that the leadership team at Providence St. Joseph is leveraging, by going right to the source: caregivers. According to CMIO Michael Marino, a key priority has been to engage with those on the frontline and ask simple questions like, “What would make your life easier?”

In this interview, Marino — who happens to be a physician — talks about the key initiatives his team is working on (including a three-year journey to move to a single Epic instance), how they’re striving to stay aligned with the business side, the changing landscape when it comes to managing opioid use. He also discusses what he learned during his brief CIO stint, where he believes retail health is headed, and how the CMIO role has evolved.

Chapter 1

Chapter 2

• Path to the CMIO role
• Being interim CIO: “It honed my understanding of the entire picture.”
• Burden on physicians & nurses
• Engaging caregivers: “We’re going to talk about what we want to take out.”
• KLAS’ Arch Collaborative
• “It’s an exciting time.”
• Evolution of the CMIO role – “You have to be part MBA, part physician, part tech executive.”

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Bold Statements

To be honest, as much as it’s a great, interesting challenge to argue about servers and WAN — and I can certainly have a conversation about that now — improving the experience for our patients and our caregivers is my first love.

Sometimes within healthcare systems, the supporting technology is a little clunky. Your logon is slow or the network goes down. It’s the red-light phenomenon. No one cares if the network goes down when you’re not busy, but if you’re in a crisis and it crashes, that’s different.

We need to prune the EMR, because after it has been implemented for a while, you start to add things. When you first turn it on, it’s pretty lean, but as organizations start to optimize, they add order sets, alerts, nursing assessments, and rules. They get bigger and bigger. Documentation gets longer and longer.

If we lose our physicians and nurses because they’ve decided to do something else, we’re in big trouble as a society. And so I think putting a focus on maturing the tools and adding mobility will become increasingly important.

Applying those same options into practices or hospitals is where we need to go. I think the mistake we made in the past was looking at a trend that’s leaning toward one of those, and putting all of our eggs in that basket. I think we finally got bright enough to understand that we’re going to have to provide access to all of those.

Gamble:  The last time we spoke, you had a different role with the organization (as Chief of IS operations and Clinical Systems). Now you’re CMIO of Providence St. Joseph’s. Can you talk about how that came about and give your thoughts on having this role?

Marino:  To paint the picture of my own journey, I was CMIO for St. Joseph’s Health — the legacy system, which included 17 hospitals. Just before the merger, the CIO at St. Joseph’s left, and I was given the opportunity to fill that role. It was a great opportunity. It honed my understanding of the entire picture much better than if I had been a pillar on the sideline. I filled that role, even though the title changed a few different times, during the merger.

As we were trying to tighten up the merger, the president of operations realized we didn’t need two CIOs; in addition to myself, there was one on the Providence side. But I was also asked not to leave if the other person was chosen. As it turned out, Janice Newell, who was then CIO of Providence Health and Services — and my senior by about a decade of experience — was chosen to be the CIO. She quickly came to me and said, ‘I’d really like you to take your skill set and be the CMIO for the whole organization. We’ve got a lot of work to do.’

To be honest with you, as much as it’s a great, interesting challenge to argue about servers and WAN — and I can certainly have a conversation about that now — improving the experience for our patients and our caregivers is my first love. I got to go back to doing what I’m best at.

 

Gamble:  It’s nice when things work out like that.

Marino:  Very nice.

 

Gamble:  I imagine an important part of the role is managing the frustration that physicians often feel with technology, especially when it doesn’t perform as promised. Has that been a key focus of your role?

Marino:  You spend a lot of time as CMIO in what I refer to as the translational space, where you’re trying to make changes based on peoples’ complaints. When you think about it, technology within the healthcare is still really new. I was having a conversation with a tech executive who asked if we still had mainframes, and I said, ‘Healthcare never had mainframes.  We don’t go back that far with technology.’

And so, as we’re doing all this work, we’re trying to focus on physician and nursing efficiency, because of what has happened with our EHR, and basically every EHR across the country. When I first documented using an electronic record in 1994 as a resident in the University of California, it was simple. It was trying to fix physician handwriting issues and make things easier to track, but you could type things in there. It wasn’t prescriptive of how you did it. It helped improve workflow. For physicians, it was an easy win, because you didn’t have nurses calling about your poor handwriting.

At the same time, regulations are changing, and we’ve had more and more issues between different constituencies about whose job certain asks are. And so we moved work around within the EMR, and a lot of it has fallen on the physicians and nurses. I’m sure you’ve read the same things I have. Burnout rate in doctors and nurses is somewhere between 50 and 60 percent. The number one thing that gets cited is EHRs, and I think that’s a three-fold issue. Sometimes within healthcare systems — and we’re no different — the supporting technology is a little clunky. Your logon is slow or the network goes down. It’s the red-light phenomenon. No one cares if the network goes down when you’re not busy, but if you’re in a crisis and it crashes, that’s different. Our infrastructure team is doing a lot of work to try to stabilize that, but with redundant WANs, so that if somebody cuts the line up the street, which happens occasionally to our clinics, they have an SIP trunk coming from a different area.

We just had a meeting where we brought 204 caregivers together across nursing and physicians and said, ‘We’re not going to talk about what we want to add. We’re going to talk about what we want to take out. We’re going to look for efficiencies.’ And that’s going to be our focus going forward. EMRs aren’t like Outlook or Excel where you use it the way Microsoft sent it to you; EMRs are buildable. They’re configurable. You can add an assessment or a checkbox, or have an alert that pops up if you’re afraid something is going to be forgotten. Some of that is great.

With some things, like best practice alerts in Epic, you might need them for a while, but then you probably can take them out because you’ve changed the behavior, and the pop-ups become annoying. So we’ll sit down with caregivers and ask, ‘What can we improve? What configurations can we take away?’ And as I’m talking to my colleagues who are strictly on the clinical side, like our chief medical officers and chief nursing officers, and they ask what we can do to help, I said, ‘Send us requests to remove things.’ We need to prune the EMR, because after an EMR has been implemented for a while — whether it’s Epic, Cerner, or Meditech — you start to add things. When you first turn it on, it’s pretty lean, but as organizations start to optimize, they add order sets, alerts, nursing assessments, and rules. They get bigger and bigger. Documentation gets longer and longer.

I’m a pediatrician by clinical vocation; I still see patients in the free clinic, and I’ll notice the EMR notes will be 12 pages long. That’s ridiculous. But we’ve added this question and this checkbox. Instead of documenting negatives, we document positives and negatives. So if I ask, ‘Does anybody smoke at home?’ and you say ‘no,’ then it’s not a risk factor. Do I really need to write it down? No. I only need to write it down if somebody does smoke. But we document everything, and it becomes bigger and bigger.

 

Gamble:  Right. I can imagine physicians and nurses were happy to participate in conversations about trying to take things out of the EHR and improve efficiency.

Marino:  I’ve very happy about that. The other thing we’re doing is working with KLAS’ Arch Collaborative. We’re getting feedback. Instead of sitting a bunch of experts in the room and saying, ‘This is the problem,’ we’re actually going to caregivers and asking, ‘What would make your life easier?’ And a lot of what we’re getting back is follow-up training. EMRs are so all-encompassing; people don’t use all the components, or don’t use them well. And so we’re coming in to look at that or use tools that are built into some of the EMRs to understand where people are spending their time and compare it to the national averages. Maybe they need help with chart search, or how they order, or completing documentations. There are some big opportunities and some big wins. I think it’s an exciting time to change things versus just rolling out EMRs.

 

Gamble:  As a physician, are you encouraged to see more awareness about the burden that physicians and nurses are facing?

Marino:  Yes, I think it’s truly important. As the baby boomers are aging and we have a demographic that’s going to need more and more care, if we lose our physicians and nurses because they’ve decided to do something else, we’re in big trouble as a society. And so I think putting a focus on maturing the tools and adding mobility — maybe not at 100 percent but putting it in the workflow so that you can move from device to device — will become increasingly important. Part of the time I want to sit on a computer and use a big white keyboard, but other times, I want to be able to just check labs on my phone. And then there are things like natural language processing. A few companies are exploring virtual assistants for the EMR so patients can have the Alexa experience.

 

Gamble:  Is it a challenge having to deal with so many different preferences among users?

Marino:  It’s certainly an ongoing challenge. I think what we’re starting to do — not unlike what we did with patient preferences — is understand that people need it their way. Early in my career, I was part of initiatives, either in the medical group or the hospital, where we thought providers were going to want 100 percent mobility on a small device. And so we bought devices and stacked them on the floors, and went in the clinics and gave everyone handheld devices where they could write prescriptions. The problem is, what happens is you need that 5 percent of the time or 25 percent of the time depending on the individual? You can’t put all your eggs in one basket. I’m sitting in my home office with my laptop open, and I’m talking to you on my iPhone. I have a desktop behind the laptop, and there’s a tablet in my briefcase. And that’s for business and personal life.

Applying those same options into practices or hospitals is where we need to go. I think the mistake we made in the past was looking at a trend that’s leaning toward one of those, and putting all of our eggs in that basket. I think we finally got bright enough to understand that we’re going to have to provide access to all of those.

 

Gamble:  When you think about the evolution of the CMIO role, what stands out most to you?

Marino:  I think it depends on where you are as an organization. For most organizations, when they first had a CMIO, it was in a single hospital or a single medical group, and it was somebody who was a little tech savvy and had some pull with the physicians. It was, ‘Give us your tech opinion when we need it, and keep the natives from growing too restless.’ Then it evolved in the hospitals to working on things like order sets and care standardization. If you look at us, we’re a $23 billion organization; I have a department of 600 people with a budget of less than a million dollars. You have to be part MBA, part doctor, and part tech executive. It’s a lot of conversations like we’ve been having around what to do about physician burnout, and how to scale it across an organization. How do you sit at the table and make business decisions about things like devices and then turn around and sit with physician colleagues and talk about whether you use normal saline or lactated Ringer’s for sepsis, while at the same time being able to manage a budget?

It’s not unlike what we’re seeing in a lot of physician executive roles. I had a conversation the other day with our chief value officer, who’s a physician. She said, ‘It’s the same journey without the technology. How do you go from being the person who just did relationship management, which is what physician executive roles were 20 years ago, to being able to make business decisions and clinical decisions together in real time so that care gets better and more affordable?’ In the US, we used to drive care to be fancier and better; now people are saying, ‘It’s not affordable.’ Is there a way we can understand the value equation to that?

 

Gamble:  Right. These are really important conversations. Well, that about covers what I wanted to talk about. Thank you so much. I appreciate your time.

Marino:  Great. Thank you for the opportunity.