In the past few years, there have been more discussions about the importance of incorporating social determinants into the overall care picture, and for good reason. Factors such as income, education access, and housing “drive a lot more in terms of health outcomes when compared to the different procedures or treatments we offer,” said Gregg Nicadri, MD, CMIO at University of Rochester Medical Center. “As technology teams, we need to give our caregivers more information about the person they are seeing so that they can make sure the care plan they’re offering makes sense.” The question has always been, how can organizations move the needle to better serve their communities?
The answer is by leveraging a multilayered approach. For URMC, part of that approach has been partnering with patients to ask important questions and explaining why the data are being collected — and what will happen going forward.
It’s an area of great importance to Nicandri, who recently spoke with Kate Gamble, Managing Editor at healthsystemCIO about his team’s key areas of focus — particularly in terms of leveraging ambient technologies to ease the documentation burden. He also talked about the role virtual reality can play in improving training, the ever-evolving CMIO role, and what it takes to drive change.
LISTEN HERE USING THE PLAYER BELOW OR SUBSCRIBE THROUGH YOUR FAVORITE PODCASTING SERVICE.
- On Covid’s impact: “Everybody always talks about the telemedicine and telehealth aspect of COVID, but there were a lot of things we did to modernize our overall infrastructure during that period of time as well that were really exciting.”
- On change management: “We’re very good at making people aware that change is coming… Where I think we fall down a little bit is the desire; just because we tell people a change is coming, it doesn’t really mean they want that change.”
- On leveraging ambient technology: “We’re starting to use ambient methods to understand the conversation between the doctor and patient and generate a structured note. From that, they can then be reviewed and it can save time.”
- On the evolving CMIO role: “When COVID happened, we had to rapidly evaluate new technologies and come up with new strategies. I got involved more in a senior leadership discussion where we would work together to figure out what is the appropriate governance and how are we going to execute on change management.”
- On social determinants: “As a technology team, we need to give our caregivers more information about that person that they are seeing that day, so that they can reflect on that and make sure that the care plan that they’re offering makes sense in that situation.”
Q&A with Gregg Nicandri, MD, CMIO, University of Rochester Medical Center
Gamble: Hi Dr. Nicandri, thank you so much for your time. I look forward to speaking with you.
Nicandri: My pleasure.
Gamble: So, you are CMIO at University of Rochester Medical Center and you’ve been in the role since 2019, correct?
Nicandri: Yes. I’m an orthopedic surgeon and I’ve been in practice since 2009. I went to medical school at Virginia Commonwealth University and did my residency at University of Washington in Seattle, did a fellowship in sports medicine in Duke University. I started practicing in 2009 and transitioned into the role of chief medical information officer in 2019.
Gamble: I definitely want to get into that a bit more, but first, I want to talk about Covid-19 and how it transformed the way care is practiced. Can you walk through how everything changed for you and some of the lessons learned?
Nicandri: For me, it affected my clinical practice and also my role as chief medical information officer — I got to see how it affected everybody’s practice. Within medicine, each different specialty and subspecialty had differing levels of impact. For a large portion of what we do, things transitioned completely out of hospital and were done through telemedicine. We were able to ramp that up very quickly and effectively for many specialties within our organization. But there are others that aren’t able to do that; with high-touch practices, patients need to be seen in person.
And so, we came up with ways to make that as safe as possible by leveraging technology. For example, we put up a geocache gate around our parking lots so that we knew when patients arrived, and we were able to send them a text message that said, ‘check in for your appointment now and take this COVID screener.’
We knew that by doing that, we could protect our employees and our patients, and we could facilitate those in-person encounters which was significant. Everybody always talks about the telemedicine and telehealth aspect of COVID, but I think there were a lot of things we did to modernize our overall infrastructure during that period of time as well that were really exciting.
Gamble: That’s a really good point. There was somewhat of a ripple effect where it helped move things along that needed to be moved along, if that makes sense.
Nicandri: Absolutely. Healthcare pre-2020 was very different than what it is now, and that was in large part due to COVID. We had to make very quick determinations on what technology to employ and how we can do that at scale for our organization — for our patients and our providers. There’s nothing like a crisis to move things forward very quickly, and this taught us that we could be effective in doing that.
“Change management is the most important thing”
Gamble: Can you talk about the change management aspect when it comes to quickly implementing something like telemedicine? What was your approach?
Nicandri: I think change management is the most important thing for an organization to be successful. The pandemic actually made that process easier because people knew they had to change. They were receptive to change, and they had the desire; a lot of our providers literally could not practice or take care of their patients unless they adopted some new way of working. Our patients wanted to be seen, and they also understood that they needed to be open to nontraditional ways of doing that. And so, they partnered with us to learn new technologies.
I’m a big proponent of the ADKAR change management philosophy, which stands for: Awareness, Desire, Knowledge, Ability and Reinforcement. At Rochester, we’re very good at making people aware that change is coming. We send out emails. We put up posters. We do a lot to try to make people aware. Where I think we fall down a little bit is the desire; just because we tell people a change is coming, it doesn’t really mean they want that change.
During the pandemic, that barrier decreased significantly because everybody needed that change. Our traditional change management methods were effective because we gave them knowledge and people made the effort to attain the ability — as a result, we were able to stand up telemedicine in two weeks for the entire organization. Now, however, when you try to initiate things that you think are seemingly smaller changes, we can’t do that because there’s not the same underlying driver. And so, what that taught me was to really focus on making sure that either you’re building desire, or you are responding to organizational needs where there is already a desire, because you’re going to be way more successful at getting people the abilities that they need to actually execute on that change.
Burnout & the impending physician shortage
Gamble: Right. So are some of the initiatives you’re working on now that require a focus on change management?
Nicandri: I think our biggest issue right now, from the CMIO perspective, is clinician and provider burnout and attrition. I recently had my 20-year medical school reunion, and a survey came out around the same time for people of my age. According to the survey, 35 percent of those people said that they were looking to retire early; 25 percent said they were looking to get out of medicine all together within the next couple of years; and 50 percent said that they were going to decrease their direct patient care hours in the next year.
And that’s in the face of an existing physician shortage that we expect to get worse, because we know that we’re not producing physicians fast enough to handle the population. And now, more people are saying they’re going to retire early. It wasn’t too long ago that physicians were practicing into their 70s and 80s because it was such a great job and people really enjoyed doing it. Now, I hear more and more that especially those physicians at that stage in their career are moving out, whether it’s due to all of the administrivia and things that we need to do, or other factors.
“Bringing the joy back to medicine”
And so, one project we’re focused on is trying to bring the joy back to medicine and leverage technology and augmented intelligence to partner with us so that we can do the things we enjoy, such as communicating with patients, empathizing, and educating, and do less of the administrivia, which is pre-authorizations, in-basket tasks, overdocumentation for legal and compliance reasons, and the sort.
“DC the CC”
Gamble: How are you looking to do that? Are you looking at things like AI to take away some of those tasks or reduce them?
Nicandri: Some of it is leveraging technology that is not AI. Some of it is looking into AI, and some is just changing workflow and culture. I’ll start with the workflow and culture. We had an initiative just called ‘DC the CC.’ When we went live with the EHR in 2009, we thought it was a really good idea that if anyone was seen by a specialist, we would automatically route that note to the primary care provider. Because we thought the specialists routinely were faxing or sending their note by some other means, and so, this would be a great win for the electronic health record.
Overwhelming people with notes
What we didn’t really realize was that by sending every note, you’re overwhelming people. As an orthopedic surgeon, I might see the patient six times over the course of a fracture recovery, and we’re not doing anything to change any management. Historically, I wouldn’t send a note to the primary care provider about those. I would just send a note saying, ‘everything went well, and the patient is healed.’
Losing “important nuggets”
Now, PCPs are getting all of those notes all of the time, and it’s too much. We looked at the number of characters in their in-basket that they are reading per day — if you were to read all of those notes, it would be the equivalent of reading Lord of the Flies every single day.
They’re not able to read that. They’re just auto completing those notes or clicking buttons, and the nuggets that come by one or two times a day that are important are getting lost. But that change wasn’t as easy as just a flip of the switch. Because some of the primary care docs, even though it’s technically impossible to actually read every note in detail, would say, ‘I really want all of those notes because I might look at them some time,’ — even though they probably hadn’t in 10 years. So, it was an interesting example of the culture change that needs to happen as well as, something that would be a relatively easy technology switch.
“Diminishing the connection” between doctors and patients
Another thing we’re looking at is documentation. Providers spend about 30 percent of their time doing documentation, and oftentimes it’s more than half the visit time. For example, if you 15 minutes to spend with your doctor, the doctor actually spends about seven minutes typing and clicking things into the computer or taking notes and dictating later. And it has really diminished the connection between the doctor and the patient, because you’ve put a computer, a keyboard, and a mouse in the room.
We’re starting to leverage technology now where you use ambient methods to understand the conversation between the doctor and patient and generate a structured note. It can be reviewed later, which saves time. We’ve started to pilot this a little bit in our organization, and it has been significant for our providers that have been able to use it. Some have saved over two hours per day of documentation, which is time that they’re either getting back with their families, time to exercise or read a book, or if they desire, time to see more patients and improve access for the community.
Gamble: That’s pretty significant, especially when you are talking about things like burnout. Given your experience as an orthopedic surgeon, I’m guessing it’s something you can understand and can relate to.
Nicandri: Absolutely. It’s something I certainly see my colleagues struggle with every day. That’s why, as a chief medical information officer, I still practice, and I think it’s important to still practice. I have the benefit of understanding workflows in the OR, workflows in the inpatient setting, workflows in the ambulatory setting. I’m then able to help my team of informaticists examine and look at those workflows, examine and look at our technologies, and make sure the technology is configured correctly to support our workflows and help educate our colleagues on how to leverage the technology in their workflow in a better way, so that they can achieve a better quality of life and deliver higher quality care to their patients.
Leveraging tools to “offload some of the burden”
Gamble: Right. If there is a tool that could help with that, sure, but it’s just so much more about the workflow and even simplifying processes.
Nicandri: We use data to try to drive that. It’s interesting; nurses and doctors didn’t go to medical school and nursing school to become data entry technicians. And a lot of times, with the advent of the EHR, that’s what we feel like we’re doing. We’re basically pointing and clicking and typing data into the computer. And frankly, we’re not really good at it. There are errors, or we do it incorrectly, or it takes a ton of time and delays the efficiency of the care. This is where, finally, we’re at the point where the technology is good, and there are computers that can help offload some of that burden by automating it, whether it’s through ambient AI, or some of the large language models that have recently become available.
It’s really an exciting time to think about what medicine can be like in the future, but it’s certainly going to take a big effort in terms of making sure we’re using it in the correct way. Making sure we’re able to communicate effectively about it and educate people in the use of these new tools, because I think the way you do your job is going to change, and it is going to be better for both patients and providers. But it’s obviously important that we’re doing it in the right way.
Decreasing variabilities in surgical skills
Gamble: Can you talk about what you’re doing with VR in terms of surgical training and assessment, and how it has made a difference or helped remove some of the roadblocks?
Nicandri: Absolutely. As a surgeon, I became very interested in the way that we educate residents and surgical trainees, because there was just a disconnect in my mind. As a resident, I got to see lots of different people do the same operation on lots of different patients, and there was a huge amount of variability — both in surgical skills and technique. For example, a patient might say, ‘I saw a doctor and they repaired my rotator cuff.’ But that doesn’t really tell the whole story. There’s a lot that goes into that. The technical skill of the surgeon actually accounts for 26 percent of the patient’s outcome. It’s something that we never measure and something that is not publicly available to patients.
Often a surgeon is chosen based on word of mouth or a referral as opposed to technical ability. I became very interested in understanding how can we measure technical ability, and once we actually measure technical ability, how do we help improve it so that we decrease that variability over time? And there’s been a lot of breakthroughs recently with technology, both for assessment and training.
AI for evaluating surgeons
Gamble: That’s really interesting. When you said that statistic of 26 percent — that’s really surprising. I would think results like are a good driver to sell people on this or at least encourage it.
Nicandri: Right now, the way hospitals and accrediting organizations certify their surgical team is really just by talking to clinical colleagues and asking, ‘Is this person a good surgeon?’ I think that over time, video-based assessment is going to be very important. We came up with good assessment tools that can evaluate multiple surgeons doing the same procedure; they’ve found that the ones who score better on the assessment tool actually get better patient outcomes in real life. The problem is that having people spend time viewing those surgeries and doing the ratings is extremely time intensive and cumbersome. But now, with the advent of computer vision and AI, you can record the procedure, you can label the various steps of the procedure, and you can assess how accurately they performed. And so, you can’t improve what you don’t measure, so things start with measuring first.
Immersive VR’s enormous potential
Likewise, the technology has significantly improved; now, how we can actually train the residents to be better and to perform better on those assessments? That’s where the advent of immersive VR has played a significant role. Historically, you would buy a really expensive simulator, or you would use cadaveric specimens to try to learn how to do a surgical procedure without operating on a live patient. The problem with that is it’s very expensive, and you don’t get a lot of repetition. And so, it was very good for basic things, but very hard to reproduce for everything. The nice thing about immersive VR is that with a single headset you have the ability to teach people all of the various cognitive aspects of a surgical procedure across many procedures and specialties.
We generally work on teaching our residents basic skills in the lab: how hard do you press a knife to make an incision? How do you use a saw to cut bone? How do you triangulate a wire to hit a target in the femur? Those skills are transferable whether you’re doing an ankle fracture or a knee replacement or a shoulder rotator cuff repair. They’re very similar and most residents attain them in the first couple of years of training.
For the rest of your life, you’re learning new techniques and procedures and every single technique has its own nuances. It has a very specific abnormal anatomy and patterns that you’re looking for, different repair constructs that you are trying to achieve, and then very different orders of steps of the procedure and common pitfalls or errors that might happen. And all of those things can be taught in an immersive VR environment, which is really exciting because it significantly diminishes the learning curve.
Gamble: Interesting. It sounds like you guys are doing some very cool work. As far taking on the CMIO role, can you just talk a little bit about how that happened? Was it something that you were seeking?
Nicandri: I think many of my colleagues had a similar way of landing in the role, and that was by happenstance. For me, I had a research interest in surgical education, particularly for residents and that taught me a lot about performance improvement and technology. And as I got into clinical practice, I started to see a lot of inefficiencies that came from not understanding how to leverage the EHR and other technology tools that we had available, and I became very interested in learning more about them.
We use Epic as our EHR. And so, I went to Epic to learn how to be a physician builder, and then became interested in learning how to use those tools — not just for myself, but to teach my colleagues how to use them. And over time, became more successful and earned recognition for that.
“I wanted to have a bigger impact”
In our organization, we hadn’t had a CMIO for about three years; there was a need for somebody to help with alleviating burnout and leveraging technology within the workflow to improve efficiencies.
It just naturally happened that the position opened up. I remember thinking, ‘I’m just an orthopedic surgeon. I had never thought about expanding the role; it’s a really fun job that I have.’ But I wanted to challenge myself with new leadership skills and opportunities, and I wanted to have a bigger impact. I grew up in Rochester, which is where my medical center is. As an orthopedic surgeon, you have a certain impact, but this really would let me help increase the level of the quality of care and the happiness of my physician colleagues for our entire system, which is what excited me most.
Gamble: And since then, it seems like the role has continued to evolve and become more strategic.
Nicandri: I think we’re getting into CMIO 3.0. The first iteration, 1.0, came when organizations recognized the need to have somebody to help implement their EHRs. Usually, they’d approach someone with a technical affinity and ask them to work with ISD on the implementation.
The early EHRs were (and EHRs still are) pretty cumbersome, and they weren’t entirely well-received because if you talk about change management, that’s probably the biggest change we’ve seen in healthcare, at least since I’ve been practicing. There was a lot of dissatisfaction, and so CMIO 2.0 was focused on helping to improve and optimize clinician use of the EHR; that’s where we were right up until COVID. That’s the job I was initially hired for.
CMIO becoming “more of a partner”
When COVID happened, we had to rapidly evaluate new technologies and come up with new strategies. I got involved more in a senior leadership discussion where we would work together to figure out what is the appropriate governance and how are we going to execute on change management. It became much more of a partnership between ISD, informatics, and our clinical operations partners to strategically figure these things out as we came through the pandemic. That persisted and has certainly been a more effective and different way of working amongst our groups.
“It’s a big job”
Gamble: So now it’s 3.0, and it will probably keep changing. What we’re seeing is so interesting with the entire C-suite evolving to reflect digital transformation. You still need those core pieces, but maybe how they work together will keep changing.
Nicandri: I think it’s learning how to be more effective. It’s all about experience and trial and error and continuous improvement as you identify gaps. You have to figure out, is that a skill that I as CMIO need to evolve, or do we need to have somebody else be expert in that area? The applications of AI are certainly going to be the next challenge; that’s an exciting world of opportunities. But certainly, it is going to be a big job to make sure that it’s done right and done in a way that equitably improves care for our patients, is cost effective for our organization and doesn’t contribute to increasing the levels of burnout among clinicians, physicians, residents, APPs, and nurses.
Discrepancies in care
Gamble: Right. Another topic I wanted to talk about is what Rochester is doing with health equity and discrimination. Can you just talk a little bit more about what you’re doing there?
Nicandri: Sure. We were starting to work on this even before the pandemic, but Covid just heightened the problem of health inequity. As an organization, we were very similar to a lot of other organizations. Again, it just goes back to that surgical training paradigm. You can’t improve what you don’t measure. And so, you have to figure out what we’re going to measure and improve. For us, like many organizations, we’re number one in some bad areas. It’s number one in child poverty, and there’s a discrepancy of nine years of life expectancy between people who live less than 10 miles apart, and a lot of that is driven by health inequities and racism. How do we change that life expectancy so that the ultimate healthcare outcome is more equal across our entire population?
Knowing the population
And so, we started by deciding that we need to know our population, both on a population level, and also so we could translate that to our providers. We had an old demographic form that didn’t really allow us to capture data about who our patients were or how they identify from a race perspective. And so, we updated that and we were able to make our data more reflective of the community of patients that we take care of. We know that social determinants drive a lot more in terms of health outcomes when compared to the different procedures or treatments that we offer. But it’s a lot harder for us to understand where our patients are with those needs and how to actually move the needle on that.
Two patients, two stories
And so, it really started with us saying, ‘As a technology team, we need to give our caregivers more information about that person that they are seeing that day, so that they can reflect on that and make sure that the care plan that they’re offering makes sense in that situation.’ For example, you can see two 17-year-old soccer players who have the same injury, and you may know that inequities exist on the population level, but you’d have no idea how it relates. One of them may only be getting 0.8 meals per day and the other one might be getting 2.7 meals per day. If you do the exact same intervention, somebody who doesn’t know where their next meal is coming from, is not going to have the same healthcare outcome, or somebody who does not have the ability as an orthopedic surgeon, simple transportation to physical therapy. Again, I know that there’s a large percentage of our population in Rochester who have transportation needs, but when I have a patient in front of me for 10 minutes, I have no idea how that actually impacts them. And so, we started asking our patients those questions. We talked to them about why we were asking those questions. They have partnered with us and now that information shows up at each clinic visit, at each inpatient visit so that the care team who is taking care of that patient is aware when needs arise and can help start kind of thinking about that is, they’re coming up with care plans for the patients.
The importance of listening
Gamble: That’s so important. It’s encouraging to see more organizations really getting deeper into this, and hopefully sharing those learnings. It’s like you said, you see two patients and you have no idea how different their lives can be until you have that information in front of you.
Nicandri: There is lots of collaboration in this arena, both on a national level and a local level. We as a health system thought that it was really important to collect the data on our patients. But in order for them to feel comfortable giving us and sharing that data with us, they had to know that we were listening and that we were going to do something about it. We initially started by integrating our own local 211 directory. There are a number of community-based organizations in Rochester that not everybody knows about. I actually learned through this project that 211 nationally covers almost 98 percent of the US population. It’s a low bar because it’s just like Yellow Pages, but it’s a quick and easy way to get patients information about resources that they might need.
Beyond that, we’re partnering with our own community and the United Way. We have a systems integration project where we’re working with our local government to figure out how we can streamline this with our health system, as well as one of the other health systems in the region, and a lot of the players around data.
Nationally, a lot of work has gone into making healthcare data interoperable. Our systems are finally starting to be able to talk to each other. The ONC has started to say, ‘Okay, from an interoperability standpoint, this data around demographics and social determinants of health is important and we want it shareable among organizations through the EHRs.’ I think that’s really going to help us start to finally move the needle on this.
Gamble: It’s really interesting. We’re in this time where there are many frustrations and there’s so much burn out, but at the same time, there’s so much progress. I would think it’s a really interesting time to be in your shoes.
Nicandri: There’s definitely not a lack of projects and needs to address. It’s been great partnering with lots of colleagues and collaborators across the country because we all share the same needs, but we only have the resources to focus on a few of them. It becomes a lot easier for organizations to fast follow when we each have different successes. And so, that’s kind of been our strategy — to focus on two or three really big things to move the needle for us. And then we look to other organizations to partner with them to broaden what we can do with the resources we have.