Published September 2021
The time is right for enterprise-wide change. More and more, health systems have been evolving to enterprise-wide communication and collaboration strategies, leaving patched-up legacy systems and fragmented technologies behind, says Si Luo, vice president of Vocera Edge at Vocera. But never before has a unified system proven more valuable than with the need for continuity during COVID, when in-patient teams needed to communicate with the care team in hospital tents. Further setting the stage for change: the industry has gotten into a very fast maturation stage, with the consolidation of disparate platforms already occurring. Players are emerging that can create an established enterprise-wide vision and can offer a flexible platform to tailor use cases, Luo says. In this episode of healthsystemCIO’s Partner Perspective Series, Anthony Guerra, editor-in-chief, interviews Luo to gain insights on today’s trends related to communication and collaboration platforms.
… all of that creates a perfect storm to pull together an interdisciplinary team and define a consistent charter that begins with, “What exactly are the outcomes that we’re going after?” It always starts with the outcomes.
I remember a time when there were over a hundred single purpose secure messaging vendors out there. Now you will find maybe at most four that are left standing.
The prescriptiveness oftentimes doesn’t come from the vendor anymore, it comes from the institution at the leadership level …
Guerra: Si, thanks for joining me.
Luo: Thank you, Anthony. Glad to be here.
Guerra: Let’s start off with you giving me some information about your organization and your role over there.
Luo: Vocera provides a wide range of communication and workflow solutions that help protect and connect care team members, increase efficiency, and enhance the quality of care and safety in hospital and health system settings and even beyond healthcare recently, as well. I came in through a recent acquisition of PatientSafe Solutions, which is a cloud-based, smartphone-centric product, that focuses on care team collaboration use cases in the hospital and integrates deeply with EHRs and complements EHR products at the mobile point in strategy. My current role at Vocera is vice president of the Vocera Edge product line, very much focused on enabling Vocera’s broader go-to-market and customer success teams and introducing, deploying, and scaling the cloud-based care team communication workflows that can complement and augment the various EHR deployments.
Guerra: How long would you say you’ve been working on the care team collaboration issue?
Luo: I’ve been deep in the product space for close to 12 years now.
Guerra: What’s your original education?
Luo: My education background is based on bioengineering and bioinformatics with an eye toward system engineering. Through a rather chance encounter, I got involved in the problem space related to hospital workflow and realized there’s just never a shortage of problems to solve, so I’ve been in love with this problem space and also with our customers’ challenges ever since.
Guerra: Very good. Let’s describe the problem as you see it. When we talk about a typical health system, there is no typical health system. Some are going to be very advanced, some are going to be not very advanced. Let’s talk about care team collaboration at the average health system. We’re going to talk about the state that you see as sub-optimal. Describe that.
Luo: I’ll start on a few ends of the equation and then bring it together at the end as well. Let’s start on the user end of the equation and what “typical” looks like. In fact, we did a 200-plus health system survey with HIMSS a couple of years ago, and that showed us the average clinician at the bedside has to contend with at least five disparate sources of clinical and collaboration contacts in addition to the EHR, with more than four communication modalities. This means they are dealing with more than voice, text, and paging, all included in the paradigm, and perhaps three or more devices, depending on their settings of care or how many settings of care they have to traverse in order to just close the loop of their care teams on any given shift. And that alone spells the definition of fragmentation.
This level of fragmentation can result in accelerated clinician burnout and safety issues, especially in between the boundaries of hand-off, and there’s actually a fair amount of literature in safety and quality journals around that already and certainly patient experience challenges. I think COVID would probably bear that out even further in terms of all the user experiences around workflow. And then if you look at what it actually takes to deploy and even manage the current set of fragmented technologies and the burden you create on the IT team, the challenge is actually compounded there, as far as the typical health system goes: the break fixes as far as hardware is involved and the network adjustment, just to make the technology even work, and the steadily overwhelming support volumes at the internal IT help desk before it even gets to the vendor side. These are all previously hidden costs that a health system can no longer ignore in an increasingly pressurized environment going forward. And that’s how I would describe “typical” today.
Guerra: So, you’ve got the two sides. You’ve got the use issue. And there you mentioned having multiple devices. Just practically speaking that means I need to look at multiple devices to not miss a message, to not miss something important that’s going on. That can be stressful with a lot of dinging and binging on a lot of your different devices and you can miss something.
Luo: Absolutely. And even on different applications – so it’s hard to know what’s the most realistic context around the patient.
Guerra: And then the support issue as well, so it’s difficult for the clinician and difficult and expensive for IT to manage all these applications, and you’re dealing with all the vendors; contracts are coming up for renewal. And these devices that we’re talking about, are they owned by the health system—are they bring your own—or is it a combination?
Luo: It’s typically a combination. For in-patient, we see more usage mainly through the health system’s device fleet and that’s centrally managed by IT. But oftentimes the break fix is going over to biomed and that creates a lot of different issues there. But increasingly, with consumer-grade devices breaking into hospitals and networks by way of patients bringing them in; clinicians bringing them in, particularly physician usage; bring your own device creates a very complex and challenging puzzle for IT to solve.
Guerra: You mentioned you could have as many as five sources of data. You could have three or more devices. You’re going to have health systems that are on the spectrum. Some of them are going to have two and therefore their fragmentedness is not so extreme, and some have five and they’re more extreme. Does that relate to the acuity of the problem, meaning the more systems, the more devices, the worse the problem?
Luo: That’s typically a good realistic way to look at it. The fragmentation is oftentimes driven by the pervasiveness of different use cases and the underlying system; whether the platform that they were previously using is unable to address an enterprise-wide use level case or a departmental one or sometimes tied to a particular user only. For instance, institutions may have elected on their own to deploy a HIPAA-compliant secure messaging product that oftentimes is a single purpose and oftentimes facing physicians only, and gradually when they need to layer on nursing and allied health professionals, and recently some of the triage teams that are necessary to support some of the virtual care use cases, the patient care communication becomes yet another layer. So, it’s typically fragmented, driven by use case on a narrow basis, versus on an enterprise-wide design basis. If that makes sense.
Guerra: It does. So if I’m a CIO, I’ve got a lot of things going on. So my first question here is: how do I know if I have a problem if I’m a CIO. Is it always going to be that I’m hearing complaints, that I’m hearing issues? That’s how I know that I have a problem? What if there’s a problem and you don’t even know it? If you’re a CIO and you want to be conscientious about this, I’ve got three systems out there for care team communications. I haven’t heard about any problems but it’s very possible that there’s some dissatisfaction. Do you have any thoughts on what they should do? Should you go out and investigate, should you do surveys, what are your thoughts there?
Luo: I think there are typically increasing layers of involvement on how you might diagnose if you have a challenge here. The first one is actually within all CIOs’ disposal, which is a quick look at the spend management inside the equation. Telecommunications is actually the most overlooked area to spend overall. You may be having a phone system over the course of the last three decades. You may be modernizing it. You may be linearly scaling it and increasing your licenses without even knowing that. Take a look at just how much capital in an operating dollar – and I say operating because it requires a certain amount of overhead for the break fix, for the support, for some of the increasing amount of complexity out there. Has that trend been going up or going down either expectedly or unexpectedly, and why?
And then that breadcrumb trail can kind of lead you to: what about software spend across all these things? Are they getting more expensive over time? Are they getting more complex over time? Are there any ad hoc services that seem to be continually piled on to that software spend from the respective vendor and why? And then gradually, as you inevitably pull on that thread, it leads you into these boundaries of intersection where true cross-team collaboration occurs, between physician and nurse (how satisfied are they with this protocol and approach?); between the nursing team and the allied health, the therapy teams in particular (how consistently are the messages getting across, how easy is it to triage around the patient?)
Then, get involved with the clinical counterparts and ask them, what do you think the rate limiters are when it comes to patient experience? What certain levels of clinical quality are most sensitive to care team collaboration and hand-off? And when you put together the spend picture and dip into the user experience picture, and then conclude it by contrasting that with the ceilings that your institution may be running into in terms of quality improvement that are workflow driven, the picture may be brutally apparent in terms of how big the problem actually is.
Guerra: So you like as a starting point for a CIO diagnosing an issue, you like going to the spend.
Luo: Yes. The spend is usually the easiest place to have an a-ha moment.
Guerra: How do you know what the spend should be?
Luo: To clarify that a little bit more, I think you have to look at the trend, to see if that spend is trending faster than you expected. I think what tends to happen in the traditional break fix, support-heavy area, the individualized add-on services just to make the technology work better and better, tends to proliferate with any given vendor. That’s sort of trying to make a patch on top of a patch on top of a patch. While the underlying situation is, the institution will really need a refresh approach versus continually optimizing on a legacy product that way.
Guerra: Ok, so let’s say you are aware you have a problem. You know you’ve got too many systems. What’s next? It all comes down to governance. You want to let the businesses make the decisions of where they see the need. So tell me how that’s going to work from CIO diagnosis to integration for consideration into the governance plan?
Luo: That’s a great question. What we’ve seen with the most successful institutions that have gone through that type of process and subsequent transformation is the CIO tends to bring together the inter-disciplinary team that’s typically led by clinical informatics on the one end and certainly the clinical counter-part in the CMO and a variety of stakeholders together, to look at defining an enterprise-wide strategy and vision around the notion of care team collaboration and vision. It’s oftentimes when folks look back at the existing investment, they realize the initial use case and scope has certainly evolved and changed into what it is now. And they realize that now the technology landscape and the vendor landscape have consolidated and evolved a few times more. More options are increasingly becoming available when you’re looking for that one unified platform that will address a variety of use cases, and that spells out consolidation and optimization opportunities.
But all of that should not start without a cross alignment on that overall structure, and that’s what we’ve actually seen the most successful ones do, when they put pen to paper, so to speak. They define what the mobile expense charter should look like – particularly when core EHR vendors are rapidly moving toward enabling a mobile version that’s available on the smartphone-centric experience for their physicians and increasingly for their nurses — and even introducing other avenues of communication within it as well. So, all of that creates a perfect storm to pull together an interdisciplinary team and define a consistent charter that begins with, “What exactly are the outcomes that we’re going after?” It always starts with the outcomes.
And then, to find the key workflows that could get you to that outcome if these workflows were redesigned and consistently deployed. Only then should you really be approaching which vendors to consolidate away and which new vendors to bring in and what type of technology planning should come together. We’re a huge believer in that, and we’ve seen over and over again the most successful customer start at that strategy level that can be truly enterprise wide.
Guerra: That’s an interesting point you make. As a CIO, you need to know what the market’s offering so you can recommend new technologies to your organization. What’s the best way to stay up on those developments?
Luo: I think today the good news is there is no shortage of avenues to find out the market landscape. I think there are a variety of industry analysts. Gartner puts out some really great research around this space of clinical communication research. KLAS continues to profile a variety of different market segments around this. And certainly, through healthsystemCIO and similar forums, folks are starting to exchange past experiences together, as well. I think, just as an aside, the clinical communications base, as you’ve watched it over the course of the last decade, has really started into a full maturation stage, as I would call it. I remember a time when there were over a hundred single purpose secure messaging vendors out there. Now you will find maybe at most four that are left standing. Over time, the industry has consolidated significantly. The requirements have evolved significantly; and I think the industry is evolving toward the fact that it will be very similar to the EHR landscape where there may be only three or four players that matter and offer a variety of different emphases for you to choose from. And all of this information is increasingly available through industry research, as well.
Guerra: Is there anything else you want to say about the new paradigm you envision?
Luo: Yes, absolutely. I would start with painting a picture of what a better paradigm for care team communication might look like. I think to tie back into the current state, from a before and after and to and from, on the user experience end, a better paradigm of care team communication can go from fragmented to consolidated, disparate to unified, and lacking true closed-loop actions to highly reliable closed-loop execution from any form of communication or actual task around an adjusted care plan execution, based on the nature of the communication sent and received.
On the IT maintenance and solution life cycle, a better paradigm would require minimal IT overhead and ideally supports continuous delivery via cloud. We’re moving into the 2020s; you can leverage cloud-based solutions in a way that can get the vendor side to provide a fully managed service from security updates, stored scaling, mobile device management, and even partnership with the device manufacturers – where mobile phone provisioning and device replenishment can all be offered as a managed service, whereby you reduce the overhead spend, create some economies of scale and really take the platform forward in a renewed way. Those are all the opportunities that the current landscape is increasingly available to offer for health system CIOs.
Guerra: Let’s talk a little bit more about getting from here to there. The CIO is sitting back and saying, “What am I in for? This sounds big, but we need to do it.” Is there anything that they can do even before they get to the stage of looking for a particular vendor to get their house in order?
Luo: Absolutely, that’s a great question. I think the most important part is a fundamental mind set change about how important it is to fix this. It requires the IT leaders and informatics leaders to come together with their clinical counterparts. The most important part is clinical stakeholders can no longer see communications technology as just an IT issue. And we really need to come together and recognize one brutal fact. We, as a whole industry, have been trying a variety of tools and technologies over a decade to go after this unified clinical communication experience but have gotten to a certain point somewhere in the past and got stuck there. The main underlying reason for this is a lack of an enterprise-wide alignment on a true sense strategy; there’s also a lack in an associated governance model and the commitment required to scale it forward. So, before any institution even goes out there to select a vendor or decide on a device, they need to understand whether they need to refresh their network or not.
We continue to be very passionate about advising our clients: it doesn’t matter what you do, whether you invest in our solution or not, it’s important to create enterprise-wide governance with a clearly defined charter for you to define what you want to invest in and how this enterprise-wide strategy would bring physicians, nurses, allied health and even the broader support roles together, versus treating them as departmental and one-by-one with another set of fragmented things going on. So that’s really the most critical first step, is that governance model behind the defined strategy that’s highly visible versus, “this is an IT-led initiative” only.
Guerra: For someone who’s further down the road, any best practices you want to offer for executing a project like this successfully?
Luo: Let’s say a strategy has been defined but oftentimes the drop-off occurs at the post-contract implementation end and there’s still a great degree of possibilities in quality and the consistency of roll-out experience. I think when it comes to an implementation approach, we do need to take a chapter out of some of the more successful EMR implementation paradigms that were prescriptive in restricting the different degrees of freedom in the beginning. Like all types of IT in the past, one that doesn’t attempt to boil the ocean and deliver every single use case.
Instead, an implementation should deliver significantly impactful wins on a defined basis on different rollouts throughout the solution lifecycle. These can focus on key target metrics of adoption by user cohort and key impacts on clinical workflow; letting the wins drive the sustainable change in management and change in improvement. That’s better than saying, “We have selected a product and we need to get it live in a certain amount of time and place,” or worse yet, to be all things to all people all the time, preventing the solution from getting out of the gate successfully.
Guerra: You made a fascinating point, something that I’m so interested in as someone who runs a business as well, and it is customization versus being prescriptive. As a service provider, you feel you know the best way to implement your software and your system, and you explain that; “here’s our process. This process works very well. And we’ve adjusted it a billion times.” Would you say that the most successful of your customers embrace that approach and are able to work with what you want to do?
Luo: Yes, and I would say the most successful customers actually embrace an adjusted approach whereby they really rely on the internal governance team to define that prescriptive set of deployment guidelines. Example being, if you have a deployment team, that sits on the clinical communication governance committee with a CMIO leader, with a CNIO leader, that will be able to gather all the disparate things and the thousands of use cases all the departments wish to do all at once, and say these are the choices we make right now, and those are the choices that we will make later on and with key design criteria at every point in time in order to move it forward.
So that still is a more federated input model, but a lot less of trying to be all things to all people. The prescriptiveness oftentimes doesn’t come from the vendor anymore, it comes from the institution at the leadership level and the front line can see and experience what it’s like to have a fully supported deployment model versus, “We will start with one prescriptive way and at the first sign of constraint we will slide back into a fully customized void.” When it comes to the change element later, that’s the most difficult. We’re talking about potentially changing some institutions thirty years plus weight of, “How do you call into a surgical unit and how do you call out of a surgical unit,” and those type of call flows and workflows are very much built into the institution’s “muscle memory,” even if it may be an inefficient “muscle memory” due to the past constraints we’re in. And it’s going to require a ton of change management. Without prescriptiveness coming from the inside leadership, vendors can only go so far before it becomes a no-solve situation, too.
Guerra: Would you say you are prescriptive on some things and flexible on others?
Luo: Yes, I think that describes it fairly accurately. We would provide a set of design parameters into the deployment strategy. For example, when it comes to physician bring your own device, here are the typical areas of sensitivity in terms of their perception of privacy and their perception of control. And then when it comes to shared fleet design in terms of shared devices for the frontline team – here are your design criteria against your known existing workflow. And based on the design criteria, there’s a set of trade-offs that we offer the customer, and the customer oftentimes – the most successful ones among them – do decide what tradeoffs they’d like to explicitly make. And they make those trade-offs and they make them very clear to the front line to help guide the deployment process.
Guerra: This issue seems to me like it should not be a hard sell. Care team collaboration is healthcare at its most basic level. Is it a hard sell?
Luo: I think in the past it’s been hard to get true enterprise-wide alignment. That’s why you get a lot of departmental excitement and sometimes its driven by IT and sometimes it’s driven by nursing and sometimes it’s driven by the medical team that needed a secure messaging solution very quickly. I think it becomes a harder sell in terms of how hard it is to truly align those stakeholders into an enterprise-wide platform visibility. That does take cycle, that does take time to get people aligned together, but once that’s decided, the momentum behind such a strategy is very strong.
And one of the things we’re very encouraged about at the Vocera team at large is what the pandemic has done in highlighting the necessity for collaboration. We’ve seen customers with this type of solution deployed enterprise-wide and how adroitly they have dealt with all the changes throughout COVID. The communication between the in-patient team to the folks in the tent hospitals, the triage teams that work on a cross-continuum basis using an enterprise model, versus those that are only partially deployed that struggle with how efficiently people can communicate and coordinate. I think as we go through the post-pandemic investment priority, when we layer in the requirements for true virtual care, the requirements for careful and efficient care coordination and the requirements for a mobile-first experience, this sell and this type of alignment ought to get easier and easier to explain going forward.
Guerra: What part of your work gives you the most satisfaction? A sale is great, but a sale is only the beginning.
Luo: The greatest satisfaction I get is absolutely from a successfully implemented and sustained – and I think sustained is the operative word here – sustained improvement from their previous paradigm of a fragmented nature of communication and collaboration into a truly consolidated and unified one. And it can be expressed in actual clinical outcomes, whether it be in throughput, whether it be in patient satisfaction, whether it be a quality indicator, and oftentimes all of those on a metric stand-alone – it still has that drive report-card feel to it. But the story that customers tell their own internal staff as well as external teams on what they’ve been able to accomplish gives me the most satisfaction.
I’ll raise a very recent example, there’s a customer in Florida, a huge health system that actually published an internal article on the entire mobility journey with Vocera Edge, and both the before challenges as well as the after. This is not a marketing-driven case we put out on our own website, this is something that the customer itself initiated and actually published in a lot of the local publications around that case. They were passionate about telling the story of transformation. Signing the contract was the very beginning of the journey – to actually drive through the implementation strategy, fixing a lot of the underlying issues, that’s really the hard part. But for the end goal, for them to be able to tell the story in such an emotionally impactful way, it really, really reminds us why we are continuing on this journey altogether.
Guerra: That’s great. We’re just about out of time. Any other thoughts you want to add?
Luo: The parting message for our CIO colleagues out there is that we do believe the industry has gotten into a very fast maturation stage, whereby the consolidation of disparate platforms is already occurring. There will be players that are emerging that can create an established enterprise-wide vision and can offer a flexible platform to tailor use cases on the right device and against the right integrations to support you well into the future, and this is the right time to look at this as part of a transformation strategy.
Guerra: Alright Si, thank you so much for your time today. I think the audience is really going to enjoy this.
Luo: Thank you. My pleasure.