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On first blush, you might think Vincennes, Ind.-based Good Samaritan Hospital is just another small community healthcare provider in the heartland of America. At 232 beds, how much could be possibly be happening on the IT front? But upon closer look, it’s clear this organization is different. Good Samaritan offers a range of medical services, as well as some of the most progressive technology available today. Of course, it doesn’t hurt when your CIO has been chairman of the HIMSS board. To learn more about what’s going on at GSH, and pick the brain of a top CIO about HITECH, HCI Editor-in-Chief Anthony Guerra recently talked with Chuck Christian.
GUERRA: Do you advise physicians that they might not like the HTIECH deal, but it’s the best they’re going to get?
CHRISTIAN: Well, I agree with that idea. One neurologist said to me, “Well, when it starts costing me because of decreased reimbursement, then we’ll move.” And so, basically, they are establishing their financial pain point. “When it hurts enough, then we’ll move, but I’m not moving until then.” And I think a lot of physicians are like that, because I don’t think the industry has done a really good job of working with the physicians on the value propositions that are important to them.
And the other thing is I don’t think there has been enough peer-to-peer communication between the physicians and those who have been very successful. Sometimes people just assume that a physician has been successful because he’s a computer geek doc. Well, that’s not necessarily true.
There’s a 10 physician practice about an hour and a half from here in Corydon, Ind. We went down and had a long conversation with their docs, looking at the software they’re using and how they used it, and they’ve been using that EMR for about two years and trying to get a handle on the good, bad and ugly. They have 10 physicians, and they just built a brand new building around the new workflows that they had designed for their electronic medical record. I found it really interesting. There’s no place to sit except in the physician offices and a few other places. Everybody stands because they’re in constant motion anyway. There’s no reason to have a place for them to sit. The gambit of physician adoption runs from very high to not really low, but it’s not as good as it could be. One physician, who really adopted the electronic efficiencies, said, “Look, I don’t work on Saturdays and Sundays anymore. I’m typically out of the office by 6:00 every afternoon, and I’ve increased my patient workload volume by 30 percent.”
GUERRA: That’s pretty impressive.
CHRISTIAN: That’s why I’m going, “Wow, you truly are an ally.” Then he’s got two partners who actually started the practice, who are family practice docs for a long, long time. Well, they’re still using a little paper here and there, more than what they would actually confess to. They’re still doing charts and finishing up stuff on the weekends. They have not gotten the benefits out of it that the others have, and I’m not really sure they want to. They’ve been practicing medicine about 25, 26 years, and this is what they know, and they basically both confessed to say, “We’re going to retire in the not too far distant future, and we really don’t want to spend the time to reengineer everything. We’re doing what we need to do right now, then we’re going to kind of fade away into early retirement.”
I think the paltry amount that the federal government is offering the docs is just a drop in the bucket of what it’s truly going to cost the practices to automate, but it’s something, and something beats the heck out of nothing. So we just need to continue to move forward.
There’s very few insurance companies I know of that will pay a physician for an e-visit, for example. I read this piece just the other day about this mom that got up in the morning, she was a nurse. She worked at a hospital. She has a two year old, and she got him up to take him to daycare. She noticed that he was running a fever and he was screaming, and she pulled out her otoscope. (My wife is a nurse, she needed an otoscope with four daughters). His eardrum was red, inflamed and bulging. Guess what? He’s got an ear infection. So she calls the physician office, and asks him to call in something for the ear infection. “Nope,” he says, “sorry, you’re going to have to bring him in.” So she can’t get the prescription. She picks up the phone, calls her nurse supervisor, “I can’t come in today. I’ve got to take my son to the doctor,” and the doctor can’t see her until 2:00. So the kid misses a day of daycare and the insurance company’s charged $150 for the office visit, the doc spends 35 seconds, looks at the kid’s ear and says, “Yup, you’ve got an ear infection. Here’s your script. See you.”
And it could have been done either over the phone or at a mini-clinic. I recently read an article about mini-clinics that are staffed by caregivers like nurse practitioners, physician’s assistants that have prescribing authority, that have a very narrow band of illnesses that they look at and diagnose and treat effectively. Those mini-clinics don’t require all the trappings of a physician’s office. The mother I described could have gotten the same thing done for $35-40 and still been able to get to work for at least half a day.
GUERRA: How do CIOs prepare their organizations for this future state of healthcare you describe?
CHRISTIAN: Well, I’m doing a whole lot of listening because there’s a whole lot of stuff out there. One thing about information technology is that it used to be the mystical dark side of the hospital. Now, keep in mind, I’m an x-ray tech originally. I spent 14 years in radiology, and I’ve had about 25 years in healthcare ITs. That tells you how long I’ve been in healthcare. Technology is no longer all about bits and bites and twisting the knobs and turning the dials and the little blinking lights, like it used to be a long time ago. It’s about how you use technology appropriately to have an impact upon process, make it better, make it safer, make it have a higher quality. And so it’s going to take a lot of partnership and expertise to improve healthcare, and that’s one of the nice things that I’ve got to do is work with a much, much wider array of individuals in different aspects of healthcare, not just putting in an EMR or a PACS system and that kind of stuff but figuring out what’s the impact upon operations, patient care, and now that we have this data, what do we do with it.
And so I guess the advice is that most of the benefits we’re going to get from the technology, I call one-offs and that means you really don’t know what you can do with it until you get it. You have a pretty good vision and so you implement it, but only then can you say, “Now I got this, what else can I do?” And I’ll give you a couple of examples.
When we were putting in clinical documentation about 10 years ago and my team was working with nursing – they are all nurses and so they understood the intricate workflows and the accreditation requirements and the patient safety things that we had to do – they started looking at those processes and determining what we could do with the data. So we built protocols into our admission assessment where, depending upon a review of the patient’s skin, we asked: are they at risk of it breaking down to form decubitus ulcers, do they already have an ulcer, does the wound team need to look at that. It used to require the nurses to remember to make a phone call or send an order down to someone from the wound team to come and look at the patient we just admitted up in room whatever, or to have the nutritionist come and do a nutritional assessment with the patient because they may be malnourished. Maybe the patient said, “I’m dizzy,” or they have had vertigo, maybe they’re at fall risk and that kind of stuff – they had to remember to do all those things.
So now what we’re doing is making the data work for us. Depending upon how they score that patient when they’re doing an admission assessment, things happen automatically. The folks in dietary will automatically get a notice that there’s a patient admitted who met the criteria or fell below the threshold for the nutritional assessment, so they need to be reviewed. The same goes for the skin scoring and all that stuff. So how do you to make the data work for you. Some of those things can’t really be envisioned when you’re thinking about putting in clinical documentation, because when we were putting together the business case for clinical documentation, that stuff was never thought of. So it’s those one-off opportunities that you find once you start putting those tools in the people’s hands who really know the processes. That’s where you make an impact.
And so that’s why I say you need to have a lot of conversations and listen and be open-minded. I’m a lifetime learner, and it’s what I tell my children. Just because you get out of college doesn’t mean you’ve finished learning. If you’re not open to learning every day, you’re missing a vast opportunity. It may be a good thing, may be a bad thing, but I learn something every day.
GUERRA: So to be successful as a CIO today, your management and collaboration skills must be as polished as your IT knowledge?
CHRISTIAN: Yes, I absolutely agree. The only metaphor I can come up with is the architect and the contractor. The CIO has to be the architect. They have to have the skills to be able to communicate and listen to what the customer is wanting in their building and that kind of stuff. They need to be able to know enough about the pieces, parts that go into it, they know how to design it and how it all fits together, but then they’re going to let somebody else build it and maintain it and do that kind of stuff, and then they’re going to work with the interior designers to put the furniture in the right place and the color schemes and that kind of stuff.
I think any CIOs in healthcare who think it’s about wiring hubs and writing interfaces are not going to be very successful, because they are going to be relegated very quickly to the technical side of the house. They’re not going to have the opportunity to talk with the business people and the medical staff, because there’s a language that you have to learn in IT which you may have to unlearn to be effective. I think that’s one of the reasons you’re seeing some successful CIOs come to healthcare from the business world. You’re seeing other folks that are moving around – and not necessarily up from the technical ranks – into the roles of CIOs. You’re seeing quite a few physicians that are moving in it from the CMIO role because they have those skills to navigate the relationships that you need to manage in order to get these things accomplished and be successful.
GUERRA: I guess it goes both ways. Some people have told me how important it is that the CIO has the deep technical knowledge. It sounds like the role requires many skills.
CHRISTIAN: Well, that’s exactly what I was going to say. I think if you look at management as a definition, management is getting work done through other people. I’ve been very blessed. I have an outstanding team. My CTO is a retired navy officer. He did systems work on aircraft carriers and submarines. He knows more about virtual storage and that kind of stuff than I ever can hope to do. I mean I can get in a room with the vendors and him and I can talk about what our vision is, what we need to do, and conceptualize it, but as far as when it gets down to actually installing it, that’s not my role. I don’t have time to do that. I have to have great people to do that, and I have to trust that they know what they’re doing.
The other thing is it’s my job to make sure that if they don’t know that stuff, they’re on the wrong bus in the wrong seat. I need to have them transitioned. I need to put somebody in there who can get the job done. We’re doing this all together, and it’s like a great big machine where every cog and every wheel has its role to play.
I’ll use a football analogy or metaphor for you. I listen to a lot of CIOs talk about how they’re the quarterback, and they’re the commander of the field, and that kind of stuff, and that’s just not really the role that I play. My role is I’m the center. I’m the guy that hands the ball off to the people who really know what they’re doing. I also am going to stand out there and run interference for them to make sure they have the opportunity and the time and the tools to be successful and accomplish our goals. And if I don’t do that, if I’m just the guy running on the backfield looking for where to throw the ball, I’m not sure that’s the right position for me to play.