Things are moving quickly along a number of dimensions these days at Adventist Health West, the Roseville, California-based health system that encompasses 20 hospitals, more than 2,800 inpatient beds, more than 245 clinics and outpatient centers, and more than 50 rural health clinics across several western states. Adventist Health West clocks more than 1,000 patient visits per hour and more than 6,600 visits a day, and serves 1.7 million patients every year.
What’s more, the health system is continuing to grow through expansion and acquisition. Not surprisingly, for Adventist Health West’s healthcare IT leaders have a lot of processes to manage and tasks to take care of these days.
It is in that context that Loretta Sloan, an assistant vice president at Adventist Health West, presented regarding IT management and governance at Cerner Ambulatory Summit, hosted by the Kansas City-based Cerner Corporation, and held last month in Kansas City. Sloan and her colleagues have been partnering closely with Cerner as their core EHR vendor.
Describing some of the processes that she and her colleagues are currently involved in and which she described in her Cerner Ambulatory Summit presentation, Sloan spoke with HCI Editor-in-Chief Mark Hagland about the range of challenges and opportunities facing her organization. Below are excerpts from that interview.
What did you talk about in Kansas City last week?
So what I presented last week was, I had started with who we are and some of those statistics and about our mission and vision. But then I dove into was our comprehensive transition from a lot of paper-based practices in 2011 to being fully implemented today. All clinics are except for our clinics in the state of Oregon, who were already using Epic for 10-12 years, so we haven’t transitioned them at this time. So they’re EHR (electronic health record)-based.
How many months did it take for your organization to transition to becoming fully electronic?
Our first go-live was in May 2012, and our last was June 3, 2015. In that last go-live, we actually converted those clinics from another solution to Cerner, so they were already not paper-based. Our last paper-based practices converted to being electronic in June 2014. All the other conversions were from other solutions, so it basically took two years to transition from paper-based to electronic. And we’re acquiring practices or having them join us, all the time.
What were the biggest challenges involved in making the transition?
I would say the biggest challenges were around standardization. The way I would describe it, our clinics came together, a lot of practices came together, to be part of the Adventist Health organization, so there wasn’t a great deal of standardization, so we were standardizing while implementing, which increases the level of change management involved.
So the core challenge was the standardization of processes operating within the clinical workflow, then?
Correct. Our approach was to work with Cerner on some of the best practices as well as other organizations that done this with different systems, to determine best practices in our design and to create an overarching workflow design, which meant that some organizations had a lot of change to implement, and others, less, because we were moving towards a standardized workflow design.
What have been the biggest lessons learned in standardizing both workflow design and EHR implementation at the same time?
We were trying to meet the October 1, 2014 ICD-10 deadline, so time was the biggest constraint for us. If I had to do it over again, I would have done more standardization prior to the implementation, so we weren’t doing everything at once.
But little did you know that Congress would step in and foul up your plans!
Correct. But we were fairly far along already. And we were also converting our revenue cycle systems all to the Cerner system, meaning all the hospitals and all the clinics. We started that process in 2013, so when we hit 2013, we lined up all of our EHR timelines with the revenue cycle timeline, too, which was very aggressive initially, but when Congress changed the ICD-10 deadline, we changed that a lot.
Yes, that was a ‘wow.’
Given everything we’ve been discussing, what are the biggest pieces of advice you have for large health systems acquiring more clinics and hospitals?
One thing that has been our approach is that there needs to be an overall, system-wide executive sponsor and business owner—and we’re talking the business side. In physician services, I was the business owner, and my boss Don Jacobson, was the business owner. This gave IT to move conflicting requests through a business owner model so that IT wasn’t having to moderate conflicts. So they didn’t have to be in that position; they shouldn’t be.
From a governance standpoint, getting all the stakeholders together on the same page is generally very difficult, yes?
Yes, it is very difficult. And we made the decision that the business was the driver. IT and the vendor are enabling the technology for the business to do their business and for the clinicians to provide the care. So we made that collective decision with the group. Then we sat down and figured out how we would work together. It was all of us together: Cerner, IT, and Adventist Health System Services. We decided how to make this work, given how spread out and disparate we were across organizations. And that was very helpful, because we had that relationship defined from the very beginning. We evolved our governance model from an implementation governance model to a support and maintenance governance model, but we never changed from that triangle project management leadership model.
People say it’s the people, process, and change management issues that are most difficult, not the technology ones per se. Is that correct?
I would agree. And that’s part of why we manage the way we do here. On our team, there’s me, and then I have a manager who is tasked with implementation work, and that person helps drive the people in the clinics making decisions and preparing, and it’s really a liaison between IT, senior executive management, and clinical staff and physicians. And that way, we have a very consistent process from clinic to clinic. Part of this also involved converting 12 clinics from Epic to Cerner. Meanwhile, 25 clinics will remain on Epic for now.
So you’ve had to be kind of flexible and make a few exceptions?
Yes, our goal is to be on a single system across an entire enterprise, but you have to consider the situation in the moment, and you don’t want to standardize to the extent that you make a change that has negative consequences for your business or for your clinicians or patients.
What will happen in the next few years at Adventist Health West?
We will continue to grow. Our implementation process—as we continue implementing, our goal will be to bring practices onto standard solutions. That will take continued work for our clinicians. Additionally, we will continue to implement Cerner’s improved solutions. A great example of that is that Cerner has developed specialty-specific playbooks that take standard workflow and modifies and fine-tunes it for physicians, for cardiologists, for example, versus primary care physicians. So we are in the process of implementing those right now, and those improve efficiency of process.
We will continue with another type of optimization. There’s optimization in technology, and then optimization in workflow, and that means going back and revisiting those physicians in the staff, how they’re identifying potential improvements. It’s very difficult when you go live to make all those changes. So our normal process is to circle back six to eight weeks later and look into skills optimization. For one thing, we have more providers and staff all the time. We’ll also be moving more and more into the population health space now, preparing for value-based payment models, and we really will focus… the patients are always at the center of what we do, so we will continue to look at changes we need to make to improve outcomes and patient experience, but we also want to improve provider satisfaction and quality of life, so we can start getting them home a little earlier every day. And it’s a process; you just have to keep working at it. And some of that will be improvements Cerner gives us, and some will be workflow optimization to use the system in the most efficient way.
And I would recommend that people have a model in mind, especially if they’re spread out, for identifying physician champions—not necessarily before go-live, but after go-live, you need to identify physician champions, because you need those individuals to help you with optimization work after go-live, so having a physician champion model is important. It is also important to keep in mind that part of the reason for our success so far has been a strong partnership between ad among the business side of our organization, IT Services, and our vendor. One is not more important than the other; when the partnerships around the table are good, the chances of success are all that much greater.