James M. Walker, M.D. spent 12 years at the Danville, Pa.-based Geisinger Health System. During that time, his title evolved from chief medical information officer to chief health information officer, to reflect the broad, multidisciplinary approach to clinical transformation that Walker and his colleagues at Geisinger have striven for. What’s more, Walker continued to practice medicine part-time, until November 2010 (his clinical specialty was internal medicine). Geisinger is just famous for its ProvenCare program, which has combined evidence-based care pathways with pricing guarantees, in areas including elective coronary artery bypass graft (CABG), elective percutaneous angioplasty (PCI), bariatric surgery, and perinatal care. In the CABG arena, for example, the implementation of the ProvenCare program has led to a 44-erpcent drop in the health system’s 30-day readmission rate, and a half-day shortening of average total length of stay (from 6.2 to 5.7 average days LOS).
In February of this year, Dr. Walker transitioned to a new position, as principal healthcare informatician at the Malvern, Pa.-based Siemens Healthcare. He spoke with HCI Editor-in-Chief Mark Hagland recently to discuss his transition and what he hopes to accomplish in his new position. Below are excerpts from that interview.
What led you to make the transition from Geisinger to Siemens?
You know something about our success at Geisinger; we had really started to do enterprise process redesign, and really had started to make dramatic changes in quality and efficiency. With the Keystone Beacon Community, we had created a pretty successful effort to extend learnings across the community. And with the experience of that, I realize there were a lot of organizations that don’t have Geisinger’s resources; and even for Geisinger, it’s sort of slow and expensive to do everything as a one-off process. And I was on the federal HIT Standards Committee, and working with some other projects and initiatives.
And I sort of over time came to the conclusion that if somebody didn’t design processes to become efficient and useful, and put those into solutions, the U.S. healthcare system would never get to process-enhanced care. So when Marc Overhage [J. Marc Overhage, M.D., Ph.D., chief medical information officer at Siemens] came to me sometime in 2012, and looking at what he and John Glaser [John Glaser, Ph.D., CEO] are doing at Siemens, it sort of just made sense.
James M. Walker, M.D.
What were you hoping to accomplish, coming into the role?
Just what I said, to understand and to study how to create cost-effective care processes, reliably, reproducibly, and build them into health IT solutions that really work for the whole care team. You see, part of the issue right now is that most of our products have been focused on doctors, and some on nurses, but really, there’s a whole care team out there, and to me, that team has to be patient-focused. And if we want to engage everyone, all the way through to case managers, and home health, and first responders, really, everyone, to provide high-quality care, whatever and wherever the need is, then you’re talking about a different kind of health IT solution that understands care teams; you need to be able to flex, since every organization uses different processes.
Maybe they have care teams, maybe they have community-based caregivers, maybe not. And so, how do you help different organizations, wherever they are in terms of their understanding of the care team and care processes, to improve cost-effectiveness and quality? I lead the Siemens Health Services Innovation Center, and that’s what we’re trying to accomplish.
How many people are in the Innovation Center?
By next year, it will be about 40 FTEs, with a range of skills and backgrounds, all of them focused more or less on this challenge that I’ve been talking to you about.
As someone who has been a practicing physician and a clinical informaticist and led clinical transformation efforts, how in your view do we get physicians in practice engaged in helping to build the new healthcare?
I would say that up until now, it wouldn’t be unfair to characterize healthcare IT as trying to help doctors and nurses do what they did before, faster. And the problem is, there’s just too much now. You can’t simply try to help them do the same things faster. That’s why process redesign is so important. For example, what if you said this to doctors and nurses? We’re going to redesign a current process so that doctors only do what doctors need to do, and nurses only do what nurses need to do. We did that at Geisinger, shifting certain processes to call centers; and the clinicians really appreciated it. Another example involved lab test results; we made it a 10-second process for a doctor to send her or his patients a reminder to engage in healthy lifestyles and exercise along with their lab results. We later did the same thing with reminding patients about flu shots or scheduling them for that.
That’s why I’m so passionate about getting process redesign right, so that doctors and nurses can let go of the administrative trivia, and focus on what’s important on behalf of the patients, and focus on getting care management right—and that way, everybody wins. You will recall that there are over 40 elements in the CABG protocol.
That’s the 41-step clinical pathway that was created for CABG under the ProvenCare program, correct?
Yes, that’s it. And it becomes unaffordable to manage such processes on paper. You need the electronic health record, and then a business process management set of solutions behind that. The complexity of all the processes involved in care management can be daunting, which is why it can be difficult to make sure that Mrs. Jones gets reminded to get her diabetic eye exam. And that’s one of the things that brought me to Siemens. There are very few health IT vendors with a robust business process management system at the heart of their solution—often described as a workflow engine. That is something that is still just starting to be used in healthcare; we’re late compared to many other industries.
There’s a feeling in the industry overall that we’re still relatively early on the journey of 1,000 miles, when it comes to clinical transformation and core IT solutions. Do you agree?
Yes. I do believe that we’ll make a quantum leap in the next five years in producing solutions that are far more sophisticated, efficient, and better. We have an infrastructure, a basic set of software and services, that really do poise us to do the kind of process optimization that needs to be accomplished; and very few vendors are in a position like that to achieve that kind of process in any short timeframe.
What should CIOs and CMIOs be thinking about right now, per the movement towards the new healthcare?
I think one of the things is to really help their organizations prepare for this new healthcare, as you call it; to use the workflow or business process management engine, requires organizations to optimize their processes. And Al Casale [Alfred Casale, M.D., the cardiothoracic surgeon who led the first implementation of the ProvenCare process in the elective CABG arena] led the way; and the first miracle there was that the seven cardiothoracic surgeons sat down and talked together. So what’s needed is to get everyone in a clinical area to sit down and talk with each other. And that was one of the miracles that took place at Geisinger: the first time, it was like pulling teeth, and it took nine months; by the second time, in perinatal, everyone knew where the process was headed.
So, educating everyone about the process change, and finding ways to educate everyone about the power of process change, can be so powerful. Doctors and nurses aren’t chuckleheads; they don’t resist change just to resist change, but because things have been dropped on them that haven’t improved their workflow or their lives. I’m convinced that that’s at least 80 or 90 percent of it. And then the other thing for CIOs and CMIOs, is to really think about workflow engines and business process management software.
In my previous position, I started saying, we’re going to need heavy-duty business process management software; and can we agree together what we would do with it? Can we agree on one that we would run financials and clinicals on at one time? So that’s another element, on the business management and planning level, to make the case for this. I think most leaders of most organizations will realize in the next few years that they need business process management. If you’ve begun to think about processes and everyone’s needs in your organizations, you’ll be sort of ready when the CEO says, OK, we’re going to do business process management now. And that will be a piece of work for most organizations.