With 4,000 team members, not-for-profit AtlantiCare delivers healthcare through more than 60 locations throughout southeastern New Jersey. The organization includes AtlantiCare Regional Medical Center, a 567-bed teaching hospital with campuses in Atlantic City and Pomona, along with an IT business called InfoShare. HCI Editor-in-Chief Anthony Guerra recently had a chance to talk with AtlantiCare CIO Dan Morreale, who also serves as CEO of InfoShare.
AG: I was looking on your site and I noticed something interesting — you are corporate CIO for AtlantiCare, and also CEO of InfoShare — AtlantiCare’s information technology division. Can you tell me a little bit about that?
DM: AtlantiCare, as a conglomerate, is six different companies. InfoShare is one of those companies, and it is the technology arm of AtlantiCare. We also sell some technology services to some community-based physicians as well.
AG: That sounds interesting. I suppose you’ve found that structure to be the best?
DM: No, I think it’s been a little bit of a challenge, and we’re trying to change that. We, at AtlantiCare, have our businesses set up in the following way: the five businesses are the medical center, which is two hospitals and a bunch of outpatient activity; InfoShare, which is the technology company; we are half owners in a partnership with Blue Cross/Blue Shield and that’s known as our health plans company. Behavioral Healthcare is set up as a separate corporation, and we have a division known as Health Services, which is primarily physician offices, gymnasiums, and some more storefront space. The health services run our childcare activities; we have a very large childcare program.
Those are the five major businesses, and we all interact. We’re all part of AtlantiCare. We’re all fully owned subsidiaries of AtlantiCare. AtlantiCare is our prime responsibility, but structurally we have these business units and each business unit is expected to maintain profitability and keep their staff happy and grow the business, and that’s what makes this job just a little bit different from an ordinary CIO position.
AG: Are you familiar with other healthcare organizations that are similarly structured, or do you think you’re fairly unique?
DM: This model was very popular back in the ’80s, where CIOs try to convince their CEOs that they can turn information technology into a profit center. I know there are a few models out there. I can’t tell you that Jack Wolfe (CIO) at Montefiore (Medical Center) has probably got the only model in this area that works effectively.
AG: Tell me about some of the specific challenges that arise because of the structure you have in place?
DM: I think some of the challenges really center around the way tasks need to be prioritized. From a business standpoint, I have external customers that I need to keep happy. I have internal customers that need to be kept happy. My medical center is my biggest customer and pays me the most money, and demands the most, but the other companies have just as important demands and the process by which we prioritize all of those things is a challenge. I want to keep my biggest paying customer happy, but I want to keep everybody else happy as well. How do you dole out resources, how do you keep everyone engaged? And the needs are very different across the platform. The needs of the medical center are a whole lot different than the needs of the daycare center, or the needs of a physician’s office. It’s what makes the day full and interesting.
AG: With most IT purchases, there’s an ROI discussion. But some of these patient safety implementations don’t lend themselves to that very well. Do those discussions take on a different tone when you are, essentially, an independent company that’s providing services? Is it basically, if you can pay, we will do it, like most companies?
DM: No, I don’t do that, because part of the challenge that I had when I joined AtlantiCare was getting each of the organizations to sing from a similar prayer book, all the AtlantiCare companies. Prior to my arrival, each company would go out and buy whatever technology they wanted, and then dump it on our lap and say, ‘Okay, now you guys figure out how to make this work.’
We really needed to change that model and establish some standards and help our customers to go out and make selections of hardware and software that we thought were effective and fit within the security and technical structure that was in place. That was one of the first changes that we needed to do. It’s happening, so we’re getting there. Officially, we have a rule at AtlantiCare that is, if it uses electricity, InfoShare needs to take a look at it before the purchase order’s released.
AG: Is there a minimum dollar amount?
DM: No, we’re doing it across the board, because the last thing I want are those $49 software packages that sit on one PC, and we try not to do those. I’ll give you an example: human resources sent in a purchase order request just a month ago to buy two copies of some software that cost $29 each. We looked at it and said, ‘Is this something that everybody needs and, if it is, why am I buying just two copies?’ We sat down with human resources and we looked at their intention and realized that they need probably eight or nine full-blown versions of the application, but then we need about 5,000 licenses to access and read it; not change it but read it or make it available. Then we asked is that something we can put on the Internet, and is there something that’s got to be loaded on each PC, those kinds of pieces.
We sat down with them and redefined the scope of what they were trying to do. They were looking for a tool to make the little boxes and lines, and they tended to just print them and send them to everybody. We were able to show them that, if they get the tool and get the right licenses, that we can load it online and we can put it on our intranet. We can make the process paperless, we can empower the departments to make changes as they need to. Then we put together a whole little process review for that mini-application to manage that kind of stuff. That’s the stuff that we do on a regular basis.
AG: So, it’s important that you get things brought to your attention before they’re purchased?
DM: It really is a critical piece.
AG: Do you find that you have that relationship with the AtlantiCare hospitals and other entities of a vendor and client? Are there service-level agreements?
DM: No, there are not. I’m trying to move away from that, because the effective use of technology and the effective use of software is really dependent and contingent upon this cultural shift to what I like to refer to as people being digitally savvy or digitally and electronically aware. The most significant thing that InfoShare does, I think, is be a change engine for that culture. That’s really the direction we want to go. So I don’t want to be in a position where people see me as a vendor and have to buy services. I’m trying to make it all a fluid, dynamic, and integrated part of everyone’s daily workflow.
My efforts have been to the contrary of SLAs. I’ve been taking my people and just putting them out in the different business units and helping them to understand what our users need. We are solving the question of how do I make using these various information systems simpler, easier, more intuitive, part of what they do and, at the end of the day, save some time and effort.
AG: In your organization, who has the responsibility for effective, not only initial adoption, but deep adoption, in terms of all the doctors, all the nurses?
DM: The misnomer is that IT rolls stuff out, and that certainly has been the mentality at AtlantiCare until just recently. Specifically, in 2008, we were able to help the organization recognize that IT projects are not only those projects that center around infrastructure — PCs, cabling, storage, that kind of stuff — but any kind of software application needed to sit with the business units and to be considered a business process.
This is the first year where I have no application installs on my business plan. But I’m doing a whole bunch of stuff where we’re making that big push for CPOE this year. We have a laboratory system, anatomical, pathology, and blood bank system coming on line. We have some booking systems in our emergency department in dialysis, and then endoscopy that are going live.
Each of those now sit within the business unit; the business unit is responsible for reporting it and InfoShare, and the technology department, is responsible for making sure the technical aspects are there and integrated. We’re helping to redefine workflow and process, which is not something that we’re really good at. We don’t have a strong skill set in that. It’s one of those things we’re trying to change this year, and managing the budget to do that piece. This is our first year of doing that. I’m hoping that, as we move forward, we’ll be able to push more and more of that responsibility onto the various business units and keep the technology company setting standards and doing the integration piece. That’s something we’re meant to do.
DM: I think, to be successful, we have to be less like vendors, and we have to be more like our case user partners. I think we have to be sitting side by side with our clinicians, with our support staff, helping them to understand how using the technology fits into their workflow and can better enable them to be more effective. I don’t think you can do that from a vendor position. I don’t think you can do that with a service-level agreement. I think you can do that by rolling up your sleeves and getting your arms dirty with the business unit or department that you’re working with and making it a joint effort. So, for me, I’m moving away from that whole vendor concept, and trying to position my staff outside the walls of InfoShare and next to the users, running side by side.
One of the big things I’ve done in 2008 was kick everybody out of their desks and say, ‘You’re spending X number of days in the hospital or in the health plans or in health services, listening to them, hearing peoples’ issues, helping understand what they’re doing.’ A well-educated IT tech is going to be my best customer who then, hopefully, will get an understanding of the challenges that the business has, and help the business to express their issues so we can offer help.
AG: You find fascinating things that you never would have realized when you walk the floor, don’t you think?
DM: Absolutely. The discovery of shadow processes, I think, is an entire industry that we haven’t yet acknowledged, and there’s probably a whole professional consulting world out there that people aren’t pursuing. It’s very, very real. More importantly, when you set out to aggressively integrate an organization, the way that we’re trying to do at AtlantiCare, all of the things that you are sloppy at are under a magnifying glass, and then become so blatantly obvious you’ll need very serious effort at the corporate level to fix.
My example to you is that we are busy helping our community-based physicians deploy electronic health records and connecting them back to the hospital and to each other. So AtlantiCare is building this health exchange within the AtlantiCare organization and our community-based physicians. We are even providing a grant and stipend to community-based physicians who want to adopt electronic health records, if they participate in our health exchange.
When we started to do that and we built that integration engine, the challenges were there, and I think in the back of our head we always knew they were there, but never gave them the credence that they needed. The differences in 125 Main Street (with “Street” spelled out) or 125 Main Street (with an “Street” abbreviated as “St.”) which are such a source of kick outs in an integration platform. As a human, you see through that stuff, you generalize, but in a data exchange, it’s a challenge. So now we have to go back and kind of hardwire, where we can, all of those selections on a registration process and then, if we’re doing that, how do we simplify and make our registration process more effective?
It’s one thing against another, so it’s kind of like we’re banging our head against a wall saying. ‘Why did we ever say we wanted to integrate our 216 information systems?’ It was a much easier world when every system did what it needed to do. It’s all of those things that the banking industry and manufacturing have wrestled with and solved, that are now coming to the forefront of the effort in healthcare.
AG: Just based on that, do you think CIOs have a lot to learn from other industries?
DM: I think we have an awful lot to learn, because none of the work we’re doing is new; someone else has already done this. I think our real challenge is figuring out how to solve it with the healthcare budget as opposed to a banking or manufacturing budget, because those industries generally spend more in technology than healthcare does.
AG: Is it possible to solve it on what you call a healthcare budget, or is the correct dynamic for CIOs to make a case that they need more money?
DM: I think we’re going to have to do both. CIOs have been saying they need more money forever. But, at the end of the day, I don’t think we’re going to see healthcare in the near future spending at the 8-9-10 percent of company’s revenue range. I think that’s many, many years away. So in the meantime, we’re going to have to learn to be a little bit more creative.
AG: Are there any particular ways that you glean some of these lessons from other industries, anything specific?
DM: I think every example has a lesson in it. Does any one thing spring to mind? No. But I like to listen and hear what other people are doing and how they’ve worked these things out, and then look for an innovative way to apply it to what we do.
AG: Is it hard to get IT-type folks out of their cubes and onto the floor?
DM: Yes, absolutely.
AG: What do you think a CIO can do? Are there any methods or programs you’ve put into place to get these people more comfortable?
DM: Yes, we’ve made it part of their job description that they have to have contact with users. Actually, we made it part of their job description so that their weighting and their merit increases would be somewhat contingent on that in a very, very small way. Next year, I’m going to roll it into my bonus program, so that having not done that is going to negatively affect our bonus. But, having effectively gone out and sat with our users will positively affect bonuses.
I think we’ll use that methodology to help shift that culture. There’s always a danger of taking propeller heads and putting them out in the real world. My comfort level with propeller heads is you put them in the basement, you slide a peg through the door, and you let them do what they have to do. My engineering staff is still there and I’m keeping them there. But for my application guys, those are the ones I want out there using it. I’m going to start there and, if we get a good level, then we’ll talk about the propeller heads. You need to keep them engaged, and that’s a different challenge.
Many, many years ago I read an article, and I wish I remembered where or who the author was. The article was called “Managing Einsteins.” It’s really about the different styles that you need to manage these very bright, socially recalcitrant individuals. You really need to be on the scene to keep things going. So, it’s part of my daily working platform. I go down there and visit them every day, but I don’t do it alone (laughing)!
AG: Let’s talk a little bit about some of your major projects. You mentioned this year was a big CPOE roll out, tell me a little bit about that.
DM: This is our CPOE year. My board has been asking for it, they’ve been promised it for eight year and the organization was never able to deliver it. But this is the year that we’re doing it. At the end of 2007, the beginning of 2008, we brought a pilot live in our pediatric unit. They have now been live for the better part of six months and having dramatic success. They are doing, not only CPOE, not only placing their orders, but their documentation online as well. In discussions with our physicians, we decided that that was going to be our approach. That we were going to do CPOE and physician documentation all at once. As our doctor said, let’s just get the pain over with, let’s just do it once and get it over with. That’s our model and, by the end of 2008, our goal is to have 75 percent of our docs using the CPOE system, placing their orders online by themselves. That’s our 2008 goal. Then, in 2009, we’ll refine that and then go after the holdouts and the ones that need special attention and special training.
We are doing it, essentially, by department and, of course, we’re starting with the department of medicine first. We are rolling through a series of relationships with the departments where we’re sitting down, working with them, defining their order sets, defining their care plans, not doing a whole bunch of physician specific stuff, but more department specific stuff, and we’re going to be bringing them live one group at a time.
AG: What particular vendor are you using?
DM: The same as our clinical system.
AG: Are you using a number of different vendors?
DM: Yes. Prior to 2007, we brought all of our nursing documentation online. In 2008, our physicians are going online and that’s how we start to close the electronic record and build it. We also had a little bit of a shift in 2006 when I joined the organization and went from a closed shop — that being only by Cerner or McKesson (as McKesson is our patient management system and financial system) — to more of a best-of-breed approach. My theory is that for those boutique services, you really need to find the tools that work best in that workflow model.
We have a whole bunch of boutique systems that we’ve brought online and are bringing online, in various departments — the emergency department, endoscopy, dialysis, the neonates, the NICU, and all that stuff. It’s really a very special need, so we’re going to have special need applications.
AG: For those boutique applications, what are the minimum IT requirements that will make them work in your overall architecture?
DM: We have a technical requirement platform that each vendor has to meet. But more importantly, we are looking at the road map for the application. We want all of our clinical information, at the end of the day, to reside in Cerner PowerChart. But we want a lot of that data to be discreet. What we’re finding is that, in these smaller systems, they can send me a file with the information, but not necessarily the discreet dataset. So, part of our contract negotiation is to build into the contract the acquisition of discreet datasets. And this discreet data really centers around, on a more grand scale, the other 26 data elements in the continuity-of-care record. Primarily, what we’re looking to get is discreet data elements in our Cerner environment.
In some cases, we have workflow issues because, where does entry order happen, and we’ve been solving those on a one-to-one basis. For example, in the NICU, the order entry is going to happen in Cerner, but in behavioral healthcare, my order entry is really happening in the booking system that behavioral healthcare is starting to install. Then again, looking for the continuity of the data elements that we want at the end of the day, it actually requires that we sit down and think about what we want to call our electronic health record and define that.
AG: As a CIO, how do you decide how tight or loose you’re going to be? For example, you could have come in and said we have Cerner and McKesson, and if you want something that either of those two vendors provide, let me know. If not, I’m not going to put it on the platform. You have decided not to do that, to be more flexible, but not without your limits. So, how do you decide where to come down on that discussion?
DM: I think, again, it all comes back to that culture thing. I think, at the end of the day, what any CIO is doing — and it would be an interesting to study to see if CIOs recognize this — is that we’re cultural anthropologists. We need to go in and shift and change the culture. I don’t think you enable that by being dictatorial. I guess you can do it, but certainly that’s not my style. I think if I want to shift the culture and get better use of a digital environment, then I need to provide tools that work for all my users, not for IT. I think that’s the difference.
Look at it this way, if you look at something like Amazon, why is Amazon so eminently successful? The reason is because they’ve used technology to help their users. But in healthcare, we use technology to help ourselves. We’ve done it exactly backwards. So, I’m looking to try to change that model.
AG: How important is the CEO’s role to your effectiveness? Tell me about different CEOs you’ve worked with and how critical it is, how much of an effect it has on your job.
DM: A good CEO makes my job easier, and a good CEO is someone who is supportive of technology, supportive of transition, and supportive of the behaviors, or supportive of squelching the resistance behaviors that are a natural part of any kind of cultural change. I’ve had CEOs who the docs would walk in and say, “I’m not using it, it’s disturbing my practice, and I can’t care about this unless … ” and the CEO has turned to them and said, “Gee, you’re my largest admitter, and it’s going to really hurt me to lose you, but I’m sorry to see you go,” and to mean that. I’ve had CEOs when the doc comes in and says, “Well, right, we’ll just do something else.”
It’s very important that the CEO believes in what we are trying to do, not only in their head but in their heart, because when it comes down to, “I’m not doing this and I’m your number one admitter,” they’ve got to have the chutzpa to say adios muchacha, we don’t want you.” And that’s a challenge. It’s a hard thing for a lot of CEOs to do, particularly given the condition of hospitals in New York and New Jersey, struggling for a financial existence. To draw that kind of line in the sand is a brave thing to do.