Christ Hospital, a 381-bed acute care facility in Jersey City, N.J., offers a range of services from primary angioplasty for cardiac patients to intensity modulated radiation therapy (IMRT) for those battling cancer. The medical staff includes more than 500 physicians, most of whom are board-certified in specialties ranging from allergies to vascular surgery. HCI Editor-in-Chief Anthony Guerra recently had a chance to talk with CIO Martin Grossman about his work at the hospital.
AG: Since I met you at the show, I’d like to know your impressions of HIMSS this year.
MG: It looks like everybody is excited about the new standards that are being presented to get folks that develop EMRs to be interoperable, and it looks like folks are trying to figure out how to do the HIE-type of conductivity now that RHIOs have not quite done what they were advertising they were going to do. HIMSS itself was great, and it’s interesting to see the different strategies that the major vendors have to address – the long-term solutions.
AG: When you talk about the standards that are being released, anything specific you have in mind; CCHIT or HL7?
MG: CCHIT comes particularly to mind. I’m actually pretty excited by that, I think that has a great degree of potential. For me, at a community hospital level, I’m going to be given the chance to do this once, and probably not again. (CCHIT) helps me with an objective view on the evaluation of the different niche of vendors, because one of the considerations I have when selecting the clinical information system is to see if it will last pretty far into the future. The way I see that working right now is through the use of the standards that have been employed.
AG: What do you have in place now?
MG: We basically have a McKesson shop for the transactional part of IT. We are just beginning to embark upon our clinical journey, if you will. We have a pretty robust lab information system and a suite of lab products (also McKesson). I have GE’s Cardiac Cath suite of systems. The first part of this year, we’re going to employ GE’s OB data systems, the perinatology systems, and some others. So we’re really concentrating on some of our product lines that we want to go ahead and enhance and provide them a value-add to get to be state-of-the-art. We’re beginning to evaluate more robust, advanced clinical information systems in preparation for the EMR/EHR journey that we’re about to embark on.
AG: We may be getting into semantics here, but how is an EMR different from what you currently have in place?
MG: An EMR is basically an electronic version of paper charts that folks are used to seeing in a medical records department, the old medical record department. So, you may have an X-ray film and you have the health record and you want to see that electronically, so you may have a mini-PACS or a PACS that will be employed to create that in a visual format. The same thing with your history and physicals, your nursing documentation, your labs, all the different components of that chart; and to be able to use that chart concurrently by different healthcare providers, interdisciplinary. So the pharmacist can see the drug that they distributed to the nursing floor at the same time the nurses administer it and can look at things like allergies and any other types of clinical alerts that need to go in the dosage. It really assists in patient safety, and that whole closed-loop medication effort that folks talk about.
AG: The products that you have from McKesson currently don’t give you that view?
MG: No, we have processes in place that provide the same, or very similar, function, if you will, but the automation of going electronic will greatly enhance our ability to apply that much more effectively and safely.
AG: Are you looking at McKesson for your EMR?
MG: They’re going to be one of many that we’re going to look at. There’s grand scale like the Epics of the world that have a pretty robust system but a very expensive system, through to McKesson, which is more midrange, but not as integrated, more interfaced. Then you’ve got even Meditech that are not as expensive but not as flexible in dealing with other vendor devices. That’s the journey that we’re going on, as a midsize urban community hospital. We do have our challenges, and we’re trying to fit our technology needs with the reality of the financial world.
AG: Are those the three that you’re looking at?
MG: No, they’re samples of suites of products that are not so expensive, midrange expensive and very expensive, and then a different degree of integration, if you will. I’m really looking for a truly integrated suite of products, rather than a lot of stuff that requires a heck of a lot of interfacing.
AG: What are the main pieces in the IT architecture that you want, the main applications that you want to be able to exchange information?
MG: On the ED application, with the pharmacy application, with the nursing documentation application that results in what’s called an eMAR — all that working in conjunction with our ancillaries: the labs, the radiologies and cardiologies.
AG: So the more vendors that are in your shop, the more difficult that becomes?
MG: It becomes more difficult when you’re dealing with interfaces because each interface has a point of failure. If that interface goes down, then that information is not being transmitted to another part of your continuum. So, if you have an integrated product, the risk of a piece of information not being available at the point of care, at the time that it’s needed, is mitigated. So that’s pretty much the desire that I have is to, obviously, provide the right information to the right person at the right time; have the information correct.
AG: Are you looking at an integration engine product, like a DB motion, or Inter-systems, these types of things?
MG: Yes, and you’ve got your Axolotl, stuff like that. We’ve actually started looking not just internal to the hospital, but external to the physician practices. The physicians are our customers, too. We have to be able to incorporate their workflow and capabilities in their offices with ours, too. We’re also looking to grow into that ambulatory EMR, if you will.
AG: It sounds like you’re doing significant work in-house right now. Is it important to get your house in order before you work on integrating the associated practices?
MG: Yes, and that’s what we’ve done over the past couple of years. We’ve actually done a huge technology refresh of our basic IT infrastructure, and some of those peripherals in the ancillary department, in preparation for the opportunity that we have now. We’ve done a tremendous amount of work on the networking infrastructure, a tremendous amount of work on our communications infrastructure, and our ability to work with storage devices and disaster recovery, etc.
AG: So, you’re looking to leverage the relaxations in the Stark Law?
MG: Yes, we are, but I want to make sure that, as we provide opportunities for our physician customers, that what they connect to is pretty nifty too.
AG: Can you tell me anything about the internal debates that goes on around building your budget? How do you justify the Stark-associated spend?
MG: It is something that we should be doing, I guess, would be the best way of saying that, in order to provide a better service to the patient. That’s because, as the patient presents to the hospital, they’ve already probably seen their physician in the community. From that encounter, the physicians probably have some information that would be of assistance here, as we provide another set of care in another part of the continuum. Of course, when we discharge them from the in-patient side, and they go back to their physician, we have information that that physician will require for follow-up care. When you look at markets and such, there could be some market differentiation amongst the facilities that have that ability. The bottom line is: what type of care are you providing to the patient?
AG: Is it a concern that, if you are not the first mover, a competitor hospital will beat you to the ambulatory integration?
MG: Yes and no. I guess another question is: is it always good to be the first person on the block to do something like that? I would say, if you’re providing a great service that they adopt and it’s useful to them, then yes, that could be a differentiator. If you are just the first one to provide the technology that they don’t really use or is cumbersome or not of value to them, then I don’t see that as being an advantage.
AG: So it’s not something to rush into and get wrong?
MG: No, you have to get it right first, I think.
AG: Are you bringing the doctors in, having them sit in on demos to look at some of the ambulatory records? Are you trying to integrate them into the process of selecting what you’re going to offer them?
MG: Yes, actually we have and, particularly for us, the first step was in that OB system where we’re beginning to do the finishing touches of the planning for the implementation. We’ve engaged a large part of the physician staff and they’ve been very helpful, actually. Of course, we’re all waiting to see if the advertisement’s true and we provide them with service. Quite frankly, that is going to be one of our real first endeavors. The end result’s going to be like an OB-oriented EMR. These physicians are pretty excited by that. There’s a little trepidation going on because some of them are not very used to technology, but it’s exciting nonetheless. We’ve had great response so far.
AG: Have you figured out if you’re going to offer them one product or a choice?
MG: I don’t think we have the opportunity to offer many different types of products for the same function and, in this constrained environment, we’ve got to be pretty selective as to what we select and purchase. So the pre-selection process will engage the physicians and other clinicians throughout the house for these systems that provide a function. It is very critical because, like I said before, once we’ve selected a system and we’ve installed it, we’re not going to have too many opportunities to try that again.
AG: Have you come up with any final list of ambulatory products you might offer?
MG: No, not yet, but that’s part of that EMR/EHR journey.
AG: Are you going to leverage the CCHIT information on who they’ve certified in the ambulatory space and work off that?
MG: Yes, I’m going to use that as a first-blush list.
AG: Actually, I think you have to use that list in order to underwrite those costs.
MG: Or else you can be hurting from the start.
AG: Right, so that is not much of a choice there. Do you think the CIOs in community hospitals of your size face unique budget challenges that larger competitors may not have to deal with?
MG: Absolutely. Again, the larger academic medical centers have many different sources of funding, and great endowments and all that good stuff. We have to make do with our operating capability. The source of our funding, in general, is through operations which, in the state of New Jersey, that type of margin is very tight, it really is. So it takes us a while to make these decisions, to purchase these systems, because it is a large part of our capital budget. The good point about being the CIO in a community hospital is, once that decision is made, execution of that happens pretty quickly, once we do all the due diligence and get everybody onboard.
AG: Who leads the way over there? Your CEO? Do you have a board?
MG: We have a board and mainly business folks in the community. The CEO, Peter Kelly, is leading the executive suite and leading the hospital. We do have an IT steering committee, and Peter provides his horsepower behind the IT steering. IT technology refreshment is a big, big part of the strategy of the hospital going forward.
AG: Many CIOs say that the views the CEO and board have on technology can make all the difference. Some see it as a strategic enabler and some as a cost center. How would you describe the environment you’re working in?
MG: Actually, both. The pure utility aspect of IT is looked at tactically, if you will, and that’s the expense part, but the strategic part is becoming a larger part. You still have that expense center tactical part when it comes to the phone systems; that’s a utility. For example, you’ve still got a phone on your desk and the expense associated with that. You’ve got your servers and all that type of stuff, just to keep the infrastructure running.
AG: We talked about Stark a bit, it sounds like leveraging that is one of your main projects over the next year or so. What would be a couple of others?
MG: Really going full-blown on the advanced clinicals, that’s the biggest portion of the strategy here. We developed the infrastructure, we’re poised at a point where we can take advantage of that. The Stark relaxation helps us bring the parts of the healthcare continuum in sync with us. When you’re talking clinicals, you’re talking pretty large, dynamic changes in your clinical processes and the opportunities for clinical improvements are almost transformational, if you will.
When we’re talking about the ED system, the pharmacy system, nursing documentation, and all this is geared towards improving your clinical outcomes. Not just, necessarily, for the sake of technology. That’s really the key focus of the strategy. The senior clinical executives are very much onboard and gleaning a lot from this effort, too. So that’s a very good bonus from a CIO’s perspective, where you have a chief medical officer and a chief nursing officer pretty much championing the refresh that needs to be done.
AG: How do you manage some of the more nuanced parts of the CIO job, such as promoting clinican adoption?
MG: Actually, a steering committee is a real good thing to communicate and champion the role of technology around improving clinical outcomes. This is a very difficult subject matter for folks that aren’t technical in nature. It’s critical to be able to talk about patient safety enhancements and articulate that to the financial folks, while concurrently being able to articulate some of the financial aspects to the clinicians. I find it pretty interesting, it’s challenging. So you’re straddling the financial and clinical folks and, in that sense, you facilitate the dialog between the two.
AG: You talked about going through some RFP work in terms of vendor selection. Can you share any best practices around that?
MG: Yes, and I’ve been around the block a little bit too. I’ve worked in a Siemens or SMS environment before, and I’ve worked in other vendor-supported organizations before, so I understand vendor loyalty to a point, but I think we’re pretty savvy enough not to fall into the sales cycle, if you will.
AG: Who do you think would be susceptible to that? Maybe a junior CIO?
MG: It depends. If you’ve got a CIO that is very strong on the technology side, but is not familiar with the healthcare environment, you may have somebody that could do great on the technical services part but doesn’t understand the clinical workflow, or the impact of a decision on the clinical workflow. Those folks can be susceptible because they’ll listen to some of these sales folks that can speak the terminology maybe better than they can on the clinical side and want to believe them.
AG: How do you approach vendors? Do you approach them as adversary or ally?
MG: At first, I see if they’re going to try to exaggerate a bit. My first approach, really, is to just listen. Give them an opportunity to provide their sales pitch and listen to what their strengths and weaknesses are. Then, you start asking some questions, very general at first, and that helps me determine whether they’re in the ballpark for the functionality we’re looking for. Then you get more specific; whether from the technology side or from the clinical side, or both.
I’m fortunate in that I’ve got some pretty decent staff here and they have been very good at vetting vendors and determining what their strengths and weaknesses are. They bring it up to me, and then I view it from the executive perspective and make sure it matches the strategic direction, whatever that function is, with the hospital strategy.
AG: Do you ever find that the people vendors send to you are a little too green and can’t answer all your questions?
MG: Yes, and they try to do that with the community hospitals more than academic medical centers, because they think that community hospitals probably don’t have the folks that are as knowledgeable as academic medical centers. Unfortunately, they can fall in traps every now and then. When that happens, I will let the vendor know if I think that the person is offending, if he’s green and doesn’t have the knowledge that we’re looking for. We will, generally, give them a second shot and, at that point, if they fail to recognize what we’re trying to achieve, then that’s just a bit of information that we keep as we’re evaluating the vendor.
AG: That could be a red flag of how, if they’re sending you that person for the pitch, that could be an indication of who they’ll send you for the implementation and the training.
MG: Right, and one of the strategies that we try to use is to find out who they will send for the implementation when we’re in the sales negotiations or the contract negotiations and try to put them at risk, too, for the implementation service. So if they send us somebody green at a point, or where the implementation timeline is not realistic, or the resources aren’t provided, or they’re overstated, we’ll know that early.
AG: If you could assign us a story, what would you like to read about?
MG: What does true integration mean? You know it from a tentacle perspective but how does that relate to, again, the big push across the nation for better clinical outcomes? Again, more concurrent, real-time information versus a retrospective perspective at times, a topology of how to achieve true integration, regardless of vendor. Basically, making the environment vendor neutral — that’s the golden egg that a lot of folks are trying to get to. The only way that I can see that succeeding, or having a chance of succeeding, is that requirement for standardization.
AG: So to learn how you get the data from wherever it’s sitting, in whichever bucket, whichever data silo, to the front of the clinician’s eye, when they need to see it, in a way they can appreciate it to effect care?
MG: That also really works with their clinical workflow, rather than the clinical workflow trying to work within the technology.
AG: And that’s what we’re all looking for, right?
MG: That’s it. We’re trying to make sure that the doc next to the patient doesn’t have to go through 14 different screens to achieve something they can do on one piece of paper.