AG: Let’s go back to what you mentioned about the head of the ED, and how this person was able to understand what you were saying and compromise. Have you come up against other situations and could you give advice to other CIOs and CTOs that come up against an individual that’s not so amenable to reason; that sticks with a, “No, this is what I want, make it work because I’m bringing a lot of money into this hospital,” attitude?
LF: I don’t know if Ben is going to agree with me or not. We may see the world a little bit differently, but my experience here is that we've got some really dynamic, very colorful personalities, but the people really are very collaborative and they are team players. They do see the bigger picture. The people that I’ve worked with, particularly on this vision to move towards integration with the inpatient and outpatient community, they have been pretty agreeable to work with us. Would you agree with that, Ben?
BB: I do agree with that.
LF: The cancer center is a really great example. We have a world-class cancer center. We’re building a physical building, I don’t know if you saw the construction across the street, we’re building a five-story facility. It’s a dynamic group, and they have really wanted to have an EMR and practice management. They desperately need it, they’re a big practice. But they have been very, very willing to wait, work with us and partner with us so that they can be part of this vision, rather than going off on their own and doing their own thing.
AG: Ben, what are your thoughts on that?
BB: There has been no department that has said, “I am doing it,” and then actually has done it, because there are really good partnerships here, and we have a really good governance model. A department just can’t go out and buy something. We don't want to use the big hammer; sometimes we use the little hammer. They can’t just go buy something. We have a pretty good purchasing process here, where it needs to be cleared with finance and IT. I need to sign off on every requisition or Lex has to sign off on every requisition that gets processed here. When finance or purchasing sees software, computer anything on there, it comes to IT to get signed. You’d rather not use the big hammer. You’d rather have that taken care of with conversations first. But we have to approve the technology that comes in here because we have a pretty good governance model around that. So we try to work with them first on discussions and solutions, if they know what they want.
There has been no one who’s just gone totally off on their own. We consolidated under Lex. We consolidated all the IT so no one has little servers on their desks. We have our full data centers here. We offer so many more services to what they can do. So yes, there’s push back, like Lex said, with the ED, but everyone still wants the same goal and they see the better vision of getting it together.
LF: And leadership, strong leadership really makes the difference. We have a very strong president. He’s a brilliant guy. He has built this place into what it is over the last 25 years that he’s been president. He’s a very strong leader.
I’ve worked in institutions where the leadership is weak. And when you have weak leadership, it becomes very political and you do have territorial power. It’s very, very hard. I worked for New York University before I came here, not the hospital but the university. In academia, it’s all politics. Everybody has got their own little kingdom, and you can’t get things. If you have a strong leader, it makes all the difference.
AG: Let’s play off that. I like to ask CIOs and CTOs about the relationship with the CEO. Many have told me it really is very critical to them being happy and successful. They need to be supported. Tell me how important the CEO vision is and what you want and need from a good CEO.
LF: I think the CEO doesn’t have to have a technical understanding at all. He doesn’t even have to like really IT, but he has to have a sense of the value, that it’s necessary for the organization. The CEO has to empower the CIO and then stand behind that person. And that’s the situation we have here. I was fortunate when I came into this role in 1997; it was at a critical point. Things were changing, the technology that we had at that time was not really that strong. The president and the board understood that we had to make major investments in technology. We did, and from 1998 through 2002 we invested almost $50 million in the infrastructure. That was the first piece of it. But over the whole 12 years, we put well over $110 million into the infrastructure. That’s just to get us where we are here. We grew the department from less than 20 people to over 100 people.
To go back to your question, the CEO needs to understand the value that this is a necessity. It is not just producing paychecks and patient bills. Ultimately it will be the lifeblood of the organization. It’s going to carry the information to do the patient care, to keep patients safe, the quality of care as well as the efficient operation of the organization.
With that value you have to have a person that you trust. And you have to give the person the resources. If that person is able to deliver, you stand behind them. Now, 12 years is a long time. CIO shelf life is not all that long. It’s about four years. I consider myself really fortunate. I’ve had really great teams working with me.
It’s not the CIO alone that does it. It’s the team. We established credibility very early in the game back in ’97-’98, and I think having done that avoided having the kind of problems, that plus the fact that we had strong president. He knew where he wanted to go. He knew he was putting a lot of money into it. He trusted the people in power. The people here are really very good, collaborative people. We never had those kinds of showdowns. If we did, I’m really blocking them.
BB: I think to add to that, a topic that’s been open recently is IT alignment and IT alignment with business. A year ago, we changed reporting to report to the CFO, from the COO to the CFO. I’m happy about that alignment. I guess it puts us more in harms way but in a good way, because as long as we show successes, the CFO also puts investments into your projects. So it’s a direct partnership and relationship with the CFO that I’m enjoying a lot. As Lex was saying before, we kept getting support because we were also showing successes with our projects. So that alignment has just gotten better over the years.
LF: The medical center has been very successful. It’s done very well in caring for patients, very high marks, very financially successful since this president has been in power. We’ve always been making money. We’ve never had a year when we didn’t make money. That means a lot. We have the resources to make these investments.
AG: You mentioned getting credibility. It sounds like early successes are important for tenure of a C-suite IT executive. Can you talk a little bit about how important it might be for a new CIO to get out of the gate properly, because early failures are hard to recover from.
LF: I think Ben could speak to the technology. I think the most important thing is really relationships. The CIO, whether it’s a new CIO or an older CIO, has to really be a people person more than just a technology person. They have to be able to see a vision and communicate that vision and build relationships. I don't know very much about technology anymore, I used to be a programmer years ago. But I rely on Ben and the other people to really understand the technology. But I have really wonderful relationships with my colleagues, and that’s the whole thing, getting people to buy into the vision to work with you, to trust you.
I think a new CIO has to be somebody that’s a people person and that has to be real. That’s not just something that you put on, you either are or you’re not. And you have to be sincere. That’s just my take.
AG: From a technology angle out of the gate, new CIO, what are some good first steps? How do you get the lay of the land?
BB: To touch a little bit on what Lex said, IT is a business and IT is moving to be more and more like a business. I probably recommend that a new CIO does not attack it with full technology; you are going to over-tech people. You need to attack it with alignment from a business standpoint. How do you get quick wins? You work on workflow, process reengineering and things like that which people understand, and then edge in technology a little bit. If you go full force today with technology at someone, they’re just going to shut down. So for the CTO as well as the CIO you’ve got to attack it from a business standpoint.
IT now is a business. It’s no longer the little black box of technology that’s out there. The CTO role is a lot of vendor relationships and a lot of looking at technology and bids. When I do that, you need to work with the departments on a business level. You have to talk about the solution, where they’re going to go from here, how their workflow is going to be better, how they’re going to save resources. And then when you improve that with success and get a win on it, that's how you start gaining your supporters.
LF: Technology is just the tools. If you’re a landscaper and you tell them about a wonderful rake, it doesn’t work. It’s not about the rake, it’s about the garden you’re going to be creating and the value of that garden.
BB: Technology has changed to more of a commodity. Before, IT was that black box, you had your solution, it was proprietary. Now it’s a commodity, so it depends on what you do with it … what you actually do with that technology.
LF: People understand, 20 years ago, before the advent of the personal computer and Windows and everything, we had the mystique. IT people could say anything, but now many of the people around here are much more knowledgeable than I am, and they’re working in the department. My kids are more knowledgeable. It is different.
AG: Let’s talk a little bit about interacting with the clinicians. You mentioned that the easy wins were workflow and process engineering. To me, that’s the hardest part, getting clinicians to embrace a new workflow, a new process. Clinicians want to practice care, they want to give care. Good luck if you try and get a physician into a training session for a new application. How are you dealing with that, how do you bring them on board and get them to embrace these new tools?
LF: We went through this with CPOE, it’s very difficult. You now have this going around the country. (CPOE) is almost impossible in an environment like this where we have really community-based physicians. We don’t have a large population of residents. You go to Montefiore Hospital in New York, I think they’re 100 percent CPOE, but they’re all residents. You come here, you’ve got a handful of residents and you have 1,500-1,600 community docs who go to a number of hospitals. If you get to mandate CPOE, it’s really, really difficult.
What we did about five or six years ago, we brought in what is today called a CMIO. We picked somebody, he is no longer with us, he left us recently, really a brilliant doctor with very strong credibility, very good business sense, a lot of charisma. He really worked with the physician community. He was the evangelist. Because of his credibility, he was able to move them. And we moved to maybe 40 percent CPOE, which is not bad in an environment like this with an old system that really is not geared toward physicians.
AG: How important has the CMIO role become? We recently wrote about the “CIO’s New Team.”
LF: I attribute much of our success to the fact that we had a very strong CMIO for a number of years. Now he’s moved on and we have somebody else who has equally stepped into the role, and she’s doing a fabulous job. But we have that model here. We have the CTO, the CMIO, reporting to the CIO. We also have the director of clinical systems who is a clinician (a nurse), with a whole group of clinical informatics people, as part of the CIO organization, as well as the technical people. I think you need that. If you have that decentralized, it becomes somewhat more difficult. The CMIO role is really critical.
AG: Let’s talk a little bit about Stark and what you’re doing on that front. Do you have a strategy for that or are you going to wait maybe until you get Epic in place and then extend out the Epic ambulatory product?
LF: The intention is to host the Epic ambulatory product. What we’re going to do as part of the first phase of the implementation is to do a pilot with one or two community physicians with Epic to introduce it. Then we want to offer it on a subscription basis within the confines of Stark — whatever we can finance, we will. But our vision is to be able to offer this to as many of the community physicians as want to have it. Right now, we’re not underwriting anybody.
AG: When do you envision that — and I know you have the whole Epic thing to take care of. What’s your vision for when this might happen?
LF: The pilot for physician practice we plan to be implementing next year, and in early 2010 to have it operational in the private physician’s office. From that point we would do a slow roll out. We have to determine how we’re going to do this in terms of Stark or what kind of subscription fees we would pay, what we could afford to underwrite ourselves, and then we would offer it and roll it out in 2010-2012.
AG: Do you have a goal for completing the Epic rollout?
LF: Which piece of Epic, because we’re doing it in steps? Our first phase will be to replace the inpatient system, including the hospital along with the ambulatory centers, the ER, radiology, and critical care. That big critical core piece of it, we’re looking to go live in the second quarter of 2010. It’s about 18 months, but it’s going to take us a while to do it, and we haven't signed a contract yet with Epic. We’re pretty close, but we’re hoping to start the implementation in September. That would give us about 18 months. That would be the first phase. And part of that first phase would be a pilot for community physician offices.
The second phase would be to replace the Siemens Invision System for patient access and patient accounting. We would start that in the summer of 2010 and look to complete that by the end of 2011. While that’s happening, we hope to be rolling out to the community physician offices who want to subscribe to the ambulatory piece.
AG: The New England Journal of Medicine came out with something about three weeks ago — they did a study that said the uptake in a real full-scale ambulatory EMR was about 4 percent, which is incredibly low. Based on your discussions with physicians, do you know if there’s any uptake in this area?
BB: We did surveys of our community physicians and our numbers were about 20 percent having EMR today. And the other 80 percent were looking for it. Some 70 percent were willing to look at or sign on for our service.
AG: And that would be available around 2010?
BB: In phases, yes.
AG: It’s probably the kind of thing nobody minds waiting for?
LF: They all want to know how much it’s going to cost. A lot of them are saying to us, ‘We’ll be your pilot so we can bring physicians there to see it, but we want something for it. Not only do we want it for free, but we want you to … .’ When it comes down to having to make an investment, then we’re going to see really who is interested.
BB: When we did the survey, some of the top concerns, obviously, were around cost. A physician practice is not going to drop six figures on an EMR, we’re talking about family practice physicians that are not in the specialty areas. The ones that have EMR now, I visited a lot of their offices. We extend out our EMR to their offices when they’re attending physicians here. So they have access to our PACS, our EMR, and our EKG and OB, to their offices.
AG: So they can see in to the hospital system?