Northeast Hospital Corporation (NHC) represents the acute care hospitals of Northeast Health System, Inc. (NHS), an integrated network of hospitals, behavioral health facilities, long-term care and human service affiliates offering Massachusetts North Shore residents general and specialized medical care. NHC hospitals include: Addison Gilbert Hospital in Gloucester; BayRidge Hospital (psychiatric) in Lynn; and Beverly Hospital in Beverly. There are also two outpatient facilities in the corporation: Beverly Hospital at Danvers, Medical and Day Surgery Center; and Beverly Hospital Cable Center in Ipswich. Recently HCI Editor-in-Chief Anthony Guerra had a chance to talk with CIO Robert Laramie about his work to strengthen NHC’s infrastructure so point of care applications are always available.
GUERRA: You’ve been the CIO there for just over two years. Were you promoted from within the organization or did you come from outside?
LARAMIE: My role is brand new at Beverly Hospital. Previously, there was not a chief information officer in the organization. I’ve been in healthcare IT for 15 years in various roles such as working for a vendor, being a consultant, and also working at a large institution, which was Lahey Clinic, before I came here. So I think I’ve seen all sides of the fence with regards to healthcare IT, the ways that it’s implemented all across the nation in large and small organizations. As the organization looked at what was happening in the industry and was finishing up a five-year master facility plan, they decided that strategically they needed to create this position which I was recruited for.
GUERRA: What was it about the position that attracted you?
LARAMIE: It was two phases for me. One, I had my own consulting firm for eight years, which I sold because I didn’t want to live on a plane anymore. The other factor was that I think, over the next five-10 years, healthcare is going to have such dramatic changes, and IT is now going to be, I think, one of the driving factors to support what’s going on. So I just saw it as a truly exciting opportunity to get back involved on this side of fence and really have a dramatic impact on the patient care process.
The other part was that having lived in Massachusetts for so long, I knew a lot of the executives here and I knew what the organization was about, so I had a lot of confidence coming in that this would be a great place to work.
GUERRA: Did you do an inventory of the organization’s software systems before you took the job? Did you investigate the administration’s attitude toward IT?
LARAMIE: I had the luxury of having other executives in other hospitals that I could talk to because I had worked with executives here in their past careers. So, I had some capability to get insight that other people wouldn’t have had, insight about where the individuals had come from and how they were to work with. We did have conversations throughout the process that confirmed this was a very entrepreneurial thinking, forward-thinking organization. That analysis has been supported over the last two-plus years that I’ve been here.
The other part of it was that during my interview process, I spent half a day with the IS staff walking through what they do, the things that they have challenges with, really get the lay of the land for the department and what I was taking on.
GUERRA: What are the main things you want to know before taking a CIO job? You mentioned the culture; would it also be the IT budget you’d have to work with? I would assume you want to make sure you’ll be given enough resources to do the job, and the budget says a lot about an organization’s priorities.
LARAMIE: That was the most important thing to me. I sat across the desk from the CEO and said, ‘Where is IT in your priority list?’ The response I got, across the board from all executives, is it’s in the top three for the organization looking forward. They had spent strategically on facilities and a new ambulatory care center, so they knew they had to start investing in IT, as it was now a strategic objective for the organization to implement the type of systems that will improve the patient care process.
GUERRA: I understand you’ve made some changes to your IT environment. Tell me about that.
LARAMIE: We’ve changed the whole technical infrastructure that supports Meditech here. When I came here, I knew that to accomplish our clinical system strategy of improving patient care with the modules that were being discussed and prioritized the infrastructure had to be solid, and it wasn’t to where it needed to be to support these point-of-care applications.
So we replaced completely our storage area network and our server environment to support Meditech. We built our wireless capabilities to be 100 percent across all of our campuses, so that we would be able to support the type of form factors that clinicians might want to utilize to treat the patients. We also wanted, obviously, to offer them mobility throughout the organization. We’ve done the significant infrastructure changes to prepare ourselves for CPOE implementations, for bedside medication verification, for electronic medication administration records, and the list goes on for us, as far as our clinical strategy.
GUERRA: So you saw that the underlying infrastructure would not support what you wanted to do with the software applications?
LARAMIE: That is absolutely true. The thing that I always say to my colleagues here is that it can’t be slow and it can’t be down. We were in a situation where we needed to improve the performance of our infrastructure and expand the capability that governs our infrastructure.
GUERRA: So you’ve taken steps to fortify that infrastructure, and how did that relate to your increased usage of CPOE?
LARAMIE: That allowed us to be able to have confidence that when we went to the bedside the performance of the application and the infrastructure underneath it would be adequate for our clinicians.
GUERRA: What version of Meditech are you on? They have Magic out there, Client Server and now 6.0.
LARAMIE: We are on Magic 5.62, and we’ll be migrating to 5.64 in January.
GUERRA: I’m not intimately familiar with 5.62 versus 5.64 versus whatever is in the middle of 5.64 and 6.0, and then there is Client Server. Why upgrade to 5.64 and not something else?
LARAMIE: Do you mean something other than another application or vendor?
GUERRA: I mean why not go from 5.62 to 6.0 or to Client Server? Why go to 5.64?
LARAMIE: Two main reasons, from my perspective; one is cost. Just over a year ago we spent a significant amount of money on our infrastructure to support what we needed to do. Second of all, we’re in the middle of our clinical implementation strategy, and I’ve just trained every doctor on CPOE; the last thing I want to do is change that environment on them and retrain them and have to go through that from both the nurse and the physician perspective.
I am hesitant to do that until our doctors are using this version for a while and we can plan accordingly for 6.0. We’re going to have to spend even more money on our infrastructure to support Meditech than we have in the past.
GUERRA: You mean if and when you go to 6.0, or in any case?
LARAMIE: If we go to 6.0. We are fine in the environment that we’re in right now as far as our infrastructure because we’ve just spent a lot of money on it. So we can run our current infrastructure for another two or three years without having any significant cost. I don’t want to have to go to the board and say I need to spend whatever six-figure or seven-figure dollar amount to go to 6.0. Also, I don’t want to retrain all my clinicians to utilize the applications that they’ve just learned to use.
GUERRA: You might lose some of that goodwill you’ve gained.
LARAMIE: It potentially could do that, absolutely.
GUERRA: Have you had conversations with Meditech to find out which versions of their software will be certified?
LARAMIE: We have had conversations with Meditech, and they’ve assured us that all their versions of Client Server and Magic will stay certified. They are in the process of getting 6.0 certified as we speak. You know, 70 percent of the community hospital marketplace is on the Meditech environment. If I put my Meditech hat on, it would be very shortsighted of them to just certify 6.0 and not have their other applications, which are more mature, be certified. It would impact a significant amount of their clients.
GUERRA: Is it possible that the user interface on Magic is not Web-like enough to get physician buy in?
LARAMIE: I don’t think that Meditech would be the issue. I think the issue would be getting the clinicians brought into this is an acceptable way. One of the things that we did to make sure that occurred -- because there is a perception around Meditech’s architecture, look and feel -- is that we focused a lot on their clinical order steps and also their workflow issues. We really used an optimization process and made it more user-friendly and clinically focused than it comes out of the box with Meditech. We went live with our surgeons and, right now, we’re at 96 percent of all of our orders going in. So, it is a workable application if used in the right areas.
GUERRA: I had always heard that Meditech was one of the least customizable pieces of software. Are you saying that’s not accurate?
LARAMIE: Even if you’re talking in general in the industry, you can work with it by using the terminology that the physicians use on the screens, rather than some of the terminology that matched the billing codes per se, so that makes more sense to them. If you create order sets and you lay that on top of the screens, which is possible, it makes more sense for them and makes it easier for the clinician. Is it always going to be point and click rather than function keys? No, you’re not going to get those little things that exist in Web-based versions, but you can make it reasonable for them.
GUERRA: Have you looked at 6.0 much? Is it more of a Web-type interface?
LARAMIE: It’s more towards that direction, but it’s not truly, in my opinion, Web based. It’s more of a client-server type application.
GUERRA: Did you have your CPOE-adoption strategy correct from the start?
LARAMIE: What we did is we have three main campuses and a lot of physician practices, but we implemented on one of our campuses first. After that, we took a step back and I said, “Okay, what did we learn, what did we do well, and what things do we need to improve as we move forward?”
We took that step back into the lessons learned type of approach, and what we also did is we realized that the team that needs to lead must be more clinically focused – it has to be lead by clinicians and not by the IS division, which is how it was in the beginning before I got here. We also realized that we needed a physician champion to be the one that’s out there and understanding and talking to the docs and getting them to buy in.
What we did is we took a two-month hiatus on implementation while we refined our project team to be multidisciplinary, including our pharmacy rep on the team. It was led by the nurses. We made nurse super users out of that team and we dedicated some of their time, three days a week, to learn the CPOE environment and to recommend improvements. We developed more order sets for our clinicians so that it was much more user-friendly for them. We also got the organizational commitment to make sure the resources we were putting in place were dedicated for the next phase of the implementation, rather than that it was their secondary or tertiary responsibility.
So our whole team was dedicated 100 percent to the implementation and their secondary and tertiary responsibilities were assumed by other people for the short term. We also put in a strong support structure with, basically, elbow support and really robust training for our clinicians. We positioned our training office at the door where the doctors come in and out of the organization, so if they had 15 minutes, they could stop in, and there was someone there from 7:00 a.m. to 7:00 p.m. everyday, especially as we got closer to go-live. So essentially we just took a step back and said, “How can we do this better? We did it at one campus, we need to refine it and improve it,” and that’s the approach we took, which became wildly successful here.