Question & Answer with David Muntz, Senior VP and CIO of Texas Health Services
Barry Jacobs: I want to start out with your strategy and approach to
clinical transformation.
David
Muntz: Clinical transformation is about changing people, processes, and
technology. Technology is last on the list and it should be. Though I'm a computer
professional by choice, I'm not a fan of technology for technology's sake. In
fact, our clinical transformation efforts should reduce the amount of information
technology that we have to support. I'm hoping for some relief.
There's been a major shift in the way we approach our stakeholders. IS participates in the creation of strategy. We depend upon a collaborative effort to finalize the strategy. The worst thing that IS could do to clinical transformation is try to dictate changes to the clinical staff. My boss gave me good advice and I try to follow it: "Lead with your ears." At THR we have a very sophisticated information services governance process that engages the users. In fact, we are major supporters of the JCAHO standards associated with the IM (information management) review process. IS provides staff to help end-users determine their knowledge needs, then work with all facilities to set priorities. The list of "to-do" items is always longer than our list of available resources. For clinical transformation, we have a need to coordinate a wide array of activities and introduce changes in a controlled fashion to keep from overwhelming ourselves and our customers.
For us, clinical transformation is all about alignment. We need to take all of the activities associated with quality initiatives, the process improvement functions, and information technology changes, identify the overlap and then coordinate rather than duplicate effort. Think of this as three circles being merged together. In the ideal state, the three circles will have significant overlap, but still maintain some independence.
BJ: How do you get sponsorship with the physicians, clinicians, and executive board members for these new approaches?
DM: I haven't had to work as hard to sell the vision this year as in year's past. THR created a strategy based on what we call the "blueprint for healthcare delivery." It utilizes a great metaphor — the Patient and Family Journey; a graphic unifies our entire strategic plan.
The press and congress are the other forces that make selling the vision much easier. The LeapFrog group has come to our city led by the publicity surrounding the Institute of Health reports. Couple their efforts with the frustration insurance companies cause physicians and congress, and you begin to understand the shared pain among the stakeholders you listed in your question. Another element is our mixed blessing of financial success. Better than expected financial performance might suggest you shouldn't change. Truthfully, we're thankful we're generating capital for new buildings, medical technology upgrades, and system replacements, but we know people are working too hard just to get the results. We're convinced our staffing shortages could be reduced significantly by improving processes, simplifying the way we do business. Finally, you look at increasing volumes. We know demand is going to increase and more medical professionals will be needed to perform procedures and care for patients. That gets back to doing clinical transformation. Is there really a choice?
BJ: What kinds of available tools are useful for CXOs and board insiders? What would you recommend?
DM: We can't solve all problems with just one tool, but web browser based portals have been a real benefit for us. THR started a long time ago with basic intranet and Internet Web sites. As we got more sophisticated, so did the portals. When the demands for easy access to information became universal, we decided to use portals for the people who aren't as comfortable with the technology as we in information services are. Our first efforts were focused on three groups: internal employees, physicians, and consumers. We have a separate approach for each, but we use the same tools. All the primary e-development was done or led by information services. After getting to a certain level of sophistication, we turned over management of the consumer portal to our marketing group.
THR is a system of 13 hospitals and the technology proficiency of each executive varies, but all of them would be comfortable going to Amazon.com to shop. Given that, we mimic the capabilities of web sites on our intranet. The first information we stored there were documents from committees and councils. We still produced paper at meetings, but stored copies on the intranet. Then we started posting color-coded monthly performance metrics.
For the physician, we began long ago with a portal to replace a clumsy "green screen" terminal. The advantages were immediately obvious, but the adoption slow. After a refining the design, we now we have more than 3,000 subscribers, 60 percent of whom are physicians. CareGate.net does single sign-on to give the physician access to wide range of reference material, access to patient information, and a lot of other features that have requested. We make regular enhancements based on physician feedback. Our goal is to make noticeable improvements no less than quarterly.
For the consumer, we have a bilingual web site at www.texashealth.org that offers an incredible array of information. Content includes a personal health record for individuals and families. It features the ability to pay bills, sign up and pay for classes, seek physicians, get maps to facilities and make appointments, and fill out forms for elective surgery. This makes the patient and family journey much easier and keeps them better informed.
The last two populations we addressed were the employees and trustees. The employees have a place where they can go to do activities historically done by the human resources people. Employees can manage benefits, change pertinent data like demographics, and even view their salary history and paychecks.
The trustee portal just went into production in late March 2003. It provides information to our community board members wherever they happen to be. The job of distributing material on paper can be replaced. This gives us much greater flexibility. There are hundreds of board members on our local boards and their subcommittees. Think about how much time and effort we can save. Early response to the trustee portal has been very favorable.
BJ: What do you do to help non-health care types, who are involved with medical services, understand values and terms?
DM: The metaphor of a journey is something that seems to resonate with anyone who has used health care. For purposes of communication and understanding, the journey is divided into phases from the time you think about asking for help till you're out of the system.
More specifically, there are four universal intentions that affect both patients and providers affect on every step: valuing a patient and family's time and energy, treating the whole person while valuing the individual needs, keeping the patient and family informed throughout the journey, and giving the patient and family a sense of control. That appeals to everyone on any kind of a journey, but particularly in a health care setting.
If you extend this journey idea to the physician, you see they're on a journey, too. Our employees must use the same universal intentions for the physicians. This is pretty eye-opening when you first hear it. I can remember the clarifying moment when it was first exposed to me.
BJ: How do you drive change in the way that doctors and clinicians provide care?
DM: No disrespect intended, but the answer for physicians is "one doctor at a time." The truth is that they're in an increasingly challenging environment. Our challenge is to compete for their attention. If you can get it, they'll listen to the evidence you have to present to determine if our efforts will be meaningful. But for the first time in a long career, I'm not having to push them, I'm feeling pulled by them. Physicians get it.
For the other clinicians, the trick is trying to convince them their work will be safer and more satisfying after making the transformation. That isn't easy. There are so many interactions, so many touch points in the delivery of care, coordinating efforts to make effective change becomes a real challenge. Fortunately, or unfortunately — depending upon your perspective — they're generally overworked and frustrated. While they're ready for change, they don't have time to experiment. So we don't start work until a long design session has taken place assessing and planning for the impact of a change. In this multi-hospital environment, we create a series of collaborative sessions with information technologists, vendors, and clinicians from every facility. Our most successful projects bring in physicians right at beginning.
BJ: After you've developed your strategy, you've got buy-in; you've got different systems and change occurring, how do you go from the idea stage to the operational stage?
DM: There are a combination of things we've tried and we apply each on a case by case basis. Sometimes a pilot program is used. Most pilots work in self-contained activities with few touch points. Sometimes we try the "big bang" approach. That's where the interconnections are complex. Our most recent thoughts combine a franchise model and a component approach, a hybrid of what I just discussed. We try to create a franchise model we can repeat, but use a pilot or component part from an existing location. The real key to these approaches is user acceptance. Any approach can fail or succeed depending upon if people buy in. People and processes are the key to introducing technology. It's all about balance.
