Building the Airplane as It Flies

Albert Oriol discusses the challenges of implementing a new technology infrastructure while keeping your healthcare institution up and running with EHM’s Anna Lee Alden.

“The trickiest piece in my mind is, if need be, can these applications be deployed fairly quickly?”
-Albert Oriol

In the ever shifting arena of healthcare IT, Albert Oriol feels there is one important aspect that hasn’t changed: safety. He believes that improving the safety and the quality of the care to patients needs to be at the forefront of what healthcare institutions do.

Oriol, who is CIO for Rady Children’s Hospital in San Diego, says he believes this can be done while creating efficiency in the system. “This is not to be taken lightly,” he says. “We don’t duplicate a system full of inefficiency with automation; we need to remove that inefficiency in our care-providing process before we automate or as we automate, but definitely safety needs to trump any other aspect of healthcare activity.”

At Rady Children’s Hospital, Oriol and his team are currently undertaking a major system implementation. Oriol has been through a similar process in Denver at the Denver Children’s Hospital and was also part of the team that did this at Sarasota Memorial Hospital. He says there are clear benefits from a patient care standpoint in terms of the availability of information to providers to allow for quick decision-making and the availability of clinical decision support to avoid potential errors, as well as the shaving off of inefficiencies across the system is definitely there.

“When we were in Sarasota we did a study that showed turnaround time for tests and after putting in computer physician order entry (CPOE) we went from an average of eight or 8.5 hours to under two hours,” he explains. “This is the time that the clinician is waiting for a decision to be made in terms of closing that decision, which results in quicker decisions that impact the care that the patient receives and helps get patients out of the hospital sooner.

“We’ve seen all kinds of other improvements: we’ve seen increased compliance with pain assessments – not necessarily that before it wasn’t being done, but it was maybe not being documented or documented properly. There are secondary benefits in terms of now you can document what you’re doing, which means you get paid for what you’re doing as opposed to in the paper world where you get paid for what you remember to document because you do all your care during the day and you wait until the end of the day to do your dictations, which become your documentation. When you’re documenting real-time, when you’re ordering real-time, all that data is captured and then those charges are captured as well, so that obviously helps also.

“The third thing that’s important is: as organizations move to having IT be the bloodline that supplies healthcare professionals with the information they need to make clinical decisions, they need to be up and they need to be up all the time. There won’t be the tolerance for a system that is not always there, that goes away, so the importance of a highly available super reliable infrastructure is paramount.”

Oriol points out that unfortunately most organizations haven’t had the means or the focus to invest in a robust infrastructure. Historically, organizations have invested in an application layer to take care of functional needs, and at some point that application layer is too heavy and it doesn’t have the foundational infrastructure to support it.

“The trickiest piece in my mind, going back to closing the loop in the stimulus package,” he continues, “is, if need be, can these applications be deployed quickly? You might take more or less time to think through your processes and try to optimize them up front or not or, but the deployment is bound to happen when it happens. Having the underlying infrastructure to support that is a different story. That takes time because you can’t close your current hospital to deploy new infrastructure. You’re building the airplane as it flies, and that will be the tricky piece in all of this.”

New priorities
Oriol has mixed feelings about President Obama’s plan to have all health records available in electronic format within five years. “Across the nation, people are feeling bearish. Different organizations who have started this will have no problem admitting it. A small percentage of folks are already there. In the children’s space there are probably better adoption rates than in the adult space and for most folks, if they don’t have something in place they’re well on their way to make it happen.

“There’s a small portion of the overall provider arena that will get there, but as far as getting there before penalties hit I think in the children’s space that is relatively doable. Of course everything is marked with the caveat that until we know more about what the actual required use is, it’s hard to tell.

“Historically, for better or worse, children’s hospitals have seen the need for real time clinical decision support, because children are not small adults. They have their own little areas of characteristics and things that make their treatment special. You can’t just treat a kid like you would an adult but less, and so there is a need for clinical decision support so that you can do things like weight-based ordering and making sure that you’re dosing correctly. It has probably been more prevalent and identified as an earlier must-have than in the adult world.”

According to Oriol, the other tricky piece in the puzzle is finding the professionals to work through these implementations. He believes the economic stimulus package will set the fuse and that we will see a lot of new projects either started or sped up. This will require people who know what they’re doing.

“In the last six to nine months we have been seeing more qualified people becoming available as the economy has slowed down. We’ve had access to some pretty phenomenal people that we couldn’t touch with a 10-foot pole before, because we couldn’t afford their rates or they weren’t there a year or two years ago.

“For the last six months or so some of these folks have become available, as the closet has shut on the capital side. As people figure out the need to put money in in order to take advantage of the economic stimulus package and to not get penalized for not complying, that workforce component will be critical on the IT side. Those folks who thought that because we’re in an economic recession, we need to take drastic measures and reduce pay and do the types of things that people have to typically do in a recession will find it challenging in an IT environment where we will have more work than resources to do it. I’m concerned that this might become a tough market in terms of employee retention and recruitment for folks who have the right skills. You can’t create those skills in a month or two; it’s going to take a while.

“Those are the two challenges: one is infrastructure and the other one is the manpower – the brains to make this rollout happen on a nationwide scale.”

Identification
Another challenge standing in the way of the development of national computerized patient healthcare record system is the lack of a single patient identifier. Oriol believes this to be a big issue, and one that needs someone with the political will to resolve it.

“I come from Europe – I was born in Spain, and when I turned 14 I got assigned a card and identity number and had to carry it with me everywhere I went. So I’m probably less paranoid about Big Brother than your average American. I think that without a single patient identifier, it will be tougher to exchange patient information across the board, especially in a society like American society. Somebody can be born in Boston and go to school in Detroit and have their first job in Miami and their next one in Denver and the last one in Seattle and they’ll retire in San Diego.

“I think it’s possible to make it work, if a political agreement can be found. The mechanics of it are such that having a true cradle to grave health information system, you either have a national patient identifier, or you give the information to the patient and let them manage their information.

“Wherever possible, I think political minds should be working to make this a reality. It’s been 10 years or more since we started talking about a national patient identifier with the first HIPAA provisions, and so far it’s been futile at best. There is hope, but something needs to change in the prevailing political mindset to want to make this work.”

Security is another issue in the implementation of electronic patient records. Oriol says the role of security is huge, but that it’s also huge in perspective. “I used to wear the security hat in a couple of previous roles. By default I wear it here as well and we also have an information security officer, so it’s certainly a concern to me in that I feel that protecting the confidentiality and the integrity of patient data is paramount. We need to figure out how to make this happen without it becoming a barrier to better patient care. We need to make sure that we build the security into whatever solution we provide, but we shouldn’t let security trump better quality of care.”

One of the other challenges Oriol outlines is that most application providers have built their applications and databases to work in a pre-genomic state. He says it will be critical for them to figure out how to incorporate a new order of magnitude worth of data that their EMRs can use to fire personalized medicine and medical logic rules, driven by the level of information now available at a genetic level.

“There is still a lot of growth to be accomplished here. There’s a lot more that we don’t know than we know – this is why application vendors have been somewhat cautious about getting into this space. We still need to define what it is that we want.

“EMR can definitely play a role and it will be critical to be able to utilize the information to personalize the care that we provide, but I would say we’re not even in the infancy of this. We’re still in the womb.”

Albert Oriol is Vice President, Information Management and CIO at Rady Chlidren’s Hospital and Health Center in San Diego. In his previous role, Oriol directed the IS Program Office and Privacy/Data Security Officer for The Children's Hospital in Denver.

Oriol’s background and expertise center around project and portfolio management, IT quality assurance, process improvement/management engineering, emerging technology assessment, and information security and privacy. His teams have led large scale EMR implementations and infrastructure deployments.