Podcast Episode Transcript: In search of innovation: The role of the CMIO

With L. Gordon Moore, MD

Gordon: Hello, this is the 3M Inside Angle Podcast from 3M Health Information Systems and this is your host Dr. Gordon Moore, and with me today is Dr. Rick LeMoine. He is the chief medical information officer for Sharp HealthCare. He’s responsible for providing medical direction and physician counsel for clinical effectiveness and information systems. Welcome Rick.

Rick: It’s a pleasure to be here, thank you.

Gordon: Rick, you and I had a chance to chat before and I wanted to talk about your role at Sharp and something that I find interesting, specifically around the idea that an organization has thought to place a key leader in the space of looking out for new things that are happening in the industry that could be brought back and integrated within the healthcare delivery system. Did I get that right, and is that what you’re doing, and then how did you get there, and what do you do with that?

Rick: Yes, I think you got that right. My title is chief medical information officer and yes, I do a lot of the things that a CMIO in an organization our size would do. But I think if you talk to 10 CMIOs you would have 10 different job descriptions, and one of the things that is a little bit different about my role is nobody reports to me. Often CMIOs are very involved with the day-to-day operations of the EMR. I’ve had the fortune to be able to look at it from let’s say a higher level up there, at least a couple of thousand feet. Then having to deal with shutdowns, that kind of stuff and then as part of my role over the years I’ve been interested and the organization has been interested in looking at the potential for new technologies that might not be at first directly associated with medical care.

Also, things that I’ve learned from talking with other CMIOs, other leaders around the country that might be applicable to us in Southern California, I find that I just really have the privilege of doing something like this. It has been absolutely phenomenal the last few years some of the things that we have taken a look at, some of the things that we are interested in, and some of the things that we’ve passed on.

Gordon: And I’m fascinated by those things but before we go there, I’m curious about how did you get into that? It sounds like quite an enviable position.

Rick: I’m an intensivist by training. I went to medical school in Nova Scotia at Dalhousie. I did my first bit of medicine at Dalhousie, and then did my fellowship in pulmonary critical care at UCSD as a Medical Research Council of Canada fellow. I did that for about three years, went back to Dalhousie, taught for a bit, went into private practice in Cape Breton an area of distinction for the coal mines that it used to have and was involved with the miners there. I moved back to California, all this will make sense in a minute, and worked at Sharp HealthCare as an intensivist with several other people who I had been in the fellows class with at UCSD. And UCSD was just a phenomenal place to do fellowship, in critical care they were really at a leading edge.

And Ken Moser who was our fellowship director was really at the top of the game in terms of an editor, a writer, a researcher, and it was just a phenomenal introduction to pulmonary and critical care medicine. I stayed here at Sharp in San Diego until about 1989, then I went back to Canada, back to Nova Scotia  and became involved in medical politics, led the doctors’ union back there. I led that for a couple of years, and then did a little over a year as a high official, as they say in the department of health in Nova Scotia. And that was an education in itself; remember Canada has a single payer system, cradle to grave responsibility for patients. So it was really going from the bedside with a single patient who was incredibly ill to a responsibility I had basically for physicians and hospitals in Nova Scotia.

And it was drinking from a fire hose every single day in terms of learning the mechanics of that and how it was so different from the PPO/CMO managed care world of Southern California. I moved back to California in the very late 1990s, I think it was 1998 as an intensivist. Then a couple of years later I was asked to serve on the executive committee for Sharp HealthCare where I reported to the CEO and nobody reported to me, your classic consultant role. That was fun and gave me the opportunity to look at a lot of things that Sharp was involved in. Over the years I ended up doing more and more with information systems and was involved in our decision to start an EMR process.

We had already way back in 1984 put an EMR system in that made our ICUs paperless except for the physicians, and then in 2008 we partnered with Cerner and did an installation at our hospitals of their EMR system. That’s where the CMIO part of it came, but I was always given the leeway by our CIO and our CEO to look at other systems and see what other people were doing. I also had the advantage that Sharp doesn’t have a corporate CMO so around the executive table I was the go-to doctor and had a chance to participate in a lot of the decisions around the acquisition of new hardware and new programs that the organization would get involved with. So it’s really been fascinating.

And then in the last couple of years as technology has advanced there has been more opportunity for me to look at some things that are going on around southern California in particular and see how they might affect Sharp HealthCare.

Gordon: For those who may not know Sharp well, could you just give me a sketch of the organization?

Rick: Yeah, that’s a great idea. We are the largest healthcare provider in San Diego County, and we are essentially limited to San Diego County. We’re an Integrated Delivery Network (IDN), we have our own health plan. We have a market share of about 30 percent if you look at hospital discharges. Remember we’re in California where you cannot have direct employment of physicians but we have a multi-specialty medical group; Sharp Rees-Stealy that has today I think a little over 700 physicians and covers the usual gamut of specialties that you would expect of that size. We have an IPA organization that represents around 900 physicians and they’re again a large number of physicians who are completely independent of those other two organizations who come to our hospitals and clinics.

We have four general hospitals and we have three specialty hospitals, including a very large women’s hospital that does just under 10,000 deliveries a year. We have the largest in-patient behavioral health program in San Diego County, and we have a very active rehab program at one of our hospitals. So a full service organization and has a great history, we’ve been going strong here since 1955.

Gordon: Thank you. That is quite an organization. And now I’m thinking that because Sharp has so many different irons in the fire they’re probably dealing with a lot of issues, so it brings me back to your comments about looking out for interesting technology solutions or things that you could bring back to your system. Are you working that agenda across the board of the plan, the IPA, the medical group, or do you focus on aspects of that?

Rick: I try to take as broad a view as possible. Everybody around the leadership table has as a responsibility to be on the outlook for things that will improve what we do, bring better efficiencies. We have a great mission statement and it’s to be the best place to get care, the best place to work, and the best place to practice medicine. If you keep that in mind it really does give you the leeway for a broad view of what’s going on in the world. What I tend to do, what I try to do is keep my eyes open and my ears attuned to what I hear, my eyes attuned to what I read. And it may be that I would recognize that this is something the behavioral health people would really be, or maybe should really be interested in and I’ll approach them. What happens then is that most of the time they all say, “Thank you very much; we’re already on to this.”

Some of the time they say, “Thanks very much, we’ll do a bit of digging to see if this would work. Or thanks very much. Can you find a little bit more?” And when the response comes back about finding out a little bit more that gives me the opportunity to take a personal deeper dive and basically go from there.

Gordon: Can you give me an example of something like that, behavioral health or what have you that you’ve gone into?

Rick: I had the opportunity to sit in on the strategic advisory council for Johnson & Johnson, and several months ago as part of that we did a visit through the Health Management Academy to Verb Surgical in San Jose. Verb Surgical is a joint venture of the Google and Ethicon division of Johnson & Johnson, so they have a heck of a pedigree and they’re interested in looking at digital surgery, robotics, and other pieces of that. I thought this was just absolutely fascinating, the approach  they were taking in that they recognized right off the bat that this had to be more than just a different way to build a device, but really needed a platform that would be able to connect with disparate EMRs and disparate healthcare organizations.

Because from the onset they had to go democratizing this kind of surgery, and that would involve collecting as much information about patients before their surgery, during their surgery, and after their surgery in a fashion that is a lot detailed, a lot deeper, a lot more comprehensive than what we generally do today. I thought this fit perfectly with the mission that I described previously for Sharp Healthcare, so I got very excited about this. I was able to have a couple of conversations with the leaders at Verb on my own to make sure that I understood what they were doing and how a community organization like Sharp could take advantage—I should have said earlier that Sharp is not involved with academics or teaching programs, it’s purely a very high performing community organization.

And then I came back to our leadership and said, “Hey, I had this experience. I talked to these people, I really think there’s something there.” And the rewarding part of doing this is when the boss and the assistant boss and other folks around the table say, “Hey, that’s great. We agree, we think this is something that maybe we should look into. What do you suggest next?” The next thing we did was we took one of our very senior leaders, our executive vice president and eight surgeons who do robotic surgery and went up to have a tour of the facility and a discussion with Verb as to how a community organization like Sharp could get involved with something like this. That’s one example, that relationship is continuing.

Actually we’ve had some very recent discussions and plan on hosting the Verb folks down here in a few weeks or a month, and we’ll see where it goes. But it’s already impacted the way our robotic surgeons think about things. And I think it’s very important when we come back from these sessions or these trips that we spread this information around the organization, and get everybody involved as much as possible.

Gordon: When you do that work of spreading, it sounds like you’re the point person for connecting with others and bringing that information to them. At some point though I imagine this starts to intersect with data that your organization is developing and analytics to say, this is working well and that could be part of, in this case the Verb relationship, where they know how to measure the impact of the thing that they’re bringing. Is that the kind of thing that you do, or is that something that you have others in your organization follow up on?

Rick: I think one of the important things that I have to do is make sure the people who would be impacted by innovation have the opportunity to get involved early to know about this early. We have a relatively small innovation committee, it’s settled in information systems where actually part of our strategic plan is to look at this in the next couple of weeks. And probably expand it around the organization a bit wider than it is now, but every couple of months we do a lunch and learn session where we invite mostly folks in information system to present an idea for innovation that they have.

Initially I thought that we could get four of these into an hour so the first time we did it I looked at my watch and 35 minutes into the first presentation people are still asking questions. We had to fine tune that a little bit, but I think that’s the kind of activity that helps to spread the notion of innovation around the organization, and get as many people as possible involved.

Gordon: Have you run into spectacular failures? And really what I’m after is sort of lessons learned and how not to do it.

Rick: I don’t know about a spectacular failure, but one of the areas that I felt has always needed some help is how organizations like Sharp communicate with their physicians. Now remember we have these three groups; we have almost employed, the folks that are Rees-Stealy foundation model. We have pretty good ways of communicating with them, less so with our IPA (Independent Practice Association). It’s a little more difficult to make sure the message is getting through to them, and of course the independents are all over the map in terms of often not wanting to use, say our Sharp e-mail system. And it becomes much more difficult, so a couple of years ago I stumbled across a product that will go unnamed today because it’s no longer valuable.

I thought it was tailored made for the ability to contact a group of physicians, all of the physicians on the med staff, all of the physicians at a certain hospital, all of a certain specialty at a certain hospital, and thought that this thing was going to go like crazy. I engineered a little bit of a roll out and the thing fell flat on its face. I did a couple of post mortems on it; I think I was overly optimistic of both physicians wanting another vehicle to get information nd overly optimistic on how easy it would be to curate interesting content. If you don’t have content and you don’t have it regularly people don’t look at it regularly, and then when something important comes along it sits there in their inbox and is never read or utilized. I learned a big lesson that time.

Gordon: That sounds very similar to the idea that if this new process or thing is not part of my normal workflow it’s going to be a struggle for me to engage. Am I getting close on that?

Rick: I couldn’t have said it better myself.

Gordon: Yeah, that’s something I think about a lot and then I see the electronic health records companies are obviously very interested in managing the workflow and the connection in the space. And sometimes that works well, sometimes it doesn’t so I think one of the concerns I’ve seen is technology is not quite what we wished for. Are you hearing from a lot of clinicians that the EMR is wonderful and great, or is awful or a mixed bag?

Rick: I think it’s very much a mixed bag, and there are many reasons for that and there are a number of physicians in our organization like every organization who rue the day they first had to log into an EMR system. I think a lot of the difficulty with EMRs relates to the timing that they became available; they were deployed by organizations like ours, and this perfect storm of meaningful use, ICD-10, and several other initiatives. All well-meaning, all relatively necessary that just came together at the wrong time and all of them required a physician to do something extra often nowhere near the top of their license within the EMR.

Some things that I consider kind of silly like this two-midnight rule that CMS has or had where a trauma surgeon saves somebody’s life who’s been in a horrific automobile accident, has multiple broken bones, multiple head injuries, chest concussion, contusion to the heart. And then has to say at the end of their note describing all these, “I think the patient will have to stay in the hospital more than 2:00 midnight.” I mean, it’s loony tunes and there are so many things that are calling to the doctor to do this. And it really is way below top of license; it’s been shown that not practicing at top of license is a great way for doctors to develop frustration and to be unhappy with their workplace and their work situation.

Gordon: Yeah, I completely agree. The storm I think comes from maybe well-intended policies that then cascade into rules that are in aggregate getting between clinicians and caring for the people who come to them. I see that as a big problem and I presume that’s part of what you’re searching to solve as you’re out there surveying what’s new and what can improve the lives of the Sharp organization.

Rick: Absolutely and one of the things we always have an eye on is how to optimize our EMR systems and how we could lessen the burden of the EMR not just to physicians, but to all the clinicians, to our nurses. And frankly, pharmacists are in one of the most difficult positions of all our systems, and I know this is standard in other EMRs and in other organizations. The alerts that are presented to pharmacy staff—our physicians think they have alert fatigue; it has to be alert exhaustion for our pharmacists. On the physician side, we often fine tune the alerts so that doctors only see the highest level of severity of alerts, so with drug interaction only the most serious, only the most complex, whereas pharmacists usually get bombarded with all three or four levels of drug interaction.

And it is just amazing to see what especially a hospital based pharmacist has to look at because in most states a pharmacist has to approve the ordering of medications by a physician to have them dispense within a hospital. And then it’s a lot of work.

Gordon: Well, that is where I hope we get to go, and I wonder where do you go when you’re out searching for good ideas and new things?

Rick: I try to go to my colleagues in the CMIO and CMO field as much as possible. I love going to health management academy meetings. One of the things we have there is this notion that what happens in Vegas stays in Vegas, so we’re not afraid to talk about our failures as well as our successes. And that is absolutely crucial in this field. I’ve been fortunate to be invited to sessions like the strategic advisory group that Johnson & Johnson has put together and have been invited to a lot of the incredible sessions that 3M puts on. It’s the networking with those kinds of meetings and those kinds of sessions that really open doors and helps to open one’s mind to what’s possible.

When you’re in medicine and you’re looking after patients it’s okay to steal ideas from other people. You’re not really stealing them, imitation in this regard really is the highest form of flattery and it is something that I enjoy telling my colleagues, “We’re trying to do this a little bit differently here.” And I really enjoy sitting down and listening to what others are experimenting with, what’s been a success, and what they have had to go back and retry or rework.

Gordon: Well, Dr. Rick LeMoine, thank you so much for your time and insights today.

Rick: It’s been my pleasure, thanks for asking me.

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