HIStalk Quotes
HIStalk Interviews Toni Rienzi, Director of Clinical Information Systems, NYU Medical Center
posted 05/16/2007
Inga is doing so well with her HIStalk duties that I decided to give her a try on what could be the hardest type of assignment - conducting an HIStalk interview. That requires several skills - a healthy curiosity, coming up with interesting questions that allow the subject to come across honestly and accurately, and to get it all transcribed.
She hit it out of the park, as you're about to read. Is there anything that lady can't do?
I've done a lot of CEO interviews, but I always wanted to open it up to interesting folks like Toni who work in other areas or roles. If you know someone who would be interesting to readers, e-mail me or Inga. And thanks to Toni for spending some time with HIStalk readers.
At the suggestion of a reader, Mr. HIStalk had me contact Antoinette (Toni) Rienzi, Director of Clinical Information Systems for NYU Medical Centers. NYU has long been forward thinking in terms of fully implementing physician order entry and recently implemented their second CPOE, the Eclipsys Sunrise system. In addition to hearing about the latest implementation, Toni shared with me some of NYUMC’s computer history, going back to the days of dumb terminal and Lucite light pen days.
I understand you have been with NYU for a number of years…how long exactly?
Oh gosh, a long, long time (laugh.) I started as a nurse and worked in various leadership positions, and when we first went with the computers I was asked to go with that.
When did NYU first go with computers?
In the fall of 1979 I was asked to work with the computer systems. I was the pharmacy analyst and worked with other ancillary departments in the hospital, such as cardiology.
How was the IT department originally set up and how has it evolved over time?
We had a unique set-up here at NYU where the IT department – which was very small – was made up of clinicians who had worked in various other departments. They came from medical departments, so they understood workflow and the lingo. We took them from the clinical role and we gave them the opportunity to learn the software applications, programming etc.
The usual set up in healthcare was that you have the clinical analysts and then the programmers. We did things a little bit different and we combined the functions into one role. The analysts met with the users and then translated the needs into functions within the application. We continue to use the model.
What system did NYU use originally, how did it function, how was it implemented?
The hospital looked for a number of years for the best of the best clinical applications but there weren’t that many. After a number of years and site visits they finally decided on Technicon, today’s Eclipsys. There were a handful of hospitals, maybe a dozen or so, that had already implemented that system and it was integrated. It did registration and you could enter results and also interface with other departmental systems.
It was innovative for healthcare because it truly expedited communications between the doctor and ancillary departments. You were able to immediately communicate a requisition to the various departments. You no longer need to transcribe, type an order, get a runner to send the order, etc. Within seconds, the ancillary departments knew what to do. At that time we were the only institution that had 100% order entry. The physician directly interfaced with the computer.
So when did you go live on the first system?
The IT team came together in the fall of 1979. In January of 1980, a team of 17 people started to go to programming classes and learned about the application and functionality. Fourteen months later, the first nursing unit went live. We did one unit at a time and it took 14 months to get the whole hospital live on the computer. At that point on, there was no more paper order entry except for when the system went down. If it went down, we pulled out the “downtime boxes” that had forms that the staff would use.
As time went by the staff had no idea of what the manual procedure was. Periods of over four-hour downtime were very, very rare until 9/11. Our data center was downtown at Rector Street, so we were affected greatly by 9/11. We were down four to five days and we had to go manual and recreate some data.
Tell me about the size of your facility (providers, patients, etc.)
At the time of the first system, it was NYU hospital only and 500 to 600 beds. The Rusk Institute for Rehab was later added next door. Then had started a relationship with The Hospital for Joint Diseases in the 90s. Today we have three facilities and we rolled out (the new project) to all three facilities.
I understand that you had an extensive implementation program for your latest system.
Yes, we trained over 5000 people and it took about two months. We had online training that people could do at home or our library or the nursing unit. It was a combination of online and hands-on training. We offered 24-hour-a-day training. We first started with 200 super users that were a mix of different levels of personnel - regular staff, nurses, nurse managers, interns, nurse practitioners, some attending physicians - that got extra intense classes. We gave a lot more information to them so they could serve as a resource to their colleagues and co-workers.
So the new system is Eclipsys Sunrise? When did the change occur and why?
We had the old system for a long time and it was DOS based. Then Windows came along and you could do so much more. Even though the DOS based was powerful and fast, you didn’t have the state of the art you get with Windows. The clinicians were looking for a lot more alerts. For example, they wanted prompts to alert them of any implications. Although we had done quite a bit of customization with the old system it wasn’t enough.
In 2001, we started looking and we engaged Capgemini to help us with the search. We had looked at about 10 vendors and then we narrowed to it to four. The four came in and each did two-day presentations. We had a script based on what the old system could do for us. We wanted to make sure the new system could do what the old did. We didn’t want to lose functionality. We had about 250 clinicians participate in the evaluation process. We had each clinician fill out a form at the end of the demo to grade the systems on different functions. At the end, the score was highest for Eclipsys.
And when was the decision?
We made the decision to go with Eclipsys in 2002. It took about a year to decide. Then, another year to plan for the implementation. In the old system, it also took care of our registration and we had to find another registration system, so we had multiple projects going on simultaneously.
It took us awhile to get it all together. The first phase of the implementation on the new system gave the doctors a patient list and results. At the same time we also implemented single sign-on. One of the complaints we used to hear from the clinicians was that we had so many sign-ons and passwords with all the different applications and you had to change passwords all the time. So we went out there and looked at a system for one point of entry. You could go to that application for one single sign on.
Sentillion Vergence is the application that is in front of all the applications. It uses just one sign on and password and syncs with all the applications and then can move seamlessly between applications. It also carries the name of patient across applications. It was a huge effort but worth the pain.
During the planning stage we had to maintain the old system because we had to add drugs to the pharmacy and create order sets for clinicians, etc. We also had task forces formed to work on the development of the new system. We had to hire more people, some strictly programmers to write reports, and more clinicians and more nurses.
So when did you actually go live?
We went up March 24th. Big bang, three facilities, one weekend. The old system went down and everyone was on paper as we rolled out each nursing unit. We had groups of what we called back loading teams. We had to upload current orders on 700 patients from the old system. We couldn’t convert them because the language and mapping were totally different. We printed reports from the old system and had nurse practitioners and physician teams, about 100-120 people, divided in three shifts entering orders to new system. It took us less than 24 hours to do this and there were more than 14,000 orders.
You must have fed them well.
We had real good food (laughs). We had to compensate them. It was fantastic. I had staff working 24 hours around the clock. We had a command center and we logged over 1000 calls the first few days. We manned the command center for two or three weeks so anyone could call in with a question if they needed help.
Did you also have training people working in the units?
We also had people in purple coats, we called them Purple People, who were identified as an IS resource. The application is very rich and has lots of functionality. Even though staff went though training, they still needed help. The support factor was really, really instrumental in the success
How did staff embrace new technology?
Throughout the planning and building we had multiple task forces. Two weeks ago, we had our first post-implementation meeting with the nursing task force. I was anticipating lots of complaints or not enough people showing up. I was stunned. We had about 45 people attend from the three facilities, all nurses. Their enthusiasm was great. I didn’t take anything as complaints, but legitimate recommendations. It was gratifying to see how they embraced the new system. I was so, so amazed. I said to my boss, Dr. Pravene Nath, Senior Director of Clinical Systems, “You should have been here! You missed a great meeting!”
Anything you would have done differently in hindsight?
Oh my goodness no. The planning end was very important. We had different levels of committees and had administrative support. Planning, planning, planning was the key. I know that Dr. Nath wouldn’t have done anything different.
From experience with the previous CPOE, we knew what worked and what didn’t. To get the physician buy-in, you need a lot of order sets based on their specialty. We had about 100 in the old set. We created about 130 in the new system. The order sets were a tool for them to make order entry really easy. Knowing (the order set needs) from having implemented previously helped. The increased number of orders was like a carrot to doctors.
Anything you think you did particularly well that you would recommend for other hospitals?
Get the clinicians involved in the decision-making. The system is their system, not the IT system. You have to listen to what they need in order to do their work. You become a translator/interpreter of what they need and articulate the needs. You have to include them or it will be a huge rebellion. We had so many different task forces – physicians, nutrition, nursing, radiology, lab, pharmacy, multiple therapy groups, blood bank - almost every department. Involve people across departments in the evaluation process.
And you had no conversion, right? So how are you accessing the old information?
The only conversion we had was migrating patients from the old system to the new. It is not difficult to access the old information because of the single sign-on where the patient context carries across. Within the new clinical application, there is a tab for the old HIS system. All you have to do is select a patient from the new system and it brings them to the old screen. It is seamless to go to the old system. It really helped the staff with the transition.
So, what were the phases you went through and what is left to do?
Phase I was just the patient list. Whether it was an attending or resident who sees the patient, the patient is registered to the attending physician. The first thing he sees when he logs on is a list of his patients and results. They could select patients from the list and got to results retrieval and see results.
Phase II included order entry and some documentation, such as nursing admission notes, initial assessment from various departments, therapy documentation.
What is left is creating the rest of the documentation for the physician. Nursing has quite a bit in the system. We need to finish up therapies and H&P. We are now beginning the formation of the task forces to move the rest of the documentation forward. The H&Ps are on paper still, except for OB, neonatology, and the nursery. Eventually all will go into the Eclipsys system, from admission to discharge. We hope by the end of the year we will have all the documentation on-line in the new system.
Anything else you would like to share with the readers?
We are very proud that NYU was one of the first hospitals in the country to have physician buy in for a CPOE. It was such a plus. It amazes me when I hear hospitals and medical centers where they are rolling out multi-million dollar system and nurses and ancillary staff are entering things on paper. You are missing the benefit of the computer. It saddens me when healthcare has not moved to having each individual discipline entering their own information.
We were at the forefront even 27 years ago. I was part of that and it makes me very proud. I feel very, very fortunate that here we have the type of administration and school of medicine that has seen the value of the capital investments made and has enforced their use from Day One.
comments (4)
1. Matthew Grob left...
05/16/2007 6:26 pm
As the reader who recommended an interview with Toni, I'm thrilled to see
that not only did Toni do such a great job expressing what is so important
about what works with clinical implementations, but that Inga did such a
great job as well. Kudos to both of you!!!
2. Nick Valadja left...
05/17/2007 9:48 am
Excellent interview. I am the Corporate CIO of the West Penn Allegheny
Health System in Pittsburgh, PA and we just activated the Pharmacy
component at our largest quaternary hospital on May 15th. Our total big
bang activation is scheduled for June 9th followed by implementation of
Sunrise at 3 other facilities. More interviews like this are very
beneficial to us.
3. Matthew Holt left...
05/18/2007 2:44 pm :: http://www.thehealthcareblog.com
Nice interview, but to shit on the carpet--how come with all this great IT
before Eclipsys and even better now, NYU Hospital came out as the worst
performing academic medical center the nation in terms of costs per outcome
in the recent Dartmouth studies? At the least it suggests that IT doesn't
halt wasteful practices. or now that the "outcomes" company is t the helm
we'll see resource use per outcome go down at NYU
4. Pravene Nath, MD left...
05/23/2007 4:34 pm
It's true, IT doesn't halt all wasteful practices, particularly those
practices which are related to attitudes about end-of-life care. We
haven't yet found a way for IT to influence the cultural beliefs of a
physicians, and more importantly patients, on this matter. That's not to
say that IT can't or shouldn't help here, just that it's not a
straightforward matter of efficiency and outcomes alone.
