HIStalk Interviews Toni Rienzi, Director of Clinical Information Systems, NYU Medical Center
posted 05/16/2007
HIStalk
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.