An Exclusive Interview with Denni McColm, CIO of Citizens Memorial Healthcare, Bolivar, MO

Two HISsies nominations intrigued me: Citizens Health in Bolivar, MO for Best Provider Healthcare IT Organization and Denni McColm as Most Effective CIO. A comment was added: "It would be nice to see someone win who's not in a $500 million a year IT department." I did my homework and found that this little health system with its 74-bed flagship hospital was the sole 2005 winner of the HIMSS Nicholas E. Davies Awards of Excellence, awarded for EMR accomplishments.

I dug up Denni's e-mail address and asked her for an interview, which she graciously accepted, saying of the HISsies nominations, "It  is an honor for CMH to be included in the poll. Maybe even more meaningful than the more 'formal' awards."

Denni's modest recap of the stunning IT accomplishments of this little hospital sold me instantly. I've known a few big-hospital CIOs who took liberties with reality when describing their own personal wonderfulness and what their organization was doing far better than everyone else. Not Denni. My BS detector was fully silent as I tried to drag some bragging out of her without success. She made me remember why I loved working in small hospitals -- they just get the job done without worrying about winning awards, getting job offers, or conforming to widely held but illogical industry beliefs. The didn't realize that 100% CPOE was supposed to be an impossible dream until they'd already done it back in 2003.

Citizens Memorial is a lot like at least 80% of American hospitals in size and location. Despite being wildly over-represented at almost every table, big academic medical centers don't really have it all figured out despite an earnest willingness to tell you otherwise. If you want to understand how RHIOs should work or whether CPOE can be successful or how IT can be both effective and cost-effective, then you need to talk to someone like Denni McColm. And since the HISsies voting is nearly over, I hopefully won't be accused of rigging the ballot when I say that Denni and Citizens both got my vote. The nominator was right ... anyone can do great things with a ton of money, but it's nice to see someone doing even greater things with far less of it.


Tell me about yourself and how you ended up as CIO at Citizens Health.

I’m from Bolivar. I grew up here and went to grad school at University of Missouri at Columbia. I was involved with the hospital as a volunteer in college and thought it would be a good place to work. The CEO has been here since 1982 and encouraged me to come in 1988. He’s the visionary.

After my MBA, I  came here in an HR role in the late 1980s and was director of finance for about ten years. I was asked to take control of the Infocare project in 2003, which was a modernization of all systems. We didn’t even have e-mail then. We felt we had the continuum of services but were behind in technology. We thought we were just going to catch up, but I guess we’re a little ahead of some hospitals now.

We have a fabulous team of technical experts. People think you can’t find them in a rural area, but we have them.

Project Infocare hasn’t been just IS-driven. It is organization-wide, with the support of the board of directors and staff. Our only problem is keeping up with what people want. Everyone wants what we’re doing, which has been different from hospitals who have a problem getting people on board. Departments here want to be first.

How is the Citizens IT function structured and what's your budget?

I report to the CEO. I have two people who report to me, one an IT manager for the technical side, the other an applications manager. They each have about 11 people who work for them for a total IT department of 25. We have 40 super users in the departments who are paid a stipend for their work to serve as additional liaisons to the departments.

The IT budget is about $2 million a year, about 2.3% of the organizational budget. The organization has about 1600 employees, so we have about one IT employee for each 64 employees, probably in the middle range but less than a lot of bigger places.


You’re hospital is a Most Wired and Davies winner, the first ever rural health system and the first nonacademic medical center to win the Organizational Davies award. How does a 74-bed hospital even have a CIO, much less an award-winning IT department?

I don’t know if it’s our organization-wide approach. We did extensive planning and included everybody who would participate in the selection process. When we decided to go with MEDITECH as our core vendor, we had another whole series of planning meetings on how we were going to roll it out. It was an effort of the whole organization.

Our CEO is a real visionary and led the organization. Physicians were happy to have the tools, but a few of them were difficult. The CEO stood with us and told everybody that we needed to do this. He encouraged us to invite those people onto our decision-making teams, even though it was hard.

We have been well-funded for an organization our size. When the board made the decision to do the project, they financed it through a bond financing project. We didn’t have to fight for resources during the implementation.

We have a physician champion who was an early adopter of technology and another who is less technical but is a good role model.

Our support for physicians involved one-on-one training. Small hospitals can do that. We did 30 minute training segments and the doctors liked that. They could start using the system part-time before they were really supposed to because everyone around them was using the system. They could practice and get used to it.

We have a physician resource center with nine computers and dictation phones right off the med surg floor. Our physicians don’t want to see patients carrying a tablet PC or laptop. They didn’t do that with charts and they don't want to do it with computers. They want to see the patient, get their impression, then disengage from the patient and family and concentrate on documenting what they’ve learned and then enter their orders in a quiet place where they can focus.

We had a staff person in the resource center every day all day to solve problems for the physicians. They’d build order sets and favorites for them right there.

We have eliminated the paper chart. I’m baffled that hospitals get halfway there and then don’t do it. Without that, you don’t get the financial or clinical benefits – you’re still paying people to move paper around and store it somewhere. The final day we went live with EMR and orders, we scanned the few documents we hadn't figured out how to get into the EMR. That was December 1, 2003, when we rolled the chart rack off for good.

We’ve done the same thing in the long term care facilities over the last year, scanning the final documents and getting rid of the charts. In the physician offices, there's more paper, so we just stop adding anything new on paper. We'll pull charts only for a while and gradually thin them out.

We’ve been lucky to get a couple of grants to help out. We received an AHRQ grant for $500,000 a year for three years. Just today, our Congressman, Roy Blunt, delivered a check for $450,000 from the Rural Utilities Services, part of USDA, for a distance learning and telemedicine grant program. We’ll use this for things we couldn’t afford, like interfacing the lab analyzers in the rural clinics into the hospital system and therefore into the EMR. We can also digitize some x-rays from the outer clinics into our PACS systems and can implement a patient portal. It will also help with the equipment we need for bedside medication verification


What do you think of the Most Wired award

It isn’t weighted toward the clinicals, whereas we’ve weighted our investments that way. We didn’t make the main list, but we made the rural list. When I first filled out the survey, I hesitated because I didn’t want our users to think we were focused on portals and business transactions, which hasn’t been a priority for us. I didn't want them to think that we had to win. We needed to stay the course on the EMR no matter what Most Wired measured.

The recognition was good for our staff. We were on the Most Wireless list because our nursing documentation is wireless. That was a great compliment.

We pay only a little attention to what other hospitals do. We’d never heard of the Davies Award. I was at the bar sharing appetizers with someone from HIMSS. She asked what we were doing and suggested we apply. I had too look it up to see what it was. I figured nothing gained, nothing lost. It’s a very nice honor and it’s great to have won.

We’d like everyone to be electronic. It’s very annoying to get all that paper from other hospitals since we have to do something with it. That’s particularly true of doctors' offices. For inpatients, we scan just 12 documents, but from physician offices we get a lot of paper. We want those big hospitals down the road to get electronic.


How are your EMR and CPOE applications being used?

About half of our admitting physicians are employed and the rest are community-based. They all use it because there’s no paper record. We have 100% CPOE. Our physicians would not go up to a nurse and demand that they enter orders for them, which I hear happens some places. We’ll accept faxed orders from their office for ED patients, but they want us to pre-admit their patients so they can enter orders. There’s peer pressure.

Even independent docs have system access. One office is on campus and doctors in the off-campus ones that we don’t own have Citrix both at the office and at home. Many orders are entered from home.

Doctors see the value of having all that information available. That sentence or two from a nurse about a patient’s condition tells them a lot along with our record. They don’t have to work from memory. They log on and see the most recent vitals, pain assessments, and I&O to make their decisions. We have one doctor who sleeps with his laptop on the nightstand so he can handle nighttime calls.

It’s hard to measure that quality of care, but every physician will say yes, it has definitely improved with the EMR. Our intent with EMR and CPOE is that patient can enter our continuum of care, we can get their identity, and physicians will have access to their information. EMR and CPOE were a way to get that done.

The alerts are nice. Doctors override a good number, probably eight for every one they accept for medications. We’ve tweaked them and they're good now. What would have happened if that one order hadn’t been changed? That's 365 times a year that we may have helped a patient.


What words of wisdom do you have for hospitals struggling with CPOE?

Get the commitment before you start. Actively solicit issues and problems during the process. Follow up with physicians. We made that mistake in not getting back to the guy who brought up the issue, so they didn’t know we’d fixed the problem sometimes. Invite even the most vocal negative ones to the table, no matter how much it hurts. Some of our most negative doctors are our best users.

Phasing is important. We eased them in and gave them a few things to get started. There wasn’t one day where everything suddenly changed.

Physician champions are important. I have a key person, Cindi Lockhart, who works with the physicians directly. You have to find someone who enjoys working with physicians and who isn’t threatening or judgmental to them. Cindi was the ward secretary right out of high school, became coordinator, and then took this role. What are they going to say, that it’s too hard? She’s been doing it for them for 17 years.

I don’t think CPOE is a good first step. It may seem like low-hanging fruit, but it isn’t. We built the foundation first and made sure we had the core clinicals in place before we went to CPOE. You have to have an integrated pharmacy system to make it work. Re-entering printed CPOE orders into a pharmacy system doesn't make sense.

One thing we did that we wouldn’t do again is to bring the physicians and nurses up at the same time. We should have brought the nurses up first. As things went electronic, there was a time where it was part electronic and part paper, so to create a record for outside use required two steps.

We haven’t done bedside medication verification yet. It wasn’t available when we started. We have an online MAR, but we’ll implement the bedside part this year.

We saw CPOE as part of the whole EMR project. Part of the price for doctors was that they had to input their orders.

The physician component was floundering when I took this role. We went through discharged patient charts and put a time on each part for it to become electronic. In June 2003, we set a finish date of December 2003 and we made it. All the negative press about CPOE might make it hard to do today.


Do you think small, rural hospitals will participate fully in RHIOs?

I don’t think you should be able to use the term "interoperability" until you have something electronic to share. The models out there are so provider-oriented. We're hoping for a more patient-oriented approach in our area, where patients choose to send their records somewhere.

If you had patients involved, you wouldn’t need all those searching and indexing algorithms. If you think about Branson, Missouri and their huge influx of visitors, you realize that regional is not enough. I don’t want a regional infrastructure of competitors sharing my medical record. Surely someone’s thinking about Google for healthcare. I should be able to give someone the code to see my information when I want them to.

MEDITECH’s EMR has a very structured layout. A CBC is the same no matter where it’s done in MEDITECH. The structure is the same. MEDITECH to MEDITECH is an easy interoperability answer. They can merge EMRs from multiple hospitals into one because of their structure. If every major vendor was like that, you’d have no problems.

The whole argument about standards and interoperability is puzzling to MEDITECH. Those standards already exist in their world. If you could map their standards to those of other vendors, you could do it, but I don't know if other systems are like that. Maybe those groups should just talk to MEDITECH and use their standards because they work.

Our docs call MEDITECH the bulletproof EMR. We had a three-day downtime due to hardware failure, but even then they could see data even though they couldn’t enter orders. The EMR came back up perfectly. They still had access to the entire medical record.

We consider the EMR the centerpiece and were protective of what went in it. Each patient has one record from multiple encounters from multiple sources. They still had access to all of that. We just put out a physician shortcut to the EMR directly instead of through the regular screens. We had no idea that it would work while the system was down, but it worked perfectly. We’re MEDITECH Client-Server weren't sure they’d know how to bring us back up, but they did.


What do you think of MEDITECH as a vendor?

They’ve been really good to work with. People sometimes got frustrated during the implementation when they wanted something they didn't see, but  MEDITECH is much more likely to undersell their functionality than to oversell. It got to be a joke that we’d make a wish list and then find that the functionality was already out there.

We do site visits for them. We figured it would be good to have our staff and physicians show it off to reinforce what we’d done. It’s nice to hear the docs say nice things.

We haven’t found MEDITECH to be that rigid. There’s so much more functionality than we thought we’d get. We were surprised at what it would do. They listen to our suggestions, although sometimes they just say no. Privately held employee ownership makes a difference in how they respond and stick to their long-term vision for their success. Talk to anybody at MEDITECH and they have ownership of the product and the company.


What other vendors do you use?

For PACS, we have McKesson’s Quick Study Radiology, an ASP. Perceptive Image Now is our document management vendor. Mostly everything else is MEDITECH and those three vendors make up our clinical record. We use LSS and PCTC, both MEDITECH partners.


What’s your average day like as CIO?

Lately, meetings, meetings, meetings. It seems like I have to work all night to get everything done. I meet with my managers every two weeks to go over timelines and to plan. We have demos of new products.

We're deciding how to upgrade imaging. I guess most big-hospital CIOs don't get involved at that level [laughs.] We’re probably more at ground level than big hospital CIOs. I participate in any training that I can when we’re bringing in new tools. I go to the board meetings and report to them and demonstrate some part of the system at each meeting so they can see what we’re talking about.


Are you ever jealous of big-name hospital CIOs with annual IT budgets that are probably larger than that of your entire health system?

I don’t know. They seem to flounder around in those big organizations. Some of my key people have worked in large organizations and are loving it here and having fun. If it came with bureaucracy, I wouldn’t like it. A couple more million dollars would be nice, although we’re already a bit overwhelmed getting the projects done we’re committed to.


You’re like the small-college football coach who gets national attention for beating the big schools. Do other hospitals try to recruit you and would you consider leaving?

I haven’t been tempted to leave. We have the family farm here. I live a mile from the closest town and it has only 90 people. The nearest Internet access is four miles away. I’m getting it from their water tower. One of our docs built his own tower to get wireless from15 miles away and offered to help me, but I’m too far away over a big hill.

It’s flattering to be asked. I wouldn't say I’m not interested, but I have lots to do here.


What do you think are the most important issues facing the healthcare IT industry today?

We’re in great shape when it comes to resource allocation because of the national EMR attention. We have to focus on building a system before we talk about interoperability. Pressures will be placed on IT to produce because of all of the attention on quality and safety. I'm speaking to a quality group shortly and I know they'll hit me with hard questions about what IT can do for quality and safety.


What’s the coolest thing about living and working in Bolivar, Missouri?

I’m from here, so it’s hard to be objective. We’re close to beautiful lakes, so you can sail here even though we’re far away from the ocean. I don’t have to have curtains on my windows, I’m so far out of town [laughs.]


Who do you admire most in the industry?

I’m new enough that I don’t know that many people. Dr. Halamka has a good handle on things that are important and is so articulate. Carolyn Clancy does a great job. AHRQ does well because of her leadership. Howard Messing of MEDITECH for being willing to make hard decisions that are the right thing to do.


Do you read HIStalk?

I’ve just started. I’ve been meaning to look at it for a long time because people keep telling me about it. Do you do it by yourself and after a full-time job? It must be a fun hobby. I know you are influencing the industry, so you should feel good about that.