"It’s time for health systems to change focus from optimization to transformation"

Stephanie Lahr, MD, CIO and CMIO, Monument Health in conversation with Paddy Padmanabhan, CEO of Damo Consulting on the Big Unlock Podcast – “It’s time for health systems to change focus from optimization to transformation”

PP: Hello again, and welcome back to my podcast. This is Paddy and it is my great privilege and honor to introduce my special guest today, Stephanie Lahr, CIO and CMIO for Monument Health in South Dakota. Stephanie, thank you so much for setting aside the time and welcome to the show.

SL: Thanks, Paddy. I’m super excited to be here.

PP: You’re most welcome. So, can you tell us for the benefits of our listeners a little bit about Monument Health and the populations you serve. I understand you’re also affiliated to the Mayo Clinic in some way, can you talk about that too.

SL: Sure. So, Monument Health is a not for profit healthcare system based in Rapid City, South Dakota. We serve most of western South Dakota, parts of eastern Wyoming and some part of east of northern Nebraska as well. We have five hospitals, three of which are critical access over 40 clinic locations. We participate in caring for most medical specialties other than transplant and complex pediatric care. We have long term care facilities and home health pharmacy services as well. So, we have a pretty broad spectrum of comprehensive care, serving rural environments which is several hundred miles between us and it’s like really any other substantial healthcare center. So, with respect to our relationship with the Mayo Clinic, we are part of the Mayo Clinic Care Network, which is a designation we are really proud of and has been in place for just about a year. As a member of the Mayo Clinic Care Network, we have special access to Mayo clinics’ knowledge and resources. Our physicians and clinicians have an opportunity to collaborate with their clinicians in an effort to get in a rural setting, allow our patients to get more of the care than they need and be able to stay close to home, while we take advantage of that additional resource set at no additional cost to our patients.

PP: You mentioned rural a couple of times and I’ll come back to that because maybe it’s defining a unique attribute of your health system or the populations that you serve.

But I wanted to ask you briefly about your title and your role. You have an unusual role, you are both CIO and CMIO for the health system. Could you maybe briefly describe the scope of your responsibilities and where digital initiatives fit within the organization context?

SL: Sure. So, I am an internal medicine physician by background. I came to what was Regional Health, now Monument Health, about four and a half years ago, and I was recruited to come here as the CMIO to lead the clinical aspects of an EHR replacement across the entire health system. The CIO that I reported to at that time began to make plans for his retirement. Shortly after our go live, the CEO really saw the value in having a clinical leader with knowledge of technology as the best fit to lead the information and technology division moving forward. Given that there’s such a tight integration and rapid evolution of technology as an enabler and transformer of healthcare. So, it was sort of decided that a combination role of CIO, where I have the responsibilities for the strategy and the management of the tools that we use across the health system to enable care delivery and business efficiency, etc., with my clinical knowledge, my background in informatics, to then be able to leverage those skills together to make sure we were really choosing the right tools at the right time to solve the right problems. And fortunately, given that broad scope, I have a super great team who helps me keep all those responsibilities in motion. More specifically, all of the caregivers and technology that surrounds everything from our telephone systems to our data centers to our EHR and third-party systems, to our patch system, to our financial and revenue cycle systems report through me. The one thing that doesn’t report through me directly is our enterprise intelligence group. They report through our Chief Performance Officer, which was another decision that was made at the time that I took on both of these roles. A very close friend and colleague and partner of mine who was also within the IT division at the time, became our Chief Performance Officer. And so, our enterprise intelligence and analytics lies under her direct authority, but our teams work super collaboratively together. And that’s been something worked quite well for the last couple of years.

PP: That’s a very helpful context. And you mentioned that the technology environment is evolving rapidly. COVID has accelerated technology enabled transformation from years to months. I hear all the time that what was expected to take five years through transformation has effectively taken place in five months. Can you talk about how COVID-19 has impacted the pace of transformation at Monument Health and about the initiatives that you’ve launched specifically in response to the pandemic?

SL: Yeah, this is such a great question, because it really allows us to highlight some of the powerful and positive things that have come from such a challenging and difficult situation and a situation that is still so rapidly evolving. So, what was interesting for us is, coincidentally, around the time when this all came to the forefront in March. We had just brought a big team together and brought in a consultant. And some of this flavored by the landscape of both the financial licensing, all of the different kinds of complexities that go on in creating the environment in which we are able to do things that we do. We put together a telehealth strategy, and what we were really looking was at a two-year plan. And within about a week of that big meeting of bringing everyone together, we suddenly had a two-week plan. And within about five days, we had every specialty across the entire health system live with telehealth visits. Now, there’s certainly room for optimization of the tools and the workflows that we’re using within telehealth. But it was a really exciting time for us to see just what we could do when everybody was rowing in the same direction and had a common goal. So, that’s one really exciting example that I’m proud to share.

PP: That story is so familiar to me when I talk to health systems executives across the board. The order of magnitude of the change, the number of telehealth visits to the increase they made with the pandemic, that is across the board. It’s been a dramatic change, but for the most part, everyone seems to have pulled through. I think optimizing the technology environment is an ongoing process. So, I guess over time, all will settle down. What about the remote workforce? Can you talk about that? How did you enable them?

SL: Yeah, absolutely. So, my IT team had already been transitioning towards a work from home model part time. This was really advantageous to the whole organization. We didn’t realize how lucky we were to have already been making those moves because we had established a really strong foundation for the technology that was needed and the bumps in the road might be living in a rural geography. One of the things I often talk about to some of our physicians is that as we talk about wanting to do telehealth visits from home and things like that, I remind people I sometimes have physicians and other caregivers who live between two slabs of granite here in the Black Hills. And that can create some obstacles when it comes to create connectivity and those kinds of things. But we already had experience working through some of those challenges. We had a robust virtualized desktop environment. So, from a security, workflow, and even from a policy perspective, we had done a lot of the work with HIPAA and compliance and those teams to have a foundation. So, that was actually almost too easy for us that we didn’t even really take a lot of effort. It was more just in a matter of figuring out that who else beyond the IT team needs to work from home? What additional hardware might they need in order to do so? And we’ve been really successfully enabling several hundred of our both clinical, but not directly patient facing caregivers, as well as many of our corporate service caregivers to be able to work successfully from home for the last seven months. And I really don’t know that I see those teams ever coming back to our physical spaces in the way that they used to be before. So, that certainly has been a really positive thing. I think a lot of our caregivers have appreciated that opportunity, both from the standpoint of how it impacts their personal ability to make decisions in their own personal safety and how much they want to be interacting around other people, depending on what their personal situations are. It is also something that has allowed us to have our caregivers adapt to so many of the other cultural things that have happened in the landscape in the fabric of our society. Everything from schools and our other support systems, whether that’s daycare or other childcare options, all have become more complex and having opportunities to be able to keep people productive and working successfully at home, I think is a huge win and something I think that is here to stay.

PP: It’s such a great example. And when people talk about telehealth and virtual care models, they’re mostly talking about how you deliver care to your patients in a direct and interactive kind of way. But this is a great example of how you’re actually enabling your remote workers, caregivers, clinicians, using technology to work just as effectively as they would if they were on campus. And that’s a great example of digital transformation. It’s just that one doesn’t normally get to care about what happens in the back end of technology enabled care delivery. They’re mostly focused on the front end. So, thank you for sharing that. I’d like to talk a little bit about your CMIO role. Can you share what are some of your top priorities, as CMIO today, especially in a post-COVID-era?

SL: Yeah. So, I will tell you that during the time period of the early days, as we were trying to understand kind of clinically how all this was going to come together. And for us, because we’ve had a bit of a delay in the pandemic impacts on our numbers and are really seeing probably higher numbers now than we really have ever before. It’s a very interesting experience to be a physician who is not on the front lines. And so, it has been really important to me to offer to my colleagues, both the physicians as well as the other clinical team members, tools that can help them help patients and also keep them as safe as possible. So, telehealth is one of those options. I think it’s traditional. Some of the more common things that we think about telemedicine as far as a patient being at home and a physician being either at home or in their office and being able to maintain that relationship and the connectedness, which is wonderful. But in our hospitals, there are really challenging situations that we’re asking our clinical caregivers to walk into every day. And if there are elements with technology that I can use to help them monitor a larger group of patients with a smaller number of caregivers or providers that would allow them to have safe interactions with those patients, where instead of having to go into a patient’s room two or three or five times a day, they may be able to go in just once or twice. That has been, really very important to me to make sure that I was supporting my colleagues in that way. Bigger picture than that kind of outside response to the pandemic is that I think, we are seeing more than ever that clinical care is hard work. It’s emotionally, physically, and intellectually hard work. And the people that are providing that care need all the tools they can get to make them good at their job. Whether we’re talking about nurses or therapists or physicians, they’ve all gone through years of training and specialization and licensing to be the best that they can be. And we have so many great and burgeoning tools available to really help augment what they are capable of doing, because the data sets that are available are not getting any smaller. The human mind is not getting any bigger and the day is not getting any longer. And so how do we really help people be efficient, avoid burnout. The whole other aspect, I think that’s really exciting right now is both my combination of clinical background as well as the technology side and informatics is that of patient engagement. And how do we engage with our patients to take on more responsibility in their own healthcare is to encourage them and educate them and move them toward a more positive future. And then just in general, all healthcare systems have an opportunity to improve quality and efficiency. One of the underpinnings of that is a strong data and analytics framework. I talked a little bit about our partnership with enterprise intelligence and creating a lot of transparency around that data. We really need to be transparent there, both within the healthcare system about what we’re doing and where opportunities are for improvement. We need to be transparent with our patients about how we’re doing and how the information is related to their care. I feel like data is the language of transparency. That’s the thing that’s going to get us to the transparency where we can all be kind of on the same playing field is when we have widely available and accessible data.

PP: You mentioned patient engagement, and that is something we talk about a lot on the show, especially on the digital front doors. But before that, I just wanted to go back to the theme of your rural populations from a CMIO standpoint. I imagine that you’ve been managing your chronic populations and other high-risk populations remotely for a while, because that is just the nature of your landscape. How is the pandemic changed any of that, especially from technology enablement standpoint?

SL: Yeah, it’s very interesting. As you mentioned, because of the nature of being as rural as we are, we have to manage patients who are not right next to us. They may be hundreds of miles from us but I’ll be perfectly honest, until recently we were doing that with pretty antiquated tools, mostly telephone calls, paper fliers, questionnaires. And there are a few reasons for that, we still are in our area in a relatively heavy fee-for-service model. And as we move into value-based care, there’s more resources available to sort of prioritize how we do this chronic disease management strategy. And so, we’ve been slowly working our way there. But I think for a long time, even though we were doing it and we knew we weren’t using the right tools to do it, we had some degree of analysis paralysis around just executing on what are the tools that would help because there’s so many out there. Which one to use it, what are the benefits and which group wants to use it and how are we going to manage it and how are we going to standardize. And then a year and a half goes by and you haven’t made any changes. And so, one of the really fantastic things to come out of the pandemic is we now know what we can do in a super short period of time. And there is no wasting a year and a half with analysis paralysis. So, another example of things that we did is our CEO came to me just shortly after things got started in the spring and said: ‘hey Stephanie, we really need something for the community. They have lot of questions. We’re working on the web site and that’s going to be one element of it. But they might need more support than that. We need to funnel them to the right location. Do they need to tele visit? Do they need an in-person visit? Should they go to the emergency room? If they need testing, how are we going to set them up for what can we do?’ So, I brought back some options. A lot of which were actually kind of a quick outsourcing opportunity. And she said: ‘well, I don’t think we can afford that. What else can we do?’ So, five days later, we went live with a nurse triage that is clinically managed by myself and my Ambulatory Medical Information Officer who works for me. And I pulled all of my nurses out of clinical informatics and they all started answering phones. And we created a COVID-19 nurse triage line. And we created an opportunity for patients to call and interact with us and ask questions and in some cases just get counseling and reassurance that everything was OK. And then we took it a step further and we rolled out some functionality within our electronic medical records system to be able to do remote monitoring of these patients. And so, through the use of some thermometers and devices to be able to check their pulse ox, their oxygen levels, and then some tools that we use through our patient portal, we were able to manage a really large number of people who are sick with COVID-19. But not sick enough to be in the hospital but are still scared and still have questions. We monitor them every day, we get this information back into the system, we feed it up to other areas when necessary, and recontact those patients when necessary. And so now we’re looking at something that was created essentially out of IT as a temporary process to get us through in “kind of this crisis situation”, which we now realize is no longer a crisis situation. It’s more just a part of the fabric of our lives. And how do we morph that into something that we can maintain and sustain and expand. So some really great things that we’re working on there, one of which is we’re going to be rolling out a new tool where instead of needing to call and interact with us to, for example, schedule testing, you’ll be able to go to a secure interactive portal on our web site. Whether or not you have a patient portal account or my chat account and look at the schedules across the geography of our health system, find the one that’s most convenient for you and schedule your own test. And you don’t have to interact with anyone and then you drive up to that location and you’re able to get your test. We have methods then to be able to get you your results. And again, if you’re positive, we can offer you a home monitoring program. So, we’re working on both the combination of the workflows as well as the tools that allow us to do that. But this is really the first time we’ve taken a system approach in doing it. It’s been very educational for the whole organization to see how centralizing this can be of benefit to everyone. And now we’re really starting to look, as we get to handle this, what are those other areas like diabetes management, heart failure and some of those other chronic disease situations that you mentioned where we know we’ve got patients that live on a farm seventy-five miles out of town and they’re not going to come in. So how do we interact with them where they’re at?

PP: Very interesting examples, especially the one where you talk about repurposing your nurses towards a nurse triaging function for the near term at least. Now, that’s a segue into some of the automation and digital engagement opportunities that when I talk to other health systems executives, I see them investing in. So, you talked about patient engagement and if we look at digital patient engagement besides telehealth, what are some of the other opportunities we’re looking at from especially an access standpoint. The example of the tool that you gave for scheduling COVID-19 test is fantastic. What other opportunities are you looking at? Could you give us a sense of what you’re thinking about right now?

SL: Yeah. So, some of the things that we are looking at are tools that will allow our patients and their families to get updates on things that are happening, particularly when you look at the inpatient environment for hospitalized patients or patients that are going through surgery. Right now, we limit the number of visitors even when we’re not limiting the visitors and if your family lives one hundred miles from here, they are likely not going to be all coming to Rapid City, for example, when you have your surgery or if you’re hospitalized. So, we are looking at some tools that help keep both the family and the patient, depending on the scenario up to date on what’s happening and creating sort of automated tools. Whereas different elements happen, and different progress is made that it automatically let people know that we’ve had sort of a successful transition to a next stage. But also allows for personalization so that if there are things that need to be more specifically shared or discussed with a patient’s family, we can have a portal in a way to be able to share that information. So, I think a really major opportunity is a combination of using some automation, but also bringing in the personalization. And I think that’s going to be the key in healthcare. As we look to automation is how do we maintain a personal experience using automated tools so that our teams can do more and can take care of more people, but it still feels personalized. I think there are a lot of great tools out there and if we look at the airline industry, there are some cool things that they do. When they call, volumes are high, when they need to make adjustments to things in the way they communicate with us has all become very automated. It’s not super personal, but we don’t have an expectation that the airlines interact with us in a very personalized way. We also have to take it a step further. In healthcare, we can leverage the same tools that they are using, but we have to push them to go a little bit farther so that when they reach a certain point or certain scenario develops, we can add personalization into it as well. So, we don’t lose that connectedness with our patient population.

PP: OK, we are coming up to the end of our time. Stephanie I’d love to close out with one more question. You’ve had to live through some dramatic changes in the wake of COVID and some fascinating examples you’ve shared with us. If you had one best practice that has emerged from this experience that you would like to share with your peers in other health systems. What would it be?

SL: Yeah, I think this is really poignant at this time for me, where I’m at and what I’m talking with my teams about a lot right now is it’s time to change our focus from optimization to transformation. As a leader in healthcare IT It’s not only appropriate, but essential for us to take the lead, I think we over time have been reluctant. Even as a physician, I at times set myself aside and say: ‘well, operations really have to own and has to lead this. You have to have a strong, partnership.’ But the reality is operations is trying to operate the business today. They don’t necessarily have the time and the skills and the connections to understand what else is out there, to change the work that we’re doing today from one kind of work to another and really transform it. And so, the optimization of work will always be there. But we’ve got to start thinking transformation and we have to as IT leaders, be willing to lead that charge tightly connected to our clinical and operational counterparts. But we really have to take the lead.

PP: That is so well said and we’re going to have to leave it there. It’s been such a fascinating conversation. Stephanie, thank you so much once again for setting aside the time and all the very best to you and your team. I look forward to staying in touch.

SL: Absolutely. Thanks so much.

We hope you enjoyed this podcast. Subscribe to our podcast series at  www.thebigunlock.com  and write to us at  info@thebigunlock.com

Disclaimer: This Q&A has been derived from the podcast transcript and has been edited for readability and clarity