Dr. Richard Wittman — The Stanford Experience

so a few years ago we at Stanford we're at entrapped for occupational health IT solution our medical record and we need to make a determination on what our path would be moving forward essentially we'd had the record since clinic inception approximately five years before and at that time the clinic was was small it was a medical surveillance

entity with one nurse and one physician and since that time our our needs had changed and we had grown in dramatic ways the solution that we had was an old version of the vendor software it was clique intensive not much was automated it was difficult to pull reports and ultimately was not meeting the functionality that we needed

but in terms of thinking about who we were going to move forward with and what that process was we had a first recognize not just whether it's with this vendor or a different vendor that we move forward with them we had to recognize who we were where we think we wanted to be and with whom did we

want to advance and this internal introspection kind of led us to think about the fact of where we fit in the piece of that miss fear that was Stanford and we were at the time and we still are a smaller but equal component of a larger health and safety team and to insert ourselves and be a fully

functioning member of this team we recognized that we needed to collaborate with these groups and in a far broader way than what we were currently doing we had grown us as a clinic to with our care encompassing full workers compensation care injury treatment and follow-up medical surveillance for infectious disease in animal care travel medicine fitness for duty

exams we had expanded to covering over 20,000 employees and 15 personnel on the clinic but that was our clinic and a and how as a group could we move forward with health and safety and how could we leverage this medical record we're looking to get to bring us there so the procurement process we were pretty eager in

in trying to move ahead with our initiative and our gung-ho operations manager I went to our local vice provost and and basically stated well you know we have an idea we need to upgrade our medical record we've some good things in mind we want to do for the university it might cost a little bit more upfront maybe

just a little extra zero on the on the datasheet but it's okay we're gonna go ahead and do that just need your approval please sign this Thanks and the the Provost nodded an agreement agreed that as a group we could move forward together but also also displayed or told us a path that we needed to take to

move forward and what we needed to understand is part of this procurement process is not just to we're beholdin to but who the provost and and the groups that are funded for us what do they need to just to do to justify this expense and so he set us on a path that ultimately proved very very helpful

in terms of the growth of our clinic and it led us to consider other ways that we could expand what we're we're doing as a group now a process that we thought might take three months maybe six months turned out to be well over a year even close to two years from inception and in fact this wasn't

the first time we tried to get a new medical record two years before we gone through the process and had been turned down so there was a lot riding on this effort because realistically if this were not approved it could be a number of years before we move ahead with another record and and really it would affect

not just what we do internally to the clinic but our role within the university and we were looking and we are looking and continue to look to expand our health and safety role so as first partnership we looked internally to health and safety but external to our group and recognize that our health and safety team environment health

and safety had needs that basically were in concordance with ours and one of the major deficits that they had was the injury reporting on campus was paper-based this was essentially when injury occurs an employee would fill out a paper form this would go to the supervisor and then this would then go to health and safety for a

variety of reasons there are significant lag times and even when Reports reviewed it could be two to three months after an injury where some critical injuries were actually reviewed for an or an analyst analyzed for cost or even for in terms of a prevention and and so we recognized that they had a need for an online system

that they could access that had incident reporting and tied into our medical record and and the reason for this is another another constraint that Health and Safety had was injury analysis we're relying on a third-party vendor to prepare reports these reports are often based on either incorrect or incomplete data and then it analyzed this data based on

questions that weren't even pertinent to us so we want to grab grab this and take hold of this and our pitch to health and safety was we can make a whole campus wide incident report that can be accessible online we can control the data we control what comes in we can control the questions if it's not doing

what we want we can change the questions and then we can use this data with our population to do analysis and analysis in a far better way than the insurance companies could because we actually had better data or would have better data so that was one internal group and they were very interested in the process human resources

had similar issues so work status reports reports that go to the supervisors or to HR when employees out of work the HR representative spent a lot of time tracking these down determining up to date restrictions on employees whether they're work-related or not and at Stanford again this is largely a paper-based in someone email based system we offered

them what if you could have and this these are pie-in-the-sky thoughts we weren't really sure what was out there but if you could have online access real-time to work restrictions for all the employees that you supervise or all the employees that under your purview and they seemed interested now for us this was also of high import because

HR managed the peoplesoft and the registry database and they had control of this and we needed to be integrated with this database to move move had with the medical record that we had and so it wasn't pure altruism that we were trying to coordinate with them but in fact for advancement we had mutual goals and we could

work together for this one key vital party that we also needed to work with was IT our health and safety team had IT and that was internal to us and this IT was responsible for vetting anything in the in Health and Safety that was electronic in any in any way but essence also managed their own databases which

had health and data surveillance information on infectious diseases and animal care and and these things were these were components that we want to bring it to our our database and our record itself but most importantly they integrated and they had a history of long integration with university site security internet security office and the privacy office and in

this in this whole process the most rate limiting factor in terms of an adoption of a medical record was convincing a university based IT department involved in handling medical personal medical information for a riot wide but for a wide variety of the campus population including to some degree undergraduate students convincing them that the medical record that we

wish to choose is compliant with their needs and that part of the process that involvement of the security office and in the privacy office could be a three to six month vetting process when they're actually involved but their wait time for a project could be well over a year so we had to seek them out before we

had any idea what medical record we wanted to get them on the list and to schedule a time so they'd be able to review things because there are larger institutional projects larger Hospital interchange projects cybersecurity issues that that are paramount compared to a smaller Ock health clinic essentially then these other groups procurement general counsel the C suite

the higher level executives our pitch to them was was somewhat similar but broader they're very interested in employee health there's employee based wellness programs on campus and this product that we were trying this this goal that we had was to pitch total worker health now in terms of driving and moving this process along just managing with these

disparate groups risk management IT health and safety all the groups that are mentioned just scheduling meeting times and setting agendas is is a significant job on its own let alone trying to bring a group of people who tend to have various interests who do not want to go to a to be literally and instead take a more

secure route circuitous route so what we wanted to do is we is assigned a point person who could really manage this process and manage this process firmly and with resolve and we chose our local our clinical operations manager and this operations manager we benefited from the fact that she had private private practice background significant budget expertise including

working in the clinic with a constrained budget and this was very important for the groups that we reported to understand that we were actually by just budget conscious and really focused on not just the product but the way and the cost that that would be necessary to achieve this and and we needed someone and this is I

think a really good plan about the process is not who could just handle all that but who was also a connector someone who could take all these disparate groups and these different personalities bring them together with this sense of humor and move the path forward and and I think the first time that we went through this process

when we didn't succeed with this one of our mistakes was not choosing the correct point person and and so early on in the process thinking about this is really really important now in assembling the team the team globally refers to the people and all the groups that I represented before but even internally who with me and the

other clinicians and the health and safety team are going to make this determination and we realized that we needed to have a core group of people who were present on every vendor evaluation and as part of the process to provide consistency but also alot wide range of data and this included not just the clinicians or myself but

our medical assistants industrial hygienists and other people who we wanted to have a role in this medical healthcare this medical record initiative moving forward and I think that had us thinking more and more globally this again is not just about us it's about our partners and and how we can with this record potentially bring their visions together

so I think you know some of this is just setting up the infrastructure of what of how we want to set things up and and the planning that we needed to do but that's totally disregarding what we actually wanted the record itself to do and and really the first stage of this was developing a list of pain

points and you know in thinking about that how many how many here are using an occupational health record electronic health record for medical charting the number of clinicians here and and some others now of those how many are a hundred percent happy with their medical record and and I know one can say that but with Sir just

name one what's your highest pinch point what's your and it doesn't have to be you but what's the biggest barrier that you have with your record and and think about this to yourself now for me for us this was the the fact that everything was very very manual and it's really easy to figure out you have a

paper questionnaire that needs to be scanned in by someone by hand brought into the system indexed hopefully we'll be able to be read because of legibility and then transcribed by a clinician so the note because they're trying to take that information to the note itself all these steps in the process pretty easy to say that we want

a process that takes a scanned document and makes this more automated but and this is one one item in a wish list what we did is we took together the wishes of industrial hygiene of health and safety various members and the fit testers and the surveillance folks as well as the people in our clinic from the billing

specialists to the admin assistants and what was on this list and this took a long time to prepare now we certainly we used Excel spreadsheets there Google shared Google Documents now you can use Trello or slack or these other tools to be more collaborative in real time with some ease we created a list of well forty categories

of places that we wanted to improve and well over a hundred specific line items of either nice-to-haves must haves or pie-in-the-sky type type goals and and so then became the fun part of the process so this this is very labor-intensive but extremely extremely important if you do not define what you need with your record then when you

go through the process those get a lot that gets lost there's too much going on and you need to had to be able to develop that checklist and get that against each of the vendors so the fun part was our operations manager notes we started a benchmark other places places that we know who does Berkeley use who

does UCLA use but ultimately even institutions that we know prior connection with parallel academic institutions with research and hospital content um I guess components of the medical care that we did we call call them and we talk to them about their medical record we had interview sheets that we set up just so we make sure we talked

on specific points we use the networks that we had or a local a calm or Woma or nursing networks one of our sites is a Department of Energy Research Lab and so we contacted the all the other office of science labs had because Department of Energy has specific requirements that go beyond what the university requires for electronic

safety in terms of cybersecurity and we found out what all these sites were using for their medical records and this is fun this is interactive get ourselves out there it's sort of a growth opportunity for the clinic and even our typical sphere event interest we conducted online research searching by Google is actually can be a pretty effective

way to find out record find records that are their records even that nobody is using new records that are that are starting to rise up and then we can we could view demos and other things on those vendors websites and so we said we contacted the vendors directly some explain the process to them scheduled demos and essentially

provide guidance for the presentations now what we did is we took our pain list and the categories on the pain list and we organize them into essentially a letter that we provided a single-page letter to these vendors and we said we want what ultimately turned out from a group of 10 to 15 vendors the six first-round finalists

vendors six of them we're gonna give you 90 minutes a webinar with our team these are the this is what our interests are and please come prepared and so the vendors vendors got this list and basically what's on there so things that are broad categories user-friendly and intuitive interface scheduling patient portal work status reporting scheduling interfaces with

lab interfaces with outside vendors interfacing with hardware equipment simple things but but things that we wanted to be addressed and what we did is we let them run with it so when we started the call we let the vendor show us the software on their own with very little guidance at least for the first part of portion

of the call maybe they would show us what they did best maybe they would show us how easy it is to use hopefully they paid attention to this and they were trying to address what our needs were although that wasn't always the case and what was really interesting in the process is even without our prompting even without

interference these these medical record entities nationally known well-vetted stumbled and these experienced outreach teams could not actually had with often we word here oh this doesn't seem to be working today I'm sorry this is really slow this is something new that we just developed and we'd realized right away without doing anything though some of the problem points

that they had with their record I was totally fascinating and then on top of that that gave us the time when we actually want to direct them toward what our list was we could step in and throw a little wrench in the issue and see how they they applied no we understand people have bad days and sometimes

presentations don't go as planned and and so what we did is we allowed them an opportunity to answer questions afterwards in an in an email that we sent out pretty uniformly to the group's describing things that we felt we might not have been clear on now what we did is we took their scorecard this one-page event this

one-page list of topics we wanted them to address and we created a scorecard ourselves with high priority items and low priority items and a rating of three was zero meaning no functionality and three being highly impressively functional generally two or three meant they could do something pretty pretty darn well and we took our team and our team

was consistent from vendor to vendor and this is important if you're trying to grade something you want there to be internal consistency and for us to have different clinicians in different IT people in different health and safety people in for these six vendor meetings would would throw off sort of the base of what we're trying to do

we want there to be a team that had this really kind of embedded comparison in their mind of what to do and so they they graded and everyone graded separately and so a purely objective I mean early numeric and at the end we we compiled these and we saw was there a difference between these groups on occasion

there one vendor might have a zero in one category from some people in a3 and others and it could be because we'd six vendors coming in and some people zoned out or weren't paying attention or maybe they didn't understand what happened and so we did have some qualitative discussions about where where the vendors lay but ultimately we

relied on the numeric and if someone disagreed the majority averaged out but that's kind of where things things lay now that all being said what what ultimately happened was that ad who was at one medical record was either highly successful or impressively successful in eighty to a hundred percent of the areas on that checklist to the other

vendors were in that sixty to eighty percent range and these were the three vendors that we moved on to our final stage it became clear in going through the process even without crunching the numbers that these three vendors are in the lead but it still was very very helpful for us to see objectively what that meant and

this is an example of what a what a scorecard comparison scorecard we used and this is I think in terms of understanding the budget application a procurement process it's very very important to have a summary document that explains to someone who doesn't really care too much about the issue and doesn't want to delve too deep what the

heck you were doing and in this case we put all in this one in five records on one sheet with the categories we were judging them by with relative comments about what their strengths and weaknesses were and and having these comments is is what was also helpful because the process was six nine twelve months long and when

those vendor demos were to three months ago it starts blurring in mine it becomes hard hard to remember so taking clear notes afterwards and having these notes put together in this cat in this way helped us go back and remember what what was going on and now the importance of this and going back to the importance of

this pain list one of one of the things on here that's their state's appointment reminders scheduling or appointment reminders and so we could clearly ask a vendor does your system have appointment reminders and across the board they would say yes but what was really interesting was if we ask the question in a little more detail what kind

of appointment reminders do you provide we provide appointment reminders for only surveillance cases or only for injury cases or only until their due date we don't provide reminders or after or emails when someone is overdue when they're overdue they're off that system and now they're on another system that we don't actually function with and so and in

another case we if someone missed an appointment we don't let you know as well and so understanding that one broad question doesn't get the answer that you want that you really need to have these detailed questions that you hit each record with because some of the things and one of the main things we need to do for

medical surveillance standpoint is bring all the people who offered overdue in miss the loss to follow up on our occupational injuries and make sure that they're emailed to come back and we want to automate this process so that we can free up our staff to do actually what they're trained for versus these mundane processes and so we

started with six vendors the top three score is advanced and at before we moved into the second phase we emailed each vendor a list of 40 to 50 technical questions that were put together by the IT group and the IT group put this together in advance of the security review so a lot of the same questions at

the Security office we need to answer we asked the vendors up front and happy to share this list at any point we additionally asked the groups for a list of the pricing scheme and we might have 30 users on our medical record for over 20,000 30,000 40,000 records what would it what is your pricing scheme per year

what other fees do you include and it we didn't keep this general we said you have a maintenance fee do you have an up keep feed you have a cleaning feed you have a hosting fee trap we just listed off all these fees because we didn't want the process and and us to be and us to essentially

look look worse later when at the time after we've gone through this process procurement states tells us you left out fifty thousand dollars worth of annual fees and and for one or two of the records this was actually a showstopper as well so for the second round we scheduled a deeper dive with the groups this was two

hours face-to-face or or webinar webinar webinar based the first 60 minutes we had our health and safety our core team would been there for all six records ask mundane routine and then critical questions ad-hoc to the to the group so we did not tell the vendors what we were gonna ask them for we wanted them to be

able to respond on the fly show us how you print this show us how you navigate to this and and really and hit them in a more stressful situation to see if what we observe during the first time would hold during the time after that following this these partner groups these groups that we work to integrate with

which is risk management HR epic IT a bunch of other groups we brought them them in and they asked questions that were mundane to them if we wanted these other groups to be on this record ensure with us did this record meet those needs as well and we needed that from a budgetary standpoint but also from a

functional functional standpoint and so we had patient portals and supervisors advisor portals displayed displayed for them the interesting part of this and having having a team that you're willing to have a little too many cooks in the pot of cooks in the kitchen actually the you know they're you create a opportunity for a lot of disagreement and

and strong personalities to over take over take the the dialogue and push it in a way that me myself might not have wanted it to go our team would have won not wanted to go but the Lari of that is the epic IT group in an example we had them around for the final round and they were

grilling each medical record system about what to us what is crucial integration with what Stanford Hospital does we use it for for x-rays we had used it for billing we order labs and and we view medical reports so we need we really desired functionality for integration with epic system and what the what the IT personnel we're talking

and much of it was was technical speak but it was pretty apparent even the non-technical people there that one or maybe even two of the finalists didn't have the expertise to integrate with epic in a secure way in a timely way and really in any meaningful way that was going to have that team approve this this record

as a vendor and and so we were willing to take risks by having these other groups involved because in the end and led us to less buyer's remorse once we got to the end stage altum Utley - another key thing is is just like when you study for a test that you want to look at old test

questions and and sort of really kind of do something pragmatic and impractical we contacted end users of all these records and either sat face-to-face with them or a webinar tour web chatted or talked in detail about their experience not just with using the record but with the migration process and the whole kind of ADA A to Z

interchange that they had undergone and this was very very helpful for us so from this phase two we created a scorecard and and this is nothing nothing fancy this is actually excel based and color coded and you know in a week or but functional way and more simple but functional way and really what it did and these

vendors may or may not have been this may not may or may not have been the actual ratings that were given but we were able to pull out and this was four or five pages of items like this every line item of things that we were interested in with each of the three records and whether or not

grossly they met didn't meet or might meet those needs and when we want and when we want to submit this and we've submitted this to our our Provost for approval quickly again they can look at this CEO broad categories see a question within it one under we did too due diligence but to be able to just visually

see quickly where one record stands out compared to another or another and and this this this is highly important but goes back and the foundation for this is based on that pain point list that we made for six months with help of all the rest of our staff and and so again the foundation makes this whole process

easier and again it makes it more consistent to do so there we go so in making the business case we put together a 25 page report could have been overkill that was probably written text and diagrams plus multiple appendices which listed all these all these reports that I mentioned the wish list the score cards the cost justification

the vendor analysis final reports and the executive summary that really brought this down into one page and now in thinking back to the procurement process why was this even important and and maybe maybe this was too much but in perpetuity at Stanford through two years from now five years from now as long as we have this medical

record our Vice Provost Provost group might need to defend the choice of this expense down the road to their superiors and this document which probably Nolan would read it entirely entirety would be the the foundation for that and and so we want to make sure we were successful and and in this in this case ultimately it was

approved the this was an internal document we put together just in thinking about how a new record would help us and we twenties and we were trying to automate as much as we can and so if we had ten minutes of ma ma time scanning a document indexing and now the new record if the scanning is automated

becomes two minutes of an MA time that differential in time we turned into a monetary value for the clinicians for the medical assistants for the admin assist and this was not a pitch we made formally but internally the number here is about 150,000 per year the true numbers depending on the estimates could easily be a third of

that but essentially what we were recognizing is we're clearing up at least a full amaze salary or time for them to do the work they were trained for and to help the growth of the clinic and the health and safety of the university rather than on tasks that should be done automatically by a computer or our system

and and this in itself this this this time of this framework helped us understand that the true costs of this system were less than than what it might be the this was a final sheet that we included this was another four to five to six page document that took all our current pain points in the left column

that we developed initially all the goals that we'd had at the start for what our new record would be and the right-hand column was what the record that we ultimately chose what functionality would it have and how would it meet our not meet those goals enlarge in large degree it met the goals that were on there but

essentially someone could take a look at this and understand where we started where we ended up and feel happy with that process so ultimately we notified the selected vendor that there are a choice we notified the incumbant vendor the one that we were using that we were moving away now this vendor was involved in the process and

did not make our final round so they're aware that we were moving on but in thing in in even this step of the process we wanted five six years of medical record data to migrate successfully and without issue from this record to our new record and and we needed their support for this they could have made it

harder it could have been a lot more of a barrier and in fact the fact that we kept an open dialogue with them we were very honest throughout the process and they remained very professional that this process worked very well in streamlined one of the other things we did is we ensured that there was significant overlap between

the two records either so we had six months potentially budgeted where we would have two medical records and ultimately we didn't wind up keeping it that long but for la is not just in deployment of the new record and a migration from the old record but in fact because of delays internal to Stanford with the procurement process

and with the IT approvals and ultimately even when something is closed it can take a little bit of time in a red tape in a red tape academic environment and this allowed us even at that stage not to be left kind of high and dry from a clinical standpoint so in brief summary in thinking about this process

you know when you make a move to a new medical record you have to it's a big endeavor and and how much of a pain or how much pain points do you have with your current record that is that is that enough to prompt you to move on and for us this clearly was and it clearly was

four years and in delineating these points and then understanding the steps that we need to go through from a procurement way management standpoint from assembling our team that's a wide range of people both internally and externally to weigh in and help with the process we as a clinic ourselves grew and it's not not just grew kind of

intellectually or emotionally but we grew from being sort of a one-off clinic in a small part of campus and as part of a component of maybe you know recognized health and safety to becoming a larger player with risk management with HR with with all these other disparate groups around campus and in fact now have a much more

leverage to push these national are these these campus-wide initiatives for health and wellness and part of this process enabled us to make a case for a new medical clinic at a time where even budgets on campus were being constrained and so in fact in a couple months they start breaking ground at a new clinic or we'll have

on-site PT on-site acupuncture larger space and education and training we can bring in some of the wellness teams for nutrition talks and so this this discussion on medical record which seemed initially to have nothing to do with the rest of our role on campus ultimately has has propelled us forward and it's been a really really positive experience

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