Chapter 15: Instituting Multi-disciplinary Care and Electronic Medical Records
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Description
In this chapter, Dr. Ecung sketches some of the major changes she saw during her years working for the Physician in Chief.
First she talks about the process of adopting electronic medical records. She explains that under David Callender, the institution looked at a variety of vendors and determined that the MD Anderson-developed system, ClinicStation, exceeded what was on the market. In 2014, she explains, leadership decided to adopt the EPIC EMR system. She talks about the pros and cons of ClinicStation and notes that the administration planned on a $250 million loss when instituting EPIC.
Next, she talks about the process of supporting the evolution of multidisciplinary care at MD Anderson, a process that involved helping faculty and staff understand what it was about and then managing the transition of practice to a team approach. She talks about the difference between physically bringing the different specialties together versus creating a culture of collaboration. She talks about some of the strategies used to foster collaboration, including the importance of cross-training nurses and holding planning conferences with faculty across specialities. She talks about the importance of spatial support in design of clinics, developing teams, holding formal conferences, and including multidisciplinary teams in patient visits, the latter resulting in a “show of force for a patient.”
Dr. Ecung talks about working on the Clinical Effectiveness Committee that formalized multidisciplinary approaches in the MD Anderson algorithms of care. She points out that the Sarcoma center did a costing of each algorithm.
Identifier
EcungWB_C15
Publication Date
2-27-2017
City
Houston, Texas
Interview Session
Wenonah Ecung, PhD, Oral History Interview, February 27, 2017
Topics Covered
The University of Texas MD Anderson Cancer Center - Institutional Change; The Administrator; Overview; MD Anderson Culture; Working Environment; Institutional Processes; Growth and/or Change; Obstacles, Challenges; Institutional Politics; Professional Practice; The Professional at Work; Leadership; On Leadership
Transcript
Tacey Ann Rosolowski, PhD :
Over the course of your roles with Clinical Operations, have there been kind of shifts in the prevailing concerns, or for one thing, the institution continued to grow. You know? Were there certain types of challenges that arose over time, that changed?
Wenonah Ecung, PhD:
Oh, yeah. I guess the first major shift that I was really a part of, aware of and a part of, was when we shifted to multidisciplinary care. So that was the first. Probably the next major undertaking, of course, when we went through the financial crisis in 2008, 2009. But we were responding, as was every other industry throughout our nation. So the next major shift would have been executing the Electronic Medical Record, Electronic Health Record. In between there, we had a period where we had consultants come in, and we thought we were going to have to do a big layoff. But we didn't. We did a small one, I think it was, like, about 500-some people, and that was aroundwell, that was the early 2000s, if you will.
Tacey Ann Rosolowski, PhD :
Talk to me a bit about the Electronic Medical Records. What were the conversations about, leading up to that?
Wenonah Ecung, PhD:
Well, we had triedwe hadwhen David Callender was in office, if you will, we had looked at several vendors for an Electronic Health Record. And with each vendor, we had come to realize that our Clinic Station, which was a home-grown tool, exceeded what the vendors could provide. So we spent a lot on consulting fees, but we didn't get a lot, because we didn't actually end up executing. And then when the decision was made to go withwho did we go with?
Tacey Ann Rosolowski, PhD :
EPIC?
Wenonah Ecung, PhD:
Epic, yeah. A lot of the faculty were, I guess you would say, somewhat suspicious, because they knew what ClinicStation could provide. And EPIC had never handled an institution as large as ours in terms of numbers of faculty, number of patients, square footage or anything.
Tacey Ann Rosolowski, PhD :
What was it that ClinicStation could and could not do?
Wenonah Ecung, PhD:
Tacey, I'm not sure of that, because I wasn't intimately [involved] in the conversations. By that time, Bob was on board. And he was in those conversations. I don't know whether it was the link to others outside, or what.
Tacey Ann Rosolowski, PhD :
Sure.
Wenonah Ecung, PhD:
My role became extremely periphery to it.
Tacey Ann Rosolowski, PhD :
Well, I 'm sorry, I kind of derailed you.
Wenonah Ecung, PhD:
That's okay.
Tacey Ann Rosolowski, PhD :
Kind of what, in terms of the conversations that you were part of, how did that conversation evolve from the consultants?
Wenonah Ecung, PhD:
From the consultants?
Tacey Ann Rosolowski, PhD :
I'm sorry, so you looked at various vendors and saw that ClinicStation kind of exceeded. But then there was the moment
Wenonah Ecung, PhD:
Right. So that was in the David Callender era. And we stayed with ClinicStation from there, until what? This is 2017, so we put it in 2016, so two years prior to that would be 2014. So it was at that point that it was decidedand that's when I became periphery to the conversationthere was a decision made that we needed to adopt an Electronic Health Record, and that ClinicStation wouldn't suffice for being it. And I knowyeah, that's prettyI just really wasn't in those meetings.
Tacey Ann Rosolowski, PhD :
Did you have a personal perspective on this at the time?
Wenonah Ecung, PhD:
No. It was whatever was going to be readily available and easy to use for the faculty. I had worked with my own physician's office where I had had the experience with them, where they had shared how difficult it was to bring it up in terms of still having the patient feel they were the center of the conversation, as opposed to the computer was the center of the conversation. And I really can't give you eye contact because I got to look over here at what I'm doing. So I had that perspective. I knew a lot of the physicians, like I said, I had grown up with, so it was going to be a huge change for them. And they really hadn't bought into it. I knew it wasI was in the bigger meetings in terms of the expense, I knew it was going to be a huge, a tremendous expense to the institution.
Tacey Ann Rosolowski, PhD :
What were the numbers that were being discussed?
Wenonah Ecung, PhD:
Oh, it was in the millions, millions. The year welast year when we actually executed on it, we budgeted for a $250 million loss.
Tacey Ann Rosolowski, PhD :
A loss. Wow.
Wenonah Ecung, PhD:
Loss.
Tacey Ann Rosolowski, PhD :
What were the sources of the loss?
Wenonah Ecung, PhD:
Well, that was because as we were bringing up the system, we knew we had to bring down other systems. And when I say "bring other systems down," that meant that literally, we couldn't have as many patients coming through. And if patients don't come through, then your revenue drops, right? So that was planned. But apparently they ended up losing a little bit more. And then we lost even more.
Tacey Ann Rosolowski, PhD :
I'm always curious about the shift to multidisciplinary care, since that's so key, core, to what MD Anderson is about. I know you spoke a little bit about it in a previous session. But I wonder if you had some additional thoughts on that kind of returning theme, over the course of your career in the institution?
Wenonah Ecung, PhD:
Returning theme?
Tacey Ann Rosolowski, PhD :
Well, you talked about it when you went to work with Developmental Therapeutics, and then with those other roles, and then again the Clark Clinic. Howand then of course the institution had made the formal decision to adopt that, rather than have it be happening piecemeal, because it was an interest of individual faculty.
Wenonah Ecung, PhD:
Right.
Tacey Ann Rosolowski, PhD :
How did you see that changing from that individual interest to a moment when it was, like, okay, that's what really what we're about?
Wenonah Ecung, PhD:
Oh, okay. I think there were two critical points in time. One was the planning of it, the envisioning of it, and trying to help people understand what the concept was all about, and how it was different from what we were doing. And when I say "help the people," I really mean the faculty and staff. Because the initial planning wasn't really with patients. It was convincing faculty that this is the direction we need to go, and that it really is going to be different from the way you're currently practicing. Then I think the other transition in time was when it took place, and not only did it end up being beneficial to the faculty, but it ended up being beneficialwe knew it would be beneficial to the patients. But the patient began to experiencetheir experience improved as a result of multidisciplinary care. So for them, they were able to experience I no longerhere I am with cancer, my counts are low, I'm exhausted. And I've got to walk throughout this huge institution. First I'll see my Med Onc. Then I've got to walk this distance to go see my surgeon or my Radiation Oncologistthey no longer had to do that. It was all in one setting. And they began to realize that not only is it all in one setting, but these three guys are talking to each other about me. So the level, the depth, of the conversation has changed in terms of whatever the plan was. [ ] Now they've got the experts altogether and debating on the direction that it should be going, that we should go. So I think that changed. I think those were the two critical points. Initially, even though the vision was bringing the faculty together so that you could have space where you're all discussing and making decisions, initially what took place was, we physically brought them together. There were still barriers. My room is Med Onc, your room is Surgery, my room is Radiation Oncology. So this is my territory, your territory, not our territory. We've just come together in the same space, but we're not truly collaborating, if you understand what I'm saying. And I think it took us a while toand that was heavily dependent uponthat was a large role of the Center Director, the CAD, the Center Administrator Director was to help bring these folks together. Not just in the space, but now to create the venue for the conversations to reallythe need, the recognition that there was a need, and how to bring these conversations together. So that took us some time.
Tacey Ann Rosolowski, PhD :
I mean, that's a cultural change.
Wenonah Ecung, PhD:
Exactly.
Tacey Ann Rosolowski, PhD :
I mean, you can make people live next door to each other, but
Wenonah Ecung, PhD:
Right. And they don't talk to each other.
Tacey Ann Rosolowski, PhD :
Yeah. Exactly. So, I mean, I know you talked a little bit about this. But was sort of the array of strategy a Center Administrator Director might use to bring those conversations about?
Wenonah Ecung, PhD:
Mmm. One of the things that I did as the Center Administrative Director, I made sure that we formedand I probably talked about this beforeteams. So the initial teams were a faculty member, it might be Dr. Tacey, and it might be Wenonah as Dr. Tacey's nurse. But Dr. Tacey also had a support person, a clerk that followed that team. So that was the initial. But after that, it was Dr. Tacey, Wenonah, but I also have this nurse that's Medical Oncology over here, maybe Pat, who cross-trains to work Surgery. And Wenonah cross-trains to work Medicine, to where Dr. Pollock gets to know not just Wenonah, but he gets to know Pat. And Dr. Benjamin gets to know these other two. So it was slowly, if you will, interjecting others into their team to where they developed a level of confidence. And what are you going to begin to ask? Pat's going to be out, is Karen going to cover? So there was some level of confidence. Then with the faculty having what we called "planning conferences," where the Radiation Oncologist, the Med Onc, the surgeon, the Pathologist, the Diagnostic Imaging individual would all meet at a specific time to maybe discuss X-patients, where they were, X-patient is new, here's what we're thinking about doing. Pathologist [confirms] the tumor type. There's discussion of that. If it is, then Medicine and Surgery and Radiation chime in in terms of what they can do, or what shouldn't be done. So it was those multidisciplinary planning conferences. So we had the space, then we build the teams, and then you have these medical conferences that are multidisciplinary in nature where we're all talking together. And then for some of the centers, like us, we would have it to where Barb was a new patient and you're being discussed in conference today, you would come up. And you'd be placed in an exam room when conference was over, the three major disciplines would come out together and talk to you. So it was a show of force for the patient. And can you imagine being a patient and sitting there, and previously, yeah, you went to see each one, but now you have all three in the room. And they're all three in synch in terms of how they want to move forward.
Tacey Ann Rosolowski, PhD :
Now, I neglected to look on your CV to see if you were involved in any way with the Clinical Effectiveness Committee that developed the algorithms?
Wenonah Ecung, PhD:
No. I wasn't. I wasn't on the committee. Alma Rodriguez
Tacey Ann Rosolowski, PhD :
Alma Rodriguez, yeah.
Wenonah Ecung, PhD:
headed that. That was her domain. You know.
Tacey Ann Rosolowski, PhD :
I was wondering if there were any observations you had about that, or thoughts on that in relationship to multidisciplinary committee?
Wenonah Ecung, PhD:
Now, I wasn't on that committee. But pre-that committee as a Center Director, I had the fortune of working with Peter Pisters, Raph Pollock, Bob Benjamin, and the Radiation Oncologist. And we developed an algorithm for the different tumor types within Sarcoma. It was not only a treating algorithm, we took it a step further and costed it out. We worked with the Business Office to cost out each algorithm. Then we were able to put it into play, so that our folks that were responsible for the business center, that were responsible for helping me bring in the new patients would get a call, and they'd be able to use the algorithm and say, well, this person has this diagnosis, they've had this treatment, which takes them to this [part of the algorithm]. And they'd be able to offer preliminary guidance on cost. Yeah. But that wasI think that was pre-Alma having Clinical Effectiveness.
Tacey Ann Rosolowski, PhD :
And what's the advantage of something like that?
Wenonah Ecung, PhD:
Huge, in terms of whether or not my insurancea lot of times our business centers were having to work directly with insurance companies, and convince them that Anderson is the right place. And part of the convincing was the cost. What was that patient going to be getting for that cost that they couldn't get at Centers of America, if you will? So it was huge.
Tacey Ann Rosolowski, PhD :
Is there anything else that you'd like to add about the VP roles and Clinical Operations?
Wenonah Ecung, PhD:
I think we've covered everything, to be honest.
Tacey Ann Rosolowski, PhD :
We have covered a lot. Well, I wanted to ask you about the graduate work, because we didn't really talk about that. And I imagine that that also helped you step into the teaching role, as well.
Wenonah Ecung, PhD:
Oh, absolutely, it did. Yeah.
Tacey Ann Rosolowski, PhD :
If you want to talk a bit about that?
Recommended Citation
Ecung, Wenonah B. PhD and Rosolowski, Tacey A. PhD, "Chapter 15: Instituting Multi-disciplinary Care and Electronic Medical Records" (2017). Interview Chapters. 703.
https://openworks.mdanderson.org/mchv_interviewchapters/703
Conditions Governing Access
Open
