Chapter 07: A Career Change to Information Systems and the Challenges of New Technology
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Ms. Houston talks about how MD Anderson did not offer much leadership development support in the seventies. In the mid-seventies, she became involved in the Oncology Nursing Society (at both the local and national level) to build her leadership skills, and also absorbed a great deal via on-the-job training. Summarizing the qualities of a good leader, she says, “A good leader can go on vacation and no one knows you’re gone.”
She then describes her shift in career from nursing to Information Systems: despite the fact that she knew nothing about computers, Dr. Mitchell Morris invited her to come to work on the Electronic Records Committee in 1997 because of her experience with both in-patient and out-patient care and her knowledge of forms and documentation (and because she was a fun person). Next, Ms. Houston describes the first project she worked on as Coordinator of Clinical Systems –Patient Care Information Systems (’97 –’99). She was part of a group comprised of two others from MD Anderson and 4-5 consultants from a software company, and strategized adoption of the Computer Based Patient Records. One of the first tasks, as she said, was to involve more MD Anderson staff and phase out the consultants. MD Anderson was an “early adopter” for technology and worked with software for dictation, pharmacy orders, and records. She stresses that they were looking for software that could assign a patient a single record number that would follow him/her across in-patient and out-patient care. She explains why this is important for patient safety, particularly those receiving chemotherapy whose total dosages must be closely monitored.
Next Ms. Houston explains that Clinical Systems purchased a brand new product from Cerner Millennium [Health Information Technology] (though they stopped implementation a couple of years later). They adopted the Cerner Millennium product to speed requests for records and processing pharmacy orders, as well as to coordinate and consolidate patient care by reducing repeated work. She stresses that the MD Anderson record systems provides data in the form that MD Anderson users need. She is particularly pleased with the electronic reporting of laboratory data and vital signs. In contrast, she outlines the continuing challenges with regularizing data entry for physician dictation. Information Systems has adopted a system form M*Modal that processes natural language. The aim is to move physicians away from their habitual way of dictating to a structured output that can be electronically reported and searched.
Identifier
HoustonDA_01_20120726
Publication Date
7-26-2012
City
Houston, Texas
Interview Session
Topics Covered
The University of Texas MD Anderson Cancer Center - Building the Institution; The Administrator; Professional Path; Institutional Processes; Building/Transforming the Institution; Multi-disciplinary Approaches; Building/Transforming the Institution; Institutional Processes
Transcript
Tacey Ann Rosolowski, PhD:
Would you like to tell me now about your shift in career?
Deborah Houston:
Okay. Well, it was what ‘96, ‘97. I had been for many, many years involved in the Medical Records Committee. I was the documentation committee chair in nursing for a long time. That was the group that we made forms—the new vital sign record or the changes in the fluid balance record or whatever. I would have to go to this committee and present the form and say, “This is what we’re going to do.” So, for a couple of years the physician that was the chair of the committee who became our chief information officer at the time was like, “You need to come work on this project with us. You need to come work on our electronic medical record project.” I’m like, “No. I just took this new Center Administrative Director job. I cannot take on another project.” “Oh, you really—?” “No, I just can’t do it.” Then six to eight months would go by, and he would ask me again. “No, no, no.” Well, finally, I got asked one time at a medical records committee meeting, and I said yes. I thought, “Well, I must have had a really bad day that day or something.” It was like—I said, “I really can’t do another project.” The woman that I was talking to that day—she goes, “No. We’re talking about come transfer—come full-time work. We’re going to make a position and you come work.” I’m like, “Okay.” I said okay.
Tacey Ann Rosolowski, PhD:
Let me just quick get the detail. Who was the person on the Medical Records Committee?
Deborah Houston:
Mitchell Morris was the Chief Information Officer at the time. He had been—I don’t know if he was the chair at the time. He had been chair of that committee before, and that’s kind of when I first knew him, but he’d been here for a long, long time. Then, the woman that I had the conversation with when I actually said yes was Susan Perry. She was like the director of—I think it was called Patient Care Information Systems. She worked for Dr. Morris, and the EMR project at the time was reporting to her.
Tacey Ann Rosolowski, PhD:
What do you think it was that made the yes come out of your mouth?
Deborah Houston:
I know. That’s when I laugh. I said, you know, maybe I got yelled at by some physician that day in clinic or something. I don’t know. I had a lot of things going on. My husband had left. We were going through this change, and my husband had left Anderson. I don’t know. It’s like I said okay. It took almost four months because they had to create a position. It may have been longer than that. Then when I said that I was going to leave, I took my letter to the person I reported to in Cancer Medicine at the time. He almost had a stroke. We had to have all these meetings with the physician in chief—why was I leaving—blah, blah, blah.
Tacey Ann Rosolowski, PhD:
Who was the person you reported to?
Deborah Houston:
Bill Simeone—I mean, I reported to many people. Fifty percent of my salary was paid by him, and the other half was paid for by nursing. Anyway, I just made the decision. It took—it was a good decision, I think.
Tacey Ann Rosolowski, PhD:
What do you think they saw in you that made them so intent on getting you into that role?
Deborah Houston:
I don’t know. I think it was my knowledge of patient care. I knew—what I think. I had been there a long time. I knew lots of people. I knew inpatient and outpatient care. I knew about charts. I knew forms. I knew documentation. I knew how orders were—how you did things. That’s all I can think of. I was a fun person—I don’t know.
Tacey Ann Rosolowski, PhD:
Well, you have to choose the people you live with pretty carefully.
Deborah Houston:
Yeah, yeah. I said yes. I knew very little about a computer—about computers. I thought you plugged in a disc like you do Microsoft Word and up comes your stuff and there it is. I could hardly—I could do email. I couldn’t set up an Excel spreadsheet. My secretary would do that, but I would fill it out—I still don’t—I’m not very good at that. I didn’t know what I was getting into. I truly did not. I went to a conference right before I transferred. It’s called Health Information Management Systems Society—HIMSS. It’s this big healthcare IT conference—vendors and sessions on how to do things and success stories—a huge exhibit hall full of software vendors and computer cart companies and whatever. I spent a week in San Diego, California at this convention going around. I had no idea—I went to sessions, but I was totally lost at what they were talking about. I went around looking at equipment like this—you know, computer carts or wall-mounted computer things—just because I could relate to that. I had no idea what they were talking about. Little did I know that it was not like Microsoft Word or the recipe software you bought at Best Buy to put your favorite recipes on. It is very different. It is a whole new language. I had my eyes opened. Again, didn’t need to know how to program software. I didn’t need to know how to build servers. I needed to hire the right people that knew how to do that.
Tacey Ann Rosolowski, PhD:
Tell me about the role that you took on—Coordinator Clinical Systems-Patient Care—
Deborah Houston:
Yeah, that was the title they came up with.
Tacey Ann Rosolowski, PhD:
Right. Information Systems. That was ‘97 to ‘99.
Deborah Houston:
I came in, and I was brought in to manage the--. At that time, it was called the computer-based patient record—CBPR project. We had signed a contract with a vendor about six months before that. When I was with Medical Records Committee before I took the job, I had been on committees looking at software solutions, but I was the nursing—one of the nursing people on the committee. I didn’t care about the back-end structure. I was looking at it from a nurse. How does this software work for me as a nurse? From a nursing documentation perspective, almost all of them work about the same. To me, it didn’t matter whether we went with Epic or Cerner or whoever because the functions of how I was going to document the patient’s fluid balance or how I was going to document vital signs or the nursing assessment I did was going to be the same. I really—that’s what I was worried about. I wasn’t worried about everything else. When I got there, there were two people from MD Anderson. The rest was a consulting company we had contracted with to help with this. There were like four or five of those people and two MD Anderson employees. My job, first of all, was to get more MD Anderson employees involved and to figure out what these contractors were doing and why were they the ones managing the budget and why were they the ones—we should be doing that.
Tacey Ann Rosolowski, PhD:
Just so I understand, these four to five people from the company, they were actually here on-site at MD Anderson.
Deborah Houston:
Yeah. It wasn’t the software vendor. We had consulted with—I think they were called IMG.
Tacey Ann Rosolowski, PhD:
Oh, yeah. Okay.
Deborah Houston:
That consulting company that became HealthLink that became IBM that’s now called Encore Health. Everybody changes names. They were somebody that we had (phone call).
Tacey Ann Rosolowski, PhD:
So you were interested in why are these people running this?
Deborah Houston:
Well, it was like—we needed more MD Anderson people involved. There was a gentleman that was the manager, who is still here on a different role. It’s like we just needed—we needed more people, but we also needed more Anderson people. We started looking for—I started looking for staff. We had—I think we had a database administrator and one other. I can’t remember who it was. Oh, there was a nurse that they had hired. We started hiring staff. We hired a technical guy. We hired a bunch of people. Then it’s like, “Okay. We don’t need this consultant, and we don’t need that consultant.” It’s kind of like—we don’t need—we should keep this information with us.
Tacey Ann Rosolowski, PhD:
Uh-hunh (affirmative). You know what you need.
Deborah Houston:
Yeah. We kind of transitioned from—they were a great resource. They helped us a lot, but we didn’t need them to be running the project. We should have been running—we needed to take over ownership of the process.
Tacey Ann Rosolowski, PhD:
What did you discover about your needs when you took over that ownership? What were the criteria you (talking) look at?
Deborah Houston:
Well, it was like where were we? What were the things that needed to occur? We needed to get requirements for what people wanted to see in the system. The software was very immature. That’s what we were really starting to look at. We needed people to work on different sections of the record. You needed somebody to be working on getting all the clinical results in—the lab results—that kind of stuff—and organize how that was going to look in the chart. You needed somebody to start working on the pharmacy stuff. You needed somebody to start working on the physician dictation—all those kind of things. We just started identifying types of people that we needed and posted positions and hired staff. Several people that worked for me in other jobs came and applied. We hired people from outside. A lot of internal institutional people transferred in. It was great.
Tacey Ann Rosolowski, PhD:
Just a quick question. This was occurring in ‘96—around then.
Deborah Houston:
‘97, yeah.
Tacey Ann Rosolowski, PhD:
Now, where was that—in terms of the national timeline of institutions going to electronic records?
Deborah Houston:
We were considered an early adopter. People were moving, but we were—people had--. Well, we were an early adopter for the technology. There were hospitals that had systems that were very much mainframe-based systems. You know the blue screen kind of computer, dot, dot, dot things. DOS. It’s called DOS—whatever that stands for—DOS-based systems. The VA had one. Some hospitals had them, but we were looking for something for our institution that was more cutting edge, really—that was something that could go from an outpatient to an inpatient experience. Our patients had the same chart, the same record. You come in as a patient at MD Anderson, you get a medical record number the day you walk in the door, and that’s your record number until you pass away. That’s always your—always that number. That sounds bad that you’re always a number because you’re not a number.
Tacey Ann Rosolowski, PhD:
Right. It identifies you—(talking at once).
Deborah Houston:
All of your chart, all of your information is in one place. If you go to Methodist Hospital, for example, and you’re in the hospital, you have one system that you’re using in the hospital, but if you go see your doctor in his office at Scurlock Tower, he may have a different application. It’s not talking to the hospital. He can probably on his computer pull up your record from the hospital, but he can’t—the data is not together. With patients getting chemotherapy, for example, you need to know what they got when they were an outpatient and what they got when they were an inpatient because there’s issues with total doses or drugs and things like that that you have to know. Most computer systems don’t have an ambulatory and an inpatient component together. That’s why the product that we bought—we were trying to make do that at the time.
Tacey Ann Rosolowski, PhD:
What was the product?
Deborah Houston:
Cerner Millennium.
Tacey Ann Rosolowski, PhD:
And that’s C-E-R—
Deborah Houston:
C-E-R-N-E-R. I don’t know that we’re going to—I don’t know that we’re going to want to put brand names of products—I don’t know.
Tacey Ann Rosolowski, PhD:
That’s okay.
Deborah Houston:
We’ll have to think about that, but that was the product. We were an early adopter, meaning we knew we were buying code that had not been put into use yet.
Tacey Ann Rosolowski, PhD:
Oh, really. It was brand new.
Deborah Houston:
Yeah. Brand new. That’s what we did. That’s what I did. I helped do that. Over the next several years or couple years, actually, we made the decision to stop our implementation of that product. We’ve gone through several.
Tacey Ann Rosolowski, PhD:
Really? Interesting.
Deborah Houston:
Yeah.
Tacey Ann Rosolowski, PhD:
Before we go on and ask you why, let me just ask you another question, which is, clearly, this adopting of electronic records is just huge—huge at the institution. So I’m wondering like how it meshed with really high upper administration images of how the institution was going to evolve and be financially effective. What’s your view of that?
Deborah Houston:
Well, I think the whole idea was we were going—the idea was to put this in to make the physician more productive. He was going to be able to see more patients. We were going to have better communication. You were going to be able to see the chart anywhere you wanted to in the hospital. You didn’t have to find a chart. You were going to save time, because the chart was there when you needed it, all those kind of things. We were going to get orders to pharmacy faster. The nurse will know what you want done right away.
Tacey Ann Rosolowski, PhD:
So again, that’s sort of a physician-driven aspect—
Deborah Houston:
Right. That’s the whole goal of an electronic medical record—to coordinate and consolidate care. That is still our goal—to make everybody—not just the physician, but make everybody more productive and quit doing double work and repeating things and make it better for the patient because you’re not asking him the same question twelve times and all that kind of stuff.
Tacey Ann Rosolowski, PhD:
Yeah. I was going to ask you. It seems like a really naïve question, but what does that information system mean for an institution of this kind and an institution that is going to be confronting increasingly more complicated twenty-first century issues?
Deborah Houston:
Right. Well, I think one of the things an electronic record does is it gives you data that you can then use for all kinds of things. The system has to be configured so that you’re getting the data that you want and in a manner that that data is retrievable and structured so that it can be queried or put into databases or whatever. That is the struggle. One of the things that we have done well—like lab data—a very numerical, structured information—vital signs. You have a diastolic and a systolic blood pressure. You have a hemoglobin, a hematocrit, and a platelet that are very easy to track, that you can tabulate, you can graft, you can do all kinds of things with. That’s the beauty of electronic records. Then you can take that and a physician can say, “I want every patient that had this kind of lab test, that have this diagnosis, and I want to see that over the last year or whatever.” They can get that out of the computer systems if it’s built correctly and the data bases are there to support it. That’s our goal. That’s what the electronic record is going to give us. I wouldn’t say we’re struggling, but we’re in the middle of that transition because we have some things very structured—lab data, other things like that. We have other things that are not. They are free text or they are text documents that aren’t structured. We have lots of things on the computer. A physician can see a patient today without any—everything is on the computer, either lab results are there, the images—the x-ray images are there, the text report of the last visit, all the consultants, all the x-ray, all the pathology. Everything is there. The nurses’ vital signs are there. The medications a patient is on. It’s all there, but you can’t query it. You know what I’m saying?
Tacey Ann Rosolowski, PhD:
Yeah.
Deborah Houston:
That text blob of information that the physician dictated is exactly that.
Tacey Ann Rosolowski, PhD:
So there’s no real way of getting access to the specifics that’s in that document.
Deborah Houston:
That’s where we’re trying to now move into the piece of, “Okay. The data that is going in needs to be in a structured form.”
Tacey Ann Rosolowski, PhD:
In a structured form. So how are you addressing that challenge?
Deborah Houston:
Well, the technology has gotten better. The systems we’re developing. That’s some of the initiatives we’re doing today.
Tacey Ann Rosolowski, PhD:
Can you give me an example?
Deborah Houston:
Physician dictation. Structured Clinical Documentation. We have a project called “Structured Clinical Documentation—SCD,” where we have built tools, primarily for the Head and Neck Service—Surgery Service where instead of dictating a note that go in and do—call it point and click—the patient’s physical exam. Cardiac—you can click normal or you can say he’s got increased heart rate, hypertension, whatever, and it creates a note. In the end, when you look at it, it looks like it’s dictated, but those are all structured elements.
Tacey Ann Rosolowski, PhD:
So, basically, it’s not dictated. It’s—
Deborah Houston:
Well, the physician does click, click, click, or the physician’s mid-level provider and the physician then approves it in the end. That is one way. The other piece if we have signed a contractor with a vendor called M*Modal. M and then another capital M-O-D-A-L or E-L—I don’t know. It is a transcription vendor, but that does natural language processing. What this is I say the word lung, and it converts that into a structured data format so that you can then query those items within the record.
Tacey Ann Rosolowski, PhD:
So it’s kind of a key word search—
Deborah Houston:
Kind of, yeah. So, the physician, who is used to dictating—every physician learns how to dictate when he goes to school and starts being—seeing patients. He dictates, but the output of that is a structured document that can then be queried. Then, the plan is that we, also, then have a modified version of that where it’s a template that’s set up. You just dictate in certain pieces. That’s what we’re doing for physicians. Nurses, I think, will thrive on the structured format of the point-and-click because they already check boxes on assessment forms.
Tacey Ann Rosolowski, PhD:
01:45:5 We’re at about five minutes of five. Do you want to—?
Deborah Houston:
Yeah, we can quit and start tomorrow. That sounds good.
Tacey Ann Rosolowski, PhD:
So, it’s five minutes of five, and I am turning of the recorder now. (End of Audio Session One)
Recommended Citation
Houston, Deborah A. and Rosolowski, Tacey A. PhD, "Chapter 07: A Career Change to Information Systems and the Challenges of New Technology" (2012). Interview Chapters. 890.
https://openworks.mdanderson.org/mchv_interviewchapters/890
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