Clinical thinking

Bill Vargas has been working for The Children's Hospital at Westmead for more than two decades. When he started, its use of IT was primarily concerned with corporate functions such as patient billing and demographics. Today, as the CIO of its Information Services division, Vargas and his team increasingly deploy solutions designed to improve clinical processes. He chatted with BRIAN CORRIGAN about the changing role of technology in the healthcare industry.

How is Westmead incorporating technology into its practices?

We are a fair way down the track in relation to using IT within health - we have an electronic medical record, there are combinations of systems in some areas that are totally paperless, we have medical imaging like radiology and MRI [magnetic resonance imaging] scans online, we have implemented document imaging in the ward areas so we have a full record available to our clinicians, we have electronic ordering, and some do clinical documentation so all of their notes are captured.

What are the major functions of your role?

It's mainly concerned with looking strategically at where the organisation wants to go. We look at new technology and how we can implement it but the main focus has been on patient care. It's not about the technology itself but about how we can help the clinicians and nursing staff improve their processes.

The Vocera communications solution we've implemented is a prime example. It's a voice-activated, hands-free, Wi-Fi communications system that lets medical staff find and talk to each other. We have more than 50 of them in emergency and outpatients already with wireless moving progressively through the rest of the ward areas in the next year, depending on other projects.

We've created work process issues for the clinicians because they have to go back to a desktop so we're also looking at mobile technology and have implemented computers on wheels (COWs) in some areas. We looked at putting things through PDAs but we're dealing with legacy applications that don't lend themselves to that technology currently.

How to integrate existing clinical systems onto new devices is one of the things vendors coming into the market have to consider. Open systems are something vendors have to deal with so, for example, a PDA can place an order securely through that environment without replicating or having a multitude of systems talking to each other.

What is your main focus for the next 12 months?

Wireless would be one but we are also replacing some of the existing systems within emergency because they currently run separately from the core electronic medical records system that we're running. As part of that, we are also moving towards medications management and hope to be the pilot for NSW Health. This would cover the full medication process from prescribing to dispensing and there are lots of patient benefits.

General work includes revitalising our current technology. We have a three-year replacement cycle and continue to roll out PCs. We've also centralised printing and introduced Trim, which is a document management system. We're looking at [Microsoft] SharePoint. On the corporate side, the NSW [Health] strategy is to replace some legacy payroll with full ERP systems and we also want to work, as an organisation, with the new Health Technology body for shared services computing. We have our own facilities here but the long-term aim is to have it centralised.

Do you have any concerns about going to a centralised system when this hospital is further advanced than some in terms of using IT?

We've just got to ensure that we protect the organisation and maintain our momentum. It hasn't happened overnight, it's been more than 10 years, but we're now being driven by the consumer and their expectations are probably beyond the timeframes we can meet. We have a very large group of clinicians that have taken to technology and are constantly pushing the boundaries, then you have those in the middle that are working towards it, and the number who are resisting it is reducing because they see the benefits. The Vocera communications system I mentioned, for example, is saving 20 working hours per day in emergency alone.

If you could implement any single technology solution tomorrow, regardless of cost, what would it be?

I think the fundamental solution is some sort of directory authentication. So if we're talking globally it would be for a person to be able to authenticate, regardless of where they are in the system, and have access to all relevant information. As an individual you would have access to a multitude of applications based on whether you are a clinician or a member of the accounts department. In the future this will underpin everything we do.

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Healthcare is probably the best example of where IT can have a positive impact on our lives and yet it isn't seen as an early adopter of technology. Why do you think that is?

When you are dealing with medicine, you're dealing with individuals that have developed a certain set of knowledge and skills over a period of time that IT can only assist with. Medical work processes have been entrenched for hundreds of years so to change those processes takes time and will only happen where it adds value.

This organisation is part of the state electronic health record project, which is a pilot at the moment but will eventually make information available to GPs and patients, but you need to have a critical mass of information. Once you have that, it produces benefits for the patient and take-up will happen. One of the issues is that ...we're asking people to work with multiple systems and multiple logins, not one consolidated view of information regardless of their role.

How has the healthcare industry been impacted by the current skills shortage?

It's really difficult to gauge in the public sector because demand is always exceeding what we can fulfil. We might make savings on one side but then there are more people coming through the door. We're asking people to do more all the time and the demands of society are becoming greater. They're expecting good healthcare to be more accessible.

How about within your Information Services division?

We've been affected to an extent but one of the reasons we've been able to achieve some of the things we have is because we've had a very good retention rate. The staff that work with us have grown from within and we try where we can to develop them by giving them access to new technology and training. That's allowed us to be a little bit more self-sufficient. I have a personal issue with consultancy - there's a role for it but that has to involve knowledge transfer and a lot of the time it doesn't happen. They come in, do what they need to do and go away. If we want to maintain it, we get locked into a monthly billing cycle. You have to look at training your own staff to be able to support the environment you have in place.

Do you outsource any IT functions?

The NSW [Health] strategy is, in a sense, to 'in-source' rather than outsource. They've created an organisation called Health Technology within NSW Health that will manage the core IT systems over time. From an individual organisation point of view, we're still trying to work out how the two will work together. Will they be a service provider that we buy services from in the same way as you outsource?

There are benefits to that because of economies of scale but, at the same time, you need to be careful not to lose a lot of the benefits you can achieve when staff have a sense of belonging to an organisation. The other thing is from a cost perspective because individual organisations can assess affordability or the risks they carry in relation to technology refresh. If you're locked into a centralised model, it has to be underpinned by very heavy SLAs and you have to invest far more into that infrastructure. It may become more costly.

So how has working with Health Technology affected your division?

We have 10 staff that are now part of Health Technology but are still located here managing our computer room. Over time they will be absorbed into the greater organisation and we will lose the control we had previously with change management - when we refresh servers, for example, or what applications we put in place.

How do you feel about those changes?

I understand the reasons behind them because we are part of the group that initially supported the move. I think it will work in the long term but has to concentrate on core services where there are tangible benefits such as payroll, finance and eventually the electronic health record. It's a totally different way of working. If you log a call and they put you on hold, or tell you somebody will call back in half an hour, it's just not good enough. We've developed methods based on clinical priority where a doctor is with a patient and can't afford to wait for an IT issue to be resolved. We can take over their PCs remotely and walk them through application issues or, if it's a hardware issue, we have plug 'n' play SOEs and can replace the PC immediately.

We've seen governments, most notably in Queensland, starting to work directly with integrators instead of purchasing from the vendors. Do you think that's a model we'll see deployed more widely?

I think it has benefits because you are contracting the organisation to get an outcome and they are responsible for that regardless of the technology or the vendor they use. The issue I see with it is that there's a question of relationship with the vendors at times. Some of the vendors might be willing to go the extra mile for you, instead of putting you through the normal helpdesk or warranty period, because they know you're a consistent customer.

An integrator will get you an outcome but, unless you've developed the ongoing support infrastructure, you lock yourself into ongoing support arrangements. Hardware is commoditised now and everybody is moving towards a service-based environment. From a CIO's perspective you look at that and see that it can be fairly expensive at times. How do I minimise that? I believe people have to look at their own resources and develop those resources to overcome that.

We prefer to work with the vendors directly when it comes to hardware because we have a standard operating environment and replace more than 60 PCs every month across the organisation. You need to know the lifecycle of the PC and that all the applications delivered on it will work. The vendors let us know in advance when they're changing components and give us access so we can test them.

Wouldn't it be easier for you if all that testing was done by an integrator?

No, because we have more than 120 applications delivered via our standard operating environment that come down to users no matter where they are. If we made changes via our change management processes then we'd have to go back to the integrator to test those changes.

What are the most exciting opportunities for IT to deliver change within the healthcare industry?

I think mobility will give us the most benefit - so how do we deliver information to our workforce regardless of where they are? Then there's also convergence as data, voice and video merge. Unified comms is a prime example of that.

What's the biggest inhibitor to technology deployment in healthcare?

Change management and how you bring the workforce across because it takes a long time and training is fundamental. You have to look at the core business first, which is patient care, and that gets priority over everything else. That's the biggest change I've seen. If you go back 15 years, my biggest concern would have been Oracle financials or the ERP because they were crucial to the organisation but they're nothing compared to patient care, which is 24 x 7, 365 days a year. For us to have downtime has to be planned so carefully because everything is online. Paper records are online and we destroy them after the event so if there's a failure then we have patients without clinical notes or results. It becomes crucial.

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What keeps you personally engaged after 20 years?

I enjoy the constant innovation and change but am also motivated by working for this organisation. At one time people said we'd never get doctors using PCs; now doctors are asking us why they can't have access to everything in the same way as they do they do at home. You have technical people pushing the boundaries and they're open to ideas. The person I report to is Dr Ralph Hanson, who manages Information Services but is a clinician and was previously head of ED [emergency department]. Having that clinical input into how we think has been a huge benefit.

What's your biggest frustration?

Trying to get the funds for everything we are trying to achieve. We have a set budget and are competing with clinical services so we always need to demonstrate tangible benefit.