“Humanware” vs. Software

Interview · December 28, 2017

Amy Merlino and Tom Lee head shots

Thomas H. Lee, MD, interviews Amy Merlino, MD, Enterprise Chief Medical Information Officer and Obstetrician for the Cleveland Clinic.


Tom Lee:  This is Tom Lee from NEJM Catalyst, and we’re talking today with Amy Merlino, a high-risk obstetrician at the Cleveland Clinic. The reason we’re talking to her is because of her very important, very difficult, intimidating work as Enterprise Chief Medical Information Officer. So, Amy, first tell us, what is your job? I completely understand the OB stuff, but tell us about your focus as Enterprise Chief Medical Information Officer for an organization as big and complicated as the Cleveland Clinic.

Amy Merlino:  I thought I had an easy job, but the more you describe it, it is a bit of a challenge. It’s a physician leadership role within the information technology division, and the way I look at it is it’s providing a translating role between the medical staff and clinical needs with the technology division.

[In] the role that I play, I get to partner with other IT executive leaders as well as the executive leaders of the organization to try and understand strategic initiatives that are happening across the enterprise, and ensure that from the technology standpoint, especially around our clinical technology, that we’re supporting those.

I am able to get into the weeds on a lot of the projects and really get to the nitty-gritty of how the technology helps our caregivers, but I’m also very fortunate — and many organizations have this structure — to have some additional medical informaticists from different specialties who help with that work of translating clinical practice to the technology world.

Lee:  You are really living in that inner space between the clinical world and the IT world. The Cleveland Clinic has been using Epic for a long time now. How many years has it been, and how would you say it’s going in 2017–2018?

Merlino:  We were definitely early adopters of Epic. We started our relationship with them back in 1999, and at that point Epic was rolling out different modules, and had their more generic tools available. And over the years in partnership with the Cleveland Clinic, and with other organizations who have been with Epic for a long time, they’ve been able to develop their product into a multidisciplinary best-of-breed EHR.

How it’s going with us? From my standpoint, I would say it’s going very well. Some of our caregivers and some of our other team members may have different thoughts on it, but as I look at how far we’ve come with this tool and the relationship that we’ve had and continue to develop with Epic, I think when you look at the deployment that we have, we have some impressive pieces of technology.

Now, I’d also counter that with some opportunities for us. Starting with Epic many years ago, we were able to, as were other customers, develop workflows using the tools that Epic had for maybe different intentions, because we needed to do that. And Epic has learned from that and updated their software, where they now meet the needs of many of our and other specialists. But we didn’t necessarily adopt the exact way the Epic system was built for that.

As Epic moved forward and as we’re moving forward with this, that runs us into some issues. We have some custom code that every time the software updates, we need to re-look at that code, and there’s a lot of maintenance behind that. Additionally, there [are] a lot of tools that Epic has brought out, where they’re solving the problems in a slightly different way, but maybe even a better way than we’ve figured out, and as physicians are going from hospital system to hospital system where these tools are rolled out. But it’s my partners who are challenging us to look at our deployment and make some changes to some tools that they are asking for.

So when I look at it, it’s a lot of hard work for my team, the technology team, to think about how to get our tools to a place where they’re functioning for our end users.

Lee:  Now, one reason we’re talking today is that you recently made a comment to me that a lot of the time, where issues are frustrating clinicians about using electronic records, the real fixes, the fixes that work best, are more about fixing the way clinicians work with each other than the actual IT system, or even the interface for the IT. Did I get that right? Is it kind of like the Seinfeld thing about “it’s not you, it’s me”? Can you explain what you meant by that and maybe give me an example or two?

Amy Merlino:  Sure. I think part of that is, as we get more tools available to us, and as there’s more information within the EMR, there are some things about how we work with it — which I’ll give you some examples of in a second — but you can lose some of that person-to-person interaction.

Some of the things we think about — we’re just developing a little task force to look at an [Epic] In Basket, or how we message among each other. If different clinicians choose to send messages in different ways so that it comes through maybe as a telephone encounter, or as a staff message, or whatever the tool is — if the receiving provider doesn’t think about that tool in the same way, you may miss getting that message from them.

And for critically important pieces of information, even if you can send a message through the technology, that concept of picking up the telephone and having that conversation about the patient with that other caregiver is still essential. And we’re always getting requests to help automate the system to help tag people with what their task list is, of which patients they need to see, and who they need to go to. But if they show up there and haven’t had that conversation about why is this other provider asking me to help take care of this patient, what’s the question they’re asking, it’s really dissatisfying for everybody in that situation, the caregivers and the patients.

That’s one of the things that continues to pop up about how we work with each other. I do think there are some [other] pieces about how the systems are built compared to how doctors want to work. As the technology requirements change, or regulations change, if the IT department just throws in different regulations as one more click, or one more thing for the doctor to do, and doesn’t understand what a workflow is about seeing a patient in a primary care office, what does the doctor need to do to take care of that patient, and how can you fill in all of these other requirements somehow in the workflow so that the doctor and the patient feel like they’re interacting and having an experience where the doctor is taking care of that patient? How can they feel like they’re having that experience, capture what they need to in the computer system, but not make it seem like that doctor is doing the clerical work of collecting data? Make it seem like he’s just writing his notes and ordering the yearly lipid panel that the patient needs?

Lee:  I just this morning, seeing my own patients in primary care at the Brigham, got introduced to a program for blood pressure where patients are being given home blood pressure cuffs that are Bluetooth enabled, so their blood pressures are directly uploaded to our electronic medical record, and then to the team that will regulate their medication without even me knowing about it. That team has an 80% successful control rate, which is a heck of a lot better than the rest of health care, but it will take time for people like me to learn to work with that team. It’s better care, but it’s annoying how I learn about it — I guess, part of what you’re going through as you work more to organize providers.

Merlino:  Tom, just quickly on that. That example is interesting because our patients are becoming a lot more engaged and accountable for their care as well, and again, they’re out there with these tools. You can get a Fitbit or a blood pressure cuff that’s Bluetooth enabled, and they want to be able to interact with the care team. So I do think that there is that change from our patients also coming in where they have that data. They want it to come to us, and I think having that team to review it for you guys is great, because the other option is for you to get all those blood pressures, too, to look at all the time, which would be one more thing in that In Basket of yours that you may not want to see.

Lee:  Exactly. Exactly. Now, the last thing I want to ask you is about demographics. I don’t think of myself as old, but if someone gave me a Bluetooth-enabled blood pressure cuff I’d be thinking, “oh God.” But I know that for my children, they’d be thinking, cool, and I think the same kind of thing is going on with electronic records in that I’ve pretty much learned to do the minimum I need to get through my session. But my 30-year-old daughter, who is a neuro resident, she is a super user who teaches others how to use electronic records.

Do you think our problem is going to get better because the IT gets better, or is it just going to take time and the natural replacement of one generation with another?

Merlino:  I think it’s a combination of both. The interesting piece [is that] for many of us who remember what it was like to take care of patients on paper and know how to hand-write a prescription, which is kind of a lost art, the original design and unfortunately some of the thinking now is trying to get an electronic health record to work like paper used to work.

And I know we’re trying to think about, well, that’s not how a computer should add value to how we take care of patients. And what is different about how we think about our patients’ records and how we think about doing our documentation and ordering that could be more innovative?

I think there will be some time where we will have folks who’ve never picked up a paper chart driving the design of these tools in a different way that will help us, and then those folks who remember the paper will slowly retire, so they won’t be asking those questions or making those comments [like], “when it was on paper I did it this way.”

There are also great advances in technology. Your daughter probably also has Alexa as her friend at home who will turn on her TV, and change the channel for her, and order her groceries to be delivered. But the technology that’s coming on the consumer side that we’re all seeing, and our patients are seeing, is advancing very quickly, and to your point, everyone thinks it’s cool. Then the challenge is figuring out how to safely incorporate those tools within the health care environment and [how to] be able to take advantage of those items.

So, I think the technology will get a lot better, and our thought process of what we’re building needs to change from the concept of what it was on paper and trying to make old guys like you happy with just doing the minimum, to innovate on how we can get these tools to help work for us. Many of our EMR vendors are thinking that way as well. It’s the change that I think will take a little bit of time, but we’re all moving in that direction together at this point.

Lee:  Let me close by asking you this. When you think about the cool things that you might do in the next couple of years, what percent do you think will come from better organization of our people — humanware — and what percent do you think will be because of cool software?

Merlino:  I think it’s got to be a combination of both. The software is now pretty flexible and it’s having that human interaction of how [we] should take care of patients and how can we use all the data that we have, that we need that human and operational input to  think about how that needs to change to then be able to utilize the software.

The software can go wherever we want it to go, but we need the organizational input for it to layer onto, so it really does need that human thought process to help drive it to where it needs to go.

Lee:  Thanks so much, Amy. I can tell you that my strong conviction is that your electronic medical record and other IT systems are going to part of the Cleveland Clinic’s secret sauce for a good long time to come. Part of it, not the whole story, but a good part of it. I think that you are the best, [and] they’re lucky to have you.

We will be tracking your experience and expertise more in years to come.

Merlino:  Thank you for involving me in this discussion. It’s been great fun.

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