CIO Insight: Can you give me some history on Montefiore's use of information technology?
Safyer: In the early 1990s, healthcare in general, and especially in New York City, was going through a radical change: to its payment systems, its delivery systems, its patient care systems. And Montefiore wasn't any different. We had to rethink who we were and what we wanted to be. How would we remain successful, and grow, and do the kinds of things we wanted to do the best way we could?

So we moved on a number of fronts. At the time, we had two hospitals (we now have three), and they weren't really integrated. We decided there were opportunities for efficiency, a higher-quality product, and greater synergies. So we began a vertical-integration effort. First we added a primary-care system, and then we integrated what we already had. We also added a managed-care product. By the mid-1990s we had all the elements of an integrated delivery system.

We came to an easy conclusion—not exactly rocket science—that clinical information systems could help us make all this work. They could help us manage care, they could help us on the quality front, they could help us on the safety front, and we knew for sure they could lower expenses. There's no question we couldn't have done what we've done without IT.

Still, we knew it would be expensive. We began with an investment of $20 million to get started building the clinical systems. At the time, that seemed like a lot of money to spend on IT systems. Now the joke around here is that we're $150 million into that $20 million investment. About half of that $150 million is clinically focused, not financially focused, and that's unusually high.

Instead of just dipping our toes into the healthcare IT waters, or simply letting someone else do it, we spent a full year in this room with 15 senior people in the organization. We worked with a facilitator, and we defined, in a very lean way, our objectives and goals. We were very focused on the kind of system we wanted as the outcome. We didn't know if it existed in the marketplace. But we had suspicions that it did.

By mid-1994 we had collected a group of 40 or so people, half of whom were high-level doctors and nurses, and we traveled around the country. We visited four vendors of clinical information systems, and for each vendor we also visited their best customer.

Long story short, three of the vendors just crumbled. They couldn't handle us. We knew what we wanted, we were tough and demanding, and they had nothing. It was vaporware. We gravitated towards the fourth vendor, but the company wasn't sound, businesswise. Lucky for them, lucky for us, somebody came in and turned it into a real business. Now it's part of General Electric Co.

Wolf: What you're hearing is that the strategy and the vision of the medical center—to provide integrated medical care to the entire community—is completely linked with the strategy and the vision for the IT systems. The people running a $2 billion healthcare delivery network in the Bronx are completely versed in IT issues, and that's the core of the success of IT at Montefiore. Everybody's part of the process, not just from the periphery, but engaged and embedded in the process of how we build these systems.

Safyer: That's really where Gary comes in. Gary was in transition from being a clinician to doing other stuff, and I think he and a number of other people really understood that you can't make change with IT if it doesn't fit in your workflow, if it actually takes longer to do your job. It needs to take less time and be the right thing and not bother you. IT should become almost like a third hand.

Was it hard to model the hospital's workflow processes?
Wolf: Yes. We spent an enormous amount of time doing just that. What we learned was that as we went from nursing unit to nursing unit, from department to department, each was very different, and we had to think about what the work-process flow would be in each of those departments and on each of those nursing units. An oncology unit is very different from a neonatal intensive care unit, which is very different from an adult ICU unit.

Kalkut: That brings up a problem: Because each individual department and location works differently, their requirements may not be met as well by a single enterprise system as they are by niche systems. But then niche systems don't talk to each other easily. So there's a "federal government versus locality" argument that comes up all the time.

We decided not to use systems that don't talk to our other systems, just because someone needs something right away. We're going to develop systems that are part of our overall enterprise system. It may take more time to build. It may not have all the bells and whistles you want. But from an institutional perspective it makes sense to have that integrated system.

There's still plenty of little IT systems that get uncovered all the time. But going forward, they're not going to be here, or they're not going to get support.

And the electronic patient record was one of the absolutes?
Safyer: Yes, that's the center of the whole clinical system: one record that follows a patient from little old lady at home, to when that little old lady needs a heart transplant. We used to have 11 different registration systems. We have one now. It knows all your laboratory studies, your imaging results, the drugs you've been prescribed in the system, all your vital signs.

That record is really many records. But the doctor doesn't necessarily know that. As she looks at that record, she's actually going from the clinical information system to a lab system to a radiology system to a cardiology system, whatever, to retrieve information or make an order.

Everything that is digitizable (if that's a word) is in digital format now, though there are elements of patient records that are not yet there. Digital doctor's notes about a patient, for instance, are not yet ready for prime time. But we're currently working on that as well.

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