Automating EHR Implementations: A Must-Have for Managing Healthcare Informatics

Phil Sobol: 

Welcome to the CereCore Podcast where we focus on the intersection of healthcare and IT. From practical conversations to strategic thought leadership, let's unpack the decisions, challenges, and journey of those whose purpose it is to deliver technology that improves healthcare in their communities. Krischan Krayer is vice president of implementation and operations for Clinical and Imaging Systems at HCA Healthcare, currently serving as product director for HCA Healthcare's MEDITECH Expanse implementation initiative. Krischan started with HCA Healthcare in 2007 and has been managing the use of electronic health record platforms to support the organization's clinical initiatives, regulatory changes, and clinician usability initiatives. He was instrumental in improving EHR experience for physicians, and he got started in healthcare IT at Epic. Krischan, welcome to the podcast. 

Krischan Krayer: 

Thank you all for having me. It's a pleasure. 

Phil Sobol: 

Excellent. Well, we'd love to kick these off just to find out a little bit more about your journey, how you got into healthcare IT. And have you ended up where you planned when you started the journey or have there been some surprises along the way? 

Krischan Krayer: 

There have definitely been some surprises along the way. This was not a planned journey in that sense. I had the privilege of going to school, both undergrad and graduate school in the business space and ended up moving from southern Florida where I went to school to Madison, Wisconsin to work for a, at the time, still fairly small software shop up there- 

Phil Sobol: 

Yes. 

Krischan Krayer: 

... that was producing electronic health records. So one December I packed up everything I owned. It was a very temperature-shocking journey, and a couple days later I started up there, my first, I call it the first job I meant to keep and started a journey there working in the EHR world as an implementer and learned it for lightning speed like you do in this industry and enjoyed my run up there. But no, that was not scripted, nor was my journey down to Nashville then. I got fortunate, met a wonderful lady up there. 

We got married. We decided that we wanted to run away and go South. We picked Nashville on a map, started moving, and during the journey of moving through a friend of mine who got connected with HCA and came in here just as the EHR program, or electronic health record program was starting at HCA almost 17 years ago. And so I was very fortunate to show up here just so that the grassroots time when it was going from just an IT book of work to a true EHR-focused book of work, and I've had the privilege of being on this journey with HCA ever since. 

Phil Sobol: 

Oh, that's fantastic. And you've been in various roles over the past 20 years or so implementing EHR technologies from, like you mentioned, from Epic to vice president overseeing a large-scale MEDITECH implementation. If you had to name some of the most significant points of that EHR tech evolution, what would make your list? 

Krischan Krayer: 

In terms of points that really were inflection points for me, I'll start there. And then there's definitely some industry inflection points that go way bigger than me. 

Phil Sobol: 

Perfect. 

Krischan Krayer: 

For me, the first one would probably be actually starting at Epic as an implementer. Being on the ground in the system, configuring it for users, supporting them by the elbow, nothing beats that. The experience you get being right there, supporting a go live during night shift, helping the users through the night is something that will stick with you forever, especially 'cause I'm not a clinician. I did not come from the bedside, and so I, still up to today, I try to find every excuse I can to get out into our hospitals. Nothing replaces that presence, and I fall back on some of those roots very frequently. It's an important part of what has shaped my journey. Getting into HCA healthcare, it took a while to learn scale. 

And so scale, it wasn't one moment, but learning EHRs at scale, especially at HCA scale is a special kind of journey and education in and of itself. So that's been a fantastic part, and I think as we figure out this large scale expanse book of work will be something that we're going to continue to build upon. So scale really sticks out there as well. And lastly, I would say also not a point in time, but just some phenomenal people that I've had the privilege to be around through this journey, I've been fortunate enough to have several wonderful people that have not only been really good at their job, but they have taken the time to teach me, show me, help me. And so I think those three items probably add a lot to my journey. 

And then the EHRs have been on an interesting journey throughout it all as well, and I'll admit probably not as fast as any of us would've wished over these couple of decades because fundamentally, some of the problems are still the same. That's when I first showed up in Madison as a completely green person that the challenges are still often similar. So I wish it would've evolved further, but I do think EHRs have come a ways. I think the technology, the web-based platforms, the availability of this information anywhere you are with mobile platforms, mobile has been a huge inflection point. That makes a big difference, and I'm excited to see where it goes with the cloud layers going forward. And I do really believe, even though I couldn't tell you what it will look like, that AI will be that next inflection point for our industry. 

Phil Sobol: 

Indeed. Well, certainly everyone's talking about it. There's a lot of really intelligent people trying to figure it out, and I think we're all waiting to see where those... I think we've seen some of those first movers and those first iterations, but it's going to be very interesting to see, and I think it's going to happen very, very rapidly over the next few years where it takes us. No, that's fantastic. Another one of the areas that's really been a game changer I think is automation when it comes to changing so many of the manual functions associated with healthcare IT. So let's talk a little bit about automation when it's applied in the context of an EHR implementation like MEDITECH Expanse, how does automation play into that? 

Krischan Krayer: 

Yeah, we've, over the last couple of years, especially as we've launched this big Expanse journey for HCA, not just looked at automation as a tool for our end users or downstream processes as we run a healthcare organization, but actually have turned it inward on ourselves. We're returning automation on to IT. And I do think we're breaking some pretty neat ground there because in order to do this at our scale, you can't do this all through humans. It is way too big of a lift. And so we dug in deep with many colleagues here at HCA and across the organization, CereCore being a huge partner in that. Wonderful talent there. And it started with basics of how do you get data out of the old system and how do you just get it into the new system in a less manual way? 

So those were two important steps, and we do a ton of that now. We've really come a long way. We probably have some more opportunity, but then we've really been pushing on taking it to the next level of automation where we're trying to take critical thinking out of the process in the middle when it comes to translating what workflows or old systems we're doing, and hence how the new system has to be configured. And so the world of mapping can be automated to some degree. There are smart enough tools nowadays that can really help make that a much easier process for the users that do have to then validate the final pieces. 

The world of testing can really come a long way with automation. And so we're trying to take the pieces that historically have been even more critical thinking and figure out if there is rhyme or reason that it can be automated. Not 100%, but there are plenty of ways where we can take that and figure out what to put into the new system based on what we can pull out of the old legacy systems. So putting automation and that lens on ourselves is hugely important. We've come a long way, but we still have equally far to go. By the time we're done with this, this will be a joke. You're going to have the Expanse install wizard. You hit go on your screen, it asks you 26 questions. You answer them correctly and you're good. The system will- 

Phil Sobol: 

Amazing. 

Krischan Krayer: 

... implement it. So our goal is to build the Expanse install wizards, but we got a little ways to go. 

Phil Sobol: 

Indeed. Indeed. No, bottom line is, automation is all about saving time and really helping colleagues work at what we call the top of their license so that they're doing those things that require their brains and their skill sets and their knowledge versus just that manual banging things in, that mundane type of stuff. But at the same point, it's also sometimes you get a little bit of pushback, because it's different and people are used to hands-on keyboards. Do you have a story or an example of as we have been going through this journey where maybe that switch has gone off in the mindset of leaders or stakeholders or colleagues that, hey, wait a minute, automation is something that's serious and something that we really need to take a look at, and it's not just a nice to have, but it's an absolute must going forward? 

Krischan Krayer: 

Yeah, we got a couple. I'll share one from one of my favorite teams. I think they'll take this in the right light. So we started using the basics of automation, the exporting of data, the importing of data, probably over the last two and a half years, but about a year and a half ago, we really started educating our core product and clinical experts on the capabilities of automation and challenging them, how far can you take it? And different teams took to it at different paces. Different teams were processing it, and one team in particular looked at us in the beginning and said, "You can't possibly take the humans out of interpreting what our old EHR does and trying their best to translate it into the new. It's not going to work." And that team was our lab team. 

They were wonderful and they were very good at what they were doing, but they did not quite think that automation could go far enough for them. And so we challenged them hard and it took a few cycles. Then they got a group together and they had the first couple of breakthroughs, and over the last year they have come tremendously far. They have tools that pretty much read our old EHR, help them map the old lab test to the new lab test so we have the correct mapping. And then they pull the information, the detail of the old lab test out of the old EHR so we can correctly load it into the new one, things like reference ranges and critical values. So we don't have to by hand figure out which ones go where and then manually put them into the new system. And so that process has come a very long way in a year and a half. And so at this point, it's actually some of the most sophisticated automation we have. So that team- 

Phil Sobol: 

That's awesome. 

Krischan Krayer: 

... has done a wonderful job. But I think they would admit that in the beginning they were looking at me a little funny, wondering what I've been eating or drinking to ask them- 

Phil Sobol: 

Sure. 

Krischan Krayer: 

... these questions about how far this could go. 

Phil Sobol: 

Well, and I love you saying that because we started there to where we are now, it's one of the most sophisticated. So they were willing to look at it, dig in and work with the automation team, and I think the results speak for themselves. So certainly fantastic story and appreciate you sharing that. So you've had a lot of experience from an EHR implementation standpoint. What steps should healthcare organizations take when evaluating potential automation as they look at an EHR implementation project? 

Krischan Krayer: 

You got to look at yourself as to how open are your key stakeholders to this idea. If you don't have the people that can see the potential in it and are willing to invest in finding these opportunities and making them real, then it's going to just go in circles and you're going to lose time and energy on something that you're not going to reap the same benefits of. You really have to have an organization that has the right mindset for this, and part of that is your stakeholders that have to buy into it. 

And part of it is you got to have at least a few of the right technical leaders that can really share and educate on that vision and the actual tools 'cause somebody's got to be that initial rallying cry. And if you don't have that in your organization, you're only going to go so far. We've been fortunate between some help from the CereCore team, but then also several people here at the HCA main campus that are phenomenally versed and really champions for this work, and that is very important. You need somebody that is a strong believer and can really bring this forward. 

Phil Sobol: 

Yeah. At CereCore, we deal with organizations as large as HCA and as small as community hospitals. And you're right, you've got to factor all of those things in as well as the talent and then hopefully turn to an organization that's got that skill set to help you think through where automation can truly be a transformational aspect for the organization. So greatly appreciate that. It's been clear that over your career you've been a huge advocate for providers, clinicians, care teams. Tell us a little bit more about what it looks like to bridge the gap between that provider community and technology because it's not always easy. 

Krischan Krayer: 

It's been a real privilege. Through most of my time here at HCA, I actually had the privilege of not working in the IT organization. I worked in a department called the Clinical Services Group and was part of their informatics arm. And so I had the privilege of working alongside essentially our clinical leadership for the whole organization for better part of 15 years. And it was a really neat place to grow up, learn a lot, and grow into a leadership role while really lifting up our caregivers. And so I do think, to be really honest, other than a ton of listening, which I'm still working on becoming a better listener, a ton of time, like I mentioned at the beginning of getting out into the hospitals and the facilities as a non-clinician, if you don't do that, you have no chance of doing even a somewhat respectable job of translating and connecting the dots. 

And then lastly, I would say really embracing the translator role rather than the, "I must be right," or, "I have the answer" role. It's much more about connecting dots for people and helping them see what comes together, like the lab team than it is for me to have answers, which that would be hopeless for all of us anyway. So I think those items are things you really have to embrace a lot. And like I said, throughout my years I've had wonderful leaders including several clinicians, physicians, and others that have taken me under their wing, taught me a lot and have given me certain accountability and responsibility has taken a little risk on me and lots of listening and making sure that you connect the dots for them goes a long way. 

Phil Sobol: 

Yeah, no, that's spot on, and really appreciate you sharing that. I think you've been in healthcare for quite some time and working in that capacity, and certainly you've seen some generational changes too, where the old clinicians, physicians have begun retiring and a new generation is beginning to move in. And so how has your approach changed at all as the generational shift changes from a clinician perspective? 

Krischan Krayer: 

There's definitely been, I call it our customer community, being patients and clinicians. Your question is mostly about the clinicians has definitely evolved over the last couple of decades. There has been significant growth. The meaningful use era that really pushed EHRs to be fully mainstream, they're coming a long way, but there's plenty of gaps for any users that wanted to hide from an EHR, they could. And that disappeared during the meaningful use age. And so I think we overcame the basic change barrier of just moving to technology in general. But beyond that, I think some of the stratification that still holds true today has not changed that much. And that is that many of our caregivers are in different stages of their career and their profession, and that often drives how they look at this big change burden of bringing technology to the table. You have the early career professionals, whether it's physicians coming out of residency or nurses out in nursing school, they're very open-minded. They're still in a learning mode. 

They're trying to establish themselves, and they're comfortable with change 'cause they've been going through a lot of that through the past couple of... significant years of their career and their professional training. And so there's certain comfort that was present a couple decades ago that you still see today. Then most of them, many of them, I don't want to over generalize, but many of them really get into a groove professionally. And they are in a stage of their life where they're looking to accomplish something professionally. They're doing this for a reason. Everybody has their own motivations and whether it is entirely focused on the altruistic take care of people or some amount of business in there, which either and or both are fine, but when you show up in the middle of that stage when people are pushing hard to achieve something and you disrupt that, people are much less tolerant of that disruption. 

And so the middle of the career-driven professionals at all levels, people are going to really hold you accountable to making sure that change that you bring brings some value. And the EHR world has struggled with that. The apparent value we bring right out of the gate is not always we right there. We're more like a foundation than we are the shiny interior design. And then lastly, you get to the professionals that are towards the taper off of their career. You either find people that really just don't want to change anymore at all, and they'll tap out or they actually become quite tolerant. They're a little bit less in a rush. They're a little bit less worried about how this will add up and impact them. And often you find a lot of good champions in that generation of professionals that are past, I'll call it the peak of most aggressive part of their career. 

Phil Sobol: 

Right. 

Krischan Krayer: 

So that part has actually held true pretty well, whether it was a couple of decades ago or now, some of the other factors have changed a little bit. But beyond that, I guess the humans around us, all of us are still behaving pretty much in the same way. 

Phil Sobol: 

Excellent insight. Excellent insight. And you've certainly been in and around at least just about all of the major EHRs, and EHR platforms, they're complex. And I think you made mention of it, they need consistent care and feeding. And really, healthcare organizations around the world, they're either implementing or upgrading or fine-tuning and optimizing their EHRs. What are some of the most important things to keep in mind when it comes to getting the most out of that, in many cases, the biggest significant investment a healthcare organization makes? 

Krischan Krayer: 

Whew. Yeah, you're absolutely right. These are massive investments, often short of big capital projects and construction, the biggest ones that healthcare organizations will make in decades or in the entire lifespan of certain leaders, and a lot can go wrong as you watch the industry. These are highly complex. There's not many other technologies that touch this many parts of an organization and other industries that are all tethered together in critical ways, so definitely a challenging space to be in. I would say far beyond anything else, the two elements that make or break is far beyond what you choose with a vendor or other things is the team and the organization you build and the leadership you put in place. Any part of an organization that I've seen be successful within EHR and is pretty vendor-agnostic has been successful with strong leadership and a talented team. 

You need the right level of talent on that team. It is worth going after the right people. A weak team or a dysfunctional leadership group can botch any vendor out there, and a strong team will make any product out there reasonably functional for our users and our caregivers. So those two are probably the most critical pieces to something like this. The technologies out there definitely vary, or organizations need to take a look at what the different products offer based on what they really need; not what their wish list is, but what they really need at the heart and what they think they have, the resources to actually instantiate and make real and based on that, see if they can make the best choice possible. But far beyond which tech you pick, it all starts and ends with people. 

Phil Sobol: 

No, completely agree. Ultimately, healthcare is all about the people, and it's not just on the care delivery side. And I think that sometimes we've got to remember that as folks that are in the technology business, that it still is the people executing on the technology, so greatly appreciate that insight. And we always like to wrap these podcasts up with just some open calls for, I would call it wisdom for the listening audience. So someone listening today, they might be in the beginning parts of their career in healthcare IT or aspiring to be a healthcare IT leader, what advice would you have for them? 

Krischan Krayer: 

I'll share a couple of thoughts. One, somebody who's getting into this industry, I would say you are in a great place. Healthcare and technology have tremendous potential. And while there's been times where it doesn't move as fast as we all might wish, there is unbelievable potential for combining healthcare and technology. The amount of good that a technologist can do in healthcare, I don't want to measure, I haven't studied all into industries out there, but if you want to feel like you're doing something or you're helping the community, you're helping patients, caregivers, as a technologist, this is, I would say the best, if not one of the best places to be. The chances of your work really making a difference are huge. And if you stick with it and really lean into this industry, especially if you're a young professional, the opportunities over the next decade or two are mind-boggling where we could possibly take this. And so we're at the beginning stages of a revolution, and that's a pretty cool place to dip your toe into something new and something exciting. 

Second, I would share that you need to be somewhat patient and resilient. Healthcare is tremendously complex. Nobody has learned it overnight. Care of patients is tremendously complex. I will never be qualified for that. Running a healthcare organization is tremendously complex. Running technology for healthcare organizations is tremendously complex. And so this is a place where it is a very fulfilling stream of work to be in, but you got to be a little patient. You got to be willing to take time to learn. Some things cannot be fast tracked, such as me mentioning you got to spend time in hospitals and see certain things. You can't do that in a week and be done for the rest of your career. And so you got to have some patience and see everything that goes on in this industry and allow yourself to grow with that. And if you do that, I think a lot of good things will come your way if you invest in growing and learning and really observing the industry around you. So bring some of that patience with you as you get into this. 

Phil Sobol: 

No, it's spot on, and I couldn't agree with you more that it's such a rewarding place to be from a professional standpoint, so appreciate you sharing that. Well, Krischan, as we wrap up, any last final words of wisdom for our listening audience? 

Krischan Krayer: 

Really appreciate you guys having me on. Happy to always jump in and help with some other questions in the future, but in the meantime, we're really excited about our program here, automation being really high on our list of how we're going to change EHR implementation. These are going to become much more automated efforts, which is super exciting for the whole industry. So appreciate you guys giving me a chance to come say hi. 

Phil Sobol: 

Absolutely. Well, Krischan, thank you so much for your time today. 

Krischan Krayer: 

You got it.