Building Trust: From Expanse Rollout to High Reliability Organization

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. Today, we are pleased to welcome back to The CereCore Podcast, Lynn Falcone and Ismelda Garza from Cuero Regional Hospital. Lynn is the CEO of Cuero Regional Hospital and has been serving as a healthcare leader for more than 30 years in for-profit, not-for-profit, in government hospitals. An advocate for rural health in many ways, but one that's significant is her active leadership on the Board of TORCH, which stands for the Texas Organization of Rural and Community Hospitals.

Ismelda is the Chief Information Officer at Cuero Regional Hospital and manager at CereCore. A native of Texas, she's been serving for the past 15 years as a healthcare IT leader for critical access in community hospitals. It's great to have you both here today. Lynn, we chatted back in 2023 and Ismelda, just last year, 2024. And really, so much has been going on at Cuero. It's great to catch up. And for those of you who are interested in the backstory, please check out the notes in the link for previous episodes. So, Lynn, maybe we'll start with you and then go to Ismelda. If you wouldn't mind, just for our viewers and listeners, just tell us a little bit about yourself, your hospital, and more importantly your community.

Lynn Falcone:

Thanks, Phil. It's nice to be here again. My name is Lynn Falcone. I've been the CEO here in Cuero for the last nine years, which is very hard for me to believe that I've been here for nine years. Cuero is a great little community who loves their hospital. We're going through just a little bit of growth. We're about 8,100 people now. My hospital is a 49 bed hospital that is very active. We deliver babies, we do surgery, we have a very active emergency department. We also own and operate five rural health clinics, and own and operate EMS. So, a lot going on. We might be small, but we've got our hands out in a lot of different things. We are also the largest employer in the community. And people look to us a lot for what's going on in the community, so it's a nice place to be.

Phil Sobol:

Indeed.

Ismelda Garza:

And I'm glad to be here, too, Phil. So, you said the last time we met was 2024, and I just can't hardly believe it. It feels like yesterday, just having these conversations. And just to add to what Lynn said, I've been with Cuero for I think six or seven years. And that timeframe goes by so quick. Just a quick story on that. The first time I met Lynn and team, and I was there to do an IT assessment. And after it, I was presenting my findings. And Lynn had said, "If you could describe in one word this assessment, how would you describe it? Or the one word for the hospital, how would you describe it?" And that stayed with me. And I thought, how do I tell someone that their baby is not as attractive as they might think the baby is? [inaudible 00:03:58] the baby is going to change.

Lynn Falcone:

The baby is going to grow up.

Phil Sobol:

That's right. That's right. Excellent analogy.

Ismelda Garza:

Yeah. It was definitely just a lot of room for improvement. And six, seven years later, here we are with implementation of Expanse. And yeah, it's been good.

Phil Sobol:

Oh, that's excellent. Well, and you mentioned that it's been quite a transition over the years. And it's a multi-year journey, not only just for complete IT, but also on the EHR side of things. And as you mentioned, you've moved to MEDITECH Expanse, implemented their ambulatory. And just really the optimization efforts that you've been really navigating through or helping make it even better. So, maybe to level set, Lynn, help us understand what your goals were for investing in the new EHR. I remember you were eager to get some additional data into the hands of your care provider. So, what's it been like before and now after from a go live standpoint?

Lynn Falcone:

I think when you look back over the build and the implementation, it's always a challenge. But when we were going into this, we set out that, yes, we wanted to have data. It was important for us to be able to learn more from our own system and be able to pull some data out. We were very focused on bringing our five rural health clinics that I mentioned a few minutes ago and the hospital on the same platform that addresses efficiencies, as well as patient safety. And then, of course, the other goal was being able to offer a safer environment because of the way we document, and what gets captured, and what flags, and what have you could come out.

And I think as I look back over it, I would say we were very successful in that. Not that the road wasn't bumpy at any given point in time, but those were the goals we had going in. Getting on one universal platform was incredibly important for us, because we have patients that basically come across the hall from clinic to the hospital. And the challenges that we had with that are now much better off.

Phil Sobol:

No, that's excellent. Ismelda, if you wouldn't mind, just tell us a little bit more about the why of the technology journey. Why Expanse? Why now, the timing of that? And then really, why did you need some partners along the way as well?

Ismelda Garza:

Okay. Yeah. So, I think that the biggest part of the why is I think our legacy systems were getting in the way of patient care. So, we had two different systems to maintain and support. The clinicians and the ambulatory had one, hospital had another. A lot of those providers go back, and forth, and just nothing was consistent. So, we want the system and we have a system that we're able to provide as a tool to the clinicians to help take care of the patients, and it not be a challenge or a hindrance to them. So, when I look at it in the why, and it's really not about technical requirements. It's more about how are we taking care of our neighbors, how are we providing them trust, how are we looking at safety and providing excellence, which is part of our mission.

Another piece of that is we just needed a lot of that flexibility that we didn't have with Magic. We needed some of that scalability, mobility, and again, the ease and the consistency. Like Lynn mentioned, having that single patient record, that was really, really key for us. We just really saw how that could help reduce some of the duplication and minimize some errors. And the reason I think why we decided the now, a lot of it was there wasn't a day that didn't go by that someone wasn't saying, "Can we make this change? Can we do this? Can we get this? Can we get this integration? Can we have this talking?" All these things.

And every time we'd say, "Let's wait, let's wait." We basically were asking staff to come about with some maybe manual workarounds or maybe they're rekeying data or chasing down charts. I mean, it was just a lot of that going on. And I think that when you look at it from that perspective, that cost, it's very invisible. So, it's not something that you see, but it's such a real challenge.

Lynn Falcone:

What I would also add is the why now. Now took a long time to get there. And you heard Ismelda say it's been six or seven years and my baby wasn't very attractive, is being able to build our infrastructure to be able to support a new modern EMR, took a really long time to get there. And we were able to finally get to that point. And as people saw that it was becoming real, Ismelda mentions that, "Okay, they come up with a workaround here, sit tight, we'll get to it." And as I mentioned the patient safety end of it, when you get workarounds, you get a risk of not having the safest environment that you can possibly have. And so, Expanse has helped us conquer some of those and build some new needs as well. I'll be very honest and everybody needs to understand that your EMR isn't going to be like this magic bullet that fixes everything, because you create other challenges as you go. But it took a while to put the makeup on my baby so we could get this going.

Ismelda Garza:

Well, the analogy I like to use with that is that we were operating on a body, living, breathing that did not have anesthesia. So, that was a difficult place to be and it took a long time. But once that infrastructure was in place, now it's like, all right, now we're ready to go and this is why. And you asked me why did we choose the partner that we chose. And that was CereCore for consulting, to help us implement this MEDITECH. And really, the way I see it is we're not looking for someone to just install software. We wanted individuals, a company, a vendor that understood our realities, our challenges, our staff shortage needs. Somebody that could walk with us from our planning of go live until we are today.

And I think that Lynn and I can both say that CereCore brought that, not only from the MEDITECH expertise, but they also had that deep operational understanding that these consultants were... They've been at other hospitals, they've been at other clinics, they see what it takes. And so, it was really instrumental to our success, to have them help us stay on track and meet our deadlines. And helps supplement in some of the staffing that we were having some shortages in. And then also, just all the competing priorities. I mean, you have this big project going, but nothing else stops. Everything else is still going.

Phil Sobol:

Right. Exactly, exactly. No. And it has been a journey. And it's been fun to watch, Lynn, as you took over the organization, and Ismelda, you came in and then all of a sudden things started to happen. And this all of a sudden got remediated and this got fixed. And then you could all of a sudden start to see your team and your staff get excited. And then they bring a, "Hey, what about this? What about this? What about this?" And so, it's been very nice to see that transformation for Cuero, and an organization, and where it was to where it is today. It's been truly transformational. And I think part of that, Lynn, you've talked a lot about your vision for Cuero, as a highly reliable organization. And what's a good starting point or a goal for people, culture, mindset, when it comes to a change like that?

Lynn Falcone:

Well, high reliability is just as it sounds. You look at the healthcare industry, and you look at the airline industry, and they're very high risk. So, what do we do to reduce our risks every day when we take care of patients? And some of our activities in a healthcare system are not as risky as others, registering a patient versus giving blood. And as I mentioned, the way that a new EMR would support us versus our old one would help us assure we were doing better. We embarked on truly high reliability organization, which is developing a culture of being obsessed with no patient harm. And part of that culture is when you have a near miss or you catch something and it doesn't get to the patient.

There was a day that, oh, you didn't talk about that because that might cost me my job. Today, I think we are more successful in our high reliability, I call it HRO quest, coming through our EMR build, because that was a time that we built teamwork and we built communication. And our leaders and our staff quickly realized it's not all fun and games, and it gets ugly, and it gets challenging, and you're going to want to quit and you're going to cry. That we built that core, and starting our quest of high reliability, and really that culture where it's okay to talk about those. And not only is it okay, it's expected, because how we can fix it to keep our community coming back here.

We are blessed with the opportunity to care for this community in this county. We need to do the very best we can. As I mentioned, safety was one of my key quests going into it, is we're at the point now where with HRO, and learning skills and with the information we can gather, we're totally refining that. And it's nice to see how the team has grown, staff that have been involved, as well as our leaders. That to me it's very exciting and the benefit is ultimately for our patients.

Phil Sobol:

No, that's excellent. So, Ismelda, there's obviously an IT portion to this, supporting that high reliability organization initiative. So, could you give us an example or two about how IT is supporting that?

Ismelda Garza:

Yeah, absolutely. So, I mean, from an IT standpoint, it could be as very basic as computers that have just been aged and need to be replaced with something newer or scanners that aren't working as well in the ER. There's just so many little things that IT is so involved in, that contribute to the high reliability. And so, I think that we talk about the Expanse implementation, but it's so much more than that. And there's so many initiatives with just... We had that one example in ER and just replacing one computer, how much it had improved a clinician's experience in taking care of a patient.

Phil Sobol:

That's excellent. Yeah. It definitely goes well past the EHR. And I think, for those folks that are not in the healthcare space, I think people would be amazed at just the vastness of all of IT and everything it touches anymore, inside of a hospital and a health system. And I'm kind of curious, we talked a little bit about the non-EHR side of things. The EHR transition certainly was significant for you guys. And I'm assuming it's a big anchor component of this move and direct path towards high reliability in the organization, correct?

Lynn Falcone:

Absolutely. Not only from the teamwork standpoint, but as Ismelda mentioned, that we're talking more about. And even if we look through the optimization piece or we look at how something got built and like, "Oh, wow, this isn't happening. We can't have that." People are quick to say, "Hey, how can we fix it?" Versus, oh, there's a whole other issue that can't get fixed or something, that I feel like staff are more proactive and willing. I think Ismelda has helped build a great team in IT that's been... they get hospital operations, they get the clinical operations. And really, I tell them every day it takes a village. It's not just one person. It takes a whole village to make it work.

Ismelda Garza:

Yeah. And I would add, too, one of the things that we do is we want to hear the issues, tell us. Very open door about that, because how do we become better if we don't hear that and know that? And so, it's weird because we did go live in August, so now we're full-blown optimization. We had a shaky start in our clinics with just some of the systems. And it was a bigger change for our clinic staff than it was for the hospital. But we're in such a better place just from August until now, in how the doctors are talking about the system and using it. And I really am confident that every day is going to be a better day.

Phil Sobol:

Well, I really appreciate you all talking about how going through a major program implementation like this really impacted the teamwork at the organization. And almost got people thinking a little bit differently about bringing forth ideas, and bringing forth optimization, and taking ownership of some of that stuff. And as we know, IT is always changing. Computers are always going out of fashion. They're too slow. EHR, major systems are no different. You mentioned it. They're not static. They need optimization, and that really never stops. So, maybe, Lynn, you can start and Ismelda, follow up with some additional items. Just practically speaking, how do you build the governance, the framework, the structure for the organization, to keep that momentum going when it comes to that continuous improvement?

Lynn Falcone:

Well, I think there's a number of ways that we have the structure now with the team in IT and the people in each department, that were so involved in the build, and the design, and the implementation. That they know I want this change or my doctor wants this change, and he's jumping up and down to make sure that we get it. But if we get it, something else could not work. Or what are the repercussions of that? So, having everyone understand that and being able to take it through to look at that. And then Ismelda is really good about saying, okay, let's put it in the test environment and let's let everybody test that. So, they understand it's not I'm going to jump up and down and get my way to make it work the way that I want it. Although, some try to do that, I'm not going to lie.

Phil Sobol:

Oh sure, of course, of course.

Lynn Falcone:

And they all have Ismelda's number and my number, and they're going to message us anytime of the day and night. So, having that structure and having everybody have that common understanding to say, "Hey, I want to make this change." Or, "Hey, this happened from a potential safety event." You've got to have that governance structure to say what does it take to make that change. If not, I would say we would break something really quickly.

Phil Sobol:

Indeed.

Ismelda Garza:

Yes, because the wish was one record and the challenge is one record sometimes. But I think a lot of it is we communicate-communicate. We still have change control meetings once a week. We have huddles every day. The doctors are able to contact us at any time they would like, whether it be through a Teams message or a text, or a phone call, just really making sure that they're feeling supported. They know that they're supported, not just feeling, but know that they are supported and are seeing actionable items. And I was just thinking when Lynn was talking about that, because we did come from... Before, everyone had their own customized order setup, and so you move fast-forward to Expanse and that's not happening anymore. So, that was definitely a transition. But yeah, we just communicate-communicate.

Phil Sobol:

Excellent.

Lynn Falcone:

I think in that communication, and going back to the doctors and making sure our doctors feel like they're supported, and the heard is they were frustrated. As implemented, it had a whole lot more clicks or different clicks where they didn't have to click before. And really walking through the system with them and looking at the implications. Well, if I shut that off, here's what this happens. And being able to get the people who can help talk their language versus I'm going to go complain to the CEO, because she'll fix everything. That's not my specialty. I'm not the clinician. And I want my doctors happy, but I don't necessarily want to have a system that doesn't have fail safes in it or a number of different things.

And so, really working together, being able to get someone that the docs can have, and can make some of those great changes that make them feel better and say, okay, yes, I am listened to. And yes, it is important to them. It's not just all about the big hospital. It's also about the clinics. And I think as Ismelda mentioned, that the ambulatory was a bigger challenge for us. It was a bigger lift with a bigger change from a different system. And it was a beloved system to some and a hated system to some so, but we're definitely in a better place now.

Phil Sobol:

No, that's excellent. That's excellent. Well, I wanted to pivot just a little bit to, I guess, some would call it the hot topic that everyone seems to be talking about and that is AI. So, Lynn, you recently came back from the big annual TORCH meeting. What's the AI conversation among [inaudible 00:26:23]?

Lynn Falcone:

Well, AI is always a hot topic, as you mentioned [inaudible 00:26:26]. The last two or three TORCH meetings I've been to, AI was a major topic. And I think everybody's ready to say, how can it help us? In a rural setting, how can it help us? Because staffing and recruiting is so challenging. It was very interesting this time around that there was a speaker talking about more of the pitfalls and if this happens. And if you're actually looking at replacing doctors, no one can sue AI. So, it gave you a little balancing effect. Ismelda and one of our doctors here have really focused and looked at a number of different companies that would be a scribe. My doctors will say, if I had somebody else to do the documenting, I could go much faster.

Well, if I can't recruit staff, it's hardly that I'm going to be able to recruit a scribe. But an AI scribe might be a really good alternative to be able to help and support them through their patient care. But highlighted at TORCH is what are the pitfalls of that and what are the things we need to look at. And I don't think we're quite there or I don't think systems are quite there for what we want to look at here. And Ismelda can probably give you more technical on there. But it's definitely in terms of that AI scribe is something we're definitely watching.

Phil Sobol:

No, that's excellent. Yeah. And Ismelda, I'm sure you get questions all the time, since being the CIO. Well, hey, what about this AI, what about this AI?

Ismelda Garza:

That's the greatest thing.

Phil Sobol:

How do you handle that?

Ismelda Garza:

Everybody loves it. Everybody uses it.

Phil Sobol:

What advice would you give other CIOs in how to handle all of these questions around AI that are coming through?

Ismelda Garza:

One question at a time. So, like Lynn mentioned, one of the doctors and I, we've demoed several. And I mean, they're slick. They're really nice. They parse out the good things and they parse out all the fluff, and so it's really neat. It isn't going to save any time based on what I'm looking at, not for what the doctors are looking for. There is a lot of still cut and paste components from an EMR side. And then that's going to obviously affect how we pick up some of those value-based reporting, quality reporting that we need. And it's going to require more hard stops. And so, I don't know that that's going to be the answer just yet. But there are some other ways of AI, too, that from an IT shop we're looking at. And that's even looking to see when someone calls in the help desk and how they can use the AI to help them work through general issues.

And so, we're looking at that, entertaining that. I think it would be very helpful, especially since we do have a lot of competing priorities and it would make sense for us. But I think there's potential, but the biggest thing for me, and I'm just very realistic and just very practical, and it all has to do with cybersecurity. It is big. It is real. It is something we have to pay attention to and vet any product through.

Lynn Falcone:

I would also jump in and add that after two TORCH meetings ago, I came back going, oh, we got to look, we got to look. We got to do this. We got to try. And I think for any CEO that's looking at it is make sure in your CIO, IT director, whoever you depend on for your information technology, is have a good relationship and have somebody not afraid to tell you, okay, simmer down. We'll look at some vendors, but you've got this copy-paste. And I think that is one thing where Ismelda has been so valuable, is like, I'll come in all excited and I'm going to press, press, press. And she's like, okay, let's take it one step at a time. And I think she wasn't afraid to go look at some of the vendors for that. I think across our hospital, there are people who use ChatGPT for other documents, not necessarily in the medical record. And I'm all for it, as long as you clean it up and you make sure it sounds like it's you speaking.

Phil Sobol:

Right. No, I think that's really, really solid advice. It's one of those areas where people get really, really excited about it, but you have to have a use case. And you have to validate the use case and you have to certainly take into consideration the cybersecurity elements associated with that. And sometimes it's tempering that enthusiasm, and that excitement, and walking through your traditional evaluation process for each and every one of these. So, I think that's great advice for everybody. You guys have been through just a lot of major change and from an IT perspective. And all of that, really, it puts a lot of stress on the organization, on individuals. You've mentioned a few of those maybe points of frustration or concern throughout this conversation, even so. Would you have any words of wisdom or guidance for the listeners, just in and around as they're moving into a period or a time of a large program change or project that's going to be stressful? What are some of the things that they should consider?

Lynn Falcone:

I think number one is it's got to be communication. If you can't get out to describe the project and the why behind we're undertaking a project and why am I about to stress you out, you've got to be able to communicate your team, and get them on board going forward and keep them on board as you go. And even if you hit a pitfall or something happens, you've got to say, okay, so this happens and we're going to pivot and we're going to go this direction a little bit. That in some sense it's a lot easier to do in a rural hospital or a smaller organization, because you've just got fewer people to have to figure out how to communicate to.

On the other side of that, the more challenging end of it in a rural situation or a rural organization is it's everybody's organization. And they maybe have been here for 30 years. And if they've only been here five years, it's their organization. And everybody knows everything about what's going on, or at least they think they do. And so, really being able to set the story straight, and keep them on board and keep them engaged, it all flows back to communication.

Phil Sobol:

Wow. Excellent point. Excellent point.

Ismelda Garza:

You know that saying is true, everybody dies famous in a small town.

Phil Sobol:

Yes.

Lynn Falcone:

That is true.

Phil Sobol:

Well, I guess that leads me to my next question, which is perhaps a little bit more lighthearted, but you mentioned small town, Cuero, Texas. So, what are some of the biggest misconceptions that people who don't live where you all live, what would they have? What would some of those misconceptions be?

Lynn Falcone:

Well, I will use my daughter as an example. And she said, "How many stoplights are in town, mom?" Now she's been here several times and it's more rural than she will get. But I think if I focus it on healthcare, many people think rural healthcare is not quality healthcare and you don't have the resource to do it well. I've heard plenty of horror stories is I stopped at a hospital between point A and point B and this happened. And I think that's what's made me so driven in my organization to focus on quality, and safety, and making sure we have the tools there. I would invite anybody into my organization for healthcare. I've had my procedures here. I've had plenty of healthcare.

My family has actually come to Cuero for healthcare. So, I think from a rural healthcare perspective is, that is the biggest misconception, is that if you're small, bigger is always better. And I would say when you come here, you're not a number. You're really the person that we want to take care of. So, that's a big misconception that I think in a healthcare setting you've got to deal with. Ismelda, what would you add?

Ismelda Garza:

Yeah, I definitely 100% would agree with that. I think also a misconception is rural healthcare, you're not going to be busy. Just whether it be in the ER or even in IT, it's just a complete opposite of that. You're seeing so many different situations in an ER setting. Coming to a rural healthcare for ER is, if you want a retirement, that is not going to happen.

Lynn Falcone:

Exactly.

Ismelda Garza:

Yeah. And so, I think the other one would be, just real quick, is that we don't face the same challenges that maybe a taller hospital would. I think we do. I feel like in a rural healthcare setting, though, I do have to be a lot more innovative in the things that we have to do because of budget constraints, staffing constraints. There are so many more constraints.

Lynn Falcone:

Absolutely. Yeah. I agree that people wear so many different hats, that what they're going to do next isn't always what's expected.

Phil Sobol:

Right. I think you made mention of a few things earlier on in our conversation. And there truly is a sense of community when it comes to rural healthcare. And I think in some of the urban settings, there's a tendency for it just to be a job. Just, you go in, you do your job, you punch out, and that's it. I've had the privilege of doing a number of these conversations with a number of individuals, from CEO to doctors, to chief nursing officers, et cetera, from a real standpoint. And the one consistent message and theme that comes through is that caring for the community. All up and down, from the C level, all the way down through, whether it be janitorial staff, whether it be you name, it's about caring for the community.

And when you have that sort of mission driven organization from a rural health standpoint, it makes all the difference in the world. I was blown away when I was talking to one of the doctors and he was like, "Oh, yeah, I routinely on the way home stop by and see this patient, and this patient, and this patient, because I know they can't get to the facility." I didn't even know that existed anymore. That was so refreshing and need to hear. Well, thank you for sharing that. We always like to wrap these up. I never want to wrap them up, but we always have to. With just kind of a final call, was there anything that we didn't talk about today that you wanted to share? Any last words of wisdom for our listeners?

Lynn Falcone:

No, I think we covered it. Ismelda?

Ismelda Garza:

I think the only, I would just say, just a reminder. If you're going down this process, you're considering this, just be agile, be adaptable. And this is a cliche, but it's so true. It's not a sprint, it is a marathon. We're still living it. We're still going through it. And always have fun.

Lynn Falcone:

You always have to look for the bright side.

Ismelda Garza:

Yep.

Phil Sobol:

Indeed, indeed. No, that's excellent. Well, Lynn, Ismelda, thank you again for taking your time and sharing your insights with us. It's been great. It's been wonderful as always, and thank you.

Ismelda Garza:

Thank you, Phil.

Lynn Falcone:

Thank you for having us.

Phil Sobol:

Thanks for listening to The CereCore Podcast. We hope you enjoyed this conversation. Follow us on your favorite podcast platform for more episodes, connect with us on LinkedIn, visit our US website at cerecore.net. And for those abroad, visit cerecoreinternational.net. Learn more about our services and find resources. At CereCore, we are healthcare operators at heart and know the difference that the right IT partner can make in delivering quality patient care 24/7. Let's help make IT better. Here's to the journey.