How to Bridge the Great Divide Between IT and Physicians

Sobol: Today we welcome Dr. Charles Bell to the CereCore Podcast. Dr Bell has been a physician advocate in healthcare technology for decades, he was the chief medical information officer at Northern Arizona healthcare, and a physician informaticist at Catholic Healthcare West.

Currently Dr. Bell is a physician advisor for CereCore, providing physician leadership for electronic health record implementation and consulting projects in hospital and ambulatory care settings. Prior to joining CereCore, he was a vice president of advanced clinical applications for HCA Healthcare. He served as a physician champion for MEDITECH 6, Epic, and Cerner. That is quite an accomplishment, not many people can say that.

Dr. Bell holds a bachelor’s degree in biology from Ryder University, a bachelor's degree in pharmacy from Temple University School of Pharmacy, and a doctorate from Philadelphia College of Osteopathic Medicine. He completed his residency practicing internal medicine at Phoenix General Hospital in Phoenix, Arizona. That is quite a mouthful Dr. Bell and quite a career. So, maybe we will just start there.

We really appreciate you taking the time to join us today. Tell us a little bit about your career as a physician, your role serving out in Arizona and HCA, and then with us at CereCore but then how you've used that role as that bridge between IT and the physician community.

Dr. Bell: So, first of all, let me just say I appreciate the opportunity to join you and having the opportunity to speak on these topics today. My career actually started as a pharmacist, and I worked as a pharmacist for several years. I actually worked as a pharmacist all through medical school up until my final semester of medical school. So, I did a lot of research work as a medical student. My internship during residency took place in Phoenix. During that time, back in those days, not sure how often it occurs today, but, I did a fair amount of moonlighting, clinics, Indian Health Services, and the V. A.

So, I got a good education as far as not only private sector, but also government medicine. And once I finished my residency, I opened a solo practice in Phoenix. I went from that to a larger group and then back to a small practice and I did that for about 10 years before I transitioned and became a hospitalist. Most of my practice time in Arizona was in the greater Phoenix area, but I did do approximately six years in northern Arizona, at Flagstaff Medical Center and Verde Valley Medical Center. So, I was very familiar with that area of the state and a lot of the nuances of taking care of patients in that environment. Through all of that, I must say, even when I was in private practice in the mid 90s, I was doing electronic billing, way ahead of the curve.

You may remember, some of you who are listening to this probably don't remember or know about PalmPilots, but I actually used the PalmPilot program that was a medical program and had my patient roster and billing and things from that, probably mid-90s. So, it was way ahead of the curve. I am all about it, I love electronics and gadgets. So, in that aspect of it was a very easy transition for me.

But that led me to get involved in medical informatics long before the term was actually coined. And so, I did a lot of liaison work for physicians in IT, even when I was at Northern Arizona Healthcare System that transitioned to Catholic Healthcare West. So, the interesting thing about the transition -- Northern Arizona, we're talking about three, four facilities, two hospitals, a couple of outpatient clinics, that transition to Catholic Healthcare West at the time had 44 facilities. And then in 2010, I transitioned to HCA with the four rollouts that we had, the four sections that we did there was one where we did 52 hospitals. So, the pilot was with 22 hospitals. So, we really got to see the depth and what was needed for multiple facilities in different parts of the country.

And, oh, by the way this was ripping out a lot of processes, procedures, and comfort for physicians, nurses, pharmacies, and everyone in the system. I got a lot of great experience working through the 160+ facilities that we end up converting during my time working directly with these facilities at HCA.

As it turned out, my last day working full time at HCA with CereCore was March 20, 2020. And some of you may remember that on March 23rd something very important happened, the whole country shut down. It was starting at that time, that I began to wonder what are the options? Not only for physicians, but it became very apparent to me that there was a need for people in the community. People in the community including patients to address their needs. That has been the transition that I have made.

I went from the core bedside medicine, that was the bulk of what I did when I was in practice and when I working in the hospital it was very much intensive care and critical care. I would always tell patients, my job is to keep you from seeing me at my best, because if you see me at my best, that means you are in a critical care unit somewhere.

Sobol: That's right.

Dr. Bell: So, anyway, that is the encased version of a very long journey.

Sobol: I gotta tell you, it is such a fantastic story and journey. For me, listening through all that and just trying to understand and wrap my head around all the different aspects of healthcare that not only have you had your hands in and been a part of. You have been a part of the practice, to smaller systems, to massive systems some the largest in the United States and touching just about every EHR out there from a major EMR standpoint.

Shoot, you adopted technology before its time and before anyone had even thought about those things. You certainly bring a wealth of knowledge and expertise to us and to our audience. So, I really appreciate you laying that groundwork and foundation. I am sure that you have seen throughout that process, the change of this rise of technology, and then we went through meaningful use. And then, just all of a sudden, now the need for oh, everyone has got to be on an EMR, what does that look like, and the challenges that are faced.

The shift from physician led to, sometimes in certain instances, it seems like things are IT led and that does tend to cause some challenges inside of the organizations, inside the practices, and sometimes even unfortunately ripple down into the patient care. So, I think, you have spent a little bit of time as kind of that liaison, right?

Dr. Bell: Mm. Hmm.

Sobol: And, from the beginning to what you are seeing now, is the gap between physicians and IT, is it closing? Is there still a chasm?

I think it's probably where we are going to spend a good chunk of our time because you have kind of been in your career for a number of years, trying to close that gap, for the betterment of the organization and for the betterment of the patient. So, maybe we will just start there. Where do you see that transition and what it looks like? And then, where do you see it standing today?

Dr. Bell: Well, I will start by saying it is a forever cause for me. Because I feel like, first and foremost, I have to be a patient advocate.

Sobol: Yes.

Dr. Bell: That is my role as a as a provider, but then there are challenges that we see as providers. And, I am going to use that term broadly, because it is not only physicians, but also nurses, it is pharmacist, and this is for anyone who touches the system. Everyone is impacted by it. That is the one thing when we talk about the overview of what you are getting when changes are made, because it touches everyone in the system.

Sobol: Yes, absolutely.

Dr. Bell: So, as far as the gap, I would say the gap has narrowed, but a lot of that is because technology has changed so much, including technology outside of medicine.

You can ask the question of a physician: When was the last time you walked into a bank to do any type of business? The other part of it, when you get complaints. Complaints stating, the system really does not work for me. Well, when was the last time you got a smartphone and used it just as it was, right out of the box? When was the last time we got a computer and used it just as it was -when you got it out of the box?   

So, it takes some investment of time by the individual, whoever that individual is. It takes an investment of time to customize and individualize that tool. And that's all it is. It is a tool to help them do what they have to do to care for the patient or whatever their duty is. I think the biggest part and challenge that I see, and I see it on both sides because I spend a lot of time in a field. Phil as you know, in the trenches and at a lot of the facilities, a vast majority of those facilities that we took onto a live status, I was there.

One thing I will also mention, having worked with Cerner, MEDITECH, both Expanse, with the current platform, and with Epic, I can tell you when I walked in the facility, and I got complaints as to what the issue was, I could show you that list of complaints, but you cannot tell me what system it was.. The complaints were all very similar, no matter what the system was.

So, that meant you had to buy into the process of how do I adopt this for me and get the most out of it. I cannot expect it to do all the things that I was doing before, when it is actually designed to do more than I was getting out of the old system. The other thing I will say about that is most people who make the change to a new system, whatever system they leave, that was the greatest system that ever existed.

Sobol: Absolutely.

Dr. Bell: Rapidly, after you move from it, you think oh, well, it is not that bad. So, let's talk about that chasm. The chasm comes in where, let's say as a support person, a physician calls and says, I cannot find the X-ray that I am looking for and I need to see this X-ray. And the answer to that physician is well, we have a new program, we are working on it, it will be ready, it will be very easy for you to find that X-ray, and we are rolling it out next week or next month.

Well, the disconnect comes right there, because it is not the information I need now, it is information I needed 5 minutes ago. And now, you are telling me I have to wait a week, a month, for an open-ended answer as to when I am going to get that.

So, it raises the level of frustration for that provider. Because a lot of times, you hear the question about well, it is not life and death. Well, for a lot of cases it could be life and death and makes a big difference in getting that information because based on that information, I'm going to provide a care.

So, with how remarkable the technology is, there is a difference from an IT standpoint where something is just the latest and greatest and really great and it seems just seems very automatic on how I can use it. But it is easy, you just do this, this, this and there it functions for you.

Well, that does not work in the case of someone who is under pressure to find information right now. I cannot remember this three-step sequence, to get the information I need to have it. So, I can remember, get to it, and that it is automatic for me to be able to utilize that. So, the divide comes in and the frustration comes in, whereas from an IT standpoint, I have this great functionality and I am offering it to you and then the other side is not a great functionality, because I need it right now and is not available to me. So, there is a divide.

Sobol: Yeah.

Dr. Bell: So, what I enjoyed the most about what I did, and what I continue to do, is understanding both sides. To be able to have a conversation with the physicians to say, “you went from a paper based, or you went from a system that did not function or give you the functionality that this system is allowing you to do. You must adopt, but also understand that it is not a matter of just flipping a switch and making it work for you. It has to work for everyone.

So, once that is understood that you do have to have some patience, no pun intended, to get to where you are going to be using it. Now, that goes back to the part that I have to step back and look at it is, I do not know any facility that does not give the physicians an opportunity to speak up during the build phase. I don't know any facility that does not give physicians the ability to participate in meetings, to be in a physician advisory group or physician advisory council. I do not know any facility who does not do that.

But there is this attitude a lot and I'm saying this as a physician that we got this. Well, when you flip the switch, you do not “got this.”

Sobol: Right.

Dr. Bell: You are going to have trouble; you are going to have difficulty making that transition if you do not put some work into it to begin with. Now, what helps IT is if you started that build phase and you do a day in the life. You walk through what my process is and learn how to answer: what is the process of a nephrologist? What does that process do to the surgeon? How did they get to the data that they need to get to? When you do that walk through, you can make that build so that you minimize the hangups. You basically close that gap. But the other part of closing that gap is really being able to understand what it is like to walk a mile in that other person's shoes.

Sobol: You are spot on there!

Dr. Bell: Yeah.

Sobol: Because the physician journey, the schooling, and everything they are focused on is radically different than an IT professional.

Dr. Bell: Mm. Hmm.

Sobol: They come at the same issue, “we need to implement a system from two totally different worlds, two totally different mindsets, two totally different backgrounds, and in many instances just total viewpoints.

So, I think you are spot on and just by the very nature of having two different groups of individuals and you can see where that relationship is going to be tenuous.

Perhaps, some might consider it broken or whatever and so, I do think that you are spot on and maybe we can talk a little bit about that. Right? What are some of the best practices that you've seen, to one, I think both IT and the physician community, first have to acknowledge the differences and respect each other. And then, how do they get to that collaborative fashion?

Dr. Bell: The starting point is to understand one thing, we are all on the same team. That is the starting point.

Sobol: Yes.

Dr. Bell: We are on the same team; you are on offense, and I am on defense. And so, my role and my job are different, but without you, I can't get my job done.  So, I think just having that understanding of what the role and some of the process -- and I know -- I am not saying that we are going to turn IT folks into physicians and vice versa. We are not trying to do that. But you have to have that understanding of what is involved, that it is not a matter of just flipping a switch or making a quick change to get something done.

I sat on a lot of councils throughout my time at HCA and with CereCore and a lot of decision making went into -- we went it this way or that way. And it is really interesting because you can make a decision and a year later you have turnover and you get new people on that committee, and they want it a very different way. And you really have to document and show the reason why you made that decision.

So having that as the core then, first and foremost we are a team, and secondly, this is why this decision was made and having that historical aspect, that record and that track record of it really helps. But also understanding what the offense is doing and the defensive job is doing. Basically, as I said, you have to understand that you are on the same team. 

Sobol: Yeah, I think that is such a great insight. We are the same team working for the same goal. We are just in different roles. You are spot on. Offense and defense -- they are totally different, but at the same point, both incredibly critical to moving forward. As IT is interfacing and engaging with physicians, what should they be listening for?

What are some of those things that maybe physicians would say in passing or they might make assumptions? What is it that an IT person should be asking? What should they be truly listening for? So, that chasm can close faster without some confusion.

Dr. Bell: This is a difficult thing to do because it taps into the core of human nature. You have to listen for the message. When you have a physician, I am the IT person and a physician who is talking to me and they are screaming at me, I have to understand that I have to let things fly past me to hear them say, “I had a problem logging in.” I can work with that.

The fact that you got up late and traffic was bad, and I spilled my coffee. That is important information because that is laying the groundwork for why the pitch of the conversation is where it is.

Sobol: Right.

Dr. Bell: But I still need the details of what is going on before I can help you and the fact that they got up late, and there was too much traffic and spilled their coffee has nothing to do with me as the IT person.

Right? So, they can be venting. I cannot take that personally. And that is the part that is difficult, because we do not like people screaming at us and we do not like people being upset with us.

But we still have to get to the point, of what is the issue? And I'll give you another example of how that happens. The doctor said, “I do not have time for this.” And a half hour later, they are still on the phone still spewing, right. So, you just have to pick out the nuggets of what is the issue and what is it that I can help you with? Yeah, and so, from the standpoint of the person who is giving you the issue, they might not be able to tell you that there is a problem with single sign on. They may not be able to tell you that I left the session open somewhere. They may not be able to tell you any of that stuff, but, in essence, they will.

For example, “I was on the other floor when I came down, I tried to log in and I had a problem.” Well, they just described to you the path of what you can say. “Okay, I know what the issue is.”

Sobol: Yes.

Dr. Bell: And you can help them with that. So, that is the biggest aspect, I think is just being able to figure out all of the noise and really hone in on what they are complaining about.

Now, this happens often as well. You may have one or two physicians, maybe a handful, who complain a lot at the beginning or right after go-live from pretty early on. And then after a while you do not hear from them, and the assumption is made that they are doing okay because I am not hearing from them. But all too often, they are not calling anymore because you did not help them and you did not solve their problem.

So, why would I keep calling you? You are not going to solve my problem for me. Why would I keep calling? So, I find a workaround, or I find something else that works for me. Then, that is where you tend to find where physicians are not utilizing the system to its fullest.

Sobol: Right.

Dr. Bell: Really the challenge is that there's a hierarchy, right? I -- as the IT person -- I'm not going to scream at the doctor. But as the IT person, I let them scream and I just have to, like I said, let that noise pass and really hone in on what the issue is that they're complaining about.

Sobol: So, as you think back on your career, and, like you said, you have been through numerous of these before, can you think of a situation or two where the building of the relationship between IT and the physician, or clinician community, just worked out well?

What were maybe some of those key things that they did, whether it be programmatically or intentionally to build those relationships and to build that respect so that they could have those meaningful conversations to not only get through the project, but then to build that ongoing relationship. Because as we all know, these things are not just a set it and forget it. They are living breathing entities inside of the organization.

So, maybe some things that you have seen that you just thought that every organization should do this and then maybe a couple of things that you have seen that you thought, please at all costs, avoid doing this.

Dr. Bell: So, I will focus on what I have seen from a successful standpoint and then anything I say about the successful standpoint, you just avoid that. Okay.

Sobol: There you go.

Dr. Bell: As long as you do what is successful and then you are going to be fine because if you deviate, you are not going to be successful.

Sobol: Perfect

Dr. Bell: And so, it starts early on by having input from the physicians, it has to be a team. You have to sit side by side. You have to have that multidisciplinary team. So, everyone understands what the other person's job is.

For example, if I want the system to alert for every medication and I want the alert to go past me and let the pharmacy deal with it. Well, in those meetings, I would flip my hat and put my pharmacy hat on and say pharmacists are people too. We do not want the alert fatigue any more than you do.

So, this is how we can find that happy medium and go through a day in the life situation. By allowing everyone who is going to be impacted by the system to see what it can do as you are building it by looking at the milestones and not waiting until it is the time for training to show what the system can do, but because the whole point of the build is to get you to a point where the system is effective and useful.

 Sobol: Yes.

 Dr. Bell: That is what you want to get to. So, you want to have multidisciplinary input, you want to have exposure to people for people to see what the system can do, a direct line of communication and with that you are closing loops, and so that if a question or problem arises, the answer gets back to the people who need to hear that answer. Then you have an effective rollout, and you can move to an effective rollout.

But keep in mind go-live is like commencement. And it is called commencement for a reason. It is the beginning, right? So, when you look at the effective system, that system is nowhere near being used to its fullest extent.

So, when you start looking at optimization, that does not mean you are bringing in new functionality, that means that you are capitalizing and utilizing the available functionality to its fullest.   

Sobol: Right.

Dr. Bell: But you are not going to have that if you do not walk the walk all the way up until the starting line and then go beyond.

Sobol: You make a good point. It is hard once physicians have checked out. It is hard to get them re-engaged with that without a lot of meaningful change. And there is a lot that goes into that, and I think you touched on the commencement angle and moving forward. Certainly, going above and beyond the EHR, there are so many other things that are tied to technology that are coming down the pipe that we all have to think about getting bombarded with on a daily basis.

It started with COVID and telehealth and then this concept of wearables for the patients, hospitals, and home. Now we are talking about AI. We were at HIMMS and everyone discussed AI and the list goes on and on. So, in your perspective, how should the clinicians, the clinical community, physicians, you name it, and IT, be looking at all of this together?

What would be your guidance as far as structure and process to determine “hey, what should we be looking at, what should that process look like, what is going to be the ultimate end result for the patients just from a collaborative standpoint?”

Dr. Bell: So, let’s start with AI, because a lot of that technology has been available, even if you look at the type of head functionality. You can put in three letters and the rest of it pops up. The same thing with using speech to text, which, I spent a lot of time in that arena.

There are a lot of things about AI that have been there, but it has gone to a whole other level. Think about how that helps with diagnostics, or looking at diagnoses, or patient care and there are a lot of aspects with billing —every aspect you need to do as an organization, AI can definitely help and has been. But there are a lot of issues that it solves.

You must start by pointing out the things that the system is already doing, and we are talking about an extension. You talk about the smart rooms where you just have the microphones, and you talk and it ferrets out what the patient says and what the physicians is saying. But, that’s not new technology -- that has been out there.

You talk about telehealth. Most people don't realize that telehealth has been a thing since the early 1950s. Why wasn't it so broad? Because it was one reason why telehealth never caught on as a mainstay in taking care of patients. And that's because you couldn't bill.

So, the pandemic changed that, so the whole landscape has changed and so really embracing the tools, embracing the change in the new paradigm, it makes a difference in looking at what the system is capable of.

By doing that, sometimes you have to point out what it is already doing that’s a transition from what you were doing a year or two or five years ago. You are making that transition.

Sobol: You are spot on, because I think what you are touching on is a little bit about what we call application creep. Where all of a sudden, it is like, wait, we actually have this capability, you are just not either aware of it or not using it. So, consequently, by that, you look a couple of years down the road, and you are like, well, I have got these three things and license that do the same thing.

So yeah, I think you are spot on and those physicians that you get excited about this stuff and the IT folks that get excited about it, they need to be all on the same page, and giving that kind of honest assessment throughout the process. So, they can say, “all right, what should we be doing and looking first internally like, all right is this already available and then if not strategic path forward.” So, I think that is spot on.

So, Dr. Bell, I always love to wrap up our podcast with an open-ended question. You know that most of our listening audiences are in the IT space and CIOs. So, from a physician perspective, and from the perspective of someone who has played that translator role for years and years — what are maybe the top couple things that you think every CIO, every technologist should know as they deal with the clinical community?

Dr. Bell: I think the biggest part that helps is understanding what is actually involved in the workflow, in that workplace. So even if it means getting out and shadowing a physician or sitting on the floor, sitting in an ICU and seeing what happens, it works.

It does two things: the processes that you come up with, that you can see how they actually work in the real environment or the other aspect of it, you see how it is an encumbrance in a real environment. And you may say, aha, I know how to cut that down from a three-step process to a single click, or at least get rid of one of the steps. And that makes it more intuitive.

And so, from the standpoint of really getting a better understanding of the impact of what is going on, you have to get into the trenches. Even if it is looking at it from behind the glass so to speak. Back in the day, when they had amphitheaters and you can look at what's going on in surgery.

It is really getting to see the impact at the level that you want and that is needed. Because going back to the team concept, if I can do something as the trainer that is going to help that player to do better then I have helped. So, if I do that but I do not know if I sit in the training room all day. I do not know what that player is doing. I get out in the field and see what they are doing so to speak. Then I know what they are doing. I do not have to go out on a field with them, but I can see something that I can help them with.

So that’s what I would recommend and I think works best.

Sobol: Now, that’s spot on. What do you call it walking a mile and their shoes, or whether it's, rounding or, whatever it is whatever terminology, I think you are absolutely spot on.

You have to take the time to gain the knowledge to understand the other person's perspective to understand the other person's world.

Dr. Bell: Right.

Sobol: Otherwise without that understanding, you are going to be missing in conversation, dialogue, and execution. So, Dr. Bell, fantastic words of wisdom. And thank you so much for not only the years that we have been working together, but also for joining the podcast and for your insights for our audience today.

Dr. Bell: Absolutely, my pleasure appreciate the ask.

Sobol: Excellent well, thank you very much.