Rolling Out EHRs in the Rural Setting: An Expert Guide

Phil Sobol: Today we welcome Ismelda Garza to the podcast. Ismelda is the Chief Information Officer at Cuero Regional Hospital and senior consultant with CereCore. She's a native of Texas, and for the past 15 years has worked in healthcare IT serving critical access in community hospitals. 

She's an active CHIME member and volunteer with her local school district advisory committee and athletic booster club. Ismelda, welcome to the podcast.  

Ismelda Garza: Thank you, Phil. Thank you so much for having me. I'm really excited to have this conversation with you.  

Phil Sobol: Well, it's our pleasure. We always like to start these off with just a little bit of background. So if you wouldn't mind telling our audience, you know, how did you get into healthcare it? 

And, and maybe if you wouldn't mind then expand a little bit further and tell us just a little bit about Cuero Regional and, and the work that you do there. 

Ismelda Garza: Sure, so I like to say that I officially started my career as a web designer for an Internet service provider. So right out of college. I didn't go there. I did some other jobs, but my official was that I was there for about 8 years. 

While I was there, I was just a little sponge, and I learned many facets of the telecommunications industry, whether it was business, networking, cabling and the service part of it just really enjoyed that.  

Then one day out of the blue, I received a call from the I. T. director at my local hospital. I'd had the opportunity to work with him at a prior time.  

He said, hey, we're implementing this new system at this hospital. I need some help and I really, I think that you'd be great at it. He said, come talk to the CEO and the CFO. 

At that time, I wasn't 100 percent satisfied with my role at the ISP. So, I was like sure, let's talk to the CEO and CFO. 

So, I went into that and next thing I know I'm their new systems analyst to help build and support MEDITECH client server. That has been about 15 years ago. So, I have to tell you this funny, small world story.  

So, the registration MEDITECH Specialist to help implement MEDITECH client server at this hospital is none other than our very own MEDITECH practice manager John Walsh. It was just really very cool thing to kind of put things into perspective and how small the MEDITECH world is. 

Phil Sobol: It's fantastic and then, so how long have you been with Cuero Regional and what are your responsibilities there? 

Ismelda Garza: So, I've been with Cuero for 5 years now as their CIO. As a CIO for a rural hospital, I do a lot of things. We do wear a lot of hats, but it's from strategic, just getting day to day operations, budget, whether it be personnel items that need to be reviewed. So, we just do a lot of things. With Cuero Regional it's the hospital and then we have a remote clinics, additional rural health clinics as well as the wellness center, and a home health facility.  

Phil Sobol: Quite the big deal in that town for sure. So, recently you all kicked off a ready implementation, moving to MEDITECH expanse. And so, you know, certainly those things don’t just come out of the blue.  

There's an awful lot of planning that has to take place and things that have to get done ahead of time. Whether it be technical infrastructure or making sure resources are lined up. Obviously, you've got to work through budgeting and the board of directors, and, you know, even taking a look at what type of cultural changes or things might need to take place or to have a successful project. And so, if you wouldn't mind, maybe just give our listeners just a little bit of background as to what that looked like for regional. And, you know, what are some of those, you know. 

You know, things that you just had to have in place you had to get right before you could head down a journey of implementing a modern EHR. 

Ismelda Garza: Yeah, I mean, that's a great question. Just something, you know, I've been at Cuero for 5 years, and I would say, during that 5 years has been, has been all the prep work that we've been working on, to get us ready for this READY implementation. Part of that prep work has been just a lot of questions I would recommend other, you know, whether it be an IT director, to really take a look at their facilities before they look at their Expanse READY implementation. 

You know, we're looking at um, what's the backbone of our infrastructure? Is our network currently stable? Are we having issues? What do your IDF closets look like? 

A lot of the times, us as CIOs or IT directors, we focus on our main data closet but we do tend to forget those smaller closets. And they're a big part of our infrastructure. So, you know, what does that look like?  

And in addition to that, are your techs, are your staff -- are they confident to walk into those rooms and quickly assess and try to perform any troubleshooting, if needed? 

A big part of that prior to me, getting to Cuero, I could tell you, that that was one of the things that the techs were not confident in walking into those closets and knowing what they were looking at. 

Today, thankfully, it's a different story. We're very color coded. We're very clean and anybody can go in and take a look at it, but it took some time. It took some work.  

I always compared it to trying to operate on a person who hasn't had any anesthesia. You're trying to pick apart and trying to open and cut when this person's moving. And it's the same thing when you're cleaning up closets is -- you're working on something that's living and breathing and trying to get it all cleaned up and fixed up.  

So, that's a really big must do is taking a look at your backbone infrastructure.  

The next thing I would really say is server hardware quality. What does that look like? Um, whether it's your standalone servers or your VM clusters? Are they stable?  

A lot of times with MAGIC, especially, it's one of those set it and forget it. And so I think that that becomes a one of those mentalities. 

I'm not sure if you're familiar with this or not, Phil, but Cuero has actually had MAGIC in place for 30 plus years. So that's a long time.   

Phil Sobol: And you're right, when you move from something that is, as you mentioned, set it and forget it to something that is much more modern and pervasive. Yeah. It's a completely different ballgame. And you've got to make sure that that is all up to snuff and so really appreciate you sharing that. And I know that a lot of work went into getting that organization ready for that project.  

As we all know, it doesn't matter how much you can you prepare. There's always gotchas. Surprises, challenges creep up any time that you're dealing with these large projects. 

Because A -- it's technology and B, it's people, right?  

As a healthcare IT leader what are some of those things that, you know, are just kind of top of your mind that you think you've prepped for but you're still cautiously keeping one eye looking behind you to make sure that when they creep up, you can pounce on it. 

Ismelda Garza: So, there's probably several things, but, you know, I would add this to as well as the things that you need to look for as must-dos. But also surprises and challenges would be the wireless infrastructure.  

So we did a lot of work to completely upgrade that. But today, as recent as this week, we've had some reports of some issues with whether the AP isn't placed in the right place and it's dropping some connections for some workstation on wheels.  

And so that's been like a surprise because really we've made so much progress with that. We've developed so much confidence in it but it's hard to believe that's what it is. But we're also adding so many things to the wireless infrastructure that it's just something that we just constantly need to review and to make sure that we have it set the way we needed to. 

The other thing though I would add, Phil, is security and data breaches. These are things that we know are out there, especially when we're talking about email. We're relying on users to be familiar with the phishing trainings and not clicking on things that don't need to be. Going to Internet sites that they don't need to go. Things like that we're having to rely completely on. So that's always a challenge I think. 

Phil Sobol: It might be more than one eye, that was a third. So that's great insight. You know, a few months ago, I had the privilege to sit down with Lynn Falcone, the CEO of Cuero Regional, and we chatted about a number of topics related to rural healthcare.  

That was fascinating, as well as what she was anticipating as a byproduct of the investment in MEDITECH Expanse. Things like increased patient safety, ease of use, access to the data. All great things to be shooting for there.  

I've got a couple of questions, I think, and we'll start with, you know, how do you stay in lock step with Lynn and the rest of the leadership team there as you work towards these goals that are pervasive across the organization. 

Ismelda Garza: I know this sounds cliche. But communication, whether it's informal or formal. 

You know, Lynn, I have to say. During my healthcare time, I've seen a lot of CEOs and CFOs. Lynn is by far one of the most amazing leaders that I've had an opportunity to learn from. She's very empathetic. Very supportive.  

She, I don't know if she said this in her podcast, Phil, but she has compared a new hospital build with the EHR system implementation, and she says hands down, the EHR implementation system is a lot harder than a new build of a construction of a hospital. 

So, I think that just speaks volumes on the type of project that we're dealing with. And and how important it is to have leadership understand that. 

You know, we talked about just some challenges and some surprises as well. And I would say that when we, when we think about staying true to our goals is understanding the risk as well. 

 So, having those regular weekly meetings that we have, whether we are on a Teams meeting or a regular phone call, or a person to person discussion. We still meet regularly. 

But it's just it's really with the sole purpose of identifying those potential risks, what could potentially become a challenge, and then always what's working well. 

Phil Sobol: You talk about it being cliche, but I think this the repetition of people continuing to need to hear it's all about that communication and lines of communication and it's one thing to say something to somebody, but it's another thing to have that kind of collaborative communication where you're all on the same page, and you're all working towards, you know, those same outcomes. Right?  

And so, I think as we, as you talked about some of those things, the patient safety, the ease of use, et cetera, it's just it's critical to make sure that you're not only communicating with the senior leadership, and then with all of those end users, right? Because everyone's got a little different perspective there. 

My second question, Lynn did a fantastic job of laying out some of the challenges that, you know, particularly community in rural healthcare faces and so on and so forth. Would you happen to have any insights as to how that looks in the context of an EHR transition, or an upgrade, for rural health.  

Ismelda Garza: So, I have to start that I'm so passionate about rural health. I do think it's a part of the healthcare that a lot of people don't realize how hard they work in a regular operations day to day. And then when you add a project of this magnitude. And, really consider the limited resources, just because a lot of people don't want to come to rural America and live. Right? So you have those additional challenges. 

But when you're when you're talking about. You know what it means for patients or people in this community -- these are my neighbor's moms and dads or brothers and sisters. That could be my family when they walk into this hospital, whether it be through the ER or the clinic. That's a defining moment for them. I think just understanding that it's a potential lifesaver from getting them to an area to be stable to transferring them to a location that can provide all the additional services that's needed. 

It's such an impact. Rural health is such an impact to people in these communities. And, I always tell people, you put yourself in their shoes. They don't want to be there. Nobody wants to be at the hospital, myself included. 

Think about that and keep that in mind, because you don't want to be there.  

So how do we make these systems -- we're making this investment on this huge implementation. So how do we make it where it's a tool? How do we make it to where it's not so invasive to the patient? To help them get in and get seen and let the clinicians treat them and get them to where they need to be. 

Phil Sobol: We all in our heads know it is all about the people, right? And I think when you look at it from the lens of rural or community, it truly is -- that word community can't be overstated. 

Because everyone there, you know, it's cliche, but everyone knows each other. Right? Everyone knows the families. Everyone knows, it truly is a community and the hospital, the health system, all of those services, everyone working there are truly in service of that entire community. And the tools that we implement are in support of those people. So, you're spot on with that and appreciate you sharing that.  

One of the things that you mentioned -- you do have your day to day jobs. Right? The people in the hospital and the health system, they've got their day to day roles and responsibilities and then you add a project, which requires time from all of these individuals as well above and beyond that.  

So, it sounds all consuming, right. How do you balance some of that as an organization that probably doesn't have the resources of an urban sort of hospital setting, but at the same point needs to get a job done. So how does that work? And are there some things that, you know, potentially you look at to maybe sort of ease some of that for the organization.  

Ismelda Garza: We might need a couch for that, Phil.  

Some days, I feel like, man, I can do this all day every day. There's days that I'm just like, I just need to hide under my desk for just a few minutes. It's crazy. 

It's a constant managing, it is a constant balancing of, you get hit with different competing priorities and it could change from day to day, depending on who's yelling the loudest. I would just say that we continue to focus. 

First, during this process, you know, we're constantly looking at some automation. How can we help make some of these things easier? When we're looking at a balancing act and the implementation of the EHR, how can we take a look at some scripting, whether it be scripting services or tools to help build out this system. So we're currently looking at something like that with Tom Palakie’s group at CereCore. So, hopefully that will help us in some of this transition and help us focus on some day to day operations.  

In real world things, we have great wins and we have setbacks. But the main thing is that we just continue to continue.  

The thing I am most proud of is we have to surround ourselves with great people, smarter people and part of that is this great partnership with CereCore consultants. They've done multiple implementations. They've helped support HCA, so it helps what the skills they bring to the table and helps us meet our goals and deadlines from a READY implementation. And that also helps us focus more on the day to day things. So, it's a group effort for sure. But definitely day to day.  

Phil Sobol: And I think you, you touched on it and Lynn did as well, right? When you have everyone from a cultural standpoint bought into the mission and understanding why you're doing what you're doing and yes --is it going to be a challenge and you acknowledge that? Absolutely.  

But at the same point, there's that understanding that yes -- the pain is temporary, but the benefit is long lasting for the community. I think she summed that up well, and you did as well. So, thank you for that. 

We're coming to the end of our session together, and I always like to wrap these up with really just kind of an open ended question for you. If there's any sort of words of wisdom, lessons learned that we haven't touched on, really just any practical advice for others that might be in your position from a CIO perspective in rural healthcare and it can be tied to an EHR implementation or not. 

Ismelda Garza: I think I'll break that into two different, if that's okay, Phil.  

So, from an EHR implementation. Already, there's still so much to learn. And I really do think that you and I would probably be talking at the end of this so that I can give you some really specific lessons learned, but one of the things that already is top of mind is just all the third party applications.  

I mean, I would recommend anybody who is wanting to go through this process, or is early on in the process, get with your get with your partners, your third party vendor partners, and start looking at new addendums, agreements, contracts. It takes a lot of time. It takes a lot of back and forth and don't be afraid to negotiate. They need you just as much as we need them. But, we obviously want to be sure we're under budget. I would say, just start looking at that sooner rather than later.  

One of the things that I would say, ultimately, throughout the time -- your every day is: Don't forget to laugh. Have some fun in this role. There's a reason we're in it. Find your passion. Find why you're why you're wanting to do this and remember that your team -- they need you just as much as you need them. Sometimes you're going to learn more from them than anybody else. But I would just say, just don't forget to have fun.  

Phil Sobol: I think that's a great way to wrap this up. Ismelda, thank you so much for everything that you do for Cuero, and thank you for your time today and sharing some of your insights with our listening audience.  

 Ismelda Garza: Thank you, Phil. Thank you again for having me. It's been a pleasure.