What Matters to a Healthcare CFO? EHR Implementation & Strategic Planning Advice

Phil Sobol: Alma Alexander began her career in healthcare more than 20 years ago as an external and internal auditor. She has served as the chief financial officer at Cuero Regional Hospital since 2017. Before joining Cuero, she managed the financial operations and process improvements as CFO at Integrated Regional Laboratories, a reference laboratory owned by HCA Healthcare. She has held leadership positions at hospitals in several states, including vice president of finance at Sunrise Hospital in Las Vegas, controller at St. Lucie Medical Center in Florida, and other finance roles at Raleigh General Hospital in North Carolina and Centennial and Skyline Medical Centers located in Nashville. Alma graduated from the University of Alabama with a degree in commerce and business, specializing in accounting, and is a CPA. Alma serves as treasurer on the board of directors of the Cuero Chamber of Commerce and is an active member in our community. Alma, welcome to our podcast.

Alma Alexander: Well, thank you, Phil, I am very excited and happy to share these moments with you. 

Phil Sobol: Well, we are just thrilled to have you with us today and look forward to our conversation. So, maybe we will just dive right in. You mentioned that you have been in internal and external audit and now the CFO at Cuero Regional since 2017. How did you get started in healthcare finance? 

Alma Alexander: Well, healthcare is something that I have always been interested in, even growing up, and I decided that being on the side of medicine where you see all the blood, it was not really something for me. 

Phil Sobol: Understood. 

Alma Alexander: Yeah. But I did find accounting in the 11th grade in high school, believe it or not. I was introduced to that, and I was like, wow, that is something that I could use to work in the healthcare industry. And so, I attended the University of Alabama and majored in accounting. From there, it started where I was working, like I said, for an external audit firm. We did community health center audits. And I got a chance to go into community health centers later, into the internal audit space, worked at the University of Alabama in Birmingham, and internal audit with the hospital and school. When I moved to Nashville, I was an internal audit with a local firm, hospital organization there in Nashville, but then I ended up moving to Centennial. It started from there, as a senior accountant all the way up into where I am now. 

Phil Sobol: Wow, that is fantastic and quite a journey. And, I love the fact that early on, you had a passion and a heart for healthcare and tried to figure it  out, like hey, how can I play a part in that, even if I do not want to be drawing blood or doing those other things, which there are a few of us that are called to do so  but, certainly understand. So, maybe if you would not mind, are there a couple of callouts from your career, such as your favorite highlights that you would love to share with our audience? 

Alma Alexander: Sure. Well, being in the rural space and working in community health centers, you find that healthcare is a place where you need a heart to serve. Because you are serving people that you see on a day-to-day basis. You may go to church with them. You may see them in the grocery store. And, it makes me feel good as a person, that I have a heart to serve. It helps to be in the situation where I know we are helping people daily. And as a part of a team, from the front door to our patients being checked in, to them being given service, to the end of the day, and collecting dollars that we can turn around and give that money back to the service of our community. So, those are some of the things that really stand out to me in this world. 

Phil Sobol: Indeed.  I am curious, you have walked the halls in dozens of hospitals including Las Vegas, Florida, Raleigh, Nashville, and now Cuero, Texas. What might surprise our listeners about the financial operations of a reference lab versus a metropolitan hospital versus a rural health system? 

Alma Alexander: It is interesting that there are some things similar and different. Similar things consist of looking for revenue, taking care of costs, and making sure that you are keeping your costs down the line, whether it is the lab or the hospital, large or small. The biggest difference with integrated regional laboratories I found at the time I was working with them; was it is more of a cost center for the hospital. So, we did have revenue that would come in some local revenue, but mainly it is about controlling costs. You were not on site daily, but all the work was coming into the lab and making sure you were managing it and having the people there. Another big thing that is a day-to-day task to stay on top of is equipment, and more than anything, staying on top of leases and things like that.  And then, you move to a large hospital where it is all about staffing. It is all about what services are out there. It is the conversations with the physicians and things like that. There are many people and things to manage in a larger facility. And the thing that was different about coming to a smaller hospital, we did some very similar things. However, you have a lot more people in that larger facility that help manage everything. And it is kind of siloed, right? Whereas in this environment, in a smaller rural hospital, people wear many hats. So, you can do certain things in this environment that you would not have to do in a larger environment. But it is the same thing with keeping up with revenue and making sure that you are controlling costs, for sure. 

Phil Sobol: Yeah, well, in the rural space, you seem to be a lot closer, right, to caregiving, to that inpatient. So, you mentioned it earlier, and you did such a nice job of correlating the fact that you are in the community, and you are not removed from it. It is easy to get lost when you are in a metropolitan city of a million plus, but when you are in a local community, you are right, you cannot get lost. And so, I think it drives home that mission like you previously mentioned. That is great to hear. I think the hot topics for CFOs and CIOs can be different from a healthcare perspective. And so, what are some of your toughest challenges as a CFO? 

Alma Alexander: So, in the rural environment, it is about volume, how many patients we have compared to a larger facility, and the payer mix. So, you have got more Medicare and Medicaid patients than you would other patients. So, that can put a strain on your revenue. We are, as the hospital we are in here, a taxing district. So, we can tax those dollars to help support the facility and we take care of our charity patients as well as we have money to maintain our building and our capital campaigns that we have. Also, a medical foundation that we have is an arm that helps raise funds and provide new equipment or things for the hospital so that we can serve the community. That is one of the big differences between a small rural facility versus a large metropolitan organization. Where that is mainly all about the revenue that comes in from seeing patients for the most part. And you have a payor mix which is a little bit better than what we have, and the dollars come in higher. So, that challenges us with making sure that we manage all the dollars that we have, and that we have plans in place to make sure if we have a capital campaign—what is it we need to purchase? What do our directors need to do their jobs day- to- day and the people at the bedside? So, those are some of the challenges and the things that we face. It is very similar to the larger hospitals, but also, very unique in the fact of where our revenue comes from, even grants. We write grants that help cover costs as well.  

Phil Sobol: Indeed. Yes, it is very interesting. We hold a lot of sessions sometimes with various groups of CIOs. And inevitably, one of the topics that always comes up are some of the differences when it comes to CIOs and CFOs and how they communicate together. And there are many different things that CIOs are paying attention to right now, whether it be: AI, automation, cybersecurity, consumer- facing technologies, portals, EHR, moving to the cloud, technical debt, and the list goes on and on. From a CFO perspective, do any of those sorts of topics catch your eye? And if so, why do they grab your attention? 

Alma Alexander: Although that is a lot of things you just mentioned, and I do keep up with the IT world. My husband is in IT, and so, I find it very interesting and how it helps in the medical field all the way around. So, that is one reason that I do stay interested in it. But from a business perspective, in the environment that we are in right now, and especially where we are in this rural area, technology has really helped us. For example, cardiology, for inpatient cardiology, we do not have a big business where you have a cardiologist on site. So, we have telemedicine where our doctors can take care of patients in bed, even in another city. So, that is big and helps rural hospitals across the country. And we use that service. Also, we use it in our clinics for psychiatry, where it is very hard to find that in a rural area. So, that is one way I see how it can help care for patients. Same thing with our stroke in the ER, we have support there on that. So, then when it comes to IT itself, all the networks that we must have that communication set up, that is very important to stay relevant and stay in today. Right now, we are going through changing our EHR analysis from an old system to a newer system. And that newer systems should bring us more efficiency and be able to get the work out faster and provide information. Right now, it is hard to pull information out of our systems. Those older systems are not as easy to track stats and things. So, it is trying to pull those stats out. So, that can help us make decisions for our future. If we have a strategic plan, how do we know what to look at if we do not have that great data? And so, those things that I see are very needed in rural environments and smaller environments. And of course, they are needed in larger environments too. But here in particular, we do need to be able to make decisions from it. And I would say, some of the things that I see that maybe AI could help us with are things going forward are what kind of bedside care can be done through that world. Also, what can it do for us from a case management perspective or HIM perspective or even accounting? Those are the types of things that I have started to look at from my perspective, going into the future and how do we plan for those things. 

Phil Sobol: Oh, that is fantastic. I appreciate your insight. There is a variety of projects, when IT comes to leadership and says, hey, listen, there is this investment we need to make from a technology perspective. And you touched on a little bit, but maybe if you could just summarize, what is it that the CFO of a hospital or a health system is looking for from that CIO when it comes to that investment request? 

Alma Alexander: So, one of the things in working with our CIO, when she came on, we were looking to update our system and then hopefully go into a new EHR. And so, having a conversation with her including: what are the needs? How far behind are we? And what do we need to do to get there? So, as a part of our strategic plan as an organization, we have worked together every year. We make a strategic plan, and it usually lasts anywhere from three to five years. Then each month and each year we update it. And by using that strategic plan, we were able to make sure that we were financially ready for it, but also, working with our CIO and telling us what we needed, what needed to be  updated, what type of rules that we need around it, cybersecurity, things that we needed to do to make sure that we were taking care of our system and keeping it safe. And, just like what is the return on investment, how do we come up with showing how it is going to assist our organization? And relying on her and her expertise to guide us through what we needed done in the organization. 

Phil Sobol: That is excellent insight. I think so, many times, you know, depending on the maturity of the organization, and tying in the CIO or IT director, or whatever level you happen to have, sometimes they are not privy, unfortunately, to some of that strategic planning. And I think it is critical and it is a miss for organizations that do not include that top IT executive in those conversations because how in the world can they properly execute if they do not know? And so, I think I love your insight and perspective there. It really does go back to that strategic plan. And then how do you, as a leadership team, encompass the CEO, that encompasses operations, that encompasses clinical, CFO, and CIO? How do you all together work to make sure you are making the right decisions to move the organization forward and to achieve that. So, I think that is a great perspective and I appreciate it.  You know, you had mentioned that you all are embarking on an EHR upgrade and modernization program. And those are no small feat in and of themselves, to say the least. And certainly, a lot of work that goes into those variety of phrases from pre-planning to post go live. And, perhaps, share with the audience, are there any kind of tough decisions that you have had to make so far or along the way or critical conversations you have had to have with other leaders inside of the hospital, the board, or any pivotal moments yet? 

Alma Alexander: Yes. Well, the big pivotal moment has happened several times, about two or three years ago, of determining what system we were going to go with, and then pulling together that budget to present to the board. And the board, you know, the questions asked and then having to answer all the questions that they have and then getting them to understand how it all works. Especially now with all the changes in the way that you book equipment, software service, and all those types of things. So, all of that came into play. We got their approval, and one of the things we made sure we had contingent cost in that and made the board aware of it. Because when you are doing this, it is bound to pop up that you are going to need additional services, equipment, or this old system did this type of process, but now you are going to need the new software as a service partner to do something different. So, we made sure that we included those types of things. The pivotal thing now is we have a team that is ready and willing to do the work, but we still do not have enough hours. So, those are some of the things that we will have to plan on stepping out and getting additional help on that. Those types of things are just staying on top of where we are in the process and what is needed. It is great to see that our team is really engaged and that they want to do the work. When we just did some testing and not just brought our directors in or the people who were doing the build, we also brought people who work the front line and let them see how it works. So, those types of things that we have been able to do are the pivotal moments to me. 

Phil Sobol: Well, indeed, and I know certainly, from a leadership team perspective they are making sure that the whole organization knows the why, right? And that everyone is excited about the why and what the ultimate end goal is, and it is certainly critical from that standpoint. You all have done a wonderful job of that. From your perspective, as the CFO, what will success look like for the Expanse implementation? 

Alma Alexander: First of all, I do want to say that patient safety is my number one concern. My heart to serve, I want to make sure our patients are safe when they walk in that door.  I feel that having this newer system of being able to get all the information that is needed. And being able to trace it from our clinics, all the way through the hospital service, and just to be all on the same platform is great for us. And then, ultimately, as the CFO, I am going to go back to, are we dropping all of our claims and getting all our revenue in? 

Phil Sobol: Yes, that is right. 

Alma Alexander: Yeah. So, I mean, I would not be a CFO if that was not my big concern… 

Phil Sobol: That is exactly right. That makes perfect sense. You know, it is so, critical regardless of whether you have got a major EHR project going on or not, but that is communication and alignment with the leadership team. So, maybe if you would not mind sharing with our audience just kind of how you have chosen to do that as a leadership team, to keep that alignment, to make sure that what you are doing on a day-to-day basis, and  on a project basis, just makes sense and stays in alignment. 

Alma Alexander: Well communication is key. We are all on the same page. We communicate a lot via text. We have Teams. We are talking to each other that way. But it is also a structure, like I said, we start with that strategic plan. And we approve it through that board and the board is on board, they know what is going on. And then, weekly, we have a team meeting called SLT meeting. And it involves not just our leadership, like CEO, CFO, associate administrator, and CNO. We also have other directors that attend, including the CIO. And we go through where we with that strategic plan and then day-to-day things or projects are that are going on and give updates on those. All of us have direct meetings with our directors. All the people that report to us and they do monthly, if not more often, meetings, and we encourage and require our directors to do one-on-ones with their staff members as well. And then, one of the other things that is very unique that I think that is maybe the size, but I think it could be done anywhere. Our CEO holds a meeting every quarter, or just about every quarter. We will do all hands-on deck. Everyone has to come to our meeting where all the employees must come and listen to an update, we give a financial update and some of the things we are working on. And then, we give the things that we will be doing like Hospital Week, and we will give information about that. And we hear back from our employees. And there are different times throughout that week when you can come early in the morning, or come in the evening, or in the middle of the day, and we give information to our employees. I think that makes the difference in being able to roll out projects, make sure that we are keeping our patients first, and that we are having those conversations, not just amongst the senior team, but also, all the way down through the entire organization.  

Phil Sobol: It is all about alignment. So many times, we talk about it in the context of a leadership being aligned, but at the same point, you must then share the result of that alignment with the rest of the organization to get to where you need to go from a strategic goal standpoint. So, I think that is fantastic in that regard. Well, Alma, you know, I really appreciate your perspectives today. We always like to wrap these up with an open-ended call. Is there anything that we have not touched on today, that you would like to talk about or maybe, share some words of wisdom with our audience?   

Alma Alexander: I do not think there is anything we have not touched on but, I can just say, in this field of healthcare, keep your patient first. That is always going to make or break you. If the patient's not first, then you are not in the right business.  I like to say hire and encourage staff to have a heart to serve, and always to keep that in the front of your mind. Communication is the key to success. You must communicate. And then, not only have a plan for today, but have a plan for your future, too. So, with your strategic plans, make sure that you are covering staffing, equipment, and what do you do with your plant and are you taking care of that? As well as taking notes from your people. What are some of the things they are interested in and what can we do to help grow the organization? 

Phil Sobol: That is a fantastic summary and wrap up. So, Alma, greatly appreciate your time today. I appreciate your partnership. I appreciate your heart for healthcare. So, thank you very much. 

Alma Alexander: Thank you. And I enjoyed it. And I wish everyone peace and happiness. 

Phil Sobol: Amen to that.