Kevan Mabbutt: Welcome to Intermountain's Thanks for Asking Podcast. I'm Kevan Mabbutt, Senior Vice President and Chief Consumer Officer. And every week I'll be bringing you this podcast where caregivers ask our CEO, Dr. Marc Harrison, anything that's on their minds.

Today, Dr. Harrison and his guest connected remotely using a telepresence room, which is why the audio sounds a little different. Look out for a new episode every week and listen at the end to learn how to be a part of the podcast.

Marc Harrison:Good afternoon, I'm Marc Harrison, President and CEO of Intermountain Healthcare, and I'm here today with Dr. Mark Lewis. He's one of our internal medicine stars. Dr. Lewis, I'm really looking forward to talking with you and hearing what's on your mind.

Mark Lewis: It's great to be here, Marc. Thank you for having me.

Marc Harrison:It's a pleasure.

Mark Lewis: So, today I wanted to ask a question about our electronic medical record. I think our strategy is built around a solid EMR that needs to be reliable and stable in order for providers to really provide that care we want them to do with being able to provide safe and quality care, and have great patient experience and supports all those pillars that we're working on.

So as you know, on Monday, the 13th of August, we had a significant downtime that followed an upgrade, and so as I was working in clinic that day I had providers asking me questions about that downtime, and the two questions that they asked were, first of all, what is Intermountain doing to make sure that we have a stable and reliable electronic medical record? And the second question is, how could a upgrade be performed where we were caught so off guard that it brought our entire enterprise electronic medical record down?

I did see how it affected patient safety, and if I can just share a story with you.

Marc Harrison:Please do.

Mark Lewis: So the day after the downtime I saw a patient back in the office who had been admitted to Intermountain Medical Center, he had been admitted with nausea, vomiting and dehydration, he had received excellent care, and the hospitalists that day made a decision to discharge based on how the patient looked. But unfortunately, iCentra was down and so he didn't have all of the information available to him that he usually would have at that time of discharge. So at that time, when I reviewed the record, I saw that he had blood electrolytes that showed that his kidney function was significantly depressed to a point that I think that hospitalist would've made a different decision if he had had that information. Fortunately, it turned out great for the patient because it turned out that his kidney function has improved and I was able to discharge him with some antinausea medicine and instructions for hydration. And thankfully my MA, my care team team is great, followed up with him the next day and found that he was doing much, much better.

Marc Harrison:Well, first of all, I'm glad your patient's okay, and as we've dissected things out we actually have not identified, thank heavens, significant episodes of patient harm. In fact, tallies are still occurring ... We think patients remained safe throughout. This is a disturbing story and this is why we do need a stable, fast, effective EMR to take good care of our patients and for our caregivers to have satisfying work lives. So we are completely aligned on this part.

So let's talk a little bit about what I understand happened, and this is a bit like me talking about flying to the moon or something like that because I'm certainly no engineer, there are plenty of lessons that that have been learned through this, so first of all the engineering piece of this, wow, we are responsible to some extent. This was an engineering problem with our partner, Cerner, that we've contributed to, to some extent, and I'll explain what I believe our responsibility as Intermountain is. The intent for the upgrade was actually provide a faster, better, more stable experience, ironically, for our caregivers. The downtime was associated with server failure. The servers had been tested, but they were not tested at the appropriate loads that replicated the peak volumes that we experience in a busy system, so that was a mistake. Similarly, we have tested switchover procedures to backup servers on a number of a occasions, but a decision was not made quickly enough to swap over to the other servers. And finally, we discovered that we had insufficient downtime procedures for a long downtime. As you might imagine, work is being done all over of those areas.

There's a new CEO at Cerner whose name is Brent Shafer, Brent and I have spent a lot of time together over the last several months since he's taken over, I like him and respect him, I talk to him now about once a week. And the last week, as you might imagine, we've talked a lot more frequently than once, he is taking this really seriously. One of the things I actually did with Brent is I shared with him some notes from physicians that were sent to Mark [Breesacher 00:06:43], that talked about their frustrations, and fears and to some extent, their anger about what happened during the downtime. Now, we redacted the names of those doctors to protect their privacy, but I've shared those with Brent and I've asked him to share them with his leadership team. I did a town hall with Brent for all 26,000 of the Cerner Associates, ironically, just the week before this downtime occurred, and what I told them is that we appreciated their expertise and that this is not some engineering or science project, this is patient's lives that we're working on. He gets that. I think, increasingly, his team is getting that.

And then the final piece, Marc, I'm going to be meeting with their board the week after next, and Brent invited me to do that, I didn't ask, and he wants me to tell them what it's like to be a Cerner client, the good, the bad and the ugly. And I will share with them transparently what our experience has been like.

So my expectation going forward is that this is going to get better and better. It's going to get the attention it needs. We certainly are dead serious here at Intermountain about doing our part of things and improving where we need to. Please expect that some of my team's goals over the next couple of years are going to be significantly improve the experience of clinicians working on the EM.

Sorry for the very long answer, but does that make sense to you?

Mark Lewis: No, no. That does make sense. I think it also highlighted some vulnerabilities that we have in our downtime process. It really highlighted that we, as clinicians, really don't know what to do, and we've had some great conversations. I think the work that Mark [Breesacher 00:08:41] has done in providing that text update where you can opt into it, a text update is a great step ...

What's a good name in the six days? Yeah.

Marc Harrison:But I think Mark ...

Mark Lewis: Right.

Marc Harrison:And all he wrote ...

Mark Lewis: Exactly. Yeah, you're absolutely right. But I think we can make things better. I think we had a discussion today in our admin meeting with our ambulatory nurse manager about downtime kits and how we can make this more useful, because we're now I don't think anyone knows really what's in there as a clinician. We've kind of been told don't get into those. I didn't know. I thought that prescription pads were part of those and apparently, they were taken out when they weren't locked, and there's just some things that we need to make better so that clinicians have the tools when there is a downtime.

Marc Harrison:I really appreciate that and we need to practice with them. Just like you don't want the first time you use an AED to be when a person is really lying on there on the ground in front of you, you want to practice. I've practiced with one once or twice.

Mark Lewis: Exactly.

Marc Harrison:So I'd probably put those downtime kits into the same category, wouldn't you?

Mark Lewis: Yeah. Absolutely. I mean, I think I see the clinic doing their fire drills once or twice a year, and I think back ... I can't think of a fire that we've had, but I do-

Marc Harrison:We still do them.

Mark Lewis: Yeah, we do them, but we have a lot more downtimes and we just aren't as prepared when we do have a downtime.

The other frustrating thing is usually the downtimes are stuttering, so I was asked as leader at 8:30 that morning, do we break out the downtime kits, and the information I had is, "Oh Cerner is going down for an hour. No, no [iCentra 00:11:24] will be back up at 9:15," and I was like, "Let's not break out the downtime kits." But if I'd known at that time that it would be 9 o'clock that night I would've said, yeah, break them out and let's get to work.

Marc Harrison:Lessons learned. Isn't that what we're supposed to do?

Mark Lewis: Yeah, we really.

Marc Harrison: And we will. I actually really appreciate the tone of the conversation, Mark, because what I'm hearing is appropriate identification of the problems, sharing your concern for other human beings, both the caregivers and the patients, I hear frank discussion of the failures that were associated with this, but also, most importantly, there's a learning mindset that about how do we make things better. Wailing and gnashing one's teeth in the absence of trying to make things better is not productive, and I really appreciate your leadership style, which is very mature and very even, but really focused around how do we learn, how do we get better and how do we make sure this doesn't happen again.

Mark Lewis: Yeah. The unfortunate thing of these downtimes, they oftentimes ... We make progress, we have people getting to know iCentra better and actually using it, and a lot of times these downtimes take providers back to questions that really are relevant like, why was this decided in the first place? And that's not a useful question.

Marc Harrison:It's not a useful question.

Mark Lewis: And it's not anything that we're even going to consider, but it does take those providers back to that level which is-

Marc Harrison: I can imagine it does. I did share with Brent, when I talked to him, I said probably my biggest concern above and beyond patient safety, I mean that's always my number one concern, is the loss of trust associated with a major failure like this. And I did say to him, I said, "Look, you need to earn my trust back as well," and so I'm very much looking forward to getting the formal hot wash on what happened. I'm sure they'll have to use very short words that aren't very engineery for me, but I'll hopefully get some of it, and I'm really looking forward to watching Brent with his board. I think it's going to be very good, but you learn a lot. I have found him to be not defensive and very responsive, but intentions are easy to state. I can only measure actions and results. So that's where we are right now and I'm hoping they're going to be good.

Mark Lewis: Exactly. I think this is an opportunity for learning and improving because we are in an area where we could have a significant natural disaster that would take out the medical record and we need to be able to provide safe, effective, quality care to patients, even when we don't have a electronic medical record.

Marc Harrison:Mark, you know we're going to go ahead and go through this upgrade? I mean, our providers need a faster, more stable environment, and I'm sure based on the anxiety I've seen and the level of seriousness Cerner's taking that we're going to be well prepared for that.

Mark Lewis: Yeah, that's why we're not on Windows '95, right?

Marc Harrison:That's exactly right. But let me ask you to reflect, like you, my career has bridged the paper and the electronic errors, what do you think would happen if we just scrapped EMR's altogether and went back to the way we used to do medicine? Would that be a better world?

Mark Lewis: No, I think ... It's interesting, my great-grandfather was a physician, went back to Thomas Jefferson Medical School in Philadelphia in the late 1800's-

Marc Harrison:My dad and grandad both went to Jeff.

Mark Lewis: Is that right?

Marc Harrison:Yeah. Yeah.

Mark Lewis:And during his life he kept his patient medical records on a three x five card, and if somebody had a particularly difficult history, they might have three cards, and then all the rest was in his head. Was that great medicine? Likely not. Was it easy for him to document? Yes. Did he have the ability to do what we do now? Absolutely not. And so am I grateful for a great electronic medical record that can help me keep track of advisories, and best practice, and medication interactions? Absolutely. And would I want to go back? Not a chance.

Marc Harrison:Well, I appreciate that wisdom. The other thing I always remember is I watched a patient get killed by a misplaced decimal point from a pharmacy order that wasn't picked up. Usually they get picked up by either the nurse or the pharmacists [inaudible] say what are you doing, and I'm so glad that doesn't happen anymore.

Mark Lewis: Really that is so heartbreaking to see, mistakes like that.

Marc Harrison:So, Mark, during these podcasts I generally ask the person I'm privileged to talk with, whether they have any advice for me or any other questions they have, do you have any advice for me?

Mark Lewis: No. I can't even imagine being in your shoes. I appreciate your leadership. I appreciate your analytical way of looking the situation, trying to improve things. We appreciate you looking forward into the future because healthcare today is so much different than it has been any time in my practice of 30 years. It's an exciting time, but it's a rather unsettling time.

Marc Harrison: A little bit unsettling ... Thank you for the kind words. I'm not sure I deserve them. I will say that I am thrilled with how the organization has responded to our reorganization. Still not anywhere near perfect yet, still on the upswing in terms of evolution, the improvements we're starting to see in safety and quality tn general, very heartening to me. Anecdotal stories of the benefit of beginning to have uniform one Intermountain practices from a clinical standpoint, very interesting. I think people are actually sometimes a bit shocked as we uncover the diversity of care that patients have gotten across Intermountain without any analytic justification for why we've chosen the way we've chosen, it's just out of habit. That's the old way. The new way is physician and other clinical leaders really guiding us about what the best thing to do is and then, darn it, we should do that consistently for our patients. That's what they're expecting of us.

I am thrilled with the development of leadership I'm seeing in so many different levels across the organization. It's not to say we haven't had good leaders in the past, but what I'm seeing now are leaders who are learning to embrace change and lead through change because what we know is that the environment is going to continue to change and our success, and I think we're going to be extraordinarily successful at serving our communities and serving our patients, is going to predicated on our ability to lead ongoing, responsible, thoughtful evolution.

Mark Lewis: Yeah. Here, here.

Marc Harrison:Here, here.

Mark Lewis: I like it.

Marc Harrison:No one wants to be a knuckle-dragger and we're not going to be it at Intermountain. So thanks, Mark, I appreciate that.

Mark Lewis: Thank you very much.

Kevan Mabbutt: Thank you for listening. Join us next time for more caregiver questions and answers. You can find this podcast and others you may enjoy on or subscribe to the Intermountain podcast on iTunes. If you're a caregiver with a question you'd like to ask, please send an email to We'd love to hear from you.