Candice Friestad, DNP, MBA, MSN, RN-BC, is director of clinical informatics at Avera Health in Sioux Falls, South Dakota. She has been with the organization for 39 years.
How did you get your start in nursing, and then transition to informatics?
My original plan had been … music, piano and voice. Then I realized that wasn’t going to pay the bills and so I switched over to nursing. My parents said that’s a noble profession, and from my perspective, it was something I could work nights and then go to auditions during the day. There wasn’t a whole lot of nobility, maybe, in that decision making; it was more financial-based.
After that, I really went directly from my baccalaureate in nursing into my MSN with an emphasis on both administration and nurse practitionership. Then I spent 17 years in critical care trauma in a variety of different roles, including management. As that role became more involved with finance and technology – monitors, ventilators, EMRs – I decided to get my MBA.
To be perfectly honest, the reason for that MBA was because healthcare finance didn’t make any sense to me. Typically, if you made something, sold it, and then got it back, you were looking for profit margins and that sort of thing. When I looked at healthcare financial things, especially with Medicare and Medicaid, none of that made any sense. I finished an MBA with an emphasis in information systems, and to be perfectly honest, the financial part of healthcare still doesn’t make any sense to me.
One of the first things I did to move towards the IT realm of things was look at acuity systems, which involved time studies, Excel spreadsheets, and Access databases. This really dates, me but I remember working in something called WordPerfect before I moved over to Microsoft Word; so yes, this is where we get into the part where I went into nursing school when I was three!
I do remember from a history perspective, that in nursing, our main flagship hospital that I sort of grew up on is 545 beds. Our CFO had the only computer in the hospital and I got two hours of time on that computer as doing acuity pieces once a week. I was able to go into Excel at that point. I ended up teaching myself IT and using his computer while he was on the phone in his office because it was the only computer available to nursing at that time. That just seems like a tremendously long time ago.
Were you the only person on your staff that was taking the initiative to teach yourself those computer skills?
Yes. At that point, I had a job title called project director for nursing administration. I reported to two different CNOs and they really did not feel comfortable with that; so in order to just save time, it just made sense to go that direction. It was very interesting, because then we would need to come back from a budgeting perspective, that was also on paper at that point, and be able to justify what we needed to do for nursing, be it staffing or staffing computer programs. We went live with our first EMR, or computer documentation system, in 1990.
We were doing some order entry elements, not with physicians mind you, in 1986, and then went full scale nursing documentation in ’97. That was quite a while ago, and so needless to say, software and EMRs have changed during that period of time.
Knowing how those systems work was a big element, because in informatics, and this is what I tell my staff, part of your job is to translate. If someone starts talking about HL7 or wireless infrastructure or hardware requirements or zero clients or blockchain, you have to understand what they’re talking about because the other people that you are responsible for are caring for patients and they understand heart, lungs, vessels and where they belong.
When you were starting out at Avera, what role did you see women playing in the health IT part of your organization?
When IT first was first introduced, it really was finance-based and so that translation piece was necessary. As you’re trying to figure out how it’s all interconnected, you have to understand coding and CPT and ICD-9/10 and DRGs and how that all works in order to make sense on the clinical side. Really, the IT team at one point was three people – a data entry person at night, a financial person, a clinical person (meaning me), and then our IT director, who was really from an accounting background.
Then lab systems came on, pharmacy systems came on, and those types of pieces happened and you really did have to have, for the safety of the patient and regulatory reasons, someone with that knowledge base to be able to work with that. And also to be able to work with the technology. I really do think that was a growing piece with our IT at Avera. You have to know where it all fits and who’s going to make sense of it all.
After you’d had a few years under your belt at Avera, were you strictly focused on your career, or were you beginning to encounter the challenges of work/life balance?
I still remember taking a managerial accounting final, having the worst morning sickness and thinking, “I’m never going to finish this MBA program because, like an idiot, I’m pregnant at the same time.” And I think that is a challenge that anybody in a family situation really has to figure out how to balance.
I am married with two children. One’s a senior in college and the other one graduated two years ago. I also finished my MBA and I’ve since earned a doctorate. During that period of time, I was trying to juggle the young kids, the full-time job, school, and trying to learn things like EMRs that are more hands-on than based in a classroom. It’s helpful to have the online opportunities that are available now that weren’t necessarily available then. I had an aging parent that I had to take care of as well. Having all those things at the same time, it was truly a juggling act.
One could argue that we’ve come a long way and there’s equality of the genders, but I do think sometimes the female portion of the unit gets weighed down a little bit more. That being said, I do have colleagues, two gentlemen, who have children, and I can see that they’re wrestling with the same type of situation. It’s very difficult, because there’s only a certain period of time where you are going to be familial and how are you going to balance all that? It is probably not easy no matter what profession you’re in, but I would say this is one where it was pretty tough.
Do you have any advice to offer young women who are encountering those same situations?
There’s help from everywhere. You’ve got social systems that can help you. You’ve got family. You’ve got friends. But don’t think there’s something you can’t do because there’s not enough time or you’re not smart enough or you’re not sure. If you really want to go in that direction, I think it’s a good idea to just give it your best shot. Sometimes you learn from failure as much as you learn from success.
The one thing I’ve found is that the MBA did give me credibility. Having that degreed background and certification in nursing or nursing administration, did lend itself the credibility that, I believe at that time, maybe wouldn’t have been there or wouldn’t have necessary to be there had I been a different gender. I really hate to throw that out there because, for the most part, I’ve been very supported here, regardless of the fact that I’m female, but I do think that having the degree made a difference.
And then the other thing would be to not back down. It’s a very interesting structure in healthcare with the physician being the captain of the ship. We were just discussing this yesterday with my staff – a combination of male and female nursing and pharmacy staff. In this case, we were talking about a female physician who seemed to believe that, “I have this much power, therefore I’m going to demand this.” I do think that type of thing ha gotten better than it used to be, but sometimes you have to stand your ground and say, “This is what I believe. This is what I think should happen.” Again, always for the safety of the patient.
Did you learn that from a role model? Who have you looked to as a role model as your career has progressed?
Wow. There’s a couple that I can think of off the top of my head. I always pull out Mrs., bless her heart. She was 4’10”, the tiniest nursing supervisor. She was just frail and thin and she’s since passed, but I suppose she was probably in her mid- to late 50s when I started in my 20s. There was not a physician in the world that did not respect her and she them. In the event that she ran into a physician who decided to wield the power, that small little lady just had … it’s one of those things where it’s very difficult to articulate what it was. It’s that charisma, the sense of “I’ve got this.” The sense of “I’m not backing down.” I think she was a great role model.
From an IT perspective, I can think of a couple of different individuals that have been within our Avera footprint, as well as some of the vendors that I’ve worked with. The CFO that shared his office and computer with me was a gruff individual, but I did learn a great deal from him. I think anybody that I work with on a team basis … it just seems like everything we do we do better as a team. It is just better in the long run. That mentoring helped me a great deal.
In my doctoral program, I had a gal who has since retired, but who worked at the CDC for a while. She was just very articulate. Had 60 different articles that are credited to her and she knew her statistics backwards and forwards, and at the CDC she was a force, so I think there’s a variety of different mentors. It’s interesting that when you’re in informatics, it comes from different segments of healthcare, not necessarily just from the caregiving part of it.
Have you found yourself becoming a role model for others?
I have an individual here who’s actually leaving our department to go to a data repository writing and he said, “I really consider you my mentor.” He came from a bedside supervisory position and is looking to find out where he fits. He’s staying within the corporation. It was nice to hear that there are other people that see me as a mentor.
I’ve also had a couple of individuals – both part of our EMR implementation teams – from some of the smaller facilities within our footprint, which includes Minnesota, Nebraska, Iowa, and South Dakota, who attribute their decision to go into to nursing to my influence.
I think that’s the other advantage to nursing. You really can go anywhere with that type of preparation. That credibility of having that licensure and that bedside experience really does make a difference. I’ve seen people that have gone from bedside into informatics. From a mentoring perspective, I hope we have something to do with that.
What resources or professional networks do you rely on to stay connected to what’s going on in informatics and health IT?
Our facility is a Magnet facility. We are just starting, so that’s the ANCC, American Nursing Credentialing Center, designation. We are in the process of our fifth redesignation and so that informatics group is important from a nursing informatics perspective.
I am not a member, but I actually have the application form on my desk for the American Nursing Informatics Association. I had been a member of AMIA before from almost a biomedical piece of that. HIMSS is huge. We have a local group as well for HIMSS. And then everyone on my staff either has to hold a certification from their expertise like ARN or pediatrics or informatics. That is how I try to keep up.
Our community wants to know, what do you know now that you wish you knew when first getting into health IT?
There isn’t one answer for everything. The men and women on my staff are some of the most flexible, multitasking individuals I know, and everywhere in healthcare you have to do that. The people around you come to you and say, “Fix it.” Well, the “fix it” may involve two or three different passageways to make the best sense. That was one thing I think I learned, a little on the painful side.
The other piece, and this came fairly quickly, is that everything you do, whether it’s in healthcare, IT or transportation, is about relationships. If you can keep those solid relationships with your coworkers, with your vendors, and with your patients, that will make all the difference.
Finally, what advice, personal or professional, can you offer women looking to enter health IT today?
It’s always changing and even though you may have a degree from somewhere, the half life of your education is about seven months, maybe closer to three and four as time moves on. You need to do preparation but sometimes one of the best learning experiences you’re going to have is to just get in there and dig in – not only from a healthcare perspective, but also from an IT perspective. Sometimes you just have to do it in order to learn it.