Submitted: 9 June 2014
Two interview sessions: 26 July 2012, 27 July 2012
Total approximate duration: 3 hours 40 minutes
Interviewer: Tacey A. Rosolowski, Ph.D.
For supplementary materials:
Please contact, the Historical Resources Center, Research Medical Library:
Javier Garza, MSIS, email@example.com
About the Interview Subject:
Deborah A. Houston (b. 1950, Honolulu, Hawaii) joined MD Anderson as a staff nurse in 1972. Between 1986 and 1995 she served as Director of Nursing and in 1995 assumed the role of Center Administrative Director for Hematology (until ’97). From 1986 to 2008 she was a Clinical Assistant Professor in the University of Texas Health Science Center School of Nursing. In 1982, Ms. Houston was the first nurse to receive the Brown Foundation Outstanding Nurse Oncologist Award.
Ms. Houston shifted career paths in 1997, when she became Coordinator of Clinical Systems –Patient Care Information Systems. Her administrative roles in Information Systems expanded to Director, Enterprise Applications, Management Info Systems (’99 – ’05), then Director of Perioperative and Critical Care Informatics (’06 – ’09), then to her present role of Director of Information Systems Clinical Operations and Projects (’05 – present). She has written numerous articles on oncology nursing and on the role that Information Technology can serve in patient care.
Major Topics Covered:
Personal and educational background
Oncology Nursing: overview, evolution of, practice of at MD Anderson; nurses and multi-disciplinary teams
Nursing management at MD Anderson
Career change from nursing to information systems
Information systems as a service provider; information systems for team care delivery
Electronic medical records
MD Anderson culture
Regarding the Transcript and Audio Files
In accordance with oral history best practices, this transcript was intentionally created to preserve the conversational language of the interview sessions. (Language has not been edited to conform to written prose).
The interview subject was given the opportunity to review the transcript. Any requested editorial changes are indicated in brackets [ ], and the audio file has not correspondingly altered.
Redactions to the transcript and audio files may have been made in response to the interview subject’s request or to eliminate personal health information in compliance with HIPAA.
Interview Session One: 26 July 2012
A Nursing Student Discovers MD Anderson and Oncology Nursing
Chapter 01 / Educational Path
Why Oncology Nursing is Unique
Chapter 02 / Overview
Nursing and Nursing Management at MD Anderson in the Seventies
Chapter 03 / The Clinical Provider
Nursing Administration and a New Setting of Multi-Disciplinary Teams
Chapter 04 / The Administrator
Director of Nursing and Center Administrative Director
Chapter 05 / The Administrator
Inspirations and Observations About Changes in Nursing
Chapter 06 / The Clinical Provider
A Career Change to Information Systems and the Challenges of New Technology
Chapter 07 / Building the Institution
Interview Session Two: 27 July 2012
Recognizing Nurses and Nursing: The Brown Foundation Outstanding Nurse Oncologist Award
Chapter 08 / Institutional Processes
Information Systems at MD Anderson
Chapter 09 / Building the Institution
A Reality Check for Information Systems: Building Systems for Teams
Chapter 10 / Building the Institution
Medical Records and System Design for Faster Work and Better Patient Care
Chapter 11 / Building the Institution
Information Systems as a Service Provider
Chapter 12 / An Institutional Unit, Program
Perspectives on Changes at MD Anderson Culture and Contributions to the Institution
Chapter 13 / Institutional Change
Interview Session One: 26 July 2012 (listen/read)
Interview Identifier (listen/read)
Chapter 01 (Educational Path)
A Nursing Student Discovers MD Anderson and Oncology Nursing (listen/read)
In this chapter, Ms. Houston talks about her family background and the path that led her to oncology nursing. Born into a military family, she moved a great deal as a youngster. As her mother and aunts were nurses, she followed in their path, attended Texas Woman’s University in Denton, Texas. She began to work at MD Anderson while still in nursing school (in ’68 or ’69), choosing Anderson over Methodist Hospital, because of the higher wage ($18/8 hour shift). She describes her responsibilities at this time (dressing changes, for example). When she did her clinical rotation at MD Anderson, she was so impressed with the culture of work and care for the patients that she decided to become an oncology nurse.
Chapter 02 (Overview)
Why Oncology Nursing is Unique (listen/read)
Ms. Houston describes how important a nurse is during the frequent “life ending” situations of cancer. She explains how a nurse gets to know patients and helps them confront all dimensions of their disease, though she also describes how uplifting it is to see patients beat cancer, as she was able to see when working with many lung cancer patients. She gives an example of a life-ending situation with a patient she particularly admired, and who spoke with her about how he could help his family during the rapid progression of his small-cell cancer.
Chapter 03 (The Clinical Provider)
Nursing and Nursing Management at MD Anderson in the Seventies (listen/read)
In this chapter, Ms. Houston talks about the progression of her nursing career. She first summarizes her experiences as Staff Nurse (“72 – ’76), when she worked with a number of units: Surgical, Thoracic, General, and Head and Neck. The separation of these units causes her to observe that although multi-disciplinary treatment was a goal from MD Anderson’s inception, it became a reality in the 90s with centralization of patient services. She also comments on the role of nurses in the team of care providers, noting that before the hiring of physicians assistants, nurses helped physicians manage their patients. Next she talks about her role as a teacher and mentor once she became a Nurse Manager (Head Nurse) in 1976, and she helped nurses under her to learn how to care for lung and esophageal patients. At the time, there were only three people in nursing staff development (now there are over thirty).
Chapter 04 (The Administrator)
Nursing Administration and a New Setting of Multi-Disciplinary Teams (listen/read)
Ms. Houston sketches the next phase in her career (’79 – ’97): her move from Associate Director of Nursing, to Director of Nursing, and then into the position of Center Administrative Director of Hematology. (She was the first Center Administrative Director.” She summarizes the scope of her responsibilities in each role and then focuses on the restructuring MD Anderson was going through at the time to create “centers” for Radiation Therapy, Hematology, and other services in order to create continuity of care as patients shifted from being in-patients to out-patients or vice versa. This was part of a general institutional push to create “multi-disciplinary care environments.” Ms. Houston describes the reporting chains in these centers and the teams –made up of a surgeon, a medical oncologist, a radiation oncologist and a nurse, among other service providers. She confirms that giving clinics autonomy in this manner represented a cultural shift in MD Anderson, and its goal was greater cost effectiveness. She explains why this goal was not achieved. She then describes the roles that nurses served within the new structure. At the time, leaders in the field of nursing were becoming more vocal about the importance of nurses. At MD Anderson, however, she feels that nurses were involved as an afterthought and because individual physicians understood the role nurses play in organizing patient care, helping the physician to assess the patient, and supporting the patient who must ask the physician about his/her care. At the end of this chapter, Ms. Houston talks about her role on the selection committee for the Ethel Fleming Arceneaux Outstanding Oncology Nurse Award, which recognizes the central role nurses play in patient care.
Chapter 05 (The Administrator)
Director of Nursing and Center Administrative Director (listen/read)
Here Ms. Houston goes into detail about the operation of the different units she administered during the nursing phase of her career. She begins by speaking about the stresses associated with serving as a Director of Nursing ((’86 – ’95) in a “very physician-driven environment.” She notes some of the initiatives she took on: adding services for patients and a mentoring program for nurses, as well as setting up a satellite laboratory on the eighth floor of the Ambulatory Care Clinic. (In-patient nurses would work a week in the Clinic so they could see patients who had gotten better.) She then talks about her role as Center Administrative Director of Hematology responsible for four inpatient units. Most patients, she observes, were involved in research studies, and she describes the difference between nurses focused on patient care and research nurses, but goes on to explain the research element of all nursing at MD Anderson, as clinical nurses help the patient understand the investigational protocol.
Chapter 06 (The Clinical Provider)
Inspirations and Observations About Changes in Nursing (listen/read)
In this chapter Ms. Houston talks about people who inspired her. Renilda Hilkemeyer, “a phenomenal nurse and pioneer,” and the first Director of Nursing at MD Anderson, inspired Ms. Houston to be progressive. She learned how to conduct project and test out new work flows from Joyce Alt, the second Director of Nursing. And her late husband, Gary Houston, the first male nurse hired at MD Anderson and a Nurse Manager, involved her in many programs. This chapter also includes Ms. Houston’s observations on how technology has increased the pace of care delivered, creating a rush in the work place and altering nurses’ relationship to patients and each other.
Chapter 07 (Building the Institution)
A Career Change to Information Systems and the Challenges of New Technology (listen/read)
Ms. Houston talks about how MD Anderson did not offer much leadership development support in the seventies. In the mid-seventies, she became involved in the Oncology Nursing Society (at both the local and national level) to build her leadership skills, and also absorbed a great deal via on-the-job training. Summarizing the qualities of a good leader, she says, “A good leader can go on vacation and no one knows you’re gone.”
She then describes her shift in career from nursing to Information Systems: despite the fact that she knew nothing about computers, Dr. Mitchell Morris invited her to come to work on the Electronic Records Committee in 1997 because of her experience with both in-patient and out-patient care and her knowledge of forms and documentation (and because she was a fun person). Next, Ms. Houston describes the first project she worked on as Coordinator of Clinical Systems –Patient Care Information Systems (’97 –’99). She was part of a group comprised of two others from MD Anderson and 4-5 consultants from a software company, and strategized adoption of the Computer Based Patient Records. One of the first tasks, as she said, was to involve more MD Anderson staff and phase out the consultants. MD Anderson was an “early adopter” for technology and worked with software for dictation, pharmacy orders, and records. She stresses that they were looking for software that could assign a patient a single record number that would follow him/her across in-patient and out-patient care. She explains why this is important for patient safety, particularly those receiving chemotherapy whose total dosages must be closely monitored.
Next Ms. Houston explains that Clinical Systems purchased a brand new product from Cerner Millennium [Health Information Technology] (though they stopped implementation a couple of years later). They adopted the Cerner Millennium product to speed requests for records and processing pharmacy orders, as well as to coordinate and consolidate patient care by reducing repeated work. She stresses that the MD Anderson record systems provides data in the form that MD Anderson users need. She is particularly pleased with the electronic reporting of laboratory data and vital signs. In contrast, she outlines the continuing challenges with regularizing data entry for physician dictation. Information Systems has adopted a system form M*Modal that processes natural language. The aim is to move physicians away from their habitual way of dictating to a structured output that can be electronically reported and searched.
Interview Session Two: 27 July 2012 (listen/read)
Interview Identifier (listen/read)
Chapter 08 (Institutional Processes)
Recognizing Nurses and Nursing: The Brown Foundation Outstanding Nurse Oncologist Award (listen/read)
In this chapter, Ms. Houston talks about winning MD Anderson’s first award for an Outstanding Nurse Oncologist (1982). (She has also served on the section committee.) She briefly recounts the history of the award then describes some of the peculiarities: it carried a $10,000 cash award (now $15,000), given at a Board of Visitor’s dinner, but awardees had to keep the honor secret (no longer the case). She describes the criteria used to select the Outstanding Nurse from among the names presented by nomination: going beyond MD Anderson’s very high standards for patient care and also making an impact developing programs and materials.
Chapter 09 (Building the Institution)
Information Systems at MD Anderson (listen/read)
Ms. Houston begins this chapter by briefly describing what led her 1997 decision to shift from nursing into Information Systems after agreeing to serve on MD Anderson’s Computer Based Records Project. She then talks about how Information Systems has fit into (and driven) the 2005 restructuring and combining of Departments. She notes that much of her role involves serving as a liaison between Information Services and Clinical Operations and gives the example of working with critical care providers while implementing the Picis system to do preoperative evaluations and various kinds of documentation. She also notes that Information Systems was first perceived as a “top down” initiative, but after the 2005 restructuring, this shifted as “clients” within the institution requested services and support. She explains how IS is funded and how she helps Dr. Thomas Burke, M.D., Executive Vice President and Physician in Chief, prioritize the IS projects funded. She describes some of the challenges of satisfying the requests for IS support. They have funds, but a great deal is already committed to ongoing projects. With the case of Infection Control, for example, they have funds, but not enough people to implement and support a new IS initiative, and contracting this support would increase the price.
Next, Ms. Houston describes the challenges that come from MD Anderson’s desire to always have the newest, most cutting-edge products. In Information Systems, this can mean purchasing newly developed software that may not be ready for full-blown use. The challenge of working with MD Anderson: patients have one record that follows them across inpatient and outpatient care, so providers can keep track of all procedures and drugs given. Chemotherapy administered in the hospital must be added to treatment given in the Ambulatory Care Clinic to avoid exceeding safe dosages. Ms. Houston then talks about how unique the laboratory systems are at MD Anderson and the high volumes of tests they perform, all of which have to be tracked by computer-based patient records.
Chapter 10 (Building the Institution)
A Reality Check for Information Systems: Building Systems for Teams (listen/read)
In this chapter, Ms. Houston talks about the role she has served “an interpreter” in building information systems at MD Anderson. She explains that her 27 years of experience in patient care have enabled her to represent users’ needs in Information Systems. When information services are planned, she understands how work flows in clinical situations, how providers integrate record-keeping and data entry into their work day, and how they relate to screens and the organization of applications. While Director of Enterprise Applications in Management Information Systems (’99 – ’05), she also set up a class for technical staff about cancer, so they would have some idea of the real life situations that Information Technology users at MD Anderson deal with. Ms. Houston also notes that on first joining IT she sometimes heard, “What’s that little nurse doing here,” and won respect by performing well also noting the increase in numbers of women in the field and change in attitude. She then expresses concern about how her skill set will be replaced after her retirement, given her unique view and the respect and collaborative networks she has built over the years. In a discussion of ClinicStation software, she gives an example of her ability to facilitate users’ understanding that technology may not be the solution to their problems if what is needed is a change in work process.
Chapter 11 (Building the Institution)
Medical Records and System Design for Faster Work and Better Patient Care (listen/read)
In this chapter, Ms. Houston explains a number of devices and services that IS has implemented to facilitate work at MD Anderson. She first talks about the Alkek Hospital Bed Expansion, and how the building’s design made it necessary to give nurses the VOCERA hands-free communication devic2e. She explains why the attempt to install tablet computers in patient rooms to document vital signs and other information was unsuccessful (and how other computers are being installed) and explains the electronic white boards installed to monitor patient status. Next, Ms. Houston explains the decision made in 2005 to adopt ClinicStation. She talks about the assessment strategy and what this software allows. She explains that Information Systems has developed ClinicStation into a certified Electronic Medical Records system that meets government standards, The government takes an interest, she says, because electronic records should bring down the cost of healthcare. At the end of this chapter, Ms. Houston talks about how Information Systems customized ClinicStation to suit MD Anderson needs.
Chapter 12 (An Institutional Unit, Program)
Information Systems as a Service Provider (listen/read)
Ms. Houston explains that while she was Director of Perioperative and Critical Care Informatics (’06 – ’09), she began to work with areas in MD Anderson that still had their own IT support (surgery, and radiology, for example) while Diagnostic Imaging, laboratories, and Physical Plant had consolidated within the central Information Systems service. She explains that these departments had remained independent because IS could not provide them with adequate support, and also notes the advantages of consolidation (e.g. economies of scale, standards, protection from viruses). She emphasizes that Information Systems must be able to provide support for specialized IT needs. Ms. Houston then talks about current her role as Director for Information Systems Clinical Operations and Projects (’05 – present). She explains several projects: the further development of Electronic Medical Records and the Diagnostic Imaging Information Technology Group (upgrade to Radiology), and speaks in detail about the project, “Institutional Bar Code for Patient Safety.”
Next Ms. Houston notes that she plans to retire in three to four years, and by that time she would like to see efficient data entry for nurses and computerized systems for physician documentation, as well as completion of the project, Institutional Bar Code for Patient Safety. All of these initiatives, she says are key to safety and productivity. They are also tangible and achievable goals. As she looks back on goals already accomplished, she pleased to have started the hematology laboratory for patients and also gratified with the success of the Perioperative and Critical Care Informatics group that she directed from ’06 to ’09. MD Anderson faculty and staff are quick to ask for new technology, but the challenge is getting them to actually use it, Ms. Houston says.
Chapter 13 (Institutional Change)
Perspectives on Changes at MD Anderson Culture and Contributions to the Institution (listen/read)
Ms. Houston begins this chapter by observing that since the seventies, MD Anderson has grown so much that it is impossible to know everyone, and interactions have become more impersonal. Technology has contributed this, as people email and text one another instead of communicating by phone or fact-to-face. Reflecting on whether the Institution can become too large, Ms. Houston observes that the Regional Care Centers return in a sense to the more personal feel of the old, smaller MD Anderson. In the case of Information Systems, she says, there is no quality compromise as the institution expands into remote units. In the case of overseas units (Global Oncology), she notes there is always a question about whether patient care is delivered in the same way as in Houston.
Next Ms. Houston says that her greatest concern is to find her replacement. She hopes that people in Information Systems will continue to foster a culture in which “everybody has worth” and can feel successful in what they do. MD Anderson has given her tremendous opportunities for success and to make friends. Once she retires, she intends to indulge her love of travel (especially taking cruises), her dogs who are like her children, and her various hobbies such as needlework.
Deborah A. Houston (b. 1950, Honolulu, Hawaii) has worked at MD Anderson for 33 years and has served as Director of Information Systems Clinical Operations and Projects since 2005. In this two-session interview (total duration, approximately 3:40) conducted on July 25 and 25, 2012, she traces her career path from Oncology Nursing and to Information Technology. The sessions take place on the Main Campus of MD Anderson in Ms. Houston’s offices in Pickens Tower and the Fannin Bank Building). Tacey A. Rosolowski, Ph.D. is the interviewer.
Ms Houston received her BS in Nursing in 1972 from Texas Woman’s University, Denton, Texas and her MS in Nursing from the Houston campus of that same institution. She began to work at MD Anderson while still a nursing student and began full-time as a staff nurse in 1972. She rose to Head Nurse ’75 – ’78), Clinical Supervisor in Thoracic, Neuro, and Orthopedic Surgery (’78 – ’79) , and Clinical Nurse Specialist in Thoracic Oncology (’79 – ’86). Between 1986 and 1995 she served as Director of Nursing and in 1995 assumed the role of Center Administrative Director for Hematology (until ’97). From 1986 to 2008 she was a Clinical Assistant Professor in the University of Texas Health Science Center School of Nursing. In 1982, Ms. Houston was the first nurse to receive the Brown Foundation Outstanding Nurse Oncologist Award.
Ms. Houston’s career shift occurred in 1997, when she became Coordinator of Clinical Systems –Patient Care Information Systems. Her administrative roles in Information Systems expanded to Director, Enterprise Applications, Management Info Systems (’99 – ’05), then Director of Perioperative and Critical Care Informatics (’06 – ’09), then to her present role of Director of Information Systems Clinical Operations and Projects (’05 – present). She has written numerous articles on oncology nursing and on the role that Information Technology can serve in patient care. In 2007 she received the Association for Women in Computing Award for Leadership in Technology, awarded by Top Houston Women in Technology.
In this interview, Ms. Houston gives a vivid portrait of Oncology Nursing and the key role the Oncology Nurse serves for patients. She also provides an insider’s perspective on the organization of clinical structures that facilitate patient care and talks about her many initiatives to improve its delivery as she rose through Nursing’s administrative ranks at MD Anderson. As she traces her career in Information Systems, she traces the process of an institution adopting complex new technology. She also explains how challenging it is to create electronic applications that suit the unique requirements of MD Anderson’s patients and care providers.