Health Care Changes: Is IT Enough?

by drjim on April 15, 2009

What Else Is Needed To Make Electronic Health Records A Success?

What Else Is Needed To Make Electronic Health Records A Success?

So here’s the $19B question for you: if you were the CIO in charge of the Obama administration’s big health care initiative, do you think that the “secret sauce” that will make it all work out will be better / more IT?

Just in case you’ve not been following this developing story, one of the the Obama administration’s key election promises was to fix the broken U.S. health care system – it costs too much and delivers too little care. A main tenet of how they are proposing to do this is through IT investments. The poster child of this massive IT investment is something called Electronic Health Records (EHRs).

The administration is forecasting that using EHRs could save the government up to $77B annually! We in IT just LOVE any problem that can be solved by throwing more IT at it; however, as always perhaps we need to take a step back and look more closely at this problem.

Julia Adler-Milstein over at the Harvard Business School has been looking into this issue and she’s made some interesting discoveries. She’s found that the hope for these EHRs are that they will improve work flow, accuracy, communication with patients, access to medical history, and clinical decision making. As we in IT know, more than just IT changes will be needed…

It turns out that studies that have been done by MIT Sloan School’s Erik Brynjolfsson and others have shown that organizations (not just health care industries) can only take advantage of new IT capabilities after they make substantial changes. Oh, oh – this sounds like work.

The types of changes that organizations need to make include increased training and increased individual decision making authority. They also flattened their hierarchies, made better use of their staff, decentralized their teams, and ended up raising the incentives for team performance.

As any CIO knows, IT changes by themselves can’t solve business problems. No matter if you are talking about how to solve the U.S. health care crisis or any industries need for more automation, an IT solution will only go so far. Making the rest of the company understand that IT can provide the tools needed to solve a business problem, but that organizational changes will also be required is a fundamental job for the CIO.

Is your IT department planning on implementing a major electronic record keeping system in order to solve a business problem? Are there organizational changes planned in order to support this new system? Do you have an end user training plan in place yet? Leave me a comment and let me know what you are thinking.

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{ 15 comments… read them below or add one }

James Parnitzke April 15, 2009 at 11:43 am

Think you have nailed the real issue. But more troubling than just organizational change the real problem may be in ability for all stakeholders (think the whole system) to decide this more important than political or organizational boundaries (turf) that prevent this from moving forward. For evidence supporting this assertion just look at the number of state funded EHR initiatives underway or awaiting “stimulus” dollars. Want to guess where this is going ?

I have a humble suggestion. Stop re-inventing the wheel, we have HL7 reference models and specifications, we have had the technology to enable this for some time. The good news is there us a starting point with the HL7 Standards for electronic interchange of clinical, financial, and administrative information among health care oriented computer systems. See http://www.hl7.org/ for more about this. And see the series at one of my blogs titled “Modeling the MDM Blueprint” at http://pragmaticarchitect.wordpress.com/ for more about what I really mean here. This is a classic MDM pattern, just substitute

Patient or In-Network Provider for customer,
Procedure (ICD10, CPT4, DRG) for Product,
Third party administrator, claims carrier, and network provider for Supplier-Contract Agreement, and
Location for well location (for geo-encoding anyway)

Other domains (commercial business) have already started and are well on the way to solving the same kind of problems. For a real working example in the Product Information Management (PIM) space (which is solving for some of the same problems) see GS1 Global Data Synchronization Network (http://www.gs1.org/productssolutions/gdsn/ds/how.html) and the standards (http://www.gs1.org/services/gsmp/kc/gdsn/index.html) that make this possible.

Thx for bringing this our attention.

-jdp (Parnitzke)

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Dr. Jim Anderson April 16, 2009 at 4:03 pm

Jim: you are absolutely right – we are just starting to look at the tip of the iceberg here. What’s caught my attention is that from a technical point-of-view we all know that a single national health care electronic health record (EHR) would solve so many problems. However, due to customers who think that they are unique, vendors who need to differentiate themselves, and other various economic factors, this isn’t going to happen. We’ll be living in a world with many different flavors of EHRs. Looks like those of us in IT will have jobs well into the future…!

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Glenn Whitfield April 15, 2009 at 1:33 pm

Jim,

Great post!

Unless organizations change the way they approach tecnhology and technololgy projects, we are headed for the classic IT / Technology failure due to the focus on Technology. We need to change and focus on the process while engaging and involving the people who perform that process to prepare for the technology.

If you don’t fix the process first before you automate (add technology), then all you have is an automated mess.

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Dr. Jim Anderson April 15, 2009 at 3:10 pm

Glenn: you are correct. I am a big fan of “paper solutions” first – use pen & paper to write things down and have people exchange the paper as the process flows before you spend a lot of time/money to automate it. When it comes to health care, I’m concerned that there is going to be so much money flowing in in such a short time that the one thing that may be in short supply will be time. This could lead to some costly bad decisions. We’ll have to see how things turn out…!

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Jay April 16, 2009 at 2:42 pm

Glenn and Jim,

I agree, user ‘needs’ should always trump technology focus. We have seen numerous examples of how the opposite approach leads to higher degrees of resistance in user acceptance, lower competencies, lower productivity, and patient safety issues.

Personally, I think this influx of cash is going to create bigger problems for the adoption of technology and eventually lead to waste. As Glenn mentioned, we are still dealing with an industry that doesn’t really understand their own processes and continues to implement the wrong solutions. The focus of one portion of the healthcare industry is MONEY while the other portion is on HEALTH. If there is no diversity in the planning to combine equally responsible stakeholders in the decision-making process, something is bound to be overlooked.

If you have an abundance of budget to throw at IT, that is precisely what is going to happen. When ‘harddrive space’ became cheaper, the popular solution was simply throw more money into buying larger harddrives. Another approach would have been to closely govern and manage the content being placed on the drives to maintain efficiency, lower energy consumption, and improve data management processes.

So the issue will repeat in the healthcare industry as well. When given large budgets for IT, massive amounts of spending on IT will occur. But will it be the ‘right’ approach towards effective solutions? If Glenn’s perspective holds true, I highly doubt it.

Just my thoughts…

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Dr. Jim Anderson April 16, 2009 at 4:06 pm

Jay: so here’s my favorite health care stat that comes from, I think, Gardner: 80% of doctors STILL don’t have PCs as part of their practice. Wow – talk about an industry that still has a long way to go! It turns out that most doctors really don’t want IT solutions – they actively resist them. Sigh, maybe some of that stimulus money could be spent to change their minds…

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Jay April 16, 2009 at 5:16 pm

Jim,

First, I would like to clarify my last statement from the previous post, “If Glenn’s perspective holds true, I highly doubt it”. After rereading the statement it gives the impression to the readers that I beleive Glenn’s post contains a falacy that will not be of value in resolving the issues regarding healthcare and technology selections.

What I meant that statement to read is that if Glenn’s observations and thought regarding the needed changes are not realized and acted upon, the stimulus funding will not produce the expected improvements.

As for your follow-up statement, I have experienced the ‘resistance’ first-hand while working in a hospital’s IT shop for 5 years. Historically speaking, the healthcare industry was dominated by a physician-centric business model where all decisions and supporting functions were controlled by the practicing physician. Obviously a powerful position for the practitioner that enforced principles of autonomy.

It is easy to see where the initial resentment comes from. Technology introduces ‘new’ processes, tasks, and even a voice of opposition that often conflicts with the performance of their primary responsibilities: the establishment of treatment plans for patients.

Technology comes at a cost for physicians in many ways. Time and effort to learn new competencies. Profit constraints to purchase, implement and maintain the systems. When they elect to introduce electronic technology into records and processesing (billing, account management) they open themselves up to more regulation and compliance concerns for HIPAA. After all, the Privacy Rule concerns ALL protected health information in any form. However, the Security Rule in HIPAA is only applicable towards ‘electronic’ protected health information.

In some physician’s eyes, that is adding to the significant efforts required to comply with federally mandated regulations. So the costs for obtaining and maintaining compliance increases with the addition of technology. We are no just dealing with privacy notices, physical security measures, and process training with employees. We begin to deal with electronic measures (physical and logical) relating to how information is collected, processed, persisted and consumed.

Another barrier is how technology impacts practices based upon ‘curative’ rather that ‘preventative’ business models. I think part of the root problem here is the patient population. Our society predominantly does not seek medical care until they are at a point where curative measures are the only option, and unfortunately costs are highest.

I believe the best technology implementations for the healthcare industry are going to be in the education of the patient population. The more informed and selective they become towards healthcare that leverages technology to improve health, the more pressure it will place on the healthcare industry to adopt the appropriate and necessary solutions to provide that care. Physicians will have patient encounters with people who have researched their conditions, reviewed relevant procedures and probably advised on the financing of treatment where necessary.

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Glenn Whitfield April 16, 2009 at 5:50 pm

Jay,

First of all, thanks for clarifying your statement! 🙂

I worked for a hospital for 2 years implementing Lean & Six Sigma. One area I spend a lot of time in was Patient Scheduling. We wanted very much to move to a more web based model, but couldn’t due to many doctors offices not having PCs or email addresses. Fax & Phone were standard (this is in a top 20 city). When administration was pressed to get the doctors to change, they quickly balked for fear of the doctor sending the patients to another facility (4 major hospitals in city).

Some doctors get it and some don’t. It was very frustrating to be in a meeting where the chief of Radiology was perplexed why he could not get updates on his PDA, then go to a meeting where the doctor says he sees no reason why faxing the order/schedule is not sufficient, and he has no intent to change.

You’re right that patients can help change this attitude by forcing their physicians to use technology or taking their business to one that will. But it takes an educated patient population to make that happen. Patient education is a huge opportunity.

Glenn

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Jay April 18, 2009 at 3:47 pm

Glenn,

I have seen similar situations in de-centralized hospital organizations where individual departments were given their own operating budgets and a free hand to adopt technologies that directly supported their specific functions.

The best-of-breed approach is very popular in de-centralized structures. However, they have a huge weakness in interoperability when the organization attempts to restructure for a more centralized control model. You end up with a disparate information system that is difficult to manage and incorporate in the new business model.

I have seen entire infrastructure upgrade initiatives cancelled as a result of a single clinical support software solution that could not suppor the newer hardware. I have also seen the deployment of wireless technologies rolled back because of improper security and network policies. I’ve seen good systems fail to meet expected ROIs because the staff was insufficiently trained and no one was conducting training or audits of the systems.

Technology is not the silver bullet the healthcare industry is looking for. Start where you like, but don’t start before you understand. Surely we all understand the negative impacts of this approach: increased costs for rework, increase scope creep, deficiencies in product/service quality.

Jay

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Glenn Whitfield April 19, 2009 at 5:04 pm

Jay,

Absolutley agree! I believe you focus on the process, engage & involve the people, and prepare for technology. People who keep looking for silver bullets always seem to end up shooting themselves in the foot!

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Laura Brandau April 17, 2009 at 3:34 pm

This article and a breeze through the comments reminds me of an analogy from Kottler’s Leading Change…imagine an office all tangled in knots. To briefly summarize with some creative license: The desks are upside down, wired networks are strung all over the place, chairs are hear and there. The space is crammed and mangled. Your job as a leader is to help multiple people move things to eventually create order out of chaos.

I see the healthcare situation in a similar light. Sure we need investments in IT. Sure we need to evaluate and change organizational processes. We need a lot of people to do a lot of things to create order out of chaos, and given the interwoven environment they will likely step on each other along the way.

It is simply too mangled a situation to be a perfectly organized, linear process. Things might be worse before they get better, or they might be better but you might still be sitting on your neighbor’s phone cord. Now if you check out my blog you’ll find out I’m all about engaging with the business stakeholders and solving real business problems, but sometimes IT needs to give the business a little bit of a push by changing a few things (in alignment with the overall direction) without a perfect business/IT alignment. When people start to see positive changes from multiple directions, the real possibilities emerge.

In short, we have to start somewhere. An investment in IT isn’t the worst thing a president could do.
Laura
http://bridging-the-gap.com

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Dr. Jim Anderson April 17, 2009 at 11:03 pm

Laura: I really like the picture that you paint. I think one of the biggest problems in health care is that everything is so messed up that nobody knows which “knot” to start trying to untie. The stakes are so large in terms of lives, health, and company’s fortunes that everyone so far has been nervous to even start. It sure looks like the U.S. government is stepping up with a big pair of scissors and is getting ready to go to work on the issue. IT has a role to play, but there are a lot of other players who are going to have to step up and participate. My fingers are crossed!

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Jay April 18, 2009 at 3:11 pm

Laura,

We do have to start somewhere, but buying the tools (which is what technology represents) before you know/understand what you are building seems a bit backwards to me. Purchasing Z system does not ensure you will achieve the same levels of success your competitors have had with it. The same can be said for adopting a best practice from another organization without first knowing whether or not you have the competencies, structure, and culture to support it in your business model. The amount of funding you can loose in this approach can be excessive to say the least, and leave you no closer to a resolution than when you began.

I would still advise caution in any change initiative where technology takes a higher level of importance (driver) than strategic or tactical business goals.

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Laura Brandau April 18, 2009 at 3:30 pm

Hi Jay,

Very good point and I did not mean to say that technical should drive business goals. Alignment can happen at many levels — the vision, the goals, and the individual tactics. What I meant to imply (though did not explicitly say) is the technology can start to push toward the vision even while there are disconnects or unknowns at the lower levels. The mere momentum of making small changes consistent with an overall vision can build the momentum necessary to achieve bigger changes.

You would not pursue this type of change management for smaller problems, but I fear that if we want until all the problems of healthcare are perfectly understood and the detailed tactics are ironed out before we start applying technology to help us achieve our vision, we’ll be stuck in one horrible state of analysis paralysis.

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Jay April 18, 2009 at 4:52 pm

Hi Laura,

I understand, but I have seen successful change initiatives happen within an organization that were aligned with the overall vision before… unfortunately the overall vision was wrong. Is it enough to be content with successful changes even if we are heading in the wrong direction? Is it enough to be ‘electronic’ and ‘networked’ within our individual locations?

My question is, where are you suggesting we begin with these small changes? If it were my problem to manage, I would begin with the data tier. Data is the foundation of all systems and must be properly aligned with industry standards. Next I would probably address the transportation layers and services that govern how the data is moved between systems ensuring the confidentiality, integrity and availability of the from end-to-end.

Interfaces to the data and transportation layer is the dominion of vendor competition. There are many, many different ways to access and consume data from a user’s perspective that should allow ample vertical and horizontal growth in profits for vendors.

I simply cannot see small changes on top of an inconsistent infrustructure as doing any long-term good. Maybe we have enough consistency in existing data structures to salvage some and not have to start from scratch. But if you are going to re-invent the wheel, you better be certain it is a better wheel than the one you previously had.

Jay

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