Healthcare Information Technology Research & Analysis : Coplan & Company : IT Procurement Management, Project Management, System Acquisition

It is obvious that correctly linking a patient to their medical record is critical to the quality of care. Most large providers identify a patient using a computerized statistical match on multiple personal attributes, e.g., name, address, and Social Security number (SSN) .  They then examine the results of the search to select the correct patient.  According to the RAND | Monographs | Identity Crisis: An Examination of the Costs and Benefits of a Unique Patient Identifier for the U.S. Health Care System, the average error rate is about 8 percent, increasing with larger systems.  Larger systems are already exchanging clinical information electronically with resulting higher error rates, e.g., Regional Health Information Organizations (RHIOS). Higher Healthcare Information Technology (HIT) adoption will increase incidences of serious medical errors instead of the promised increase in quality of care.

Rand's study states using a Unique Patient Identifier (UPI) that:

...enables disparate health care information systems across the United States to allow authorized users to easily and quickly share critical health information has the potential to enhance safety and dramatically improve the quality and efficiency of the national health care system.

Privacy advocates (e.g.,  Citizen"s Council on Health Care, Health Privacy Project, Patient Privacy Rights, World Privacy Forum) say that using UPI's will add to the already serious healthcare identity theft problem. Rand disagrees with these critics, stating:

Proponents of statistical matching suggest that a UPI scheme will reduce privacy by making all of a patient’s data recognizable and accessible via the single UPI. However, if a statistical matching scheme is made as accurate as a UPI, it provides an identical capability to identify and access patient data by using its matching keys. Furthermore, the matching keys for an algorithm reveal the identity of (and other information about) the patient whose data they identify, whereas a UPI (being just an alphanumeric value) reveals nothing about the patient. And, in contrast to using personal information, being able to retire a compromised UPI and issue a new replacement UPI should facilitate reestablishing security after a breach of a patient’s health information. 

I understand both parties' concerns.  Unfortunately, this issue comes down to how much privacy you are willing to give up to increase your quality of healthcare.  Do we have to have this trade-off?

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An interesting post, Health Care Renewal: Do Healthcare Organizations Truly Want Electronic Health Records To Succeed?, lists classic reasons for HIT failures that so many of see.  For example:

...the EMR allegedly cannot be used by senior executives to gauge the productivity of salaried physicians and that the senior people feel they do not have a quality system (yet who selected it in the first place?) The end users were apparently not utilized to make the decision nor to beta test or write user requirements, and in retrospect senior leaders are doubting the system was needed at all for ambulatory. No pilot was conducted.

I agree that health care organizations do not fundamentally oppose HIT.  They just do not know how to plan their project, define their needs, acquire the system they require and implement that system successfully.

Applying project and change management best practices help make HIT projects successful. Specific best practices include:

1. Senior executive leadership championing the project
2. User involvement throughout the project
3. Stakeholder involvement during definition of requirements, selection of the vendor system, and configuring, testing and piloting the selected system

It appears the project failed to use any of these best practices.  No wonder there was opposition to this specific project.  That does not mean there is opposition to all HIT.  

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According to the Medical Group Management Association (MGMA), IT Adoption Remains Low as Costs Outpace Revenue for Physicians. Physicians pay the cost for an EHR while other parties reap the benefit.

According to John Halamka:

To make the equation work, payers, hospitals, pharmacies and other beneficiaries of savings have to gainshare i.e. share the ROI with the providers. At BIDMC, I'm paying 85% of the implementation costs of EHRs for community physicians to better align incentives i.e. doctors do the work, the healthcare system benefits from care coordination and hospitals as one of those beneficiaries can subsidize costs.

I agree with this idea, but will this type of formula work industry-wide?  I fear there will be a complex formula that results in unintended consequences.  For example, the NYTimes article on The Pitfalls of Linking Doctors' Pay to Performance illustrates how a good idea can go awry, especially when trying to change human behavior.

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Today's Prescription for Change - WSJ.com reports that healthcare is about to undergo a global information technology revolution. The Journal fails to notice healthcare is in the midst of the IT revolution and is trying to resolve the many barriers unique to this industry.  For example, the article oversimplifies healthcare information exchange challenges. This is not a technology issue. The technology exists that allows information sharing. However, there are no widely accepted and agreed-upon, industry-standards for exchanging data. My earlier post already touched on this problem. Once again the press fails to fully understand a crucial problem and sets expectations beyond reasonable levels, which makes real change more difficult.

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Leapfrog Group recently completed its annual national Hospital Survey, which identifies top performing U.S. hospitals and the challenge of implementing Computerized Provider Order Entry (CPOE).  On October 14, 2008, Bernie Monegain, editor of Healthcare IT News, quoted Leapfrog’s CEO Leah Binder, who said:

“The 2008 findings…indicate that collectively U.S. hospitals still have a way to go in addressing the technology, workflow and cultural challenges of CPOE implementation. We all need to recognize that installing a system is really just the beginning.”

One of the key challenges is overcoming physician resistance to change behavior.  For example, when replacing customized paper order sets with an electronic, evidence-based version, physicians complain that CPOE makes them “order-takers,” who just sign and date documents.  Nonetheless, applying Evidence-Based Medicine (EBM) to order sets:

• Improves patient care by providing easy access to a repository of evidence,
• Reduces costs due to medication errors,
• Increases patient safety by providing standardization at the point of care,
• Aids implementation of evidence-based practice across medical specialties and
• Provides a return on investment by simplifying the physician order set identification, review and approval process.

To successfully change physician behavior we need to eliminate two conditions:

1. Change Avoidance – People are extraordinarily clever at avoiding doing things in a new way in favor of the status quo.
2. Benefit Reduction – Conversely, people who want to get something done can do so despite the cumbersome nature of the change.  For example, physicians can reap the benefits of CPOE even if they must work with an excessive number of alerts. 

Managing CPOE projects requires effectively changing physician behavior, which involves the following:

• Providing physician leadership, who informs clinicians about CPOE benefits,
• Working with and listening to physicians to fully understand how switching to CPOE threatens the way they currently prepare patient orders,
• Taking advantage of this “threat” by offering a beneficial alternative to the status quo, e.g., providing customized, patient-specific, clinical decision information delivered at the point-of-care,
• Implementing the change with a few small teams (e.g., by medical specialty) and subsequently expanding the implementation to involve more teams, and
• Coordinating the change across multiple teams, throughout an organization, until CPOE is fully implemented.

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The University of Michigan's Department of Family Medicine developed ClinfoTracker (now commercially available from Cielo MedSolutions as Cielo Clinic) to provide preventive and disease management services at the point of care. Richard Pizzi summarized the study in HIT News on September 5, 2008.

Although ClinfoTracker is not an EHR it performs some functions that are surprisingly similar.  For example, the September 2008 issue of the Medical Journal of the American Public Health Association reported that the University of Michigan Health System (UMHS) completed a study using ClinfoTracker.  The study concluded that ClinfoTracker Best Practice Alerts (BPAs), such as annual pap smears, flu vaccines and blood sugar testing for diabetics, improve health outcomes. The need for a third party product like ClinfoTracker is an example of how healthcare fails to properly use an EHR and unnecessarily increases cost and complexity of HIT.

Don’t good EHRs include BPAs, call lists, reminders and reports on clinical reminder response rates?  I know of several EHRs that don’t require these types of third party add-ons.  For example, on June 11, 2008, the 2007 HIMSS Public Health Davies Award recipient, Neil Calman, MD, President and CEO
of the Institute for Family Health, described how their EHR notifies providers if patients meeting certain criteria should receive specific treatment.  For example, in 2006 new findings indicated women taking ACE (Angiotensin-Converting Enzyme) inhibitors during their first trimester of pregnancy had a high risk of serious cardiac and other birth defects.  The Institute immediately ran an EHR database report and notified all childbearing age women prescribed ACE inhibitors about this new information. The Institute contacted 220 women about avoiding the potential risk of delivering a child with serious birth defects by changing their medication regimen.

Good EHRs include functions like electronic flow sheets to track patients' clinical problems and BPAs for preventive care over time.  The need for third party HIT, like ClinfoTracker to augment an EHR, just underscores that users often fail to properly define their needs and acquire an EHR that does not support them, or they are not fully utilizing their EHR.

A properly managed successful HIT project for an EHR includes thoroughly:

• Planning the project,
• Defining user needs,
• Acquiring a solution meeting these needs,
• Implementing the system successfully and
• Performing ongoing system and user support. 

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I was recently performing Quality Assurance (QA) on a Healthcare Information Technology (HIT) project. The project manager failed to include change management in their project management plan. I asked her why she omitted this. She said her healthcare organization uses the nine Knowledge Areas from the Project Management Institute’s (PMI) Project Management Body of Knowledge (PMBOK), which does not include change management.

I responded by indicating she included product management Technical Knowledge Areas from the Institute of Electrical and Electronics Engineers (IEEE), e.g., requirements preparation, software testing, and training management, so why not include change management there. We cannot do that, she said, because it requires stakeholder involvement. I explained that is precisely the point. Many HIT projects fail because they do not adequately address change management and required stakeholder involvement.

Change management transforms individuals and organizations from the current to a future state. This is what HIT implementation project are all about. While it goes beyond project boundaries, i.e., change management is permanent and project management only addresses temporary endeavors, all HIT projects embrace the long-term. For example, we work with the vendor implementation team during the project and transfer the deployed HIT to vendor support and maintenance that are responsible for long-term system continuation, upkeep and enhancement.

As project managers, we don’t just hand the system over to support and maintenance; we develop plans, procedures and training, which we execute after successful HIT deployment. We need to address change management similarly during HIT projects. For example, we need to:

• Set measurable objectives at the project beginning,
• Assign project objectives to executive management to ensure accountability,
• Conduct a gap analysis with end users to determine the current and future state,
• Identify key changes by individual clinician and prepare one to two "impact sheets" showing clinicians how the new system affects them and
• Assign “resistance busters” or individuals that work with their peers, who are having difficulty adjusting to the new system.

We shouldn’t stop at deployment. We need to continue, just like system maintenance, and employ ongoing process improvement throughout the life of the implemented HIT.

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Successfully adopting and sustaining Healthcare Information Technology (HIT) rarely happens. The New England Journal of Medicine recently reported that only 4% of US doctors fully utilized an EMR.  Why does this happen? Post mortems frequently cite project management failures and user dissatisfaction.  For example, Mark Anderson, CEO of the AC Group, Inc. discussed the slow adoption rate of EMR in terms of charting a patient with paper and pen is typically faster than with a computer.

Slow HIT adoption rates raises two questions. How do we improve project management and how do we increase user buy-in? As examples, limited stakeholder involvement reduces project management effectiveness, while neglected workflow redesign erodes user satisfaction. The prevailing attitude of Not Invented Here (NIH) complicates both problems. NIH is the cultural bias of an organization refusing to consider something because it originated elsewhere.

We cannot end project management failures and user dissatisfaction without first overcoming the NIH culture in healthcare organizations. Managing healthcare organizations has many unique challenges. For examples, the industry is extremely information intensive, there are many large and small organizations that must work together, clinical and administrative management often have conflicting objectives, patient care is fragmented and complex, the industry is heavily regulated, privacy is paramount, etc.

Every industry has its unique problems, but they share many common project management and user satisfaction issues with healthcare. Focusing on the uniqueness of healthcare limits taking advantage of project management and user satisfaction best practices in other industries. For example, conducting a stakeholders analysis helps maximize the strengths and minimizes the weakness of stakeholders. Engaging users during planning, definition, acquisition and implementation gives them a vested interest in project success.

How do we as an industry solve the NIH problem together? We must start by saying NIH is not so. It limits us. It is not correct. It is based on a false premise. We must understand we have much in common with other industries. We have to look to successes in other industries and be willingly to apply appropriate best practices or HIT will continue to fail.

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 efore I taught a nine-week course on project management for health care IT, I contacted CIO’s of major hospitals and asked them what project management skills I should teach that most recruits are missing?

My students are mid-career clinicians that seek a role in IT project management. They want to manage health care IT projects to improve patient care and increase patient safety. For example, the Director of a Bone Marrow Transplant Unit and the Director of Clinical Operations each want to manage end users through all phases of an EMR project in their respective hospitals. After 10 to 15 years as clinicians, they are back in school in the Master of Science program on Clinical Informatics and Patient-Centered Technology at the University of Washington.

• The CIO’s responded to my question with the following list of skills:
• Leadership,
• Listening,
• Oral and written communications,
• Team building,
• Conflict resolution and management,
• Critical thinking and problem solving,
• Understanding and balancing priorities,</li>
• Balancing the big picture with attention to detail,</li>
• Understanding stakeholders' needs and</li>
• Change-readiness.

Responses emphasized the importance of "soft" skills, which tend to influence how people interact with each other. In contrast, there was significantly less emphasis on "hard" skills, i.e., more concrete technical capabilities, such as effective use of Microsoft Project software.

Everyone singled out the principle that the focus of projects is on how business changes, not on the technology used as a tool to support that change.

The most important tools and techniques identified included:

• Scheduling,
• Requirements definition,
• Issue tracking,
• Status reporting,
• Project costing and control, and
• Risk analysis and control.

Almost all of the CIO’s identified the need for a project management methodology flexible enough to meet the needs of their culture, for example a mix of Institute of Electrical and Electronics Engineers (IEEE), Software Engineering Institute (SEI) Capability Maturity Model Integration (CMMI) and Project Management Institute (PMI) best practices. No one cited strict adherence to a single methodology as a workable approach.

The majority considered the best project management background to include versatile individuals who have deep clinical/business knowledge that understand IT. One individual cited that an excellent source for a project manager is administrative operations where you have a detailed understanding of business processes required "to get the job done", e.g., managing central supply, purchasing or facilities management.

The response from the CIO’s did not surprise me. Most project management methodologies focus on the tangible because it is too easy to convey. The intangible, while less easy to express and learn, is just as important and requires equal time in the methodologies and while managing projects.

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