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

The Institute of Medicine (IOM), a non-governmental organization that is part of the U.S. National Academies, published a landmark study in 2000, To Err Is Human, Building a Safer Health System. This study, particularly the statistics that 44,000 to 98,000 people die every year as a result of medical error, made patient safety and error reduction priority issues in health care.

Recommendations from this IOM report focused on leadership in government and the health care industry setting a national agenda for reducing errors in health care and improving patient safety. One key outgrowth of this study was effective use of information technology and sharing information among different systems to improve patient safety. In response to this, we have projects underway, e.g., Health Level 7 (HL7) has Medical Markup Language (MML), based on XML for information sharing.

How Did Criminal Justice Agencies Do It?

In 1965, President Lyndon Johnson's Great Society program addressed, among other issues, control and prevention of crime and delinquency. This included a government-funded program to facilitate the exchange of information among criminal justice agencies. It was not until post-9/11 government programs that we saw widespread success. Prosecutors now routinely exchange case information between their own systems and separate systems maintained by law enforcement, the courts and public defender agencies.

A partnership of government agencies and private industries created the precursor to the National Information Exchange Model (NIEM), funded by the Department of Justice (DOJ). NIEM effectively and efficiently expedites sharing critical information at key decision points throughout our nation's justice, public safety, emergency and disaster management, intelligence and homeland security enterprise. The purpose of the public/private partnership was to design develop, disseminate and support enterprise-wide information exchange standards and processes that enable jurisdictions to automate information sharing.

NIEM is not software programs, databases, networks or computer systems. NIEM is cooperation. Through the cooperation of a public/private partnership, we created NIEM and criminal justice agencies now efficiently share information more cost-effectively,improve operations and maintain information for better decision-making. We now have more timely, accurate and complete information to enhance our citizens' safety.

Where Is the Health Care Industry?

We are now in our eighth year since IOM released their ground-breaking study and we have yet to establish and implement an effective solution for sharing information. Why can't we take advantage of the lessons learned from our criminal justice community and NIEM and implement a similar solution that enhances our citizens' safety in health care?

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.

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.

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.

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.

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.  

According to a Brookings Institution forum, HIT will not provide quality and cost benefits unless we change the healthcare environment.  The Forum underscored the fact that HIT is just a tool.

We need to stop all the misleading media promotions, advertisements, political rhetoric and tendencies about HIT as the ultimate solution that will eliminate healthcare costs and improve patient safety.  Unfortunately, HIT’s potential is often greatly exaggerated.  This distracts us and focuses our attention on an overly ambitious attempt to replace a paper record or medical decision making with the "magic" of HIT.  This does not work.  What HIT does is enable professionals and organizations to accumulate data-elements into meaningful information and to coordinate complex interactions. For example, HIT helps collect and enter data into graphs and reminders.  These improvements link doctors, nurses and patients across different organizations and time.  

We need to put HIT back in perspective and focus on its strengths as a tool that can practically support health care professionals.  There is a fundamental conflict between the "messy" nature of healthcare work and the formal, standardized and comparatively rigid nature of HIT.  We must balance and adjust our perspective on HIT and how it can help healthcare professionals work.   

The American Medical News reported today that 'Physician Champions' Key to Successful IT Implementation. Well dah!!! HIT industry professionals continue to argue that this industry is unique. While there are many unique attributes to healthcare, why do we keep re-inventing the wheel and identifying project management best practices as something new?

One existing solution is HIMSS. It is a great organization that prepares and maintains best practices for HIT acquisition, contract negotiations, project management, etc. Why aren't we taking advantage of resources like this?

A client of mine once called HIT procurement "a hideous business." She was talking about the abysmal and often unsuccessful process of planning through implementation for a Commercial-Off-The-Shelf (COTS) procurement. I agree with her assessment. It has always been awful, but it doesn't have to be that way. In fact, if we concentrate on doing it well, we can increase HIT success.

I did my first HIT acquisition about 25 years ago. I used a word processor and paper and pencil. It was hideous. I've lost count of the number of my procurements since then, but I decided to make my life easier by starting my own IT acquisition project management company over 15 years ago.

I thought the Project Management Institute's (PMI) Project Management Body of Knowledge (PMBOK) would offer some insight. I was mistaken. In fact, this is probably one of the weakest Knowledge Areas defined in PMBOK (a topic for another blog post). Suffice it to say, I decided to create a web-based software toolkit to support a better IT acquisition approach.

When I got into it, I realized it really was two different approaches.

The first is conventional, like this:

This approach focuses on specifying and acquiring an HIT solution. You prepare line items to describe all user, technical, administrative, contract and any other requirements. You then organize these line items in a database of categories and subcategories and present them for vendor response, subsequent evaluation and selection. Using this database makes the acquisition process easier. It eliminates such problems as reconciling RFP documents, paging through hard copy responses to conduct vendor evaluations, documenting your solution selection, etc. This significantly helps with acquisition. It does little to directly increase HIT implementation success.

The second approach is scripted, like this:

This approach uses scripts to describe your user requirements and line items for all other requirements. You provide these requirements for vendor response, then supplement automated vendor scores with scripted demonstrations for solution selection. This involves users in demonstrations that help them see the best solution in context. This approach directly improves HIT implementation by: Defining measurable objectives, outcomes and risks Preparing user requirements directly tied to project objectives Assigning responsibility for objectives Verifying vendor delivered solutions against contract specifications Identifying and comparing current and future states Improving system adoption by identifying the impact of workflow changes on individuals

Get more information on how this electronic RFP can work for you.

The Institute of Medicine’s (IOM) 1999 publication, To Err is Human, reported that 44 to 99 thousand people die annually due to preventable medical errors costing between $17 and $29 billion yearly. Healthcare is currently in a quality, safety and cost crisis. One IOM recommendation included using HIT to help end this crisis.

• Technology Management – What the project produces, i.e., the hard skills that are tangible and so much easier to address when compared to soft skills, and
• Change Management – How people transition from a current to a future state, i.e., the soft skills that are generally intangible.

Successful HIT requires broadening the definition of project management to include technology and change management. The Project Management Institute (PMI) and the Institute for Electrical and Electronics Engineers (IEEE) provide industry standards for project and technology management, respectively. There are no industry standards for change management. We are on our own to define techniques for successful HIT change management.

Based on my 25+ years of experience, I created the following formulas, which I hope will help others successfully manage HIT change. These include the following:

Successful Change

Unsuccessful Change

Successful HIT requires broadening the definition of project management to include technology and change management. The Project Management Institute (PMI) and the Institute for Electrical and Electronics Engineers (IEEE) provide industry standards for project and technology management, respectively. There are no industry standards for change management. We are on our own to define techniques for successful HIT change management.

Based on my 25+ years of experience, I created the following formulas, which I hope will help others successfully manage HIT change. These include the following:

Successful Change

Unsuccessful Change

My previous posts defined specific ways to address change management. Now it's time to identify ways to integrate them into the five the Project Management Institute (PMI) Process groups so project managers can use them in HIT project, as follows:

Vision includes:

• Providing a plan for the future with the project as a strategic focal point
• Establishing stakeholder commitment before, during and after the project
• Defining objectives and measurable outcomes to be achieved during and after the project
• Assigning objectives to accountable senior executives
• Measuring executive performance by achievement of objectives

• Understanding that an organization structure is a social construct
• Knowing that people instill this structure with ethical order, e.g., rules and relationships
• Realizing people resist change to this ethical order
• Recognizing that crisis, such as a new system deployment creates an opportunity for change
• Being an ardent project supporters or champions of this change
• Focusing energy to take advantage of opportunities provided by crisis
• Offering a new ethical order facilitating change in a nonthreatening way

Consensus includes:

• Involving stakeholders from all levels of the organization
• Requiring teamwork for project tasks, e.g., scope, time, budget, requirements, issue, risk definition
• Involving members from all parts of the organization to increase their personal stake in successful project outcome

Training includes:

• Providing individualized support (e.g., designate “barrier busters” to work with those having a tough time adapting to the new system)
• Using individualized “impact sheets” showing the before and after impact of the system on a particular person’s work. This includes designing individualized impact sheets demonstrating what will and what will not change like the following:

• Creating ongoing workflow improvement teams
• Selecting improvement areas
• Conducting system demonstrations
• Preparing draft workflow improvements
• Obtaining Subject Matter Expert (SME) input
• Encouraging widespread stakeholder review to confirm SME input
• Updating and implementing the improvements
• 
  

My previous posts defined specific ways to address change management. Now it's time to identify ways to integrate them into the five the Project Management Institute (PMI) Process groups so project managers can use them in HIT project, as follows:

Vision includes:

• Providing a plan for the future with the project as a strategic focal point
• Establishing stakeholder commitment before, during and after the project
• Defining objectives and measurable outcomes to be achieved during and after the project
• Assigning objectives to accountable senior executives
• Measuring executive performance by achievement of objectives

• Understanding that an organization structure is a social construct
• Knowing that people instill this structure with ethical order, e.g., rules and relationships
• Realizing people resist change to this ethical order
• Recognizing that crisis, such as a new system deployment creates an opportunity for change
• Being an ardent project supporters or champions of this change
• Focusing energy to take advantage of opportunities provided by crisis
• Offering a new ethical order facilitating change in a nonthreatening way

Consensus includes:

• Involving stakeholders from all levels of the organization
• Requiring teamwork for project tasks, e.g., scope, time, budget, requirements, issue, risk definition
• Involving members from all parts of the organization to increase their personal stake in successful project outcome

Training includes:

• Providing individualized support (e.g., designate “barrier busters” to work with those having a tough time adapting to the new system)
• Using individualized “impact sheets” showing the before and after impact of the system on a particular person’s work. This includes designing individualized impact sheets demonstrating what will and what will not change like the following:

• Creating ongoing workflow improvement teams
• Selecting improvement areas
• Conducting system demonstrations
• Preparing draft workflow improvements
• Obtaining Subject Matter Expert (SME) input
• Encouraging widespread stakeholder review to confirm SME input
• Updating and implementing the improvements
• 
  

The medical home dictates that the primary care physician manage a patient's care across multiple providers. To achieve this successfully we must help providers improve care using HIT.

For example, primary care physician cannot manage their patients effectively without a flow sheet. They need clarity as to the flow of their patients, the procedures related to each visit and the outcomes. With the medical home, the flow sheet challenge becomes exponentially more demanding due to increased scope of primary care physician responsibilities. EHRs include flowsheets, but who will identify the technology for clinicians? Who will provide the funding? Who will manage the HIT project, technology and change management? Health Information Exchange (HIE) is another critical technology for successful implementation of the medical home. The medical home will stumble without the efficient exchange of medical information amongst physicians.

Are payers willing to help clinicians with this technology? Payers have the money, but they rarely work cooperatively with clinicians. The issue comes down to payers making a long-term investment to the detriment of short-term profit. Will they make this sacrifice?

The Healthcare Information Systems Society (HIMSS) requested that I speak on Project Management: Ensuring HIT Sustainability Beyond "Go Live" at their 2009 Conference on April 4th. I am really excited about this opportunity to work with my co-presenters, including:

• Kim Brant-Lucich, PMP, 
Director of Process Redesign, St. Joseph Health System


• Charles Garrity, 
Senior Manager, Beacon Partners, Inc.

• Anil Jain, MD
, Managing Director, e-Research, eCleveland Clinic, Director, Quality and Research Informatics, Medicine Institute

I’ll focus on tying HIT project, technology and change management together. Kim will talk about process improvement, Chuck will tackle ROI and Anil will provide a clinician’s perspective.

I am also speaking solo on this topic for the Project Management Institute (PMI) Healthcare Special Interest Group at their March 5th Webinar.

I encourage my readers to attend these and other similar sessions to help advance these important topics and ultimately improve the success of HIT projects. Take a look at this draft and let me know what you think.

Reposted from Get Ready for EHR Failures, But Don't Blame the Software at Software Advice for Electronic Medical Records.

With the Economic Stimulus Bill signed and available to subsidize EHR purchases (for more information see "The Stimulus Bill and Meaningful Use of Qualified EHRs/EMRs"), we are seeing a dramatic increase in electronic health records (EHR) buyer interest. Assuming these buyers make use of the stimulus subsidy to buy an EHR, we expect to see a lot of EHR failures over the next couple years.

Don't get us wrong! We are HUGE advocates of EHR technology. Doctors should be using EHRs. The stimulus subsidy is great. EHR software programs (and software companies) are not the problem.

Our concern is that the subsidies won't change healthcare providers' late adopter mindsets about information technology. Providers may jump at "free software" and try to avoid penalties (starting in 2015), but will they:

• Truly believe in the value of an EHR over traditional paper charts?
• Take a leadership role in advocating adoption of the new EHR in their practice?
• Change their old workflows to match the best practices in leading EHRs?
• Take part in intensive training to learn the new system?
• Ride out the difficult stages of new software adoption and change management?

Traditionally, the substantial costs of EHR systems keep the luddites from buying technology in the face of these challenges. But with "free" EHR software, we expect more than a few providers to throw caution to the wind, buy an EHR and overlook the critical implementation and change management practices that are critical to success.

The best things in life are free, but that doesn't refer to healthcare IT. We think providers would be far more serious about implementation and adoption if they had to pay dearly for the technology.

Accordingly, here are our thoughts on why IT projects fail and how providers can avoid that fate while still capitalizing on this once-in-a-lifetime subsidy.

When and why do IT projects fail?
In 2007, the U.S. Office of the National Coordinator for Health IT reported that about 50% of EHR implementations failed. IT industry analysts widely agree that software implementations fail because of the customers. It's too easy to point the finger at software vendors or at the software itself, but failure usually is the buyer's fault. In a recent survey, one group identified the following top reasons for IT implementation failures:

• 40% attribute failure to poor planning and communication;
• 20% cite mismanagement and rejection by end users; and
• 15% blame overspending.

Very few doctors use EHRs. In fact, most predictions put EMR market penetration at 10%-15%. We all know why this figure is so low: doctors don't want to use them, practice staff is stuck doing things "the old-fashioned way," etc. Now that Uncle Sam is willing to pay for EMRs (and telling us we had better buy!), a lot more practices are going to adopt them. The scary thing, however, is that the same feelings that have slowed the adoption of EMRs are still prevalent.

Here let me present what I think are 5 critical steps for a smooth, successful EMR implementation:

1. Become a project manager. If you're a physician, you may not consider yourself a business person. However, for this project, you need to become a project manager. If you're lucky, you may have a staff member or consultant that can play the role for you, but don't count on it. First, create a project plan. Outline all the steps of your implementation so you know what changes need to occur by certain deadlines. Stay on top of the plan and hold your team accountable.
   
2. Rally everyone else. Recall that poor leadership and lack of user adoption are frequently cited as contributing factors to IT failures. You need to express confidence in the technology and get your staff on board before the implementation. Show how much easier their lives will be. Get them excited about it. Tell your patients that next time you see them, you will be a computer whiz with a slick EHR.
   
3. Buy the best training you can. The government is paying for it (laugh). Seriously though, you will need the help. It's too easy to skimp on adequate training and ongoing support. Don't risk failure of an investment because you want to save a few thousand bucks. It's worth it. Get trainers in the office, send the staff to training, implement a train-the-trainer program.
   
4. KISS: Keep It Simple, Stupid. No office becomes paperless overnight, so don't try to do everything at once. Ease into your new workflow as much as you can. Adopt advanced features after you learn how to turn on the computer. It is OK to implement bells and whistles after the initial dust has settled.
   
5. Be prepared to practice differently. As much as you don't want to admit it, you will need to adjust the way you meet with patients and how your practice operates. And if you can, make easy adjustments ahead of time. Start carrying a tablet PC or dictating with voice recognition software. It pays to work out the kinks early on.

If you follow these major guidelines - and a lot more small steps in between - you'll have a much greater chance of EHR success. Most importantly, wrap your head around being tech savvy and enjoying the new system. If you don't, you'll pay for it (one way or another).

On March 25, 2009, the New England Journal of Medicine (NEJM) confirmed that we continue to have low Electronic Medical Record (EMR) system adoption rates in our nation’s hospitals.

I’ve posted several times about previous studies confirming this.  For example, the 2008 Annual Hospital Survey from the Leapfrog Group and the NEJM 2008 study on Electronic Health Care Records In Ambulatory Care made this same point in different care settings.  

The healthcare industry just doesn’t get it. One comment from the American College of Physician Executives 2009 Health Care Technology Survey summarizes why we are so unsuccessful:  

My physician and administrative staff has been requesting an EMR for 4 years. We are continually met with the response from IT, “it’s too hard to integrate the systems, we don’t have the resources”, I find it ironic that we continue to meet increased patient demand - efficiency and care measures - while trying to limp along with IT systems that are woefully inadequate. Those in charge of IT decisions are not involved in clinical care and are not await [sic] of the front line user problems/issues. When these issues are brought forward, the IT department appears to carry more weight than patient clinical care…

We need to combine project, technology and change management disciplines to be successful with HIT. Why do we keep missing this critical point?