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?

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).

• 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

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?

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
• 
  

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

• 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.

• Initiating
• Planning
• Executing
• Controlling
• Closing

I apply these process groups regardless of project type (e.g., healthcare IT, construction, event planning).

Product management is the "tangible result" of a project. I teach this using the Institute of Electrical and Electronics Engineers (IEEE) technical process groups focusing on:

• Planning
• Designing
• Developing
• Deploying
• Supporting
• Retiring

I apply these process groups based on product type. For HIT I use the Capability Maturity Model Integration for Acquisition (CMMI ACQ) standard.

Change management is how "people" transition from a current to a future state. Because there are no formal process groups, I teach this by focusing on:

• Vision - Defining the problem and identifying the endpoint at the project beginning
• Leadership - Communicating, demonstrating and motivating
• Consensus - Involving front-line and middle management in defining what the project includes and excludes and how they will get there
• Training - Creating individualized training, avoiding technical solutions to human problems, making the environment safe for emotional expression and learning from resistance
• Workflow Improvement - Providing improvement tools during and after the "project" is over

Change management applies to both projects and products.

Hoping future HIT project managers (and the projects they manage) will succeed by only teaching HIT project management is not enough. We must use an integrated approach that combines the disciplines of project, product and change management.

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.   

I think about these questions constantly and try to come up with answers.  Some others are doing the same -- for example, in their Capability Maturity Model Integration - Acquisition, version 1.2, November 2007, the Software Engineering Institute at Carnegie Mellon University stated:

According to recent studies, 20 to 25 percent of large information technology (IT) acquisition projects fail within two years and 50 percent fail within five years. Mismanagement, the inability to articulate customer needs, poor requirements definition, inadequate supplier selection and contracting processes, insufficient technology selection procedures, and uncontrolled requirements changes are factors that contribute to project failure. Responsibility is shared by both the supplier and the acquirer. The majority of project failures could be avoided if the acquirer learned how to properly prepare for, engage with, and manage suppliers.

Based on my own experience in HIT acquisition management, I believe another significant area overlooked is change management (how to transition people from the current to the desired future state).  I mentioned several examples for managing change in an earlier post, like:

• Providing physician leadership, who informs clinicians about HIT benefits,
• Working with and listening to physicians to fully understand how switching to HIT 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 HIT is fully implemented.

Despite seemingly obvious proof that there is a better way, we continue spending valuable time and money without applying best practices and standards to our HIT projects.  Why do we do this?

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?

...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.