NPR recently produced a piece on meaningful use and the drive in the United States to get all providers to adopt Electronic Health Record (EHR) and Health Information Technology (HIT). The impetus is a simple carrot and stick strategy. Early adopters receive a payment incentive while late adopters will be penalized up to 5% from their reimbursement. The article focuses on the considerable population of clinicians that lament HIT and the underwhelming benefits that the government and vendors have promised.
Naturally, this is a subject very near and dear to my heart. In case you missed my earlier post, my primary responsibility is in managing the lifecycle of clinical information systems. While I cannot share any specific materials, I do want to discuss 5 very striking lessons I’ve learned in the past few years:
1.SCOPE: The moment you settle for more, you’ll get even more.
Maureed Dowd famously stated that the moment you settle for less than what you deserve, you’ll get less than what you settled for. In project scope management, the reverse is also true: the moment you expand your scope beyond what is required, you can expect to do even more work than the expanded scope. Most of us project managers can commiserate with this statement. How often do we agree to add a new application to our system and discover hidden service charges or human resource requirements to administer the application after it’s up and running? The point isn’t to discourage folks from adjusting your scope according to the user’s needs. The lesson is to point out that even a request that appears seemingly simple and straight-forward can avalanched into a massive scope creep.
2.Quality over Quantity
There are different schools of thought when it comes to implementation strategies. There are monolithic, big bang implementations and on the other end of the spectrum, there are the best of breed, phased implementations. While the larger implementations tend to garner most of the attention, we’re also very much aware of their failures.
Merging technology and healthcare is not merely a hardware/software installation. It’s a cultural change and it cannot be forced. If we look at the failed roll-out from Cedar Sinai’s big EHR push, the problem was NOT technological. It was a cultural one. Providers were simply not ready to adopt. Would you expect your 85 year old grandpa to start buying grocery via the latest tablet PC or google glass within a month? If your answer is no, then how can you expect an 85 year old physician to start using these high tech systems to treat a patient?
My great-grandfather was alive when Henry Ford first produced the Model T. One thing we can count on is that technology changes and it’s happening rapidly. The healthcare technology arena is no different (with a few bureaucratic exceptions). The lifecycle of implementing a new system may be LONGER than the life of the technology itself. How crazy is that? Imagine buying the latest and greatest big screen TV and learning that the moment you install it at home, it’s already beyond manufacturing support. Yes, this happens more often than you’d think.
Lastly, the human brain is wired to focus on the immediate threat and satisfaction. This applies to the providers and clinical users as well. What this suggests is that your users will be more aware of the ISSUES of the system versus everything that is functioning according to spec. Bridging this back to lesson number one, how frustrating might it be that your users write off the whole project as a failure only because the scope creep was not successfully implemented?
In HIT implementation, the small things count just as much as the bigger picture. Often times, your success (and satisfaction) rate is much higher when you focusing on delivering that high quality low hanging fruit.
3.Design with Democracy, Implement with Dictatorship
Project managers have to take on different roles throughout the lifecycle of a project. One of the longest standing problems in HIT management is the chasm between IT and Healthcare. IT is logically organized and standardized. Healthcare is a statistical art form. As much as we like to think that there is an absolute medical answer to all of our health questions, it’s merely a best “estimate” on a bell curve. In fact, over the past few decades, the medical field has become increasingly specialized and subspecialized beyond recognition. HIT is a not a one-size fits all solution for healthcare. Your Ophthalmologist might need local storage access because of their patient volume and turnaround time. Your nurses may prefer a thin or web-based client that is accessible everywhere. The point is that a successful HIT solution stems from the clinical service and the workflow itself. That’s where the low hanging fruit sits.
4.Projection can be Misleading
Our fourth lesson is one that is applicable to all elements of our professional and personal lives. Everyone views the world through their own perspectives and values. Peter Drucker calls it framing. In an ideal project, the whole team shares a frame. Frames also clash and the dominant frame is NOT always right. When you evaluate a decision based on your frame, you are projecting. Just like how our brains are wired to only focus on the negatives (Lesson 2), our projection is often limited by our frames. You may have encountered this scenario when you’re advised to not try something because your advisors have never seen it work or that you should definitely try something else because they have seen it work. Project managers have to be keenly aware to not project their own limited capacity onto their clients and eliminate a potentially great solution.
5.Relationship is Everything
When your UBER driver pulls up, do you hesitate about getting into a stranger’s car? When you use Airbnb and live with a stranger, do you wonder if the host may have skeletons in the closet? The reality is that we are progressing more and more into a trust-based economy and your relationship is your currency. I recall working with a particularly difficult individual early on in my HIT career. He would always prioritize my request on the bottom of the stack. In many occasions, I was on the brink of escalating the situation with his supervisor (there is a time and place for this) but I did not. Reluctantly, I ended up visiting his office so we can discuss issues face to face. In that instance, I learned about the complexity of his job and the bureaucratic hoops that he needs to jump through to achieve my requests. Overtime, I made a concerted effort to learn his lingual and submit my request in a way that makes his job easier. This resulted in a much faster turnaround time and ultimately, a trust-based relationship. Contents and processes can be learned, but relationships takes time and mutual understanding. As the world is becoming increasingly complicated, you can’t learn everything so learn how to ask for help. What separates a good manager from a great manager is your ability to cultivate relationships so you can make good logical AND emotional decisions.