IT is an enabler of change and not the change itself. When customers look at IT as the one solution to all their problems, it is set up for failure from the beginning. Introducing an IT system necessitates an in-depth study of existing workflows, roles and responsibilities and change management aspects in every speciality.
Healthcare IT implementation is complex, interlinked, domain sensitive and clinician focused, thereby being different from other IT implementations. The generally high failure rate for IT implementations tends to be higher in healthcare due to this complexity.
Clinicians need to be involved actively from the requirements gathering phase and given ownership of clearly defined sub areas within the project to be successful. IT should be a tool to transform healthcare delivery model and not expected to be a solution by itself.
HCIT Domain intensive
Healthcare is an environment of trust wherein many actions are performed without being specifically asked for. The single point of focus for all clinicians is the patient and roles are synchronized, each one playing a small but significant part in the care process. A study found that when a patient walks into a healthcare facility, is registered, vitals taken by nurse, seen by doctor, takes medicine from pharmacy and walks out 50+ people have to work in harmony for this to happen successfully.
Intensive training ensures that the personnel on the ground know exactly what is expected of them and they do that role with conscience. In contrast transactions in banking or the travel industry are simple and straightforward. Clinicians ranging from doctors, nurses, pharmacists, technicians in lab, operation theatres, dialysis centres, and emergency services have varying data needs and data recording responsibilities.
When a doctor charts his patient for the first time he goes into details on illness, past history, allergies, drugs being taken by patient, builds a problem list, identifies/ lists differential diagnosis, plans lab/ radiology investigations and prescribes initial treatment. The methodology followed is standardized during his training and practice over the years ensures that it comes naturally while examining a patient.
Nurses also train on similar lines to examine and document key information on the patient initially and then as patient moves through the system. The data that is recorded by each clinician is useful to take decisions for the patient and is used by the entire team. As clinicians become experienced most of this data processing is done without actually recording it on paper and it is known that consultants record only key points in their patient records.
When HCIT requirements have to be gathered in such an environment they should be involved early as only clinicians understand the significance of each piece of information. Many tools are available to assist the clinicians during the course of their work and it is important to note that none of them are mandatory. HCIT is also a tool, which if not user friendly tends to be ignored.
HCI (human computer interaction) has to offer better ways to input data as the traditional mouse/keyboard system does not fit into the busy healthcare environment. Speech recognition is now being used in radiology reporting and touch screen systems are being deployed in operation theatres and ICUs to gather data without the clinician having to actually sit and type.
Clinicians have been known to be resistant to change for ages. As an example, usage of stethoscope amongst the medical community took almost 100 years. If the systems that they are expected to use in their daytoday work is unfamiliar to them and takes too much of their time, without tangible benefit, there is a very serious risk of non usage. Every clinician has to see clearly the benefit that will accrue to his / her work to adopt a new system. Resisting change is natural and it is seen in a greater degree within healthcare.
‘Clinician champions’ have to be identified within the customer’s staff who will lead the implementation and support their colleagues later on. The resistance to change is often because of three broad reasons: political, technical and attitude. If the new system upsets an existing hierarchy or even gives an impression of doing so, it can be a serious risk.
Technical reasons such as lack of training, not being comfortable with using technology, HCI (human computer interaction) factors such as clinicians in the operation theatres being expected to remove their sterile gloves to type can also jeopardize a project.
Attitude is a subjective phenomenon and usually can be overcome by peer pressure and strict enforcement of policies. Once clinicians see the benefits they tend to voluntarily train their teams and the rate of knowledge transfer then goes up significantly. This is after all the existing culture within healthcare where peer support and sharing of best practices is common.
HCIT procurement should be done by knowledgeable personnel who see the big picture and can build a system incrementally. In the western countries it has been seen that departments usually acquire systems individually starting from radiology, cardiology then laboratory and finally the HIS / EMR. None of these systems are expected to communicate with each other initially and after significant cost, effort and time has gone into implementing it the results could be diverse systems that cannot communicate.
Rather than follow a big bang approach it has been observed that incremental adoption with the larger picture in focus assures success. It is imperative today that all systems communicate freely amongst themselves and also with external systems. Most facilities have homegrown basic billing HIS systems but clinicians are not exposed directly to these systems. Technology savvy specialties such as Radiology, Cardiology, Anaesthesia and Lab medicine should be starting point for a HCIT solution. Such pioneers are excellent ‘User Champions’ for future more complex specialties.
It is futile to incessantly discuss the many reasons of why HCIT solutions are not useful in healthcare. Success stories and proven benefits of HCIT implementation need to be highlighted to build customer’s confidence in adopting a HCIT solution. It has been seen that instead of trying to force fit a solution on existing workflows, a system that can adapt to and respond dynamically to end user needs is liked and used by clinicians. Existing HCIT solutions have limitations on their configurability, nevertheless when products are extensively customized; it becomes difficult to maintain the product over time.
A fresh approach to building HCIT solutions which are easy to customise, can be hosted on a cloud and paid for on a utility model (payasyougo/case by case) and preferably allow clinicians to tailor on their own with minimal IT support is required. With the advent of Web 2.0 (Read and Write) and Web 3.0 (Read, Write and Run) technologies and customers using Facebook, Twitter, YouTube, Apple iStore etc. the same is now expected from HCIT vendors. Author has personal experience of Anaesthetists requesting data mining features with dragdrop tools to create queries/reports on their patient data which is then used for research and academic presentations.
The government has to play a regulatory role and help identify ‘EMR Interoperability standards’ after studying the globally available standards and identifying those that are relevant, affordable in the long run without any strings attached and mandate their use by HCIT vendors. Patient data has confidentiality and privacy implications which need to be covered by Government with a legal framework.
The newly enacted addenda to IT Act 2000 which mandate vendors to take necessary and reasonably good measures to protect patient data is timely. Ownership of patient data is an unresolved question globally but the consensus has been to retain ownership of data with patient with government being a guardian for that data.
Learning from Aviation / Nuclear / Space industries
We need to learn from our predecessors who have taken the failure bull by its horn and controlled what was given up as impossible earlier. Aviation industry had some depressing statistics before FAA (Federal Aviation Authority) stepped in to rein in the problem. The FAA conducted due diligence and created open reporting mechanisms to identify problem areas which then went on to become starting points for other interventions.
Nuclear industry by nature is risky and allows no scope for slipups. Enforcing safeguards, defined protocols, ongoing training to keep personnel updated on latest skills has resulted in safety. Space industry is intrinsically dangerous and failure rates were high initially. NASA today has managed to mitigate these risks and regularly sends rockets and shuttles to space. The key is to take a holistic view of systems and blame the system and not the user of that system when failures do occur.
Transforming healthcare with IT
IT is an enabler of change and not the change itself. When customers look at IT as the one solution to all their problems, it is set up for failure from the beginning. Introducing an IT system necessitates an in-depth study of existing workflows, roles and responsibilities and change management aspects in every speciality. IT is but another tool available to transform healthcare and when its role (and limitations) is understood the chance of success increases.
A clinician who leads HCIT implementation on a full time basis starting with initial seeding of idea amongst clinicians, brainstorming with them implications of introducing the system into workflows, hand holding during the implementation and ongoing support post ‘Go Live’ should be minimum criteria in HCIT implementations.
Just mapping the paper based workflows to IT and replicating it does not allow clinicians to fully utilise the complete capabilities that IT brings in. New ways of working such as real time chat on social networking sites such as Twitter and SMS can allow clinicians to interact and mutually support each other while delivering care. Document once and reuse infinitely, auto calculating all variables, adding layers of security to ensure role based access are all possible only with HCIT.
The realisation that has dawned on health informaticians today and backed up by research is that HCIT implementation should not be treated as another IT implementation. The domain is complex, most work happens like clockwork without much communication (for example when a surgeon operates, the nurse assisting him knows exactly what instrument he needs next). Thus clinician lead HCIT implementations are realising higher success rates. Medical Informatics workforce is nonexistent today. A separate cadre of foot soldiers who can man the posts is required as bridging clinical and IT worlds, is difficult. ONCHIT is spending billions to encourage academic centres to churn out this workforce in USA.
NHS in UK supports employees to acquire additional informatics skills as it is clearly required to practice in tomorrow’s healthcare world. India has the opportunity to recognise this need and use our excellent educational system in public and private sectors to train HCIT manpower at different skill levels using modern teaching resources such as on demand learning and online delivery systems. The demand for this manpower has always been much higher than what the system has been able to provide.
HCIT is no different from other IT implementations in that it is also force fitted on existing systems without understanding fully all the ramifications of doing so. The interlinked and mutually supportive healthcare environment where trust on peers and a single minded focus to work for one goal – patient care without direct orders is an amorphous beast to an outsider to healthcare: the IT person.
A fresh approach to HCIT product development is required where the product can quickly meet the clinician’s need. Actively involved clinicians, HCIT trained manpower and HCIT aware clinicians can transform healthcare today; it is not an option but an idea whose time has come.
The article has been published here with Dr. Thanga Prabhu’s permission