Beyond Medical Informatics

Wow, I almost missed this one!

One of the original designers of the US Department of Veterans Affairs VistA system, Tom Munnecke shares his lessons learned from working with Vista (via http://www.fiercegovernmentit.com).

Here’s my quick summary:

• Build the system in a series of small steps. He calls this “Evolutionary development”
• Start with “good enough” and work fast to improve the system from there.
• Health information systems often have totally different requirements from other complex IT systems. (He proceeds to discuss the EAV model, although it was not directly named as such.)
• MUMPS may be old but it has proven itself in the field of medical informatics.

Definitely a great read!

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What do you think? Can you relate with the lessons? Are they true for you?

From: PubMed Advanced Search Page Modified. NLM Technical Bulletin. 2010 May–Jun.

The PubMed Search Builder section of the Advanced Search page will soon be modified to provide users with a more cohesive method to build searches.

This should help make searching easier. I should start upgrading my PubMed searching skills.

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Found a new e-Journal: Applied Clinical Informatics

ACI (Applied Clinical Informatics)

As the Official eJournal of IMIA and AMDIS, the online journal ACI will publish approximately 100 peer reviewed articles per year. It aims to establish a platform that allows sharing knowledge between clinical medicine and health IT specialists worldwide as well as bridging gaps between visionary design and successful and pragmatic deployment.

…

The core editorial subject matters of ACI are: Clinical information systems (including electronic medical records and systems, personal health records, physician/provider order entry, electronic prescribing, clinical decision support, nursing information systems, patient scheduling and tracking tools, lab information systems, radiology information systems, PACS, GP information systems), administrative and management systems, eHealth systems, information technology development,  deployment, and evaluation, socio-technical aspects of information technology and health IT training.

The target group of ACI is an international and potentially very influential readership, e.g.: Chief Information Officers, Chief Executive Officers, Chief Financial Officers, Medical Informatics Researchers, Nurse Informaticians, Consultants, Public Health Officials, Vendors, IT Safety Healthcare providers, Informatics trainees as well as organizations such as IMIA , AMDIS, AMIA, HIMSS or the equivalent.

I hope I get to read some of the articles. Access is not free so I will have to borrow from some friends.

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This bit of news caught my eye: California hospital says it’s first to self-implement VistA

I recently found my AMIA 2005 conference notes in one of my old notebooks. One entry read:

WorldVista Insights

• Network is System (for quality improvement)
• Deploy a process not a product
• Feedback loop is path to improvement

(Note: The parenthesis and underlines were also in the notes.)

The first line is cryptic and the third one is self-explanatory. But the second one, despite being 5 years old, remains relevant and is worth repeating.

Deploy a Process NOT a Product

Many IT project teams attack Healthcare IT implementations with a product mindset. This is a legitimate mindset, of course. Why? Because many successful Hospital IT projects start out as product implementations, such as HR or financial systems.

But Healthcare IT applications are different. They are not simply IT projects, they are clinical process improvement projects. Therein lies the difference. Let me expound with these 3 points:

Point 1: The IT product is NOT the project. The software application should integrate with clinical workflows and processes. The IT system does not–and should not–stand alone independent of patient care outcomes.

Point 2: The true project success criteria is outside the IT system. Unless the system helps the healthcare team accomplish ‘offline’ clinical tasks and patient care responsibilities, it is useless.

Point 3: Effectiveness is the key to project success–NOT efficiency. The Healthcare IT project should aim at making the clinician MORE EFFECTIVE in his work. Efficiency is useless unless it delivers the right results. An IT product can only promise efficiency NOT clinical effectiveness. Integrating process improvements with IT implementations can help ensure BOTH effectiveness and efficiency.

There are no shortcuts in Healthcare IT projects. Many failed attempts come from focusing too much on implementing the product rather than improving patient care processes.

As an old IT saying goes: ‘Don’t implement solutions. Solve problems.’

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What other pitfalls do we encounter in HIT projects? What other mindsets do we have that contribute towards challenging implementations?

It has been a silent 3 months for the blog. But it has been a whirlwind 3 months at work.

So, what happened?

First off, St. Luke’s Medical Center – Global City (SLMC-GC) opened on January 16, 2010. And with that, several systems I handled went live. Among them:

• Healthcare Information System: this is the operating system for the hospital.
• Ancillary Results Management System: this one integrates with several laboratory machines through an HL7 gateway we developed.

Secondly, several projects in the SLMC – QC went live including:

• Clinical Discharge Summary (CDS-Online)
• Last 2 modules of the Laboratory Information System with HL7 Integration

The post-implementation responsibilities kept me busy for several weeks. The scope of the activities was extensive and the tasks were critical for continued success.

The teams and I learned a lot of lessons in Healthcare IT implementations, both for ‘built’ and ‘bought’ systems.

I will be sharing several of my lessons in future posts. Watch out for them.

Last Nov. 16 to 21, 2009, we visited three US hospitals: Stanford University Medical Center in Palo Alto, CA, Children’s Hospital Boston in Boston, MA and Brigham and Women’s Hospital also in Boston, MA. We chose to visit these organizations because they are Stage 6 Hospitals in the HIMSS EMR Adoption Model.

This was our schedule:

Nov. 16: Arrive San Francisco from Manila
Nov. 17: Stanford University Medical Center
Nov. 18: Flight to Boston
Nov. 19: Children’s Hospital Boston
Nov. 20: Brigham and Women’s Hospital
Nov. 21: Flight to Manila via Boston-Detroit-Nagoya

I know, the trip was undeniably tiring. I had to fight jet lag, mental fatigue and body aches (mostly from the economy airline seats) all throughout the site visits. But overall it was one great learning experience.

Below is a summary of the recurring lessons we gathered from all the hospitals.  Items in bold are lessons that I feel are not so common and therefore need more emphasis.

Don’ts

• Don’t think of Healthcare IT projects as IT projects. They are, at the core, clinical process improvement projects aimed at improving clinical quality and patient safety.
• Don’t expect to achieve anything substantial:
  • in 1 year or less. Successful hospital IT projects take time.
  • without a governance structure.
  • without engaging users at the RIGHT level and RIGHT context.
• Don’t do too many IT projects at the same time. It taxes hospital resources and might cause ‘project fatigue’ among users and staff.
• Don’t force compliance. Forced compliance is not buy-in.
• Don’t be afraid of failure or risks.
• Don’t expect a perfectly-executed and problem-free implementation.

Do’s

• Align IT projects with organizational strategic initiatives. This helps ensure executive sponsorship.
• Create a well-thought out governance structure. Get the right people responsible for decision-making.
• Manage project and resource priorities through the governance structures. Avoid bypassing the decision-making process.
• Build the right teams around project champions. Identify project leaders.
• Make sure users are represented in the governance and decision-making process.
• Engage users at the RIGHT level. Let MDs talk to MDs. Nurses talk to nurses.
• Engage users at the RIGHT context. Understand how the systems interact with their organizational structures, processes and teams. IT systems in hospitals do not ‘work alone’.
• Plan properly. Planning takes time and involves many stakeholders.
• Manage user expectations all throughout the implementation. Involve the project leaders/champions in managing user expectations.
• Do include a ‘stabilization’ stage after implementation. This gives the hospital staff ‘breathing space’ to adopt (and adapt to) the new processes brought by the IT changes.
• Consider staged or phased implementations. This lessens the risk of ‘big bang’ failures, requires lesser implementation resources and avoids ‘project fatigue’ among hospital staff.
• Consider IT projects as collaborative endeavors between IT and users.
• Expect problems. Be ready for them.

My biggest take away from all of these is the importance of governance in hospital IT projects. For these hospitals, the responsibility for project prioritization has moved from the hospital administration and operations to the clinical staff. The clinical staff, therefore, had to work with hospital leadership and IT to create governance structures for their needs.

All three had different governance structures, which means that there is NO silver bullet for the right one. But having a hospital IT governance structure that aligns projects with key strategic initiatives, focuses on patient safety and allows user representation in decision-making increases the chances of success.

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Do you have other Health IT lessons worth mentioning? What lessons did you learn from your own implementations? Please share them below. Thanks!

When I have time to get my mind out of my hospital work, I sometimes wonder about national Healthcare IT initiatives. Where are we as a country in terms of Healthcare IT adoption and implementation?

First off, I don’t have the answer. Second, it is not a rhetorical question.

Health IT is now a ‘hit topic’ in US headlines, mainly because of the Health IT component of the US Stimulus Package. In my HIT List for June 20, I posted an article about Sweden launching a national electronic health record. According to Wikipedia, there are other nationwide projects in the UK and Canada.

Well, what about the Philippines?

The National Telehealth Center (NThC) is at the forefront of national telemedicine projects. And it is doing a very good job. But what about Hospital Information Systems (HIS) and Electronic Medical Records (EMR) adoption?

HIS and EMR adoption may be still be very low among Philippine hospitals, both public and private. Administrative, financial and inventory systems might exist but clinically-relevant applications might be sparse. I hear there are several pockets of successful clinical databank implementations, but data integration and interoperability are still monumental challenges.

Beyond a formal study of national EMR adoption, we can start doing benchmark exercises in our own organizations to see how we compare against US standards. It gives management valuable insight into what still needs to be done.

Benchmarking

Here are 2 good online resources to start benchmarking:

1) CDW Healthcare IT Checkup

The site is basically an online questionnaire. It guides the user to answer several questions about the organizational implementation of client technologies, IT infrastructure and clinical applications. Once completed, a conclusion and graph is shown to compare your hospital against CDW’s data on US hospital IT standards.

2) EMR Adoption Model from HIMSS Analytics

From the site: “HIMSS Analytics, the authoritative source on EMR Adoption trends, devised the EMR Adoption Model to track EMR progress at hospitals and health systems. The EMRAM scores hospitals in the HIMSS Analytics Database on their progress in completing the 8 stages to creating a paperless patient record environment.”

The EMR Adoption Model (PDF) and the EMR Adoption Model Descriptions can also be seen accessed, downloaded and studied for uses beyond benchmarking. It gives a rough draft of what is possible, what applications build on each other and what activities need to be done at a certain stage.

The 1st site is relatively new, but the 2nd one provides US benchmark data from as early as 2006.

National Discussion

I think we should start a national discussion on HIS and EMR adoption and implementation. The HIT advocacy by different groups and people are still ongoing, but it may be time to step it up a notch.

Benchmark data allows us to compare against other countries and establish a baseline. But we are not in a race with other countries. We are in a race with ourselves. So, the point of the exercise is not about catching up. It is about imagining possibilities, proposing local and national initiatives, and coming up with ways to improve delivery of care with the help of information technology.

Knowing where we are is NOT as important as knowing where we want to go.

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Do you have your own online resources (or maybe offline articles and studies) to benchmark your HIT activities?

Do you know of national initiatives to promote HIS and EMR adoption? How do we jumpstart one? How do we improve efforts in HIT advocacy?

People ask me often about what I do. Medical informatics can be a difficult concept.

At the start of my career, even my parents were confused. (Both my parents are lawyers, by the way.) My mother called my field "Medical Informatech", while I once heard my father describe my job as "Medical Robotics". My son told his cousins that his father "is a doctor but now he fixes computers for hospitals".

So, what is it exactly that I do as a Medical Informatics Consultant?

Let me go through what I did in the past 7 years to give you a better idea:

When I was with eHealthline, I had my first taste of project management. I managed timelines, gathered requirements and maintained project scope for a Hospital Information System (HIS) implementation for a Philippine hospital. I did requirements gathering and clinical systems analysis for an HIS implementation in Vietnam. I was part of the development team for a Pharmacy Management System for a Malaysian company.

When I worked with a Health NGO, I recommended e-learning and Web-based technologies for consumer health applications. I also developed Web-based systems. During this time, I also taught medical students on the use of computers and online resources for medical education.

When I did my Postdoctoral Research Fellowship in Medical Informatics, I did researches for Web-based medical applications, mobile technologies, information search and retrieval and human-computer interaction. I also developed Web-based medical applications in PHP, MySQL and Ajax methods.

For my current work, I do combinations of many of these previously mentioned tasks along with strategic planning, vendor evaluation and implementation reviews.

Here’s the short list of what I do for the hospitals and organizations I work with:

• Project Management
• Clinical Systems Analysis
• Technology and Software Evaluation and Recommendation
• Healthcare IT Education and Advocacy
• Software Design and Development
• Strategic Planning

After explaining all these, my mother said, "I think I now get what it is exactly that you do—you solve problems in hospitals and in healthcare mainly through the use of computers and IT."

Exactly.

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If you’re a Healthcare IT professional, how do you describe your job? What kind of work do you do?

During my lecture on eHealth Project Management, I mentioned that getting the right people improves chances for project success.

Here’s the quick advice: Get the right team members assigned to the right tasks according to their strengths. Get the right employees trained not only for current projects but also according to their career paths and the future needs of the organization. Get the right stakeholders and sponsors involved in the project.

When buildling a team, I look for specific characteristics from individual members. Beyond the basics of the job description, e.g. a programmer should know how to program, I make sure they have the ‘right stuff‘, which includes:

• Ability to adapt to change: A person that’s too rigid or structured in thinking may not belong in a field where change is constant.
• Good communication skills: Communication is key to better collaboration.
• Problem-solver: Many Healthcare IT projects are IT solutions to real world problems, which makes problem-solving skills essential.
• Results-oriented: Understand the goal, find a way and do it.
• Independent thinker and worker: I have no time to babysit people. They need to think and work for themselves most of the time.
• Insatiable thirst for learning: This is very critical to me. Team members should always make an effort to improve themselves in different areas of their responsibilities–or maybe even beyond.

Healthcare IT projects often involve a lot of research and development (R&D). The team should be competent, agile and resilient. I make sure I have individuals who thrive in challenging situations.

What if you can’t get the right person or the right team?

Then, be the right person. Train to be the right team.

During our Laboratory Information System (LIS) implementation, we had to consider HL7 integration with our legacy Hospital Information System (HIS). We looked for experienced HL7 consultants in the Philippines. We even tried looking for programmers with possible HL7 experience. But after several futile attempts, we realized we had no choice: learn HL7 or try other integration methods.

We started by reading online materials, especially the official HL7 documents. We experimented, explored and examined. We became ‘HL7-hungry’, devouring all relevant HL7-related materials we can find. We also worked on Mirth, an open source HL7 interface engine. Eventually, I became the hospital’s internal HL7 consultant and we became the hospital’s first competent HL7 integration team. The bi-directional HIS-LIS HL7 integration was a success. Right now, we are looking into other integration areas using HL7.

I was fortunate to have a good team. We eventually became the right team needed for the job. But not everyone is as fortunate. Not everyone can get the right people. Not everyone can be the right team.

What if you are assigned to manage a project with existing team members? What if you do not have control over who gets on the team?

First, make sure the right people are assigned to the right task according to their strengths. This is a Peter Drucker concept worth repeating. Many employees want to contribute but many find themselves in the wrong positions doing the wrong things. Know your people, know what needs to be done and find the right fit.

Second, make it easy for your team to be the right team. Open avenues for learning and improvement. Open your mind to different training possibilities. Nurture a learning environment. Sometimes, on-the-job training and unorthodox learning methods work best for some people.

Finally, if all else fails, the ‘reverse advice’ is appropriate: get the wrong people off the team. I don’t mean firing them or asking them to quit their jobs. There are ways to do this without being drastic. One way is to transfer them to another team or project. Another way is to assign them responsibilities or tasks peripheral or not critical to the project’s core objectives. The important thing is not to let their incompetence get in the way of the team’s progress.

People move the project forward. The right people move it in the right direction.

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What people challenges did you encounter when building your team? How did you get the right people involved in your projects? How do you handle problematic or incompetent team members? Please share your experiences.