Beyond Medical Informatics

It’s been over a month since I last written for the blog.

My life as a CIO has been very busy. The past few weeks much more so. Some of my recent activities (I’ll write about them soon) include:

• Continuing development and design of TMC PRIME—the EMR platform we are developing.
• TMC Quality Fair Week where we had a booth that featured TMC PRIME.
• Implementation of Google Apps—Yes, TMC is now on GMail!
• Initial wrap-up of 2011 projects for Year-To-Date IT accomplishments (in preparation for budget planning).
• Initial project planning for next year’s budget.
• Initial brainstorming for restructuring of IT Department.

The last one has been in my mind for several months now—probably since I started work as CIO. I found our IT organizational structure to be rigid and unwieldy. I had a hard time responding to critical IT requirements and situations. Projects were not managed or monitored well. Some projects slip through the cracks of proper implementation.

Then it dawned on me. For several years, the main IT project was the hospital information system (SHAMAN). This system started out small but has since become the workhorse of hospital operations. And the IT department was almost exclusively organized around this application—to the detriment of other IT projects.

I shared this with my IT managers:

We have an IT department that is structured to support a single software.

That can’t be. We need to change that. We have other IT projects aside from SHAMAN, like:

• HL7 Integration Platform
• Clinical Data Repository Platform
• Clinical Documentation Platform
• Business Intelligence
• Document Management Systems

Our users also have other IT plans like:

• Improved charge capturing using mobile devices
• Improved medication management
• Online surveys and patient feedback forms
• Research and patient registries

So, I pose this challenge to my IT management team.

Let’s build an IT organization that supports the whole organization including the network of clinics and hospitals we serve.

It will not be easy. Our initial thoughts focus on the following areas:

• Strengthen the IT management team with focus on strategic planning, initiatives and relationship-building.
• Build project management and systems analysis core competencies among the staff.
• Build technical core competencies for the core technologies used.
• If possible, outsource some IT services, e.g. technical support, specialized programming.

Let’s hope we succeed.

Next year will be an exciting year!

Last Thursday, September 15, 2011, we had an IT Department (ITD) staff meeting. I wanted the IT staff to appreciate what the department accomplished for The Medical City in the past year. This was also an exercise to improve our intra-departmental communications.

After the managers of the different sections of the department—development, SQA, support and technical—shared their activities and accomplishments, I presented possible projects and activities for next year. I also expressed the need to be more focused and proactive to ensure successful implementations.

I also wanted to end the meeting with an inspiring message. So I shared the Serenity Prayer:

Grant us the serenity to accept the things we cannot change, the courage to change the things we can, and the wisdom to know the difference.

I highlighted the three concepts—serenity, courage and wisdom—and then told them that the prayer was wrong.

First off, the prayer got the order of the 3 concepts wrong. Starting with “accepting things we cannot change” is not serenity—it is surrender.

Second, it’s misleading to call it the Serenity prayer when what we need to change the world is courage. It should be the Courage prayer. I wanted my IT Department to have balls!

Lastly, the wisdom part assumed it was easy to know the difference. It is not.

So, how do we know which ones we can change and which ones we cannot?

The answer: We don’t know—and won’t know—until we try.

Therein lies the true wisdom: Going through life with the conviction to MAKE a difference is the only way to KNOW the difference.

So, I rewrote the prayer for our IT Department. I rewrote it matching the order of things we need to continually support the operations of the hospital, contribute towards better patient care and forge the way into the future.

Here it is:

Grant us the wisdom to make a difference, the courage to change the things we can change and the serenity to accept the things we cannot.

Our work in Health IT is not easy. We should first be wise enough and brave enough to challenge the status quo. Serenity should be our last resort.

Amen?

Amen.

I’m currently reading "Power: Why Some People Have It and Others Don’t" by Jeffrey Pfeffer.

Although I’ve yet to finish the whole thing, one of his points struck me. Let me paraphrase it:

The "years of work experience" is not a good gauge of competencies and skills. 20 years may just be 1 year repeated 20 times.

This made me laugh. (My wife almost woke up.)

As a CIO, I need to look into the work and project experiences of consultants and vendors. That’s just part of the vendor evaluation process.

As a Healthcare IT professional, I find it essential to keep updated with latest trends but way, way better to get involved in different projects. Here is a list of Healthcare IT projects I’ve done in the past. There’s more coming in.

So, how do you evaluate someone with 10 years experience—but handled the same project, technology and methodology in those 10 years? Is that 10 years or just 1 year repeated 10 times?

Many organizations mistake project management as nothing more than project coordination. And many IT projects fail because of this misconception.

Project management is not just an activity—it is a core skill of effective management.  Project managers (PMs) are NOT administrative clerks of meeting agendas, project calendars and schedules of deliverables. They should take on leadership roles and drive the pace of the project.

Here’s my top 3 key ingredients for effective project management:

1. Accountability for Failure.
2. Effective Decisions.
3. Management of Outside Input.

Accountability for failure

It is said that success has many fathers but failure is an orphan. Effective project managers know that true accountability is being accountable not only for project success but also for project failure.

If this is clear from the start, few would volunteer to start or manage projects just for the ‘distinction’ of becoming project managers. Effective PMs know they cannot play the blame game at the end of failed projects.

Effective decisions

Project managers should have the commensurate authority to make decisions for specific details and tasks of the project. But authority is just the beginning. PMs should also make effective decisions.

Effective decisions should be both timely and actionable. The output of every decision should be a realistic action plan that is shared with the project team. Effective PMs know that the progress of the project is not determined by activities in the Gantt chart but by decisions made for the project.

Management of outside input

Effective PMs understand that many tasks and deliverables are beyond their team’s control. The bigger the project, the more groups involved. And input from these people are prerequisites for many project activities.

The PM will have to do a lot of ‘C’s: Communicate, Coordinate, Control.

Here’s a short list of tips to help manage outside input:

• Identify deliverables as concrete as possible.
• Make deliverables or task list public. Share with project stakeholders.
• Get—and document—commitments from outside groups.
• Do quick follow-ups or reminders prior to delivery dates.
• Hold groups accountable for deadlines. Report frequent delays to group superior.
• Confirm completion of tasks and deliverables as positive feedback.

If you noticed, my top 3 ingredients tackle important management areas:

1. Self – Get a true sense of accountability
2. Internal/Project Team – Effective decisions drive effective teams
3. External Teams – Find ways to manage things beyond your control

I’m sure there are more tips out there to be more effective at project management. What tips can you share to be more effective in project management? What habits, skills or characteristics do effective project managers have?

I found a great online resource: IT Execs Release Guidebook on E-Health Records Implementation – CIO.com.

The College of Healthcare Information Management Executives released a guidebook for CIOs and other IT managers with tips and first-hand experiences in implementing electronic health records in order to meet government “meaningful use” standards.

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The publication, The CIO’s Guide to Implementing EHRs in the HITECH Era, includes best practices and steps health-care organizations should take to successfully implement EMRs, from the initial planning through the final documentation of results.

The guidebook is free for the public and can be downloaded here.

Recent email discussions got me thinking about the challenges of implementing Healthcare IT for developing countries (HIT4Dev). The basic assumptions of HIT4Dev include the following:

• The US (and other western countries) are more advanced in HIT concepts and implementations.
• Because of this, they are models for HIT implementations.
• Compared to these models, the developing countries lag behind.
• There is a palpable gap.
• HIT for developing countries (HIT4Dev) try to bridge this gap.

Here are 5 tips to help meet the challenges of bridging the gap and implementing HIT for developing countries:

1) Know what can work for developing countries.

With so much HIT updates today, it’s challenging to identify the ones applicable for Philippine settings. Not every technological advancement is relevant. Many implementations and applications brought about by US regulations may not hold true for the Philippines.

A good example would be the US HIPAA regulations. The concepts behind HIPAA are legitimate, yes, but direct compliance does not provide immediate or relevant impact to local implementations as of yet. It would be a foolish waste of resources to work on that given other areas for improvement.

2) Know why it worked.

Don’t stop knowing the “What”. The biggest lessons from successful HIT implementations in other countries are in the “Why”. Understanding and insight are the best tools in bridging the gap.

Being a copycat is a sure recipe for failure. Know what factors and concepts made it work. Know the conditions wherein it will NOT work. Get a clear handle of the ‘because’ of HIT implementations and activities, e.g. “Let’s do this BECAUSE…”, “Let’s not do that BECAUSE…”

3) Identify relevant target results.

After a thorough study, ask yourself these questions:

• What tangible results can I get out of the implementation?
• What specific deliverables provide the most relevant impact?
• What measures of success matters to the local users and stakeholders?

Get the successful US model and break it down into workable and relevant targets. As the saying goes, “You eat a whole elephant one bite at a time.” Just make sure the bite is something you can chew and use.

4) Understand ALL the components of the gap.

Understand that the gap is not specific to Healthcare IT because clinical applications do not exist in a vacuum. There are technological advancements, organizational dynamics, societal changes and governance structures that contribute towards the gap. These other things matter.

Focusing on clinical applications without understanding the non-clinical environment in which it thrives is a big mistake. Many HIT4Dev teams make that mistake.

5) Go beyond funding as the solution.

“If we only had funding, this problem would be solved.” How many times have we heard that?

People who think that way when trying to bridge the gap are simpletons.

The simplest problems are those where funding is the solution. They are easy to solve. But many problems are not that simple. Pouring money into a problem does not solve itself.

Take money out of the picture when solving problems. And you’ll find the real solutions worth funding.

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Comments and violent reactions? Do you have other tips for HIT4Dev teams? Post them below! Thanks!

Singapore moves forward with their National EHR Project.

Singapore Awards US$144M EHR Contract

A consortium made up by Accenture, Oracle, and Orion Health has won Singapore’s National Electronic Health Record project, a credible source has told FutureGov.

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The National EHR project aims to connect all the EMRs in Singapore and achieve the “one patient, one record” vision.

Healthcare IT professionals all over the Asia-Pacific region should watch the progress of this project closely. I know I will. I can only hope we can start something similar in the Philippines.

I am happy to report that Nursing Informatics is growing and thriving in the Philippines.

Not too long ago, a group of Nursing Informatics professionals and enthusiasts organized themselves into an association. They now have a very active online group for their advocacy and discussions. Good for them!

I was fortunate enough to have worked with 2 of their officers, Kit Sumabat and Mia Alcantara-Santiago. I am sure this group will do well in advancing the concepts of Nursing Informatics in the country.

Here’s their site:

RNformatics – Philippine Nursing Informatics Association

Congratulations and more power!

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!

Health IT work is not easy. Projects are aplenty and deadlines pile up. Most days are manageable, but some days we try our best to get any semblance of control. On rare occasions, work can feel overwhelming, not only for us but also for our teams and our organization.

When this happens, I take time to sit back, relax and rethink work priorities. I have 2 questions that help me get grounded.

• What’s the problem?
• What needs to be done?

When I can, I share these 2 questions with my team to help them cope with the amount of work we have in our projects. A quick 5-minute run-through of these questions at the start of a task or activity puts the mind in the right focus.

The Why

The first question answers the ‘Why’ aspect of the task, project or activity. Of course, it doesn’t always have to be a problem. Here are several variations of the question:

• What specific problem are we trying to solve?
• What opportunity are we trying to take?
• What technological advantage are we trying to maximize?
• What change do we want to start?
• What business goal are we trying to achieve?
• What is the core purpose of the next task?
• Why the hell are we doing this?

The important point is that you know WHY you are doing something. When you know WHY, you have the much-needed ‘clarity of purpose‘ for the work. This clarity helps identify priorities that should be considered–and items that should be discarded.

The What

The second question answers the ‘What’ aspect of the job. It identifies the outcome and helps set specific tasks and deliverables. Here are several variations:

• What needs to be done?
• What is the specific outcome of this task?
• What is the output of this activity?
• What does ‘done’ look like?
• What’s the deliverable?
• What should I have at the end of this task?
• What the heck should I do next?

This process gives me what I call the ‘clarity of process‘ or the ‘clarity of product‘. It is basically an exercise of outcomes visioning. The more concrete or tangible the outcome, the better. Knowing how the end looks like can give us a good idea how to start.

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In my future posts, I’ll share a real-life sample of this process and other questions that come after this exercise.

How do you keep projects moving in the right direction? How do you maintain focus? What advice can you give? Please post them below. Thanks!