Beyond Medical Informatics

In his Life as a Healthcare CIO blog, Dr. John Halamka shares his HIT lessons and experiences from his recent trip to Scotland. I found it interesting that the same challenges (and lessons) can be found here in the Philippines.

I recommend you read the whole article but let me highlight what I found most interesting for Philippine settings.

• There is a national healthcare identifier in Scotland. It would be great to have this one here in PH.
• EMRs and Data Exchange are document-centric. This is easier to implement than data element exchange where mapping becomes a big concern.

We need to learn from other countries when it comes to National HIT implementations. At this point where HIT best practices are yet to be set, the successes of different groups, hospitals and countries become important resources for our own projects.

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.

…

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.

I’ve been working with HL7 for the past 3 years. And although I am not an expert (yet), I know enough to have successfully integrated several systems, including legacy ones, using HL7 version 2.x.

Project sponsors and stakeholders often have many misconceptions about HL7—what it is, what it does, and what it can do. Below are some of the common misconceptions I’ve encountered.

Misconception 1: HL7 is a software.

“How do we install HL7? Is the software free? Where can we download it?”

HL7 is NOT a software. It is a messaging standard. Something like a common language among systems so they can understand each other.

For the non-IT side of the healthcare business, IT is about software and hardware. If HL7 is not hardware, then it must be software. Otherwise, why all the fuss about it?

Correcting this misconception involves impromptu lectures about system communication and messaging protocols. About integration and interfaces. About stand-alone systems sharing information.

Still, HL7 integration commonly involves software. Some of these software can be interface engines, messaging platforms and file managers. We use Mirth Connect as our HL7 interface engine.

Misconception 2: Integration is easy with HL7.

“I thought you were using HL7. Why are you still having integration problems?”

Healthcare IT integration projects will always be challenging. HL7 makes it easier but NOT easy.

Choosing HL7 is like going to a grueling negotiations meeting with an agreement to talk in English. It’s a good starting point, but it doesn’t guarantee a win.

Decisions, processes and activities in HIT integration projects can include database preparations, staging tables, data dictionaries, field-to-field mapping and data migration. The integration may use HL7, but critical errors in these other areas can kill a project.

Misconception 3: HL7 compliance is a sign of quality software.

“If it’s HL7-compliant, it must be good!”

Project clients, vendors and even Healthcare IT professionals can have this misconception. HL7 addresses the need for a common protocol between systems. It does NOT address the features, functions and usability of the software itself.

HL7 compliance doesn’t even mean seamless integration. It just means the software has methods of handling HL7 messages—hopefully both incoming and outgoing. Sometimes, those HL7-compliant systems can be the most challenging to work with because their compliance is based on strict usage and formatting standards of specific segments and fields. They become too compliant to their own HL7 implementation, they become inflexible when working with other systems.

***

I had to deal with plenty of misconceptions—and even misgivings—about HL7 in my projects. I’ll share some more in future posts. And maybe include some lessons learned.

On another note, a lot of successful local HIT integration projects use customized protocols. Why? Because HL7 is not that well understood. So there are lots of opportunities for HIT standards education and advocacy. And that’s a challenge I’m ready to take head on.

===

What misconceptions (and misgivings) about HL7 have you encountered? How did you deal with it? What are the challenges in educating people about HIT standards?

I recently stumbled upon good news about CHITS:

First Region-wide CHITS-EMR Conference a Success

CHITS stands for Community Health Information Tracking System. More info about it here.

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.’

===

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

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!

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.

—

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.

—

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.

—

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