Why has it been so difficult to successfully deploy information technology in healthcare?

Why has it been so difficult?

From the UK’s scaled-back ‘NPfIT’, to Obama Care’s bug-stricken exchanges, to Australia’s under whelming up take of national personal health records, the recent history of health IT has not always been smooth.

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From the UK’s scaled-back ‘NPfIT’, to Obama Care’s bug-stricken exchanges, to Australia’s underwhelming uptake of national personal health records, the recent history of health IT has not always been smooth. Examples of spiraling costs, slow take-up and elusive productivity gains are found in virtually every health system around the world. Why has healthcare delivery been so resistant to digital transformation, and when big investments have been made why have strategies so often failed to pay off?

The history of technology, as it enters industries, is that people say, ‘This is going to transform everything in 2 years.’ And then you put it in and… nothing happens. And people say, ‘Why didn’t it work the way we expected it to?... . And then, lo and behold, after a period of 10 years, it begins working. 

— Robert Wachter, UCSF School of Medicine.

Examining the stories behind setbacks at local and national levels, perhaps the most important lesson of all is that becoming a digitally enabled healthcare provider isn’t about replacing analogue or paper processes with digital ones. Where implementations have failed, technology has often simply been layered on top of existing structures and work patterns, creating additional workload for healthcare professionals. The technologies that have released the greatest immediate benefits have been carefully designed to make people’s jobs or the patient’s interaction easier, with considerable investment in both the design of the tool and the redesign of ways of working. 

A pattern that appeared time and again in the stories examined was great expectations of new technology clashing against an initial period of frustration and reduced productivity. Benefits would eventually materialize — often after 2 or more years — but weathering this ‘digital dip’ was an important hurdle that has led to many transformation strategies being scaled back or even abandoned.

A case in point is electronic health records (EHRs). These are an essential foundation to any digital strategy, but rarely do they produce any immediate benefits to the frontline. In reality, most organizations see an initial phase of added inefficiencies before the tools that work off the EHR (patient flow management, e-prescribing, automated alerts and data transfer) are developed, implemented and get to work. The unexpected pain of the initial EHR implementation has caused many providers to get stuck in the dip — unable to roll back to previous systems,but unwilling to invest further to get the benefits.

Robert Wachter, in his recent book The Digital Doctor, notes that poorly designed systems have led to significant increases in time spent on data entry and multiple unhelpful alerts — with some research showing nearly half of emergency physicians’ time spent on data entry. A 2013 RAND survey of physicians across the US found widespread dissatisfaction with EMR systems, concluding that although most approved of the EMRs "in concept”, in reality they were among the principal causes of professional frustration and dissatisfaction.

Happy users is the golden criteria for the success of HIT implementation. Users should be effectively engaged throughout the project cycle. Talk to them, work with them to get what they want, realize and have them check whether it’s what they want. Then repeat.

— Dr Kim Liu, KPMG in China

Examining the widespread failures to derive the full value from digital technologies in healthcare, and what separates the stories of success, we have distilled seven important lessons about how to achieve real benefits from a digital strategy:

  1. Transformation first: Transformation comes from new ways of working not the technology itself. Organizations need a transformation program supported by technology not the other way round. This is the fundamental lesson that underpins everything else.
  2. People problems, not technology problems: While digital systems often become the lightning rod for criticism in a change program, in reality many of the problems encountered in these stories are people-based, rather than technology-based. Overcoming these issues requires organizations to invest at least as much into the programs of organizational development as they do into the technology. Clinical and administrative leaders need to have a deep knowledge of both technological and frontline care systems, and be able to reimagine how work is done. Clinical champions can help with this.1,2 In the US, it is now increasingly common to have Chief Medical/Nursing Information Officers — often at Board level. These ‘hybrid’ professionals offer a valuable combination of technological skills and understanding of clinical workflows and culture, and are in strong demand.
  3. System design: There has been insufficient attention to the design of health IT systems historically. New investments need to solve the problems and needs of the people who are going to use them, be they patients or professionals. Successful implementations take great pains to understand the complex interplay of the ‘thoughtflow’ (how clinical decisions are made), the “workflow” (how they are acted on) and any new information technology. The misalignment of one or more of these three factors explains a large proportion of the failed or challenged health IT implementations in recent history. Achieving alignment requires meaningful involvement of staff and a dedicated effort to secure continued buy-in. Too often the users of these systems are treated as passive recipients of change and new systems are ill-suited for the complex, high-risk operating environments of frontline services.3
  4. Invest in analytics: Improving productivity requires extensive redesign of work processes, the use of predictive models to allocate resources, anticipate demand and intervene earlier and the ability to learn and adapt. None of this is achievable without analytical skills being loaned or acquired by the organization and, ideally, new tools being made available to clinicians in real time. Successful providers have made significant investment in developing their own analytical and software development capacity. This enables them to generate the learning and insight from the data collected within clinical and non-clinical systems.
  5. Multiple iterations and continuous learning: Implementing technology is an on-going transformational change program. Even with careful design there may need to be a number of iterations in design. This is a continuous process and there may be several cycles — some quite painful — before systems reach a tipping point where all of this investment starts to pay off. Stories of failure often show a tendency to overestimate short term gains and focus on reducing the costs of transactions rather than major changes in workflow, automation and process redesign. Above all, commitment to an on-going journey — rather than a big bang — is at the heart of success.
  6. Support interoperability: To support coordinated care and realize the benefits set out in this report, it is essential to facilitate data contextual sharing across multiple settings. There are also a number of things organizations can do to aid interoperability. First, while customizing EHRs is important to productivity, over-customization may inhibit data sharing even when the same system is in use across multiple network providers. Secondly, while there is no consensus on whether a single system is better than multiple systems linked through middleware, it will be important to ensure you have weighed up the benefits of both. As Kaiser Permanente have found “horizontal integration trumps vertical maximization”.
  7. Sound information governance and data security procedures: A KPMG survey of 223 healthcare payers and providers found 81 percent have been compromised by cyber-attacks in the past 2 years — and only half felt they were adequately prepared to withstand attacks.4 Sound information governance procedures are essential to ensure confidential patient data is used safely and effectively. Robust and transparent IG mechanisms are also instrumental in giving patients the confidence to willingly share their protected health data across care settings — a hurdle that has created significant setbacks for England’s care. data system.5

Thought flow impacts the decision-making process, that is, it either enhances or makes it worse through the way we display digital information on a computer monitor or on a mobile device, so the concept of presenting the right information, to the right person, at the right time is very important.

— Richard Bakalar, KPMG in the US

Footnotes

1Boonstra A, Versluis A, Vos J (2014) Implementing electronic health records in hospitals: a systematic literature review. BMC Health ServicesResearch 2014, 14:370

2Broderick A, Lindeman D (2013) Scaling telehealth programs: lessons from early adopters.New York: The Commonwealth Fund, 2013

3Cresswell K et al. (2013) Ten key considerations for the successful implementation and adoption of large-scale health information technology.J Am Med Inform Assoc 2013; 20(e1): e9–e13

4Bell, G. and Ebert, M. (2015) ‘Health Care and Cyber Security: Increasing Threats Require Increased Capabilities’ KPMG.

5Triggle, N (2014) Care.data: How did it go so wrong? BBC News

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