Electronic Health Record implementation as a relationship
12 March 2018
Posted by: Matthew Grek
By Richard Corbridge.
Story-telling becomes more and more important as the message becomes more complex.
In 2016 I met a Chief Clinical Information Officer (CCIO) from an NHS Foundation Trust; they were to go live with a full Electronic Health Record (EHR), a big bang launch in a 400 bed hospital later that year. The CCIO raised a comment from one of his clinicians, "the purpose of an out-patient appointment is to persuade the clinician to review the notes!" He said that without an EHR clinical staff were on the equivalent of a first date with patients too often.
And then the story started to grow:
- How could we create an analogy for an EHR implementation that played into the story of a relationship?
- If the delivery of care is like a series of first dates without an EHR how would the story evolve with the availability of digital solutions?
- Indeed, how was the implementation of an EHR like the human relationship?
Asking a person out for that first date is a giant step; like making a decision to go for an EHR could be considered to be similar to that giant leap from ‘singledom’ to dating. Working out how to decide what is the right EHR is no easy task for any health organisation. The tactics for doing this range from huge volumes of output-based specifications to new innovative ways of testing the water, like Ireland is trying to do. Rather than creating a document with every possible permutation of need, Ireland has created a series of personas and scenarios, characters to be used to test how systems deployed in Ireland could be part of the reach for better healthcare. In some ways the approach Ireland is taking puts the people of Ireland at the centre of what is being put in place. It's a bit like checking with family and friends, before asking a prospective partner out on a first date, what they think of them! Entirely impossible in that scenario, but imagine the relationship success rate if you could do this!
Butterflies and anticipation
That first date moment for the EHR has to be a comparison to the procurement journey itself. A courtship worthy of comparisons to the best (and worst) first dates. When Ireland carried out market testing of the EHR market back in 2015 the relationship analogy surfaced for the first time. The market testing team felt the range of ‘’relationship choices’ from different vendors and how they wanted to be in a relationship with Ireland spanned everything from a 'shot-gun wedding’ to a ‘free and open relationship’.
The idea of tying the country’s entire health system to a single supplier felt almost a little ‘Fifty Shades of Grey.’ Particularly from a couple of the larger vendors who were keen to see Ireland adopt a single system country-wide: a relationship they certainly would dominate!
The trajectory to deploy a new digital health solution could well be an analogy for proposing and getting engaged, you know where you want to get to but first you have to pluck up that courage and dive in. When an implementation begins we must have an end in mind; but knowing the outcome at the beginning still, even in 2017, requires a crystal ball. I would challenge that the world is yet to see an implementation that can foresee the future, planning the benefits that we think will be released through making a healthcare system digital is as challenging as planning the rest of your life together with a new love, and yet just as essential.
Moving towards a digital fabric for health
The tools we need to plan the benefits of an EHR implementation need to be grown from others’ experience. It is why Ireland is in such a unique position, it can learn from nearly every jurisdiction in the world as it moves towards a digital fabric for health. Let’s all face it, we seek guidance from so many others when it comes to relationships, often so poorly qualified to give advice, simply experienced in the mistakes and lessons.
Digital implementation in healthcare needs to have an element of ‘fun’ with the obvious serious point at the end. Just like the traditional engagement period of time. Taking a health system on a journey to change has to be something that the team are “engaged” in and able to be part of. So much can be done to ensure ownership of implementation remains with the clinicians who will be using the system, avoidance of IT being done to the system keeps the reality check in place. Recently in Ireland the implementation of EHRs has been ‘fun’, because team cultures have been worked on. Real collaborations across a multiplicity of people types, led by clinicians who, because of years of experience running their working lives through things like multi-disciplinary teams, can get the most from so many different types of people.
Scope creep is the project killer
Keeping the end in sight at all times is an absolute need for digital health implementations. The fact is, scope creep is the project killer. So in keeping with the analogy, the end in sight is perhaps the wedding day, and here scope creep here is just as bad and often caused by not being clear who is the owner of the day (system) really! Clinical validation and decision making in the build of the EHR is crucial to a successful implementation and in particular to ensuring that adoption releases benefits. There are some scary stories in the NHS where systems with 10,000 licences are only being used by 1,000 people because the system does not ‘work’ in the way clinicians need.
The story of several electronic document management (EDM) systems in a few hospitals where black and white EDM was implemented by technologists only to discover that the positioning of the pink piece of paper or the highlight note was crucial to the way the clinician uses the system, are becoming too frequent. Bringing this back to the analogy, maybe this implementation was influenced by this being done in a “shotgun” fashion by the family of the bride? The technologist doing IT to the healthcare system, like a family insisting on the wedding of the couple. The only way to ensure this does not happen is to empower the clinician and their team to be the leader of the project, just like for the wedding day the wife to be has to be in charge to ensure the day is exactly what the couple want it to be!
Knowing that your delivery of care will change, you cannot just do the same as you always did, except now with a digital overview, or even just make it digital now and then go through business change later. Becoming a married couple requires both parties to accept the world is changing and the relationship is now a symbiotic one requiring give and take, pull and push from both parties for it to succeed. The relationship of a health organisation that now has an EHR or other digital solutions needs to bring clinicians closer to the informatics people.
Who owns the wedding?
We in Ireland talk about trying harder to remove the terms that separate technology projects from business change projects to try to erase this issue coming up. The CCIO role helps here, a shining example of one of the interested parties’ attempt to get closer to the other. However, as with marriage this fix requires all sides to be active in making it work. Where this analogy falls down is the number of parties now involved in the delivery of digital solutions, they can’t all be married to each other at the same time!
Who owns the wedding? All too often the response I hear is, the wife, the family or the ‘payer’. The tax payer of a country with a public health system ‘needs’ to own the system, after all they are the payer. And yet my advice to anyone planning the wedding is seize your day, it’s your wedding and you should be in charge, and therefore we should be empowering the clinician and the patient, and dare I say, not the media, the influencers and the trend setters.
Healthcare is not our goal; life is the goal of the system. The parallels to the relationship continue to exist beyond the initial implementation of digital solutions into the health system.
Parenting the digital baby
A clinical team will go through the pain point to deliver new life or new capability into the world. Birth of a system or the discovery that you are expecting twins is perhaps a good way to consider what happens next in a relationship or in digital implementation. Once the object of your efforts is ‘live’ in the hospital the world changes dramatically for everyone involved.
One of the key learnings that many jurisdictions have come to after a go-live is that the system being live is not the end of the journey. To maximise benefit from the system it needs nurturing; business change is a continuous journey of service improvement and the rate that technology is evolving and growing means that to simply stop the project once the new system is live would be like accepting that nothing more can be achieved. Like with a new baby the role of us, ‘the parent’ of the digital solution, is to enable learning to continue and the system to grow and evolve. The health care digital team has to learn to become the parent of each of its digital babies.
“The art of the clinician is to distract the patient whilst nature cures them,” is a quote from Voltaire. The role of technology in healthcare needs to follow a similar path, the art of digital in health is to deliver a seamless solution that catalyses integrated care delivery and can ensure that the goal of contextualised care for every person can be achieved. However, if we are to continue the analogy of relationships then we need to keep an eye out for another danger: the seven-year itch!
Loyalty to the concepts of digital health must be maintained
Once the relationship begins it becomes very difficult to stop and go back, but also the system that has been put in place needs to be continually evaluated. A happy marriage is one where all the partners continue to communicate and work hard to achieve goals and outcomes and a long term digital relationship needs similar consideration. Age old concepts of keeping the supplier hungry really need to be dropped in favour of a harmonious relationship with a shared goal in mind. After all, do we really want to consider keeping our life partners ‘hungry’ for the next 60 years?!
What is the final stage of the relationship?
A friend commented that surely its death. Perhaps that's a little tragic! Growing old together, being able to act as one whilst maintaining the individuality is a huge part of this. If we consider the matured relationship of clinicians and digital leaders then this would be a great outcome for us, particularly if we can bring the supplier into the same bed?
All then goes full circle, and continuing to find unique ways to turn on the relationship gene is part of how we continue to learn and grow, and sometimes we really do have to evaluate where the relationship has got us and make changes. As with a digital partnership, there will need to be compromises along the way that lead, ideally, to a happier outcome for all.
As that expert in partnerships, Manchester United and England footballer Wayne Rooney, is often quoted as saying,
"Perfect partners don’t exist. Perfect conditions exist for a limited time in which partnerships express themselves best."
The role of the digital healthcare leader though is to ensure that those conditions exist perpetually.
Talking about delivering all this to Ireland means I can’t in good faith finish my thoughts with a quote from a current and quintessentially English (I really hope he isn’t) footballer. Therefore, let me end with a quote from a wonderful singer songwriter from this wonderful country, Mr. Damien Rice,
“And so it is just like you said it would be, life goes easy on me, most of the time, and so it is the shorter story, no love, no glory, no hero in her sky.”
Maybe it's a moto for all EHR (or, as autocorrect continues to tell me, HER):
"Implementers now and forever more, we are not heroes in the sky and we know it’s not like we said it would be, but, we are here to make life easy. We are here to make healthcare be about life, not about technology."