The human element
BY SARAH FISTER GALE ILLUSTRATION BY PETER AND MARIA HOEY
The debate over healthcare in the United States sparked heated exchanges in the nation's presidential elections in November. While the candidates disagreed ideologically—specifically about the new Patient Protection and Affordable Care Act—the issue was rooted in some very real, and very large, numbers.
Overall, U.S. healthcare spending will reach an estimated US$2.8 trillion in 2012—about 18 percent of the nation's GDP, according to The New England Journal of Medicine. The same article predicted that by 2037, that portion could reach 25 percent, with healthcare spending accounting for 40 percent of all federal spending.
At the same time, there are signs of immense waste: as much as US$750 billion a year, according to a September study by the Institute of Medicine.
At the intersection of healthcare and IT, however, exist myriad opportunities for project professionals to eliminate massive inefficiencies, redundancies and administrative costs. However, the expected surge in project management positions in this sector has not yet materialized (see page 31).
But healthcare IT projects—in the United States and around the world—come with layers of complexity not found in other tech projects. Teams must contend with technical, political, regulatory and budgetary obstacles—which can vary wildly across suppliers, stakeholders and regions.
“In every country and every hospital, the challenges for these projects are unique,” says Sathya Menon, director of Africa operations for IT provider CSC Healthcare Group in Johannesburg, South Africa. “But they all trace back to related issues around usability, interoperability and interactivity.”
And when projects go wrong, the fallout can be sweeping. When the U.K. government was forced to scrap its £12 billion-plus electronic healthcare records (EHR) megaproject late last year after a series of delays and failures, it faced a firestorm of criticism.
PHOTO BY GORDON WENZEL
“YOU CAN'T KNOW WHAT PERFECT IS UNTIL YOU USE SOMETHING. INSTEAD, WE STRIVE FOR SECURITY AND USABILITY. THEN, WE WATCH HOW PEOPLE USE WHAT WE'VE BUILT TO SEE WHAT NEEDS TO BE IMPROVED.”
—Jim Walker, MD, Geisinger Health System, Danville, Pennsylvania, USA
The move to EHRs in the United States is also being questioned, with The New York Times reporting that automated features of some of the programs “may be contributing to billions of dollars in higher costs for Medicare, private insurers and patients by making it easier for hospitals and physicians to bill more for their services, whether or not they provide additional care.”
Despite the controversy and risks, the global healthcare IT market is expected to reach US$162.2 billion in 2015, growing at a compound annual rate of 10.2 percent from 2010 to 2015, according to Markets and Markets.
These projects run the gamut from software-based EHR systems and health information exchanges (HIEs) to infrastructure overhauls that outfit hospitals with the technology necessary to give staff access to patient data anywhere, anytime.
Whatever the scope, the biggest obstacle to success may not be the technology, but one project teams have to make an extra effort to control: the human element.
A hospital can unveil the most advanced IT system fully loaded with all sorts of cool features, but it won't do any good if the clinical staff doesn't use it correctly—or at all.
THE GLOBAL HEALTHCARE IT MARKET IS EXPECTED TO REACH US$162.2 BILLION IN 2015, GROWING AT A COMPOUND ANNUAL RATE OF 10.2 PERCENT FROM 2010 TO 2015.
Source Markets and Markets
JUST WHAT THE DOCTOR ORDERED
For an IT system to truly take hold, teams must partner with clinical staff members, making them a part of the project from the very start—even if they don't always want to.
“Clinical staff want solutions that will automate their processes,” Mr. Menon says, “but IT teams can't do that if the stakeholders won't interact with them.”
Many teams are finding that one of the best ways to build engagement is by rolling out implementations incrementally, using pilot projects to identify errors and tweak project plans before launching them across the entire network.
This lesson is based on a long history of trial and error, says Jim Walker, MD, chief health information officer for Geisinger Health System, a Danville, Pennsylvania, USA-based health services operator serving more than 2.6 million people in 44 countries.
Dr. Walker currently oversees implementation of a Pennsylvania-wide HIE system that links every clinical facility and healthcare worker. Plough the program implementation will continue for several years, the team is breaking it into dozens of small projects with specific goals and deliverables due every three months.
“One of the great things about phased projects is that it lets you work with a small team,” Dr. Walker says. “It's more cost-effective, there's less training, and it's easier to manage.”
Dr. Walker saw the benefits of such an approach on an earlier EHR project, when his team implemented every piece of the system all at once at 70 clinics. After the project failed, he reworked the implementation plan using a phased approach and starting with easy-win elements, like giving physicians electronic access to X-ray images and lab results. “Those features required no learning and delivered tons of benefits,” he says.
Once doctors saw the value of the technology, the team rolled out more sophisticated offerings, including order forms and patient care documentation. The team required five years to finish the first 27 clinics, but only 12 months to do the last 43. By that time, it had fixed the bugs, proven the value of the system and secured stakeholder buy-in across the enterprise.
“You can't know what perfect is until you use something,” Dr. Walker says. “Instead, we strive for security and usability. Then, we watch how people use what we've built to see what needs to be improved.”
SHINE WEARS OFF THE JOB BOOM
Despite all the money allotted for healthcare IT projects, the expected surge in project management positions in the sector hasn't yet materialized.
In the United Kingdom, the number of infrastructure support workers employed by the National Health Service fell from 236,000 in 2009 to 216,000 in 2012, according to The Independent. Across Europe, the healthcare sector has undergone significant belt-tightening, with budgets cut in Australia as well, reported New Zealand news site Voxy.
Even in the United States, where the Bureau of Labor expects the healthcare IT market to grow at a rate of about 24 percent per year from 2012 to 2014, the number of employment opportunities falls short of earlier predictions.
Tom Silver, senior vice president at IT job forum Dice in New York, New York, USA, blames the lag on the sector's risk-averse nature and economic factors that may be slowing major IT implementations.
“There is no doubt that this area will continue to grow,” he says. “It just may take a while.”
In August, Dice had 1,500 positions seeking healthcare IT skills, compared to more than 10,000 jobs seeking programming experience.
On the bright side, IT project managers looking for work in healthcare have an edge, Mr. Silver says. “These are complex projects, so someone with project management skills will always be in demand.”
WORKING IN PARTNERSHIP
Not every team has the luxury of collaboration from the start.
When Texas Health decided to build a brand-new, state-of-the-art hospital, the IT team wasn't fully consulted in the initial project planning process, says Joe Johnson, manager of the portfolio management office at Texas Health, a healthcare service provider in Dallas, Texas, USA.
The hospital design team factored hardware into the budget, but not any of the software applications, licensing fees or installation costs.
“We had to request an additional, separate budget for application costs, and it was tricky to explain why it had not been part of the original capital plan,” Mr. Johnson says.
Because the hospital was new, the final management staff was not in place to guide the team on key project decisions. Instead, it relied on other Texas Health hospitals as a roadmap, adding infrastructure redundancies across the new site and blanketing the entire facility with wireless access at the outset. Some key process decisions, such as defining the workflow to assign real-time tracking numbers to patients during administration, were not made until the management staff was hired in July and August.
“Some questions didn't get answered until two weeks ago,” Mr. Johnson said in mid-August. “And we are still straining our resources to get everything tested and up and running.”
The experience reinforces the need to create a true dialogue between IT project teams and healthcare staff. “With IT projects in a hospital, it's always a challenge to get the end-user perspective, because as we rely on hospital staff for input, they often have more critical things to do for patient care,” he says. “Without their input, you will struggle to get things done.”
MEET THE CMIO
More healthcare organizations are adding a new seat in the executive suite to guide IT project investments.
The number of chief medical information officers (CMIOs) in the United States rose by 20 percent in 2012, according to a February survey by the Healthcare Information and Management Systems Society. And 95 percent of U.S. healthcare IT leaders surveyed by SSi-Search in December said a CMIO is critical to electronic healthcare-record deployment projects.
The Medical University of South Carolina in Charleston, South Carolina, USA relies on its newly hired CMIO to rank projects. “Before, IT had to make those choices,” says Mark Daniels, director of clinical IT infrastructure.
As in many IT environments, the projects with the most influential stakeholders often were pushed forward, even if they didn't deliver the greatest benefit. “As the IT team, we didn't understand the benefits of the projects or who they would impact,” he says. “Now the CMIO guides our decisions” based on patient safety, quality of care and urgent risk.
Jim Walker, MD, is chief health information officer for Geisinger Health System in Danville, Pennsylvania, USA. One of his ongoing tasks is to prioritize which projects move forward and which need to be delayed.
“There are a lot of great ideas, but we only have so much time and budget,” he says. “And once a project passes a certain point in the planning stage, we won't make changes, so the team can focus on delivery.”
Jim Walker, MD, Geisinger Health Systems, Danville, Pennsylvania, USA
Having someone who can bridge the gap between IT and clinical groups helps ensure projects are both feasible and useful. “The clinicians help IT understand what they need, and IT helps the clinical staff understand what can reasonably be accomplished,” Dr. Walker says. “You can't accomplish any of that without transparency and trust.”
To avoid such issues in the future, the IT team at Texas Health now sets clear goals about expectations of stakeholder involvement. “It's a negotiation,” he says, “but we are putting a lot more onus on them to provide the required resources before we agree to do any project.”
As IT becomes a core of healthcare operations, IT teams are creating liaisons with clinical personnel and establishing staff tasked with the specific purpose of setting strategic project goals.
The more IT teams and clinical staff work together to define new processes, the more likely they will be followed.
“People are hesitant to give up their forms and customized workflows, but EHR systems are much more valuable when standardized methods are developed and implemented for data entry, storage and retrieval,” says Jennielyn Baradi, PMP, operations program manager at GE Healthcare IT in Seattle, Washington, USA.
For example, if doctors across the healthcare environment enter data in a codified manner when documenting patient care, they can more effectively produce reports across specific patient sub-groups. Doctors can also compare patient outcomes with those of other physicians using different treatment options to see who achieves better results.
Ultimately, Ms. Baradi says, that's one thing all project teams must keep in mind: “In the healthcare environment, success is all about improving patient care.”
And to do that, tech teams must look at the bigger picture. These are, after all, not the standard-issue tech projects.
“You have to understand the healthcare industry and its requirements from a holistic view rather than just concentrating on the technical aspects,” says Sunitha Blossom, former project manager at IT firm CSC, Hyderabad, India. “Traditional IT projects do not deal with life and death of human beings, but IT healthcare projects do. If the software fails to perform, it's a matter of life and death for patients.” PM
A rise in healthcare IT spending around the world means plenty of challenges for project professionals—and plenty of career opportunities.
HEALTHCARE IT CASE STUDY
TROUBLE, THEN TRACTION
The prognosis was grim for a project to build a clinical data warehouse at the Medical University of South Carolina (MUSC), Charleston, South Carolina, USA. Originally launched in early 2009, the project is still far from finished—but the outlook improved once the tech team started working with the clinical staff.
“IT TEAMS MAY FIND THEMSELVES FRUSTRATED BY THE LACK OF PARTICIPATION BY KEY STAKEHOLDERS; CONVERSELY, THEY MAY BE INUNDATED WITH REQUESTS FOR UPGRADES, ADDITIONS AND TWEAKS TO THE SYSTEM ONCE END USERS REALIZE THE POTENTIAL THESE SYSTEMS OFFER.”
—Dan Furlong, PMP, Medical University of South Carolina, Charleston, South Carolina, USA
Advanced IT implementations are often uncharted territory for healthcare facilities and their staff. That unfamiliarity can make it difficult to understand the effort it will take to build these systems and realize the ultimate value they can deliver.
“It teams may find themselves frustrated by the lack of participation by key stakeholders; conversely, they may be inundated with requests for upgrades, additions and tweaks to the system once end users realize the potential these systems offer,” says Dan Furlong, PMP, project management officer at MUSC.
Ashley River Tower, Medical University of South Carolina, Charleston, South Carolina, USA
PHOTO COURTESY OF MUSC
Mr. Furlong and his team experienced both of these extremes on the warehouse program. The medical university's research group had originally served as the sponsor, but lacked the funding to provide the necessary resources or input.
Without that, the effort floundered, says Mark Daniels, director of clinical IT infrastructure at MUSC, who took over the program in August.
Leadership at MUSC knew the warehouse project had potential, so it turned sponsorship over to the clinical side of the organization. The new sponsors redefined the project's goals, focusing on reducing the time required to do chart abstractions.
By automating several steps in the abstraction process, the team expected to cut completion time by 15 percent. When it rolled out the automated processes, the clinical group discovered an unexpected benefit: Accuracy jumped from 80 percent to 100 percent.
The head of the clinical group was so impressed, the project was expanded to track data points across the entire patient population. “Now, if we find ways to impact patient care through management of data, we do it,” Mr. Daniels says.
Over the course of the ensuing three years, the IT team at MUSC has warehoused decades of clinical data, including lab results, radiology images, admission reports, notes and medications for every patient. The team also created dozens of workflows to monitor and access all the information.
Giving doctors real-time data—including deep-dive analyses from a data warehouse—lets them adjust treatment and improve outcomes before a patient is discharged, Mr. Furlong says. “Usually with a data warehouse, you look at trends over the last month or year, but we've created a system that physicians can use while patients are still in their care.”
Mr. Furlong credits the project's success to strong leadership and integrated work teams that were able to break down the barrier between IT and clinical staff.
“You have to make it blatantly obvious that it's a clinical project, not an IT project,” he says. “We may build the technology, but [the medical staff has] to set the priorities, make the clinical decisions and define the workflows.”
PM NETWORK DECEMBER 2012 WWW.PMI.ORG
DECEMBER 2012 PM NETWORK