Prescription for the future
as healthcare and technology converge, IT project managers are helping to deliver big benefits
BY MATT ALDERTON
ILLUSTRATIONS BY RAUL ARIAS
PHOTO BY 8183 STUDIO
Electronic health records (EHRs) are just the beginning. Smartphone apps for diagnostic tools and video consultations are decentralizing delivery of care, while hospitals transition to new cloud-based administrative and analytics systems. As patients become more comfortable with new technologies and organizations look to control costs, IT spending is rising and projects are multiplying—putting project leaders in the spotlight.
Global healthcare IT spending is projected to grow 26 percent between 2015 and 2020, according to Technavio, as organizations pursue patient benefits and the bottom line.
“Technology has been a huge enabler of change,” says David Denov, PMP, senior manager, National Health Services practice, PMI Global Executive Council member Deloitte, Toronto, Ontario, Canada.
EHRs alone are expected to save the global healthcare industry US$78 billion worldwide between 2014 and 2019, according to Juniper Research. Implementing EHRs tends to improve care and patient safety as well: Organizations report increases in physician collaboration and reductions in medical errors. A 2016 survey by the Healthcare Information and Management Systems Society found that 83 percent of organizations with advanced EHR environments report improvements in clinical staff's performance quality.
But if the ROI on healthcare IT projects is clear, so are the risks. In Boston, Massachusetts, USA, a US$47 million EHR implementation at Brigham and Women's Hospital came in US$27 million over budget in 2015 due in large part to system coding errors.
“You need to be able to ask yourself: What are you going to do with the data? What kind of reports are you going to generate? What are you really trying to achieve?”
—Jebi Miller, PMP, Children's Hospital Association, Overland Park, Kansas, USA
“These projects tend to be huge and transformational,” Mr. Denov explains. “The bigger the project, the more stakeholders are impacted and the more difficult it is to deliver on time and on budget.”
So what's the prescription for success? Preventing scope creep and security breaches, for starters. And if the project aims to deliver benefits to nurses, doctors and other medical personnel, integrating clinicians into project planning and execution is a must. The alternative is a new IT tool or system that clinicians don't want to use.
Scope creep is so prevalent in healthcare IT projects because customization—rather than standardization—is the norm, says Suresh Sarojani, chief technology officer, HCL Avitas, Noida, India. The organization operates a national network of healthcare clinics. “People in other industries want to standardize requirements because standardization drives efficiency,” he says. “In healthcare, that's not seen as a good thing because providers have different ways of working and patients have different needs. As a result, a lot of IT project managers end up getting into customized feature development, which leads to a lot of scope creep.”
An electronic health records project at Brigham and Women's Hospital in Boston, Massachusetts, USA, came in US$27 million over budget in 2015.
A consultation room at a HCL Avitas clinic
Mr. Sarojani experienced this firsthand on a project to introduce EHR and new healthcare practice management systems across HCL Avitas’ clinics in 2014. “When we started, the expectation of changes from the vendor side was not very high,” he says. “But as we tried to implement, we realized that customization requests are very high.”
To prevent that reality from driving scope creep, project managers should take a more agile approach to planning and execution, Mr. Sarojani says. “Start with a much smaller baseline and plan for incremental releases,” focusing on one or two useful features at once instead of trying to introduce a complete system, he says.
In the case of its EHR project, for instance, HCL Avitas could have delivered a system that tracks a large number of patient health variables and alerts physicians to potential complications. Instead of incorporating every alert requested by every provider, however, Mr. Sarojani's team focused initially on only a handful of high-priority medical alerts, such as drug allergy interactions. That helped the project team maximize value while also managing expectations.
Scope creep can hinder not only the project's delivery, but also its utility, says Jebi Miller, PMP, director of the project/product management office, Children's Hospital Association (CHA), Overland Park, Kansas, USA. Her organization discovered that after working on a multiyear project to create a database to improve care and outcomes for a specific pediatric population.
Given the objective, the project team was led by physicians. One of the challenges, Ms. Miller says, was a disconnect among stakeholders on goals defining overall project success. The physicians were focused on individual elements that they felt were critical to collect from a clinical perspective. IT was focused on ensuring they built a tool that would support the physicians’ data collection requirements. The result was a database architecture that did not support the most important and relevant objective: data extraction. The project team quickly realized that because the database was so large and complex (1,200 data elements), it was difficult for analysts (and clinicians) to make sense of the data.
While the situation was problematic, it was not insurmountable. The team took a step back to better understand what data physicians needed to move their work forward and then identified opportunities for corrective action. In parallel, projects were spearheaded to make some fairly significant changes to the database architecture, which improved data extraction results and streamlined the data collection effort. A key lesson learned, says Ms. Miller, was ensuring the right staffing mix on future projects that require both clinical and technical expertise.
“You need to be able to ask yourself: What are you going to do with the data? What kind of reports are you going to generate? What are you really trying to achieve?”
The CHA project's initial reliance on clinical input might be unusual, however. Many healthcare IT projects suffer from too little clinical input, according to Susana Sasportes, PMP, former project manager at South West London and St. George's Mental Health NHS (National Health Service) Trust, a provider of mental health services in London, England. (She's now a project manager at BNP Paribas in Lisbon, Portugal.)
“The biggest challenge is to ensure that once you implement a certain technology, it's actually used. I've seen a lot of projects completed on time and on budget—and then no one actually uses the technology,” she says.
To avoid this, Ms. Sasportes would involve doctors and nurses at every stage of project planning and implementation. The approach pays off, she says, citing a project she led to enable virtual healthcare consultations for patients via the internet.
“Without champion users within the clinical system, healthcare IT projects are always going to be seen as technology initiatives. We want them to be seen as clinical team initiatives.”
—Suresh Sarojani, chief technology officer, HCL Avitas, Noida, India
“At the beginning it was very difficult because some of the doctors didn't see the benefit of having this project. There was a lot of debate about the clinical risks involved with having patients see doctors virtually,” she says. But adding a doctor to her team to be the project's clinical champion proved crucial: The doctor helped the team identify clinical requirements, answer care-related questions from clinicians and train end users to leverage the technology. “Having her on board made a huge difference and ensured the technology was actually used after the project was implemented,” Ms. Sasportes says.
Projects powered by rising healthcare IT spending are delivering new technologies. The goal? More efficient and higher-quality healthcare.
SPENDING TO SAVE
Projected size of the global digital health market by 2020—up from US$60.8 billion in 2013
Estimated annual savings in the United States from broad adoption of telehealth technology
32% Portion of U.S. adults with at least one medical, health or fitness app on their mobile devices—double the number in 2013
66% Portion of the 100 largest U.S. hospitals offering patients mobile health apps
72% Portion of U.S. adults aged 18 to 44 willing to use telehealth services such as videoconferencing to consult with a mental health provider
Portion of government-approved mobile health apps in a sample test with at least two critical security vulnerabilities
Sources: Accenture, Arxan Technologies, Deloitte, GBI Research, PwC, Research and Markets
HCL Avitas found clinical involvement equally powerful during its EHR implementation project. By consulting doctors, the team found that healthcare providers care a lot about how much time a new IT tool will take them to use. “Doctors don't want to spend more than a couple minutes on the technology while they are with patients,” Mr. Sarojani says. “That means asking how much we can do in two minutes” rather than just focusing on delivering features, he says.
“No one can anticipate all the threats, but a good awareness will help you forecast what risks you need to consider while planning.”
—Wael Al Hudhud, formerly of King's College Hospital Clinics, Abu Dhabi, United Arab Emirates
Clinical integration is so important that Mr. Sarojani created a clinical-technology-management office, or steering committee, to govern healthcare IT projects, which functions like a project management office (PMO). The office consists of a manager; early adopters, or “champion users,” from each of the company's clinics; and a senior clinical leader to serve as a liaison to the company's chief medical officer. Members of the steering committee assist with setup requirements and implementation, clinician training and general health IT evangelism.
“Without champion users within the clinical system, healthcare IT projects are always going to be seen as technology initiatives. We want them to be seen as clinical team initiatives,” says Mr. Sarojani. The steering committee faced some initial growing pains but is now yielding significant results. “Clinicians are not used to being managed within a corporate project system, so there was initial pushback. Once we got the right clinicians on the team, though, the whole PMO concept definitely began to work.”
PHOTO BY 8183 STUDIO
Integrating clinicians into the core of projects does more than just meet users’ needs. It also helps with overall stakeholder management. “With IT projects, sometimes people feel that a project is being done to them,” Ms. Sasportes says. “But when you have someone on the project representing their interests, stakeholders have the feeling that the project is being done with them. That makes them more likely to embrace the technology once it's rolled out.”
That thinking applies to all the various stakeholder groups involved in healthcare IT projects. “We have to engage not only the doctors and the nurses, but also the finance department, the insurance department, the human resources department and stakeholders—because they're all end users who are going to use the systems we're implementing,” says Wael Al Hudhud, former IT manager at King's College Hospital Clinics in Abu Dhabi, United Arab Emirates.
Even patients have a role to play. “On healthcare IT projects you have three big groups of stakeholders: patients, clinical staff and management,” Ms. Sasportes says. “To ensure success you need to have stakeholder involvement from all three groups.”
PRIVACY BY DESIGN
Clearly, close attention to stakeholders from the outset pays off—and the same is true with security risks. With sensitive patient medical data often in the mix, healthcare IT project leaders need to be up to speed on organizational and legal requirements.
Ms. Miller can attest to this. A current project to collect data from children's hospitals on the treatment of a serious illness took nine months to get off the ground, she says, due to concerns about compliance with the Health Insurance Portability and Accountability Act. The law governs healthcare privacy in the United States. “Once we were ready to do the work, the CIOs got involved,” Ms. Miller says. “We had to go through a whole other round of approvals to ensure security protocols were met.”
“We know going into any project that collects data that we're going to have to jump through [security] hoops.”
—Jebi Miller, PMP
Thankfully, the project team was prepared. “We know going into any project that collects data that we're going to have to jump through [security] hoops,” she says.
But when so many hoops exist, difficult questions can arise. Each risk assessment can result in new requirements being added to the project's scope. “This adds overhead, and when you're on a limited budget that means you have to start carving off features to the point where you could end up having conversations about whether the viability of the project is even still there,” says Mr. Denov. Balancing functionality and security is “tricky,” he adds. “Nice-to-have or gold-plating requirements” are the first to go.
Security features are nonnegotiable, so project managers’ only recourse is to make risk analysis a central part of the planning process.
“It starts with having good awareness of all the security threats around the world,” Mr. Hudhud says. “No one can anticipate all the threats, but a good awareness will help you forecast what risks you need to consider while planning.”
“The biggest challenge is to ensure that once you implement a certain technology, it's actually used. I've seen a lot of projects completed on time and on budget—and then no one actually uses the technology.”
—Susana Sasportes, PMP, formerly of South West London and St. George's Mental Health NHS Trust, London, England
Legal and compliance departments are important collaborators during this process, according to Ms. Sasportes. “You need to understand what laws and legal constraints to adhere to for each project,” she says. “It helps a lot on projects that include data to involve the legal department from the beginning; if you don't take into account their opinions early in the project, even if it means adding to the project timeline and budget, the project might end up being stopped or delayed to comply with the law.”
“If you build a system and try to put privacy in afterwards, it won't be easy, cheap or simple.”
—David Denov, PMP, Deloitte, Toronto, Ontario, Canada
The key to success in this regard is having a “privacy by design” mindset, says Mr. Denov. “If you build a system and try to put privacy in afterwards, it won't be easy, cheap or simple.”
CONNECT THE DOTS
Given healthcare IT projects’ unique mix of clinical and technical requirements, project leaders for these initiatives should ideally have dual expertise. But for HCL Avitas’ EHR project, it was initially difficult to find clinicians with the right blended clinical and IT mindset, Mr. Sarojani says. “Fortunately, over the last two years I've seen a lot of clinicians focused on learning and building careers in health informatics. Identifying people with that expertise and bringing them on early is key.”
The implementation is now in its second phase, and so far the EHR project has been a great success, Mr. Sarojani says. More than 90 percent of the organization's full-time doctors are using EHRs, and many patients appreciate the convenience.
“Doctors who pushed back initially because they thought it was a data-entry activity are starting to realize the value. And patients see the benefits of not having to carry their records with them during repeat visits,” he says. Patients can now log in to a mobile application and check their medical records, update their conditions and medications, and also send messages to clinic staff. “The project is a great win-win for clinicians and patients.” PM
No Paper, More Value
A project to make a breast-cancer-screening organization 100 percent electronic is on track to deliver more than just cost savings.
Healthcare organizations want to spend less on overhead and more on patient care. To enable it to screen more women for breast cancer, BreastScreen Victoria (BSV), based in Carlton, Australia, sponsored a five-year electronic records management project, which launched in 2013. Its goal was simple: make BSV a paperless organization by 2018.
“We had a situation where every woman we screened had a paper file, and every two years when she'd come in for screening we'd add a handful of forms to her file. The file would just grow and grow and grow,” says Greg Maudsley, a senior project manager at BSV. “Every time a woman came in we'd need to pay for that file to be retrieved from our archive. If we could eliminate that expense, we could redirect the cost toward screening more women.”
The project promises benefits beyond just freeing up funds for more screenings, though. Electronic record systems also can boost quality and efficiency of care. “While a radiologist is reviewing images of the breast, they can now go into our information system and have that woman's full clinical record right in front of them,” Mr. Maudsley says. “All of that clinical information is now readily accessible at the desktop to help the radiologist determine whether there's a need to recall women for further testing.”
For the project to deliver these clinical benefits, the project team first had to gather business requirements. But getting clinical feedback on design proposals is easier said than done. Because BSV's radiologists are always at capacity and distributed across the state, Mr. Maudsley had to make it convenient for them to contribute to system design.
“If they were only available at 8 p.m., we'd make ourselves available. We also did a lot of online [meetings] so people could just dial in to a teleconference and look at the design as we described it.”
A radiologist reviews breast-cancer-screening images.
A similar strategy for boosting participation worked during the implementation phase. “We had to train approximately 600 staff [radiologists, radiographers, nurse counselors and administrators] across the state in a new version of software, or a new workflow. Victoria is a very large place and I don't have 50 trainers, so we had to think carefully about how to efficiently train that many people,” Mr. Maudsley says. His team turned to e-learning solutions to remotely train his staff in virtual classrooms to complement traditional classroom training.
A turning point in the project proved to be engaging radiologists. “Once everyone knew that the clinical leaders were engaged and complimentary about the solution we'd delivered, other stakeholders put their hands up to be involved in subsequent stages of the project,” Mr. Maudsley says.
“Every time a woman came in we'd need to pay for that file to be retrieved from our archive. If we could eliminate that expense, we could redirect the cost toward screening more women.”
—Greg Maudsley, BreastScreen Victoria, Carlton, Australia
Like many IT projects in the industry, electronic collection and transmission of sensitive patient information raised security challenges. To ensure it wouldn't jeopardize patient privacy, the project team collaborated closely with legal advisers to identify security requirements early on. One piece of advice the team received, for instance, was to build email verification into the system's workflow in order to gain patients’ consent before communicating with them electronically about their health.
Although paper is still part of life at BSV, the transition into the organization's purely electronic future has begun. As of May, 30 percent of patients were booking appointments online and 40 percent were receiving documents via email—which translates into annual postage savings of AU$100,000. Mr. Maudsley is confident benefits will continue to accrue to both the organization and the women it serves. “We need a system that allows us to perform our duties as efficiently as possible so we can grow with our population,” he says. “This system will help us do that.” PM
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