Managing the Risks: Are You Scared Yet?

by Manuel Lowenhaupt, M.D.
Michele Salvaneschi, R.N., Capgemini

June 30, 2003

Nervous about the risks involved in implementing an advanced clinical information system? Good! Anxiety motivates caution and a thoughtful quest for answers to hard questions. The question is: are you anxious enough? Here are reasons your anxiety is justified.

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There are many common misconceptions about the implementation of a CIS, including:

“If You Build it, They Will Come”

In the movie Field of Dreams, an ex-baseball player receives heavenly advice
to build a baseball diamond in his cornfield. If he does, he is told, his long-dead
baseball heroes will miraculously appear to play a ballgame on his field. The
reality for clinical systems is less than miraculous. Although you may invest
heavily in a system that automates physician order entry, for example, physicians
will not automatically flock to use it. Physicians and other clinicians who
will use the system must all agree that the benefits of such a system more than
offset the effort required to use it.

One hospital’s experience serves as a cautionary tale. This hospital developed,
with the collaboration of three technically savvy physicians, a rudimentary
system for generating reports and accessing patient records from outside the
hospital. Expectations were high that the hospital’s staff of 350 physicians
would adopt the system and reduce some of the nurses’ clerical burden. At the
end of a year, the only clinicians using the system were the three physicians
who had helped design it.

The obvious lesson is that no system will deliver meaningful benefits unless
all the clinicians, from physicians and nurses to radiologists and pharmacists,
choose to use it. They must perceive that the benefits they will personally
receive from such a system are worth the changes to their work routines and
the time and effort required to learn how to use the new technology. Achieving
buy-in from clinicians requires that representatives from every clinical group
get recruited and become actively involved in the design and implementation
of the system they will use. Clinicians must participate in building the consensus
that will drive the implementation plan in order for the clinical information
system to meet its objectives.

Skilled Resources Are Readily Available

It is vital that the right mix of functional, technical, and clinical resources
be brought to bear on the challenge of implementing an advanced clinical information
system. Internal IS departments and even IT vendors often lack the depth and
breadth of talent and experience required for a successful implementation. It’s
also important to recognize that a project like this often has peak requirements
for resources during “go live” or other key phases of the project. Provision
must be made for putting in place the right mix of skills at the right times.

Implement a CIS and You Will Realize a Big Return on Your Investment

Investing in technology will not in itself produce process efficiencies or
bring about huge cost-savings. The true benefits of a CIS are realized only
when enabling technologies are combined with re-designed clinical processes
and a revamped organizational structure. Often, health care organizations are
led to unrealistic expectations on ROI by overzealous software and hardware
vendors. Significant cost savings come mostly from the redesign and automation
of clinical processes and the reduction in medical errors that a well-implemented
clinical system supports.

“Skate to Where the Puck Is Going to Be” — Wayne Gretzky

This might work for hockey great Gretzky, but it’s a bad way to choose or implement
a clinical information system. This strategy might also be termed the “smoke
and mirrors” approach: “The functionality you desire will be implemented in
the next software release. Go ahead and design to it.” All too often, when the
health care organization gets to the implementation stage, there is no product
to support the new process. Prospective buyers need to be very cautious about
vendor promises regarding future functionality. Sometimes, vendors demonstrate
features and functionality in a pre-release software version that is still being
debugged. Integrating these features into the stable, production software may
be months in the future. The only functionality you can depend upon is what’s
available in an application’s current, tested, and running-live version. In
other words, what you see is what you get.

All Costs Are Known Upfront

Health care organizations frequently underestimate the time and costs involved
in implementing an advanced clinical information system. More than half of all
projects come in late and over budget. A realistic budget requires a candid
assessment of your organization’s current IT capabilities and a detailed plan
for the information system needed to support the desired changes to your organization’s
clinical processes. The budget must include the cost of paying the people who
will implement the system, including clinicians and other operational staff.
The considerable cost of end-user training needs to be figured into the total
cost of ownership of a CIS. Realistic budgeting for a CIS is an area where experience
really counts. The best place to seek budgetary advice or guidance is from an
organization with predictive budget models and a track record of successful

Another problematic approach is to start with a target budget, then choose
system capabilities and design functionality that the budget can afford. Organizations
that pursue a “we’ll take what we can get” approach generally end up with about
one-third the functionality they need to support industry-leading applications
and processes. One organization that took this approach found that planning
to a budget is no bargain; after spending millions to develop a system that
proved a dismal failure, they terminated the entire project along with their

Implementing a CIS Doesn’t Require Operational Leadership

Wrong! To be sure, the CIO and the IS staff play vital roles in designing,
implementing, and supporting an advanced CIS. However, treating a CIS as a purely
technical initiative leads to a system poorly aligned with the organization’s
vision and the needs of its clinicians. It is unlikely to produce an attractive
return on investment. An effective system implementation requires strong participation
and leadership from clinicians and other operational personnel. Chief operating
or chief executive officers often champion the most successful CIS implementations.
The hospital’s medical staff has a key role to play in implementing a CIS that
will support the automation of patient care processes. The role of technology
is to make possible new clinical processes and clinician relationships that
give caregivers more time and flexibility in delivering patient care. The symbiosis
of process improvement and enabling technology works only when there is close
collaboration between the operational and technical staffs.

Don’t Bother Talking to the Nurses

Probably no single group of clinicians knows more about the day-to-day operation
of a hospital than its nurses. They spend more time in direct contact with the
patient than any other group. Automating the delivery of patient care will have
a profound effect on how nurses spend their time and how they collaborate with
other clinicians. Nurses from every medical specialty need to be involved in
the design, implementation, and ongoing support of a CIS, and not just as advisors.
Nurses must take leadership roles in the system implementation, and share responsibility
for meeting goals and objectives. Their participation will ensure that the core
nursing population, not just a few nurse-technophiles, will willingly adopt
the new processes and technologies.

You Can Hide Implementation Costs In Operational Budgets

The successful implementation of an advanced CIS requires the dedication of
significant human resources from many operational departments for extended periods
of time. In fact, significant operational resources will be required throughout
the life of the system to evaluate its performance and make necessary changes
and improvements to both clinical processes and the applications that support
them. These health care professionals must be compensated for their efforts.
The cost of their time should be factored into the implementation budget, even
though they are paid through their operational departments. Since it is easier
to cost-justify a small implementation budget than a large one, many organizations
ask operational departments to pick up the costs of these “loaned” individuals.
This hides the true cost of ownership of a clinical information system, and
leads to unrealistic ROI projections.

Even though individuals involved in an implementation project may not get paid
extra for their roles, there are costs associated with assigning other personnel
to cover their clinical duties. Projects that hide personnel costs in this way
tend to be under-resourced, since operational departments naturally view time
spent on these unbudgeted initiatives as a lower priority than a clinician’s
primary duties. The best system implementations need the most experienced and
talented of your medical staff, not technophile volunteers or conscripts chosen
by expediency. The best way to assure continued availability of experienced
operational personnel is to budget and pay for them. It’s worth remembering
the old adage, “Free advice is worth what you pay for it.”

Technology Is a Vehicle to Fix Broken Processes

The danger here is that the technology solution is likely to end up supporting
the current broken process. Throwing the latest technology at an inefficient,
poorly conceived clinical process actually hinders progress toward a system
that delivers real quality improvements. The proper role for technology is as
a tool or enabler of new, automated clinical processes. A combination of process
redesign and powerful, flexible technologies for storing, comparing, and sharing
information is required to deliver better, safer patient care.

With the Right Team and the Right Solutions, This Will Be Seamless

Organizations facing the challenge of clinical transformation would like to
believe that everything would be simple and success assured if only the right
mix of talents, the right vendor, the smartest implementation team, and the
most experienced consultants can be brought together to do their jobs properly.
The reality is that the path toward an operational clinical information system
is invariably bumpy. Through no fault of methodology or lack of skill, problems
will crop up. This is an exciting, pioneering journey, and discovering unexpected
challenges goes with the territory.

The realistic approach is to seek out problems so that remedying them becomes
part of the implementation plan. Expect the unexpected. The path is long and
the environment unpredictable, so pack conservatively. Bring warm clothes and
extra food, just in case. Plan for the implementation to take longer and cost
more than you think it should. Be confident that the view from the summit is
worth the climb.

There You Have It

The above list is by no means exhaustive, but exposes common misconceptions
that often lead to unrealistic expectations towards people, processes, and technologies.
Wariness and caution should guide your decisions, and for this reason, initial
anxiety and trepidation are probably healthy, since they encourage caution.
Misconceptions can be costly. Bringing them to light should encourage you to
keep your eyes open, and your anxiety level appropriately high.

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