Dining With Cannibals


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Medical IT instillations challenges and techniques.

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  • Medical IT implementations can be a lot like being an anthropologist invited to a formal dinner hosted by Cannibals. \n\nSuccess will be defined as remaining an engaged and intelligent observer of the feast, whilst simultaneously avoiding becoming or enjoying the first course of the meal. \n
  • Rashomon, the classical film directed by Akira Kurosawa, can provide a useful paradigm for understanding IT implementation challenges. \n\nA participant(s) feelings and support for an IT implementation are based on his/her culture and world view. \n\nThus the same situation or event can be divergently experienced and interpreted by different members of the implementation team. \n\nThis contributes significantly to the inevitable confusion and dynamism of the project implementation. \n
  • This high level functional flow block diagram demonstrates an idealized ‘black box’ medical IT system, where the patient is the primary system input, the IT system is represented by a transformation function and the status after action of the medical IT system is transformation of the patient’s status to that of non-patient. \n\nFrom an engineering perspective a medical encounter using the IT system can be represented by an increasingly complex series of functional decompositions starting from the highest level functional flow block diagram (FFBD) to lower and more detailed views of the process(es) using a recursive and reductionistic methodology to capture a full and complete set of functional requirements required by the system to transform the patient to a non-patient. \n
  • This mind map more colorfully represents an abstraction of clinical work seen from the perspective of multiple actors and players within a single hospital episode of care. \n\nThe perspectives of the patient and physician are more fully fleshed out than that of the other players, stakeholders, and their agents. \n\nThis reflects my more vibrant understanding of the issues facing the patient and the physician. \n\nAdditionally the enduring importance of the physician in the clinical process is driven by realization that approximately 80% of the costs of medical care are due to the decision making of clinicians and their resulting ‘orders’ and treatment plans based on their patient assessments. \n\nA physicians thought processes and clinical actions are largely based upon a renaissance-era cognitive style that involves in true Leonardo DiVinci fashion both R-sided (The art of medicine) and L-sided (The science of medicine) brain processes utilized in synchrony to develop both the possible diagnosis set and its consequent treatment plan. \n\nIt should be clear that hospital based care environment represents a level of process complexity several orders of magnitude higher than that of the usual office based care environment. \n\nThus our representation of different stake holders and their characteristic world view issues are obviously gross simplifications. \n\nThe care process is represented as a closed circuit to allow for reiterative refinement of the patient’s status via multiple hospital episodes of care. \n\nAdditionally, the circular care process implies the plan-do-study-act (PDSA) Deming/Shewhart Cycle. \n\nWithin this symbolic formalism, the CMIO either acts directly or supervises the clinical IT system champion.\n\n\n
  • There lies within the previous mind map representation an implicit explanation of the culture wars between the front line clinician rooted as he is in the medieval based guild system of training and its corresponding job-shop work environment vs the 6 Sigma model of process improvement which has been developed, implemented, and honed in the manufacturing domain, initially and best implemented in the assembly line work environment. \n\nThe process engineering schema above makes explicit the consequences of work place transformation, i.e., loss of status and loss of control for the physician as the guild master. \n\nFurthermore, given a fundamental understanding of statistical control theory, it is axiomatic that reduction of statistical variations of care processes means that the superlative clinicians will have their performance degraded while suboptimal performers will be improved towards a statistically defined ‘best practice’, i.e., regression to the mean occurs from both extremes of the statistical control limits. \n\nThis strongly implies that in an implementation the fiercest physician opponents to workplace transformation will simultaneously come from both poor performers, who paradoxically are often times the hospitals biggest hitters, as well as more problematically from the acknowledged stellar clinicians within the hospital. \n
  • This slide conceptualize five categories of barriers to IT deployment: time, expertise, access, resources, and support. \n\nIt is axiomatic that there is never enough time to plan, collaborate with peers, prepare instructional materials, explore, practice, evaluate, develop, maintain, and expand skills required for the implementation. \n\nExpertise is often times a potent technology deployment barrier. Effective technology training must be hands-on, systematic, and ongoing. Additionally, lack of technology competence is a potent barrier in the earliest phases of the implementation. \n\nAccess to and lack of hardware and software availability for training while a real is the most fixable barrier.\n\nResources need to be programmed to allow for purchase, maintenance, and upgrade of hardware and software; to provide training and support; and for auxiliary systems costs. \n\nAdministrative leadership and technical support are the most critical factors. In addition to obtaining programmed financial resources, administrative leaders must elaborate expectations, develop a vision and plan for technology integration, and then provide incentives, encouragement, and leadership in pursuit of the IT vision. \n\nNote that technical support although the last factor, is often times the Achilles heel for the implementation. Under funding or under-resourcing the roll-out can threaten the entire project in strict analogy to how the War was won in Iraq, but the Peace was lost. \n\n
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  • This slide details the most important speed bump in the implementation of provider utilized hospital based IT systems, an equation more fundamental to the workings of the universe than E=MC^2, i.e., time equals money. \n\nActual computerized physician order entry system implementations have demonstrated initial decrease in provider efficiency for their hospital based work of up to 40%. \n\nAs a specific example, given last years total decrease in cardiology revenues of 20-25% (decreased reimbursement for office based imaging + elimination of the consultation code for inpatient evaluations) such reductions of in-hospital efficiency have painful consequences at best and possibly compromise the survival of economically marginal practices. \n\nCardiology in particular had developed itself into a speciality where hospital work was minimized and revenue was maximized through the deployment of advanced in office imaging modalities which served as a potent revenue stream for the practice. \n\nTherefore, even before CPOE roll-outs, provider behavior was directed towards minimal time investments dedicated to the lower profit margins of the in-patient setting. \n
  • This slide details elements of an effective solution set to counter implementation hurdles. \n\nNote that a solution set must be engineered based on local cultures, environments, and constraints. \n\nNo single measure can guarantee a successful implementation and the more elements incorporated into the implementation plan, the higher the likelihood of success. \n\nHowever even use of all elements of the solution set while increasing probability of success does not guarantee success. \n
  • This final slide recaptures in the content of the previous slide with redundant verbiage extracted and listed in such a way as to facilitate memory of the techniques. \n
  • Dining With Cannibals

    1. 1. Dining With Cannibals An Anthropological Analysis of Medical IT Implementations Frank W Meissner, MD, CPHIMS
    2. 2. 1st Law of Reality: Life Is A ContinuouslyBlended Sequence of Rashomon Mo ments
    3. 3. Idealized Medical IT System: The Engineering Perspective Health IT System Patient+ Dis-Ease State Transition (∼)Patient (+ Coin of Transformation∫the Realm) Input High Level FFBD Output
    4. 4. Idealized Medical IT System: A Matter Of Perspective
    5. 5. Process Structures & Characteristics Job Batch Assembly Project Continuous Shop Process Line Flow None Continuous Flexibility High Low # Products High Low Investment Low HighVariable Cost High LowLabor Content High Low Labor Skill High Low Volume Low High
    6. 6. Taxonomy OfImplementation Barrier’s Mneumonic TEARS Time Expertise Access Resources Support
    7. 7. Taxonomy OfImplementation Barrier’s Mneumonic TEARS Time Expertise Access Resources Support
    8. 8. Greatest Equations of All Time 1+1=2 C=2πra2=b2+C2a/b=c/d eiπ+1=0F=maδ iγ⋅δΨ=mΨ S=0 E=hνPV=nRT ν=Η0δ I=V/R S = k(logW) C=Blog2(1+S/N) E=mc2
    9. 9. Principle Impediment - Hospital Based Systems Some CPOE Implementations Have Initially Decreased Provider Efficiency 20-40%Last Yr Avg Decrease in Cardiology Medicare Revenues approx 20-25% Without CPOE
    10. 10. Solutions To ImpedimentsTotal Commitment From Hospital Management TeamPre-deployment Buy-In From ‘Principle Hitter(s)’Pre-deployment Process Analysis and Re-engineeringEngineering ‘No-Way Back’Effective and Persuasive (Local) Physician ChampionIntensive/Responsive Pre- & Post-deployment Help DeskDetailed Daily Visibility - Sr Managements ‘Dashboard’Defeat ‘Success Has a Thousand Fathers, Failure Dies AnOrphan’ - Accountability
    11. 11. SolutionsCommitment (Sr Management)Buy-In (‘Big-Hitters’)Process Re-engineeringNo Way Back (Succeed or Die)Champion (Local Leader Is Best)Responsive (Help Desk)Visibility (Sr Management Dashboard)Accountability (Somebodies Head on the Block)