In the September issue of ACP Internist, ACP President Dr. J. Fred Ralston, describes a personal alternate universe in which he would award a Nobel prize for efficiency to someone who develops software that allows information to flow more effectively and logically into the EHR or web-based applications. These software applications would provide accurate and timely cost and formulary information on drugs and would reduce the administrative complexity of prior authorizations for advanced diagnostics and treatments.
According to Dr. Ralston, ‘Health Affairs (2009;28:w533-543) has estimated that it costs each U.S. primary care physician about $65,000 per year to deal with non-claim-related administrative hassles.’ This is a significant cost, both in terms of effort and direct financial impact on a medical practice.
There are multiple approaches to solving complex problems as outlined in the article, however simply automating existing chaos may simply result in organized chaos that runs on a technology driven platform. Without modifying existing underlying processes and asking which steps can be eliminated entirely or simply reduced through automation, it is possible to ingrain existing organizational pathology without really solving the problems.
Over the past 10 years I have been involved in a number of large information technology projects. Invariably the driver for change is driven from the top down. In an organization with financial and operational objectives that need to be met, technology is often seen as the answer. In almost every instance, these projects have failed to achieve anticipated benefits and outcomes. Looking back on these projects, what has been learned? In my opinion, a significant number of failures (and as a result, the keys to success) are related to the following:
- A failure to think differently. Right from the vision phase, a lack of understanding of the problems being solved at the stakeholder level with the ability to accurately anticipate the impact of changes on existing workflows and how the use of EHRs or software applications can result in better outcomes;
- Failures of governance. Insufficient time and effort spent engaging the organizations and individuals involved to ensure there is clear ownership of the process and the anticipated outcomes – particularly if they will require changes in job descriptions at the administrative levels and education and leadership at the clinical levels;
- Plans that were too rigid and unable to flex and change in response to changing political, operational and clinical needs during the course of deployment, testing and optimization. I talked with the lead developed for a lab results project that was highly successful and was utilized across a large geographic area. He felt that one of the main reasons that the project was successful was the ability to incrementally tweak the project – through a process that took over 30 different iterations over a 3 year time frame. Many projects allow for few change requests and impose harsh penalties for iterative type development;
- A failure to think big, but execute small. While envisioning a systems level change is key to strategic planning, the execution usually varies significantly at the practitioner, clinic or hospital levels. Each workflow must be optimized in order to ensure that the process and outcomes (after optimization) are better than they were before the new solutions are implemented or face rejection by the actual users.
While this list just begins to touch on strategies to consider when trying to effect change at a scale that is significant, it would be valuable to have the input and feedback of readers of this blog. Do these issues resonate with your experiences? Is the problem more related to software or the ‘people and process’ issues that need to be considered?
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This post is the personal opinion of
the author and does not necessarily reflect the official policy or
position of the American College of Physicians (ACP). ACP does not
endorse a specific EHR brand or product and ACP makes no
representations, warranties, or assurances as to the accuracy or
completeness of the information provided herein.