Some Factors Underlying Efficient Change Management

Recently I had a great discussion with a non-healthcare person about the role of Informatics in EMR implementation, and what kind of things CMIOs look for to estimate whether a particular EMR implementation will be successful or not.

The discussion was a great opportunity for me to really think about the big picture issues, and try to distill them into something more tangible to a non-healthcare, non-informatics audience. 

What it finally came down to, for me, was the successful planning and budgeting for the whole EMR implementation - both the go-live, and the eventual optimization and continued maintenance that come afterwards. It's not unlike buying a car - To be successful at car ownership, you have to budget for both the car (necessary at go-live) and the gas/maintenance (necessary after go-live to make the car go forward) :

While researching for this blog post, I found out this is one of the reasons why the mandatory price stickers on all new cars (known as the Monroney sticker) must contain both the price of the car and an estimate of the gas mileage :

Not only does this allow consumers to select cars with better fuel efficiency, it also helps a consumer answer the question "Can I afford this car?" before they actually buy it - A major factor for successful car ownership.

With most healthcare technology, it's pretty easy to budget for the car - vendors know this number well - but it's not as easy to budget for the gas. Vendors will often estimate the cost of optimization, upkeep, and maintenance for you, but how do you really know if their estimate is correct? Will you see the same gas mileage in your experience?

This then raises the question - What exactly are the factors that go into 'gas mileage' for an EMR? CMIOs, CNIOs, and other Informatics professionals struggle with these questions all the time, because they are important to help budget for successful EMR implementation :

• Budget well for the ongoing optimization, maintenance, and upkeep - And your EMR implementation will likely be successful.
• Budget poorly for the ongoing optimization, maintenance, and upkeep - And your EMR implementation may be fraught with struggle.

What experienced Informatics professionals know is that a large part of the 'fuel-efficiency' of EMR ownership comes from the organizational change management - How well-suited is the organization to make change? Does it contain the infrastructure and configuration needed to support efficient change management? 

These change management issues are so key to EMR implementation that in 2013, the website www.HealthIT.gov published this great primer on EHR change management :

https://www.healthit.gov/sites/default/files/tools/nlc_changemanagementprimer.pdf 

 ...which provides a great high-level overview about change culture, along with some fantastic references. (A helpful document and a must-read for any healthcare executive considering an EMR installation or replacement!)

But what are the other factors that experienced informatics professionals look for in change management? Are there other factors to look for that help better estimate your gas mileage, and thus your eventual cost of ownership? To help share some insights, I've created the following table, with some factors that I believe influence an organization's ability to manage change efficiently - In estimating the price of your gas, some factors to consider (in no particular order) include : 

While this list is by no means comprehensive, these are some of the bigger factors that experienced Informatics professionals consider before advising organizations how to best budget for their EMR implementations.

In the end, enterprise EMR success depends on correctly budgeting for the purchase, maintenance, and upkeep of your technology. It's not just your go-live that matters. Knowing the price of both the car and the gas before you invest will help you have a successful long-term implementation.

This post is for educational and discussion purposes only - Please consult your own Informatics professional before budgeting for any technology purchases. If you have any feedback, thoughts, or other factors to consider, please leave them in the comments section below!

Could Healthcare use a SimHospital?

It's July, 2014. Meaningful Use Stage 2 is underway, ICD-10 has been delayed again, the Affordable Care Act is happening, and healthcare is reforming at a pace it's never been subjected to. Change is afoot. So this has been keeping me quite busy.

So I thought I'd write a bit about the potential value of gaming and simulation in healthcare reform.

As a CMIO in a community hospital, you sometimes fill a lot of roles - Physician informaticist, project manager, trainer, workflow analyst, policy writer, regulatory guru, strategist, and practicing physician all in one. I think this is one of the reasons the CMIO role continues to expand and evolve nationally - It's helpful to have someone who sees so many facets of your care delivery system.

And as an Informaticist, to help the REAL world, you end up spending a lot of time in a VIRTUAL world, with dummy patients, dummy lab tests, and dummy tools, trying to test things in a virtual TEST environment, to make them work properly before they go into the LIVE environment. Sometimes I'm very surprised at what this virtual world teaches us about the real world. (For some Hollywood context, see Gary Sinise playing astronaut Ken Mattingly in the movie Apollo 13, where they work out problems in the virtual training environment that help save the real-life astronauts.)

Anyway, with all of the change going on in healthcare, we need to identify and train future healthcare leaders who will help see healthcare through these changes. Here is where gaming comes in.

Gaming could help healthcare, by allowing our future healthcare leaders to learn strategy in a safe, dummy, TESTING environment - No real workers, no real patients, no real budgets. If pilots can practice flying and landing planes in a simulator, why can't healthcare leaders? What if they could really experiment with revolutionary efficiency and cost-cutting strategies in a safe, TEST environment, where they wouldn't have to worry about departments or hospitals shutting down?

One thing I've learned from studying workflows is that most people behave in fairly predictable ways. Most people want to do the right thing - They want to practice their trade, make a living doing it, and be proud of their work - so if you give them enough structure and reinforcements, they will do it fairly predictably. In other words, predictable things happen predictably.

So if you were designing a healthcare simulator, it probably wouldn't be too hard to develop some common clinical and administrative avatars :

1. [ CLINICAL ] Nurse avatars
2. [ CLINICAL ] Physician avatars
3. [ CLINICAL ] Pharmacist avatars
4. [ CLINICAL ] Ancillary staff avatars (e.g. Respiratory, Dietary, Rehab, Case Management, etc.)
5. [ ADMIN ] Manager-type avatars (e.g. Nursing, Providers, etc.)
6. [ ADMIN ] Director/Chief avatars
7. [ ADMIN ] Executive avatars
8. [ ADMIN ] Board Member avatar

And in this game, with simulated budgets, each of these avatars would generally conduct themselves with a predictable degree of certainty, based on what I think are a few key environmental variables, which are all related to each other : 

1. Amount of Education/Training (includes everything from formal, professional education to organizational orientation to continuing ed)
2. Strength of Operational Infrastructure (includes everything from policies to governance to committee structure to supervision to technology to organized change management)
3. Quality of Documentation (includes everything from contracts to job descriptions to committee charters to bylaws)
4. Efficiency and Flexibility in Finance/Budgeting (includes everything from salaries to budgets to facilities and equipment)
5. Effectiveness of Communication (includes everything from emails to committee meetings to reporting structure to internal/external posters and publicity)

So in a virtual, gaming scenario, you could potentially build a virtual SimHospital, from the ground up, full of these avatars. And if you wanted it to be successful - Or really successful -  you would probably want your virtual avatars to have the highest amount of education, strongest operational infrastructure, highest quality documentation, most efficient and flexible finance/budgeting, and most effective communication.

But the real world doesn't work like that - you can't have the highest degree of all of them. You have to make compromises. Usually limitations come in the form of time, resources, or both. So to be successful, most organizations constantly work to maximize all five of those factors.

But the virtual avatars in this virtual hospital would all be continuously responding to these environmental variables, and in this way, one could build this SimHospital - A virtual environment in which the goal is to make a working, functional, and financially viable hospital. You make the decisions, you juggle the variables, and the avatars and budgets will respond to your decisions. You could be your own virtual board member.

Why would someone want to play this game? To learn safely. To experiment. To try new ideas without people getting hurt. Heck, you could even make it fun and award points for things like delivering a quality procedure without complications, or saving money. What if healthcare administrators played this game at home, competitively, trying to see who could get the highest score?

Let's face it, running a healthcare corporation isn't easy, with these many complex internal and external environmental variables that are constantly changing. But helping leaders to understand the these changing variables in a safe, TEST environment, would have enormous educational value to future healthcare leaders.

After all, if pilots have virtual simulators for flying a plane, why not a virtual simulator for running a healthcare organization?

The challenge with this whole gaming idea, of course, would be deciding : What would you award points for, exactly? Would it be :

1. Financial Profitability?
2. Quality of Care?
3. Quantity of Care?
4. All of the above?

Whatever the scoring schema is, a place for healthcare leaders to learn managerial and leadership skills safely, and try out new ideas without risk, would be a tremendous help in training the leadership we will need to see our industry through the next ten years.

What would you award points for? Leave your thoughts in the comments below! Remember, this post is for educational purposes only, and to stimulate discussion about new and innovative ways to help improve the delivery of healthcare.