Change or Transformation?


1st April 2012

When we talk about transformation in healthcare what exactly do we mean?

The Oxford English Dictionary defines transformation as “a marked change in form, nature, or appearance”. When I picture transformation in nature I have an image of the difference between a caterpillar and butterfly.

One of the most stunning transformations I can think of in the corporate/business world is the transformation that the IBM company made from being a manufacturer and seller of office equipment (typewriters, computers and so) to being one of the world’s biggest suppliers of consulting services. In the past 10 years while IBM hardware sales have hardly changed its consulting and software business have more than tripled in size.

You can be sure that this change within IBM was transformational for the way it ran its business, recruited staff, measured its performance, and approached its customers.

It is also clear that, through transformation, IBM hasn’t lost sight of its roots, instead it has built upon its capability to massively increase the value that it adds to its products through growing its services and software business.

The IBM story is completely analagous to the call-to-arms for healthcare providers. Healthcare transformation is not about stopping what we do now, but it is about transforming the way we do it to add extraordinary levels of value in our endeavors to keep people well, to cure disease, to support care providers and to reduce waste.

There are two key questions for consideration by any healthcare organization who wants to undergo a transformation:

  • How does a healthcare provider transform itself from what it is today? and;
  • What will “finished” look like?

When deciding the areas where transformation will have the greatest positive impact, it is worthwhile considering what some of the challenges are in healthcare today. I propose the following (in no particular order) are some pressing issues worldwide:

Healthcare providers are often inflexible in their approach to where, when and how services are provided to patients.

This results in an often frustrating and more unpleasant experience for patients who need care than might otherwise be the case.

Demand for service invariably outstrips supply in healthcare and this has often led to a pattern of casual, if not sometimes downright disdainful, treatment of patients.

Clinician decision making could be more-often supported by the complete, current, and timely information that would enable an optimal outcome.

This challenge is multi-faceted and multi-dimensional however it can be simplified to the following:

To treat a patient most effectively there are probably only a few key types of information that a clinician needs, regardless of the clinician’s role in the process (she might be an ambulance officer, a heart surgeon, a nurse, a physiotherapist, or a neurologist). The information needed to provide the optimum care includes:

  • an accurate description of the symptoms with which the patient is presenting;
  • pertinent details about the patient’s medical history and demographics;
  • pertinent details about the patient’s social circumstances and lifestyle; and
  • an up-to-date knowledge of appropriate therapies and interventions that might be recommended following a diagnosis.

There is an increasing amount of information regarding research outcomes and evidence-based best-practice in scientific medicine and this body of information continues to grow. As a result it is not unusual for innovation to be overlooked. The result is likely to be a sub-optimal outcome for the patient.

There is also a current legacy of paper-based medical record keeping and un-connected electronic record keeping amongst care providers. If all pertinent information about a patient cannot be accessed whenever and wherever it is needed it poses a risk to optimal care of that patient.

We are developing larger and more sophisticated repositories of information regarding encounters, treatments, incidents, and outcomes. If properly exploited this information may lead to new and better ways to provide care. If the information is allowed to languish, unexploited and unloved it represents a waste of resources and a lost opportunity for improved care.

The providers who, together, comprise a healthcare “system” is disjointed, “gappy” and difficult to navigate, this is compounded by poor information flow between them.

Healthcare systems often appear chaotically disorganized and patients suffer when care providers are not effectively sharing information or working together in a co-ordinated way.

Many significant steps have been taken to improve the flow of information in some jurisdictions (for example: between primary care providers and hospitals) but much remains to be done to include all healthcare “actors” in our attempts to communicate, collaborate and become more inclusive. In this process the optimal outcome will be achieved when prevention, cure, and supporting care providers are in alignment.

Healthcare investment decisions are, too often, driven by technology, technologists, and related services vendors.

Too often, suppliers are selling overpriced and over complex technology solutions into organizations who are not ready, or who are not able to effectively evaluate their real needs and their path to best value.

The resultant extended, expensive programs, promise too much, deliver too little and, perhaps most distressingly, cause the deferment or delay of a range of smaller, more targeted, projects that might have a greater combined impact on a health system’s ambitions.

More often than not the cause of adverse events in our health system are the result of process errors. That is they are caused by someone not doing something that the should have done or doing something that they should not have done. Computer systems and technology can help to support the reduction of such errors but should only ever be considered a a component of a program to improve the process. Not as a solution in themselves.

There is a significant and growing increase in chronic conditions in the Western World.  

The healthcare sector lags behind in adopting and using techniques that would support improved chronic care.

Chronic conditions (for example: type II diabetes, asthma, and many mental health problems) require management and often the participation of a range of actors (such as the patient, family, clinicians and allied health-professionals).

The information management infrastructure of many healthcare providers cannot cope with the complexity of this arrangement and the privacy and security concerns that are implied. While social networking tools continue to have an increasing impact on so many other areas of our lives, there remains little apparent effort to harness this paradigm to support chronic-condition management effectively.

The gap between the haves and the have-nots in healthcare is massive, and increasing, as clinical talent is drawn away from less privileged nations toward those who can afford to pay.

The tyranny of distance today is vastly reduced over that which existed in past centuries. Education, support, or advice could be provided remotely today from almost any point on the world’s surface to any other point.

And yet much healthcare, a quintessentially information driven business, is often still focused around hospitals, health centres, and other physical edifices. This results in inefficiency, expense, exposure to risks related to treatment-caused conditions.

Privacy, confidentiality and secrecy are challenges that face us all in very walk of life today.

However these challenges become all the more difficult when obsolete technologies (paper, other physical media, and pre-internet poorly secured computer systems) are used to store and share valuable information. A challenge that is further compounded when control and management of information is taken out of the hands of those who own it, the patients.

Every one of the above challenges, if addressed effectively would add tremendous value to the healthcare that a provider currently delivers. The basic building blocks of technology to support solutions in every area exist today. The next step for any provider is to agree that the problems represent the priorities and to develop a picture of “finished” and the plans to  move toward the goal.

Some food for thought

If these then are our challenges, then what is it today that we are doing well? and how might we, given the tools and technologies that are available to us, do things differently in the future?

For many roles in our professional working lives, regardless of business sector, we can live and work without going to a central office. We achieve this by communicating through technologies that are appropriate to the purpose.

We collaborate around development of documents, presentations, and even major movies with participants separated by oceans. Job interviews can be conducted over high-quality video conferencing links, pictures, video and audio can be shared without loss of quality between people geographically disbursed across the globe. Some Universities now offer full degree-level education via electronic means.

These activities are a sample of those that require the ability to effectively share information, and to pick up non-verbal cues such as body-language between the participants. We also know that attending a health care facility, particularly a hospital, increases the likelihood that a patient will experience an negative event caused by engaging with the health system.

Why then do we continue to build health-care facilities that assume 100% physical attendance of patients?

We have the ability to offer banking and many other financial transactions in a very secure and safe way to people with no more equipment than a PC at their home or place of work. In the Western world we run much of our lives on-line, paying bills, shopping, looking for work, booking travel and cinema tickets, and banking. We securely share calendars, we hold encrypted conversations using tools like Skype, web-mail, and any one of a hundred conferencing and video services.

Why then are many healthcare organizations unable to support us, as patients, to share our clinical information electronically with those who we believe have a “need to know”?

There are many examples of “peer review” technologies that enable rapid dissemination of information into the public domain as it becomes known or as knowledge about a subject is improved. Wikis are an example of this.

There are limited tools available for sharing best clinical practice locally, nationally or internationally and we need to be more effective about getting the right information in front of the right people at the right time. Despite the efforts of organizations such as the British Medical Journal (BMJ) and Map of Medicine in the UK, we need to be focusing more effort on sponsoring, developing and supporting development of, and access to, tools that support the sharing of best-practice.

The expenditure on information management, enterprise content management and clinical informatics to support decision making at all levels in our healthcare provider organizations must increase. This does not necessarily imply a further investment in technology, it implies an investment in the right people. An investment not in the technologists who were so critical in the 20th century but in the information managers who are becoming so important in the 21st century.

The technology is available TODAY, to share information securely, to link organizations, to support decisions and to find the answers to many of the problems that clinicians, allied health-professionals, patients and their families experience on a day to day basis. These technologies are diverse and many of them are not expensive. In fact the information they provide access to is often inexpensive or already owned by the people who need it most. There is technology and information available that can help us to make progress toward solving almost any problem, clinical or operational, that faces healthcare providers.

If we are to transform the way that healthcare is delivered, we need to recognize that good healthcare and good information management are inseparable.

With the right information extraordinary results can be achieved. We need to focus, not just on better physical buildings, computer systems and equipment which support our core competency, but far more upon effective management, dissemination and exploitation of the information we generate and share.

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One comment

  1. Chris Pallett · · Reply

    Successful transformations involving the implementation of IM systems in healthcare start with a clear understanding of the expected end result of the implementation. In manufacturing industry a successful implementation would result in increases in efficiency and increases in the quality of the product. Both of these implementation KPIs apply to healthcare although we tend to use the term ‘outcomes’ in place of product quality. So perhaps the question ‘What will “finished” look like?’ should come before the question ‘how does a healthcare provider transform itself from what it is today?’
    Consider the type of implementation where a project champion understands the technology available, what it can do for their organization, and what will be required to achieve the desired result. This type of implementation usually occurs within the well defined boundaries of a particular department or service where enthusiasm can be maintained within a manageable group. Compare this with a large-scale implementation with multiple key stakeholders who may not share the vision and have no idea what the finished product will look like. Many people in the healthcare IM implementation industry will have experienced both types of implementation and will know which type tends to be the most successful. These people realize that successful projects come about when clear, achievable targets are defined, stakeholders are engaged early on in the project, and everyone is working to the same plan.
    So the end result should not be a ‘go-live’ but an improvement in both the efficiency of the service and the outcome of treatment. A true ‘solution’ should be implemented with a significant number of benefits resulting directly from the implementation. With those objectives in mind the implementation plan will look a little different.

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