Management Blog and case study


The Real Challenges of the Digitization of Patient Files

August 1st 2012

Patient File

Waiting times that sometimes seem unreasonable, a shortage of family doctors, yet, millions of dollars have been invested in exploring the latest technological advances. For many, it’s not clear what happened to our tax dollars in the absence of clear and conclusive results.

This is the situation with the Quebec Health Record project, for which management control seems to have been completely lost.

In short, the question becomes pertinent: where is the problem with digitization in the health sector?


Technology, technology, and more technology!

With all the current technological potential, the interconnection protocol known as HL7, Service Oriented Architecture (SOA), cloud computing (Cloud), virtualization, etc., how is it that we still feel like we’re running in place?

Our technology toolbox is currently full enough to convince experts in the field that salvation will be found by establishing a standard technology platform that respects all the necessary criteria regarding the confidentiality of personal information.

I must admit that I am among those who believe that we already have the technological tools to achieve this infamous digital patient record, with costs and delays much more reasonable than those made public to date.

Therefore, my conclusion is that if the problem were mainly technological, we would probably have already solved it.

The extent of the health network and the diversity in current technologies probably explain a part of the technological challenge.


Reality always catches up with us

For those of you who know me, I rarely see the source of everlasting life in technology, the operational cure-all for complex productivity improvement challenges. Therefore, I will take you elsewhere to where the real challenges to the digitization of the health system lie.

I propose a simple consideration based on my experience in the health sector and the digitization of clinical care.

What degree of operational freedom does a health professional have to manage their clinic?

At the risk of surprising you, practically none, and if not none, then very little. Why?

Simply because when a health professional stops treating patients, it also stops the income for the clinic or the service for the patient.

I’m sure you know many chief executives who would announce cheerfully one morning, “Come on, we’ll stop making money today and to serve people, don’t sell anything else!”.

Oops… I used the word “sell” in an article about health… I put my foot in my mouth!

More seriously, beyond the taboo that we do not sell anything in healthcare but instead offer services to patients in need, ask any professional if they are willing to take pay cuts voluntarily, and the answer will clear.

1. My first business observation:

If a health professional cannot stop treating patients to manage, how can they efficiently manage the digitization of their clinical operations?

Since digitizing the management requires much energy to mobilize the troops.

Another reflection on the business environment of a health professional:

Have you ever thought that a health professional may have studied to practice? I stress the word ‘practice’, a medical discipline they enjoy.

For most companies that make up the fabric of our economy, it is customary for those who manage human resources, accounting, finance, technology, and general administration to be people who have studied in these respective fields and who have deliberately chosen these areas. They are people who love and want to work in these fields.

The health professional has not studied, nor have they oriented their skills to administrate, manage human resources, do accounting and any other administrative task connected to the management of a clinic. They studied to be able to do what they love, to treat patients in their medical discipline.

2. My second business observation:

The health professional doesn’t particularly enjoy the management aspects of clinical care, including the digitization of its operations. It’s a subject that they try to avoid as much as possible and that they usually delegate to the administrative personnel, who, on the other hand, does not have the authority to make the final decisions. The professional remains, despite themselves, the boss.

And so, the picture is painted, it seems fairly clear that:

  1. Under financial constraints (or, if you prefer, per interest for public health), we cannot ask a health professional to have the natural reflex to want to invest themselves in a strategic digitization project.
  2. Under consideration for personal taste, we cannot ask a health professional to have the natural reflex to want to invest themselves in a strategic digitization project.

As they say: “A leopard can’t change its spots!”

So obviously, it becomes very complex to successfully complete a digitization project as large as the QHR.


OK, that’s great, but where do we go from here?

There you have it: the big picture, but what can we actually do?

Based on the conclusions above, here are some recommendations:

1. Extreme cuts to the steps at the project planning level

If this seems simplistic for a PMP Certification holder, well, tell yourself that you may not be understanding my suggestion’s deeper meaning.

I’m not talking about regular logical cuts in the context of a project in the engineering planning stage. I used the word “extreme” for a very good reason. I’m talking about project cuts that will seem ridiculous for any PMP, but that will allow for systematic progress in small increments to ensure the eventual arrival at the destination.

In other words, given the naturally low availability (operational and psychological) of the health professional who is the key player in the process, we must develop a project management model that is entirely different from conventional models used in other sectors.

It is the intrinsic nature of the health sector that requires this process.

The best way to naturally engage a health professional in a digitization process of this magnitude is to ensure that they will be bothered as little as possible by the process, hence the need to proceed with small steps and incremental changes.

My approach is consistent with the core of Agile development methods with a hint of the Phase-gate model to ensure that everyone is always on the same page at crucial points.

Each step (activity, deliverable, etc.) should ideally result in valuable and functional progress for the health professional, even if it doesn’t give complete satisfaction. This is where I link my following recommendation.

2. Respect the guidelines, but not the ultimatums of the clinic environment.

Obviously, the final system must meet the needs of the health professionals. However, you must resist the many ultimatums that will be given during the digitization process.

Time and again, you will have comments such as “If it doesn’t do this, this, and this, it’s useless to implement this technology at our clinic” or “This system is completely useless if it doesn’t at least do this”. Be warned and informed from the start.

My comment is all the more relevant since I just recommended that you proceed by incremental steps. Therefore, in principle, a few of these steps will deliver complete functionalities in the eyes of the professional, especially at the beginning of the project.

To return to my base conclusions, a health professional generally doesn’t have the time to manage computer skills and project management skills. Moreover, he isn’t really interested in these subjects.

How can you expect to have a global and honed vision of the context, the challenges, and the best strategy to reach the goal?

Don’t get me wrong. I am not saying that a health professional is not capable of understanding what is going on. I am simply pointing out that they have, by nature, other fields of interest that come from their choices and career path.

As an experienced technology project manager, they need you to achieve their ideal vision of the computerized management of a comprehensive digital patient record.

It is, therefore, necessary to collect their input, but always to validate the direction of the project, rather than to organize the steps and/or to define the technology for the project.

I insist on this recommendation because I have seen technology and project management specialists surrender to the client all too often by having the client’s way of doing things imposed on them radically.

You must stay the course against wind and tide, constantly making sure that all the professionals involved in the project committee stay motivated by seeing the planned progress being made.

3. Manage the infamous resistance to change.

Much has been written and will continue to be written about this subject. In your implementation strategy, do not overlook, at any time, the resistance to operational changes phenomenon.

The phenomenon often has a negative connotation, as if the targeted stakeholder, the system user, was stubborn and closed-minded, which is not the case in most situations.

We must understand that any technological change resulting in changes in the usual way of doing things requires an adaptation and transition period that is long enough to unravel any psychological knots and not create mental blocks.

Resistance to change is a significant parameter in the health sector because each professional is convinced that every clinic that works in the same specialty operates automatically in the same manner.

Which, unfortunately, is false, although similarities in the fundamental concepts are, of course, present. For example, a majority of clinics manage a patient file that usually contains a medical history form.

Frequently, health professionals can be viewed as self-employed. In this spirit, they each develop unique work methods.

Consequentially, as a project manager, you will experience much diversity in the occurrences of change resistance since each person will be convinced that they have the best work method.

In summary, as long as the digitization of patient records project consists of a global approach with an operational scope that is too large, it will be, in my opinion, impossible to see the actual implementation.

The project cannot be completed except in underground mode, with basic incremental steps, by establishing functional cells that are not necessarily interconnected initially to be amassed into a final global system eventually.

But now, the project becomes much less interesting on a political level. But that’s a whole other topic.

Happy management!

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