Turning (IT) pain to gain

“To err is human, but to really mess things up takes a computer,” runs an apocryphal version of the old Alexander Pope proverb.

At a rather unusual conference in Toronto on Thursday, speaker after speaker graphically described just how messy things get when IT implementations go awry.

The conference was organized by Toronto-based improve-it-institute.org— an organization dedicated to improving the effectiveness of health care IT through measurement and evaluation.

This focus on failures represented neither an exercise in recrimination, nor a communal washing of dirty laundry. Its purpose was articulated by Dr.Tom Rosenal, Medical Director, Electronic Health Record, Calgary Health Region (CHR).

“In some ways,” said Dr. Rosenal, “milking failure for all it’s worth can be more useful than basking in success.”

With 22,000 staff, including 2,200 physicians, the Calgary Health Region is the southern Alberta’s largest employer. It has four acute care sites, 17 community health centres and three administration sites. Long-term care is provided at 18 facilities operated by the Region.

As an example of how past failures can be transformed into a springboard for future success, Rosenal cited the rollout of TDS-7000 (a patient care system) many years ago at a couple of CHR sites.

A prominent trade journal on clinical systems reportedly dubbed the project one of the two worst IT implementations in the world — along with the London, England Ambulance System.

“We did several things badly,” said Rosenal.

The first mistake, he said, was implementing Order Entry before everything else — as lab results had to be tied to an order. “So two years before users saw a lab result or an x-ray report, they were putting in orders. In other words, we put all the stuff up front and said “trust us, you’ll get stuff two years later.”

In addition, he said, the user interface was uninviting. “The screens were black and white, the letters all upper case — so they screamed at you — and it was very difficult to launch the system.”

Despite these obvious issues, any criticism of the system was not well received at the time. A resident who spoke up, Rosenal said, was asked whether he intended to continue his residency. “It wasn’t the fault of the people who really gave their lives to the system. The technology was old, and the degree of engagement by the community was low.”

Though clearly a painful experience, said Rosenal, the TDS-7000 implementation was a forerunner to success, and set CHR up dramatically for where it is going now. For one, he said, physicians at the two hospitals where TDS-7000 was implemented now have a very definite idea of what they need and expect in an IT system. “If you ask them that they will give you a clear and specific answer.”

The experience, he said, has not only created a knowledgeable group, but an engaged group as well. CHR, he said, now has a Clinical Design Committee of 32 persons, including 11 physicians. “We actually have problems keeping people off the committee!”

Rosenal said the biggest IT project challenges are usually not technology-related. “Of course you need to balance the value of an integrated system versus best-of-breed; of course you need to focus on features like stability, redundancy, performance, and security. But the biggest issues are above the technology line.”

He said a key learning from TDS-7000 is that the toughest challenges are people-related. The pain from the project, he said, has driven several positive changes from a technology and people perspective. “We understand our culture better, as well as the power shifts that have occurred as we’ve implemented systems. Maintaining a sense of humour has also been a key factor in all our efforts.”

Taking measure

According to Rosenal, while learning from failure is useful, pre-empting and preventing it is even better — and that requires clear metrics to measure the progress of projects.

In former years, he said, informatics personnel at CHR were “too busy doing stuff to formally measure any of its impact.” That’s now changed — noticeably.

In any IT project, he said, how you measure is as important as what you measure. He said different aspects of a project should be reviewed using different methods to avoid getting a skewed picture. CHR, he said, is doing this.

It has developed specific metrics for three clinical focus areas — Quality of Care, Safety and Access to Care.

These metrics, he said have been rigorously applied to evaluating the Region’s Electronic Health Record, as well as other tools such as its Enterprise Master Person Index (EMPI) and Disease Management Information System.

Speaking earlier, Alex Jadad, Director, Center for Global eHealth Innovation, University Health Network, said Canada should learn from other countries’ failures, not repeat them.

He said he has worked in healthcare informatics in Columbia, England, the U.S. and Canada, and the problems in each of these countries are the same. “In Canada, there seems to be a five to 10 year lag before we repeat the same mistakes as the U.S,” said Jadad.

He said very few health care discussions here have to do with what kind of system next generation expects and deserves, but is rather all about decreasing waiting times, the need for more health professionals and so on.

“We’re keeping our eye on the ball, but not on the game,” said Jadad, “and that’s the road to bankruptcy.”

He said apart from fancier diagnostic and treatment tools there is very little difference in how health care was administered two decades ago and today in Canada.

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