For HIS/EMR projects there is often an assumption that a technology implementation will inherently result in organizational improvement. This is often the fatal flaw of any technology project, especially in healthcare. An IT system will never heal a patient. Nor will it console a family dealing with a health crisis. It’s the care team that provides the knowledge, care and commitment to healing our sick. An IT system is a collection of wires, screens and fields. It is a tool and nothing more. It will only do what it is told to do. If it is told to do the wrong thing, it will do that wrong thing flawlessly.
Rarely is an IT system ‘broken’ or ‘unusable’ upon implementation. However, if the design and configuration process is flawed, so will the end product. This could render the IT system useless, or in a healthcare environment, worse, it could be dangerous. That said, when done correctly, digitizing health can greatly improve the quality of care and patient safety. The important thing to remember is that the early stages of planning and partnerships amongst stakeholders is what enables HIS/EMR implementations to be successful. Planning starts with a single investment: understanding how each team contributes to patient care.
Having worked on an HIS/EMR implementation for a 125 year old hospital one can appreciate being surrounded by the history and evolution of healthcare in Canada. Looking at pictures where the sick were attended to in not much more than a barn, to a highly scientific and sophisticated modern hospital in such a short period of time is astounding. However, as technology has evolved some of the other health care practices have not. Consider the progress notes below separated by 100 years. Have things improved? This is a single, and simple, example of how technology can support improved healthcare delivery. Not the care itself, but the communication and collaboration between practitioners.
Installation vs. Implementation
Often in technology projects there is a heavy focus on the physical installation necessary to run a solution. Afterall, if technology is a collection of wires, boxes and plugs, surely installing a new system shouldn’t take long right? Right! If you consider the average HIS/EMR implementation. The actual installation of technology takes on average less than a third of the overall project, and is often one of the least critical activities.
This may seem counter intuitive, however, consider a more accessible comparison: activating a new smart phone. Before a smart phone is purchased there may be considerable research performed before choosing which phone to buy. The actual purchase and activation doesn’t take long at all. But even with all the research performed prior to the smart phone purchase, the activation alone does not necessarily result in all the new smart phone capabilities being immediately usable. Nor does the activation enable the user to know all the capabilities and features of a new smart phone. Consider the time and effort required to personalize, configure, import contacts and groups and learn new functions of a new phone. It often takes a lot more time than the actual purchase and activation. It also isn’t a one-time activity. As a smartphone user you are continually learning, upgrading, installing new applications, etc. It may take weeks, months or longer before you become a smartphone guru, and usually just in time before you need to upgrade to a new device. That may be fine for your personal device. However, the learning curve that comes with new technology cannot be afforded in a healthcare setting. If left alone, the learning curve could have significant patient impacts.
This is where the term implementation diverges from an installation. The goal of an implementation is to ensure that, on launch, a technology can be fully utilized by its users to immediately realize its benefits. A technology learning curve after an installation is not an option in healthcare, which means that the learning curve must be incorporated into the pre-installation activities. This is where the majority of an HIS project spends its time, managing the learning curve through planning. Projects convert learnings into configurations which result in updates to procedures and training to staff. These upfront investments help embed the learning curve within the project prior to going live.
An important aspect of the learning curve is that it should not be limited to users, it is just as important for technologists to learn how a technology will be used to fulfill a process. This will inform how the technology can be configured. The education is a bi-directional process. As users teach technologists about their processes, technologists inform users how the tool can be configured and used to meet their needs. It is a partnership that places the patient at the centre where teams work together to co-create a solution.
Using the value stream to co-design the future state.
Value stream mapping is a Lean management technique that analyzes the current state of a process to identify and remove ‘waste’.
Lean identifies seven forms of waste:
- Transportation waste – the unnecessary movement of materials, information, or resources to fulfill a process.
- Waiting waste – resources are idle while they wait for a dependent process or activity to be completed.
- Overproduction waste – resources are producing more than necessary to achieve customer needs.
- Defect waste – process results in an unacceptable outcome.
- Inventory waste – additional resources or work in progress items that do not directly contribute or impede a process’s ability to achieve customer value.
- Movement waste – excessive movement of materials, information, or resources to complete a specific process activity.
- Extra processing waste – work being performed that is not required to satisfy the customer need.
Value stream maps provide a visual representation of a process. By having a visual map, waste can be more readily identified along with improvement opportunities.
The goal of value stream mapping is to design a more efficient future state process. To understand a value stream map, it is easiest to imagine a literal stream and its flow of water. A stream flows most efficiently when there are no obstructions to affect its current. Therefore, a current state process map, maps the flow of a process, its steps and organizational interactions, which can help identify any obstructions, or waste, that negatively affect the process’ efficiency.
As a result, like any map, value stream maps use image conventions to represent different types of activities.
A common feature amongst value stream maps are that they are comprised of nodes and connections. Node icons can vary. The above figure is not an exhaustive list. The key to any value stream map is to use a node to capture when an action occurs. Once the action is complete, a directional connection is made to the next activity, or node, that occurs in the process.
Another feature that is common amongst value stream maps are icons that identify where waste has been identified.
When obstacles or waste are identified a Kaizen burst is often used to highlight where they occur in a process. A yellow Kaizen burst is depicted in the above figure.
By having technology and business teams document current state value streams it creates opportunities to identify where an HIS/EMR can be used to help eliminate waste and improve process efficiency. If not done, implementing technology without appreciating business processes can actually introduce additional obstacles and contribute to creating a more wasteful process, usually the opposite intent of an HIS/EMR project.
Co-Design – building capability across teams
Co-design of future state processes help embed the learning curve in pre-go-live project activities. However, the process of value stream mapping has additional benefits. As team members partner to understand existing processes and design a future process they become experts in the process itself. This is important as new technologists or business stakeholders join the project. The knowledge acquired through value stream mapping will help onboard new employees.
The partnership can also extend beyond a single project technology. Teams start to advocate for each others’ needs when new technology is being evaluated, or new processes are being introduced. Stakeholders have greater knowledge of the implications of change and can ensure that future change is not viewed in isolation.
Any technology implementation is a journey. It has a beginning and end, but those end points never reflect the challenges and obstacles teams overcome to reach their goal. As with any journey having a map before hand can help navigate the obstacles ahead and reach your destination more successfully.