A Prescription for Patience: The Need for More Effective Technology Implementation and Evaluation No

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A Prescription for PatienceThe Need for More
Effective Technology Implementation and
Evaluation November 3, 2004

• Kevin J. Leonard MBA, Ph.D., CMA
• Associate Professor, Dept of Health Policy,
  Management and Evaluation, University of Toronto
• Research Scientist, Center for Global eHealth
  Innovation, University Health Network

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Three relevant areas for collaboration

• Course curriculum for MHSc students i.e.,
  executive level training case studies
• Research regarding patients accessing their
  health records
• IMPROVE-IT measuring the Value of IT in
  Healthcare

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From paper files

• patient has chest pain if she lies on her left
  side for over a year
• on the second day, the knee was better and on the
  3rd day it had completely disappeared
• she has had no shaking chills but her husband
  said that she was very hot in bed last night
• the patient has been depressed ever since she
  began seeing me in 1983
• patient was released without dressing
• the patient is tearful and crying constantly she
  also appears to be depressed
• discharge status alive but without permission
• the patient refused an autopsy
• occasional, constant infrequent headaches

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From paper files

• Healthy appearing decrepit 69 year-old male,
  mentally alert but forgetful
• she is numb from her toes down
• since she cannot get pregnant with her husband, I
  thought you would like to work her up
• the patient has no history of suicide
• patient left his white blood cells at another
  hospital
• patients medical history has been remarkably
  insignificant with only a 45 lb weight gain in
  last 3 days
• she slipped on the ice and apparently her legs
  went in separate directions in early November
• patient had waffles for breakfast, anorexia for
  lunch
• between you and me, we ought to be able to get
  this lady pregnant

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Consumerism demand for info

• Changing technology and rising consumerism has
  affected many other industries
• hockey - sports entertainment
• education
• banking - credit scoring

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Process Re-design in Other Industries

• Every industry that has effectively adopted
  technology change has done so by changing the
  process first!
• In these 3 industries, the role of the consumer
  has moved from being one of an information
  receiver to that of being a decision maker and an
  information generator or processor and an
  information producer.

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Critical Success Factors - CSFs

• 1. amount of resistance to change (i.e., presence
  of
• industry experience using technology),
• 2. amount of training before/during the
  transition (or implementation),
• 3. amount of buy-in (or contribution) from the
• different stakeholder groups,
• 4. level of consumer (or end-user) influence
  during early stages of adoption,
• 5. level of effective reporting on the status
• of the outcome measures/performance,
• 6. effectiveness in dealing with the breaks

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The Patients Role

• Patients want 2 things from healthcare system
• Care/treatment/services
• Information
• today they are capable of alleviating some of the
  volume delivery stress on the system by helping
  to manage their care.
• Patients can put pressure on the system to evolve
  and change and best way to advance IT adoption
  is by the public (both the healthy and the ill)
  putting on the pressure to improve communication
  use of IT

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Where is the leadership?

• You must be the change you wish to see in the
  world.
• -- Mahatma Gandhi

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January 18, 1988 Ottawa, Ontario   As I sat in
the car and turned on the ignition, I knew I had
only a couple of minutes before I passed out and
stop breathing altogether. My breaths became
shorter and none of my asthma medication was
having any effect. I did not know the cause of
this attack - however, I did know that I needed
help immediately. I drove myself as fast as
possible to the closest emergency room. I went
through three stop signs and two red lights. A
car was backing out of its driveway - which
forced me to drive on someone's lawn to avoid
waiting any additional minute could cost me my
life. As I approached the hospital, I debated
how to contact the emergency staff. Do I park
the car and walk casually to the door - no time!
Do I drive through the emergency room door,
certain to get their attention - too dramatic! I
decided to lean on the horn.   This proved very
effective. A wheelchair was brought out of the
emergency department (ED) door just as I pulled
in - perhaps only ten seconds after I initially
hit the car horn. I managed to tell a doctor that
I had allergies and asthma and he managed to
piece together the rest. I passed out almost
immediately thereafter. On my passage to mental
oblivion, I felt the medical staff pulling off my
clothes like there was no tomorrow.   When I
awoke, almost 90 minutes later, the medical
staff, after first convincing themselves that I
was fine, started to reprimand me. First of all,
I should be carrying a medical alert bracelet -
if I had not been able to remain conscious to
advise them of my condition, there is no limit as
to the possible causes for my condition and the
cause for me to black out, hence treatment
options would be risky. Second, I should be
carrying an epinephrine kit (with a loaded
syringe) that could be injected at the onset of
the reaction. This would then have avoided the
whole incident altogether. I was then briefed on
the costs to the healthcare system when one acts
irresponsibly. The physician kept me in hospital
overnight and I was not allowed to leave in the
morning until I had filled out the forms for a
medical alert tag. I resented being talked to as
if I was a child, incapable of managing my own
affairs however, he was absolutely correct I
took their help for granted and that was to be
a great lesson for me about the value of our
health delivery system. You see, I was given a
glimpse of the big picture, something that I had
not yet been fortunate enough to see. When the
doctors and nurses worked on me to bring me
back and save my life, I was taking their time
(skills and expertise) away from some other
patient(s) who also needed that level of care.
This resulted in reduced quality of treatment for
them and/or me, and certainly in higher overall
healthcare system costs. My irresponsible
behavior (due to my ignorance, but irresponsible
nonetheless) put other factors and other people
at risk! I vowed that day that I would repay the
healthcare system for my irresponsibility no
matter how long or how much effort it takes.
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Survival of our healthcare system requires
patient involvement

• Decision makers need info to make good decisions
• Patients must become partners in managing their
  care
• Patients must be able to access their info
• Paper documents within a fragmented health
  delivery systems makes consistent access
  infeasible

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Patients Must Demand Change!

• Need for a coordinated voice
• All other stakeholders are represented
• Creation of a National Patient Advocacy Group
• can patients access their electronic health
  record?
• how many have access to their record?
• have there been any problems?
• has this improved patient outcomes?

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Recommendations for Systems Development

• bring in the patients
• work with department and program directors to
  identify data fields and information needs and
  opportunities
• implementation will require the generation of
  user-friendly (user-seductive) DSS

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IT related Projects

• Simulation software project for design of
  patients IS
• Creation of a simulation program to allow for
  patient design of an Information System
  supporting their needs. The patients play a
  simulation exercise and through the course of the
  exercise illustrate through their actions the
  type of information that they would like.

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UHN Pilot Study

• Phase 1 UHN Patient Management Center
• 40 completed questionnaires
• hospital based MDs, Community Based MDs,
  Patients, Clerks and Residents
• Phase 2 PLT - Clinic
• 30 completed questionnaires
• Patients

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Hospital Based MDs Trainees

• Access to EPR by Patient is good, BUT
• lt 50 s/b including discharge summary
• lt 20 s/b including lab and OR notes
• 60 say patients do not follow self-care
  post-charge directives
• concerns over misinterpretation, patient demands
  for unnecessary tests, procedures

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Community Based MDs

• Access to EPR by patient is NECESSARY
• 100 all documentation s/b available
• 100 any access to data must include personalized
  information
• 60 patients do not correctly follow self-care
  post-discharge EPR access will improve this

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Patients - Phase 1

• 66 want entire content on-line
• 100 want supportive information for meds
• 90 want information on course of illness and
  expectations

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Patients - Phase 2

• 70 were computer literate - PLT patients
• 60 access helpful for self management and would
  improve understanding
• 60 both them and their MDs would be primary
  users of this access
• 40 unlikely to see health improvement
• 60 want supplemental paper hard copy
• 50 LT manual s/b available in e-format

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Patient Perspective

• Patients are not as concerned with
• Confidentiality
• Sacrificing care for privacy
• Moving to e-records
• Sharing records
• Patients are concerned with
• Wait lines, waiting times
• Getting a doctor
• Getting the best treatment

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Study on IT Investment in Healthcare

• Availability of the data required for each
  indicators calculation
• Accessibility of data sources within the
  participating organizations
• Usefulness and relevance to decision-makers
• Capability to achieve meaningful and valid
  comparisons among the organizations.

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Study on IT Investment in Healthcare

• We were able to get consensus on only one
  statistic
• the percentage of net IT costs to total hospital
  net operating costs

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Cost Profile by Organizational Grouping (All
Participants n8)
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Future of IS in Health

• Best way to ensure success is to examine the past
  - i.e., best practice, clinical guidelines, build
  business cases on evidence/previous evaluations
• Look to see what we can borrow from other
  industries
• Can also learn from others mistakes
• Provide insight into AMOUNT and TIMING of
  benefits of IT Spending

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IMPROVE-IT Institute Indices to Measure
Performance Relating Outcomes, Value and
Expenditure from Information Technology

• Common standards must be established re metrics
  and benchmarking
• Develop indices for cost, infusion, outcomes
• Reporting and Information dissemination
• Answers to what, where and when are the benefits

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IMPROVE-IT Institute

• How can we improve systems without measurement?
• Benchmarking requires metrics
• Evaluation is critical step in all systems
  development

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Timing of Benefits

• Critical for building business cases
• Helpful in defining metrics to assist managing
  what you measure (i.e., evaluation)
• Will provide valuable benchmarks

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Resistance to Change

• There is no reason anyone would want a computer
  in their home - chairman of Digital Equipment
  Corp,1977.
• Training and focus on why we need change
• Developing the right solution
• Implementation issues
• Measurement and standardization compared to
  what?
• Evaluation improvement not pointing fingers
• Must start working on solutions

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Healthcare dealing with Change?!

• Building effective IS is a constant battle
  between system designers who must deliver better
  and more idiot-proof systems and the universe
  which is creating bigger and bigger idiots so
  far, the universe is winning!