Health IT Implementation: How Complex Systems Turn Action Into the "Most Difficult Thing In the World"

Health IT has the potential to be the magic bullet for quite a few problems in healthcare, or, at least, that's how it's advertised. However, effectively implementing technology and enabling its most beneficial capabilities is much easier said than done.

While healthcare's technological systems are still several generations behind many other industries, the U.S. has made great gains in technology implementation in the last five years, both physically and in terms of technological savvy.

Consider the electronic health or electronic medical record. In 2008, only 8 percent of hospitals had even the most basic EHRs in place, according to the Office of the National Coordinator for Health IT. As of 2012, the most recent year for which ONC has data, 56 percent of hospitals had adopted EHRs.

In the same vein, the early 2000s saw several reports on concerns over EHR implementation. Now the story is much different. While Medicare, insurance marketplaces and value-based payments appeared several times on HHS' annual list of top challenges for 2013 and vulnerabilities for 2014, health technology in any capacity was nowhere to be seen. All of this bodes well for continued progress in health information technology. However, that doesn't mean implementation isn't still a problem.

According to a report from the Agency for Healthcare Research and Quality, there are four main barriers to general health IT implementation. The first is situational, including time and financial pressures, unproven return on investment, poor access to internet and technology and prohibitive cost, usually only a factor for smaller institutions. The second barrier is cognitive and physical, meaning a lack of appropriate technological training and ability to execute technical processes. The third is concern over confidentiality and liability. The last is a lack of knowledge surrounding and negative attitudes toward the technology, including insufficient research on health IT or its benefits, fear of change and philosophical opposition to information technology itself.

Luckily for everyone, these barriers are quickly disappearing. The Health Information Technology for Economic and Clinical Health Act has made sure of that. Passed in 2009, the HITECH Act's meaningful use provision makes both cognitive and physical barriers and situational barriers few and far between. The program has distributed $15.1 billion in meaningful use incentives to 220,000 health professionals and more than 3,000 of the nation's hospitals as of May 2013, according to Patrick Conway, MD, chief medical officer at CMS, who spoke on the subject before the Senate committee on finance in late July 2013.

The incentives for achieving meaningful use have even made headway on both negative attitudes toward health IT implementation and confidentiality concerns as a barrier to adoption. Yet despite the significant gains HITECH has facilitated, there are still adoption glitches. And when those glitches happen, they are major.

For example, Saint Francis Hospital in Poughkeepsie, N.Y., declared bankruptcy in late December 2013, citing $50 million in debt brought on by failed a EHR and billing system implementation, according to a report from the Poughkeepsie Journal.

Another local paper, the Times-Record, reviewed the hospital's court filings and discovered Saint Francis had flagged problems in September 2012 after implementing the new system earlier in the year, but by the time the hospital retrained staff and hired consultants, it was too late. According to the report, though Saint Francis collected $150 in revenue in 2012, it ended the year with a $7.7 million operating loss.

While this magnitude of failing isn't common, it's tough to say what magnitude is. The data on health IT failure is scattered and out-of-date. Not many are willing to share lessons from technology failures, especially in today's healthcare atmosphere, where missteps — or even the perception of a misstep — may have enormous financial consequences. Even the ONC is only in the process of collecting the data for review — reports aren't yet available for public use. This dearth of data compounds the fundamental problem: Healthcare is a complex system, and complex systems are difficult environments in which to work.

This is the thesis of a decade-old report, "Complexity and the Adoption of Innovation in Health Care," published in 2003 by the Committee for Quality Health Care and sponsored by several major government agencies, nonprofits and private stakeholders. "The behavior [in complex systems, including healthcare] emerges from the interactions among the agents. The observable outcomes are more than merely the sum of the parts," the report observes.

According to Micky Tripathi, president and CEO of the Massachusetts eHealth Collaborative, a nonprofit organization that provides guidance on health IT matters, the first incarnation of EHR implementation was a product of this type of difficulty: misaligned incentives, to be exact. These incentives discouraged providers from adopting the potentially beneficial technology, and only after the correction of these incentives could EHRs begin to take hold. In 2009, the HITECH Act was another significant factor in EHR uptake. Still, he says, there are a lot of problems with implementation.

Mr. Tripathi says the main problems he sees with adoption are workflow disruptions and unfamiliarity with technology. "The single leading indicator about whether someone would be a high adopter or slow adopter was whether they could type. If they could start using the technology quickly, it wasn't going to slow them down," he says.

For technology-savvy providers, adoption was a snap because they could see a light at the end of the tunnel. But for those who were acting as proverbial sticks-in-the-mud, it wasn't so easy. "You need physician leadership," says Mr. Tripathi about the EHR implementation process. "The workflow issue, like in any change management, takes recognizing the importance of the personal side of jobs. Engaging everyone in detailed workflow sessions assures them we're not talking about technology replacing their jobs. You can't underestimate the soft side of implementation."

In fact, truly embracing the change management process may be the best strategy for dealing with the complexity inherent in healthcare. As famed 18th century writer Johann Goethe so eloquently put it, "thinking is easy, acting is difficult, and to put one's thoughts into action is the most difficult thing in the world." Likewise, getting something done in a complex system is incredibly difficult. The Committee for Health Care Quality's 2003 report contains a few pearls of wisdom that are worth revisiting in this regard.

First, the report reminds agents of change that "actions are based on internalized rules and simple models," meaning illogical ends could very well be the product of many logical means, especially where decisions in HIT implementation are concerned. For example, stubbornness in change may stem from a desire to avoid the risk of providing subpar care.

Second, the report revisits the idea of image in healthcare: "Ideas that support professional groups' autonomy and that enhance their image with patients are embraced, while those that are believed to be counter to these desires are not," the report cautions. "A common attractor pattern for most of us is the preference for ideas that we feel we were involved in generating."

Finally, the report emphasizes the importance of persistence in pursuing change. "One of the by-products of the complexity of health care organizations is their remarkable resilience in the face of pressure; even when that pressure is one for positive change," it cautions.

Government regulation has gone a long way toward improving the promise health IT seems to hold. "With meaningful use there are more objective criteria people can use to decide objectively about the quality of technology, since it's certified by the federal government," says Mr. Tripathi, adding that a combination of system consolidation and knowledge about implementation means fewer providers are switching from certified systems to which they have committed, even if they experience trouble in the early stages. "Even the best of implementations have bad spots, and without that context, people abandon technology," he says.

However, it's important to keep an eye out for what is normal, particularly where it concerns productivity, he says. When he and his team help physician offices implement EHRs they have the offices build back up to full patient capacity while staff are learning the technology. "If after a few months they're still seeing fewer patients, it's time to reevaluate implementation," he says. "Before you decide you are making any changes, however, you have to have a good process for understanding your options. Is what you're going to move to better, or will it only introduce different problems?" 

More Articles on HIT:

OIG's EHR Vulnerability Report Sparks Congressional Debate Over MU Program

Meaningful Use Outside of the Metropolis: The Challenges of Rural Health IT Adoption

Whidbey General Hospital Blames IT System for Low Cash-on-Hand

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