Yesterday, Chilmark Research participated in the CRG conference, Driving Change Through Managed Care IT from Provider Payments to Quality, which was held in New York City. Despite having a title that no one will be able to remember, the overall theme of the event and presentations therein gave one a bird’s eye view into what payers are thinking as we march forward with healthcare reform and the digitization of the healthcare sector.
A common theme that repeated itself numerous times over the course of the day was the lack of business process maturity in the healthcare sector. Meg McCarthy, EVP of Innovation at Aetna was the first to make this statement citing this issue as arguably the number one challenge for this industry sector to overcome. (McCarthy provided some interesting details on the Medicity acquisition but we’ll save that for a later date.)
Later that day, Jessica Zabbo, Provider Technology Supervisor at RI-BCBS gave a very detailed presentation on her company’s experiences working with providers on the adoption and use of EHRs. Over the last several years RI-BCBS has done a couple of small pilots. In both cases a defining parameter of success was business process maturity. For example, the company did a Patient Centered Medical Home (PCMH) pilot that coupled pay for performance metrics (P4P) with EHR use. Basically P4P measurements were to be recorded and reported through the EHR. One of the key lessons learned was that P4P program success was highly dependent on the EHR being fully implemented and physicians comfortable with its use (process maturity). But in a Catch-22, to successfully incorporate P4P metrics into the EHR requires a very deep understanding of practice focus and workflow. Without that understanding, failure of the P4P program is almost certain.
Thus, it is with some dismay that when one goes to the HHS site to view the recently released ONC Strategic Plan for HIT adoption one sees the figure below:
What’s the problem you ask?
Where is “Process?”
Nowhere in this figure is there any mentioned of business process/workflow. Technology is but a tool. The proceses by which clinicians collect and securely share health information is where the focus needs to be with technology in the backseat, not in the driver’s seat. But this figure goes beyond just flipping the equation, it completely ignores “process” altogether putting technology squarely at the beginning, at the start to all things grand and possible if only clinicians would simply go adopt and use the technology. (Despite some wishful thinking and pronouncements, e.g. “the era of EHRs is upon us” providers are not necessarily chomping at the meaningful use bit.)
Now to ONC’s credit, they are in a bit of a bind here for to admit that business processes and change thereof need to be taken into account would most assuredly require a major rethink of what is truly possible in the next several years as ONC tries to empty the HITECH coffers of its billions and demonstrate to Congress that this program is indeed a success and is creating jobs (remember, this was passed as part of the Stimulus Act and creating jobs was priority numero uno). Unfortunately, being a job creation bill is not conducive to providing the time necessary to create and implement new business processes that are supported by IT. Business process change takes a tremendous amount of forethought before any contract is signed for any EHR, but HITECH works counter to that with aggressive adoption and reimbursement schedules leaving very little time for thoughtfulness in re-architecting processes.
In a prescient way, Chilmark predicted that the issue of process re-engineering would be one of the greatest challenges in adoption and use of EHRs and recommended to ONC in our 2009 comments that ONC consider relaxing the schedule to allow to allow sufficient time for process re-engineering. Unfortunately, it appears that it remains full-speed ahead with HIT driving a weaving HITECH truck down a narrow and winding road.
Quick note on the fly – couldn’t agree more about importance of process – I think I’ve mentioned that I was involved in automating the newspaper industry many years ago, and MAN did THAT require mastering new workflows: from assembling pages out of metal, to galleys of photo paper with cut & paste, to, ultimately, click drag & drop. And that’s just the page make-up part; the editorial workflow was a whole different can of worms, from copy boys carrying things from basket to basket to work queues in computers. Some staff made the shift, some didn’t.
Having said that, I personally agree that HHS had to say “thou shalt” with policy, because if there’s one thing I’ve learned about this industry in my 2.5 years of sniffing around, it’s that the most widespread management skill seems to be Expertise On Why Change Is Not Possible. People like that, as well-meaning and knowledgeable as they are, will never get us to the new world.
Tentatively, I’ve come to believe (tentatively!) that it’s a parallel case of the reason why we’ve not succeeded in changing our rate of accidentally killing patients. Asking clinicians and clinical leaders to change their workflow hasn’t hardly changed a thing.
So at the moment I assert (tentatively) that if one believes we must move to a more IT-enabled healthcare system, we cannot append “when you’ve got the workflow figured out.”
p.s. From what I hear, one reason the workflow is hard in health IT is that most of the systems aren’t very user-friendly / workflow-friendly. But I’m no expert in that. I hope the industry (people like you!) will start evaluating how well systems work, so vendors who suck are forced by their market to fix it.
Open to discussion.
Bravo! I couldn’t agree more with your work flow analysis! Working as a social scientist in health corporations, I can tell you that physicians and IT groups BOTH would prefer to skip the analysis of work flow and process. Adoption of new technology in medical environments seems to require attention to the domains of analysis (social, industrial and cognitive psych/sociology) that both groups do not have on their work plate…seems to be a “blind spot” for both groups. Work process analysis requires use of vocabulary and measures for which there has been no training…patience gets low for it because IT and clinicians have not been trained to work in groups. Slowly, this might be changing for patient safety reasons but not fast enough to help with the introduction of EHR technology.