Herding Cats: Rethinking our change management strategy

Herding Cats 


It has been repeated ad nauseam that “working in healthcare IT is like herding cats“, a refrence to the challenges to faced in change management of Clinicians and other supporting actors in the provision of care. In their paper “Herding Cats: The Challenges of EMR Vendor Selection [1]”.  Doctors McDowell & Michelson remind us that in the case of migrating to an EMR;

“In some instances, the process may represent only an incremental change in a partially developed computerised EMR. In other cases, it comes closer to a revolution, as it is part of a complete overhaul of a minimally computerised medical record system. In the latter circumstance, the implementation of the EMR involves much more than simply automation of preexisting processes. Strategically it requires analysis of, and change to, the underlying clinical information processes.” 

In other words, it requires a change to the actual practise of care and naturally there will be resistance from your clinicians. Which is why the authors rather cheekily allude to the herding of cats in their title.

The Value of Information 


Fundamental to the practise of medicine is the medical record. The practise has evolved to codify knowledge, track patients as individuals, part of a cohort or on an epidemiological scale and track studies and research before the information revolution – so the question is often set up wrongly,as “do we need to go paperless?”. The real question should be how much faster, more collaborative, more comprehensive, more accessible simultaneously and more persistent and available do we need our medical record to be? Popular culture is saturated enough by IT for all to understand the value of information through software, so while everyone looks looking up information on a computer and the added benefits of analytics it affords, many dislike the disruptive nature of the EMR is making providers change their workflows, be more disciplined with documentation and having to do things in certain methodologies or process steps. Resistance then often comes not from a hatred of screens or keyboards but the intrusivenes of having someone else dictate your methodology and process.

Rethinking our Change Management Strategy 


The conventional wisdom is usually to engage clinicians at the very begining and then buy some monolithic application that does everything from billing claims to medical records and struggle with integration to the myriad of anxilliary life science software that already exist such as medical imaging, pharmacy management & laboratory systems. What ends up happening is either a paralysis of choosing a system or a fallout from Clinicians who lost the vote and then provide resistance to the change that the chosen software will bring to their work.

I have from my experience adopted a different approach. Let me give you a high level overview to get you thinking;

0. Build a decent IT department with real IT experts because no matter what you choose, the fundamentals underlying everything is IT.

1. The Content Management Phase. Let those experts work on a data integration strategy – how to build a complete 360 view of a patient, from operational, financial and medicine that the different stakeholders can use at the point of need to access all the information they need about the patient their attending to. This will involve the digitisation of legacy records, from scanned images, to Optical Character Recognition and patching in existing digital information that already exist. What they will end up building is a digitisation bureau and a data warehouse that will be able to provide a consolidated patient record to any application you choose to use later.

2. The Analytics & Automation Phase. Avoid talking about new workflows and process, rather begin by providing Clinicians and Operational staff more and more access to patient centered information at their convenience on their computers and mobile devices in a secure and reliable fashion. Quickly churn out analytics from this data warehouse such as some basic measures of outcomes, productivity or even commercial insights such as revenue drivers, performing departments and efficiency of different support services.

3. The New Workflows & Standards Phase. Only change the method of input and data capture with new workflows and tools after steps 1 to 3 are established. The added benefit of having completed step 1 is that you now have a bigger selection of applications that can be used since all of them tap the record from the common data warehouse. Many experienced healthcare people reading this now will protest that this can’t be done, but honestly if step 0 is done correctly, we won’t need to have this debate.

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[1] “Herding Cats: The Challenges of EMR Vendor Selection” by Samuel W. McDowell, PhD, Regi Wahl, and James Michelson, MD in the  Journal of Healthcare Information Management — Vol. 17, No. 3

Cloud challenges for Malaysia

You can’t have a discussion about cloud computing in Malaysia without a heated debate on security and risk.

I have observed 2 root causes of the debate;

1. The cloud democratises large scale enterprise capability coupled with the ability to buy-as-you-need, even small businesses can now leverage on sophisticated enterprise grade IT. In the past, business could get away with low level talent enabling just basic IT services such as accounting, payroll and email. Now in this cloud enabled world of endless useful applications and networks like Facebook, sales force and google apps, even small to medium businesses are able to innovate and have IT capability on par with the global multinational titans. So a gap emerges, while the business units of a company can contract and outsource IT services equivalent to their larger counterparts, they don’t have access to the talent of these behemoths do to plan processes, policies, data governance, integration, architecture and security to manage this level of risk and exposure. The connected world is a two-edge sword, enabling unparalleled access to markets and communities while also increasing exposure to those with malicious intent. So companies can buy services on the cloud but not management. What is missing for Malaysian customers already sold on the commercial benefits of the cloud is someone they can trust and rely on to map their journey and steps to slowly migrate to this opportunity to get more with less.

2. Much of the IT leadership in the Malaysian corporate scene is dominated by technology management rather than actual information and intelligence. The former is the trusted resource to design, build and operate technology to provision assets to achieve limited information and automation goals but the later is a timely asset with an emerging demand. This new breed of CIO equipped with the latest technology and data science know-how and is ready to provide actionable insights to the business to gain a competitive advantage or address new market opportunities. Many vendors selling the cloud attempt to use language that resonates with the later but are selling components that still need to be pieced together by the former. So they end up running up against the wall of vested interest because they are asking the quarter master to reduce his/her scope.

I don’t have an all encompassing mitigation strategy at this point in time, but I suspect the solution will begin from driving more popular apps that will appeal to end users and providing more and more solutions on a Software As a Service or Business Process As a Service coupled by data integration services that will not leave users feeling siloed on your apps. Think about it, what kind of platforms and app stores can you build in your vertical industries that the current technology will enable, economically and securely.


A 4th “I” for IBM’s “The 3 I’s of Smarter Content”

Sometime back, IBM summarized the information revolution as being something that will be enabled by the emerging trend of the 3 I’s. Technology is allowing everything to be instrumented and therefore automated and measured, its allowing everything to be interconnected and with all this data its allowing intelligence to make sense of everything and act on it in real time.

The 3 I's of IBM

The 3 I’s of IBM

The vision is described visually in this slide deck http://goo.gl/2tVDFk and is expounded upon by a professional communicator of IBM here http://goo.gl/bsKBxf so I wont belabour you with the merits of this great framework, rather I will proceed to make this suggestion, that the following trends is the last 5 years;

  • Drones
  • Robots
  • Autonomous Vechiles
  • Brain Computing Interfaces
  • Artificial Intelligence
  • Attempts to reproduce working digital models of human Neuro Anatomy and Machinery

require the edition of an additional I to the 3. That I is ‘Incarnation’. The word best summarises the fact that we are trying to provide a body to our AI to move and exist in the real world. It also captures the fact that we are trying to Anthropomorphise our software to make it seem more human and therefore easier to use and relate to and perhaps form emotional attachment. This incarnation is also now merging the real world and the virtual one, allowing an overlay of knowledge on the real world with technology like Augmented Reality or allowing machines a body to move and interact with the real world through robotics. I am sure the geniuses in IBM can take this concept further then I can.

Consider this before choosing a system for your hospital


I once gave a talk called “How to manage your CIO” for CFOs and CEOs from the region in an event in Bangkok. My main premise was that the single biggest factor to consider when buying a system or systems for your hospital/hospitals is understanding your organisation and its IT / Informatics maturity and the vision of where you need to be in the next few years. Nothing revolutionary I know, it would even seem like it should be obvious – but you would be surprised how often healthcare providers don’t get this. So much effort and focus is spent on understanding technology, features and vendors before sufficient soul searching has been done to answer preliminary questions such as;

  1. what is going to be our business focus and differentiation over the next few years, ambulatory care?  wellness?
  2. can we ever picture ourselves as leveraging IT to unlock new capabilities and markets or is that too far fetched for now?
  3. are we looking to build a community? branches? regionally?
  4. will we build up internal IT capability or will we always be dependent on partners?
  5. do we know where we are in terms of IT maturity now? do we have a way to measure it and chart a course?
  6. will we be able to secure executive sponsorship and a competitive budget? how will we manage the BOD?

The answer to these questions have serious impact to the vendors and solutions a hospital should be choosing. The economics of Malaysia usually mean that we do not have sufficient buying power as a nation to demand customisation from mature technologies. So often buyers in Malaysia have to choose between reengineering their processes and informatics to conform to mature technology and workflows from proven overseas systems or to have something bespoked to their needs locally and risking the quality issues inherent to this option. Some vendors have strong systems but others have strong implementation skills – which is more important for your situation? Some hospitals lack the IT maturity and need a vendor who will come and tell them what to do and conform them to their image – others have such strong preferences and needs, they will be better suited to a vendor who listens and conforms. In my experience many customers do not understand themselves, thinking they are the latter when they are really the former – resulting in implementation deadlocks where they feel the vendor is not helping them to complete a task or make meaningful choices. The analogy I like to use is a golfer putting. A successful putter is one who is not only sufficiently practised but able to read the greens and choose the right stroke and approach to sink that ball.

Semantic Interoperability > Syntactic Interoperability

4 years ago when I took the Healthcare IT Portfolio of UMSC, I learned the horror of integration in healthcare, to get various bits of clinical information about a patient from its different Silos to the consolidated Medical Record. When most vendors spoke of integration, they were purely speaking on the level of syntactic interoperability, where protocols and middleware allowed for the flow of badly coded HL7 messages from one system to another. This process was prone to problems of version control, the lost of dimensions and context to the data and is an expensive and complex process. The biggest proof that this is a broken practice is that Clinical analytics was often not possible from the aggregated data. Most importantly, the machines pushing the data around were agnostic to its semantic meaning or context and therefore this limited ability to unlock automation and analytics that normally follows other industries that digitize their data.

So when I explored the possibility of semantic interoperability on top of syntactic interoperability, I was pointed to data dictionaries and codified medical knowledge and told that the only solution was getting Clinicians and practitioners to abstract and code data manually so that it was machine understandable. So I went on a quest, to look at the use of AI and Natural Language Processing to solve this problem, and was pleasantly surprised that IBM has developed some solutions on these principles and capabilities. Finally we can leverage IT for Semantic Interoperability and unlock the value of Clinical Analytics.


Questions after watching Corning’s Day of Glass

I wonder, in a world of ubiquitous, seamless, persistent & intuitive computing – will we finally have information symmetry or will new means of ensuring an advantage of asymmetry occur? If the 3D printing revolution does occur, and our fabrication of atoms really takes us into a post scarcity economy, then perhaps there will no longer be an incentive to maintain asymmetry of information – or will there? Perhaps a world of all information at your fingertips and no scarcity will be one where competitive advantage is derived from creative use of knowledge rather than knowledge itself.

I ponder this world the same way religious people ponder an afterlife.

The more sophisticated your users are…

“Our users aren’t sophisticated enough for such tools, is there a basic option?” 

The more sophisticated your users are, the less sophistication they need from their tools. 



Think of the expert sailors of old, who navigated the seven seas with nothing but outdated print maps and a sextant. Expert level sailors today can still pull this off, but if you just got your first boat its probably going to look more like this;


One button fix all apps are usually needed by the less sophisticated users – which is ironic because these tools cost more as they require a lot of sophistication during the implementation. The modern CIO has to make a judgement call, if your users are simple you need sophisticated vendors, if your vendors are simple, you need sophisticated users.


You will end up spending the money anyway – its either going to your payroll or to the contract with the vendors.

Zen: Beaten Paths reveal human behavior

An Architect (civil) friend told me a story about working around human behavior  that has stuck with me over the years and influenced my practice as an Architect of information systems.

The story is about an architect who was looking for a solution to the persistent problem of people not using sidewalks no matter how convenient they were. Eventually the foot traffic wore out new paths on the landscape and would be an eyesore.This architect had an idea, he would build all of his buildings, but defer the sidewalks. He would just plant grass. 6 months later he would come back and put sidewalks down where all the beaten paths emerged. By doing this he put the paths in the places that emerged from unpredictable trends of human behavior. This was the failure of all his counterparts, they were trying to predict those trends, and often got it wrong.


The principle that I applied to my field of work is to leave interfaces and parts of information systems to the trends that emerge, rather than trying to dictate something that people wont use. The modern enterprise is a combination of policies, processes and services that have been designed top down, but they should meet grassroots movements and trends halfway, for maximum impact.

The story also carries a fashionable new big data lesson – if we can understand trends we can capitalize on actual human behaviour, rather than our inaccurate traditions of conjecture.

Mobility in Healthcare

Mobility enables real time consumption and contribution of critical medical data to the clinicians at the point of care. Mobility is more than a convenience or trend, it can enable quicker documentation reducing errors and provide critical decision support to Clinicians at the point of care.

Defining Healthcare IT

Healthcare IT (HIT) simply put is the design and management of IT platforms and systems to enable management of the delivery of care, clinical informatics and bioinformatics. Academically, HIT is always differentiated from Health / Medical Informatics, and defined as;

Health IT (HIT) is the application of information processing involving both computer hardware and software that deals with the storage, retrieval, sharing, and use of health care information, data, and knowledge for communication and decision making (Goldschmidt, 2005).

Health informatics is the field that concerns itself with the cognitive, information processing, and communication tasks of medical practice, education, and research including the information science and technology to support those tasks. It deals with the resources, devices, and methods required to optimize acquisition, storage, and retrieval. (Conrick, 2006)

In reality though there is so much overlap, one doesn’t provision systems and solutions without mastering both the physical infrastructure and the abstraction of data to model what Clinicians need in the delivery of care. The best way to think of it is Formula 1, the strategy, engineering and management teams do everything needed to win the race except drive the car – and that is a great metaphor for what we do in HIT. The Clinician is like the driver, who uses our technology, depends on our support to do what they do best, race around that track.


There is a common misconception that Healthcare IT is a very complex and specialized domain that is very alien to normal IT, but in reality its about 80% IT, and only 20% is very specific to healthcare.

This conclusion of mine was recently confirmed in the New England Journal of Medicine June 14, 2012 in an article titled “Escaping the EHR Trap – The Future of Healthcare IT” by Dr Kenneth D. Mandl. As Dr Mandl puts it, “Only a small subset of loosely coupled Information Technologies need to be highly specific to healthcare. Many components can be generic”

The end game of HIT is to leverage technology to enable Clinical, Financial and Operational Decision Support while enabling new platforms for collaboration between clinicians, care delivery organizations and patients.
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HIT Manifesto 20130319