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.

Screenshot 2014-06-02 15.16.20


[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

Laissez faire capitalism is but a pipe dream.

Apologies for this Non HIT post, but these issues affect us all an post economic turmoil, its worth thinking about this. Economist who are usually champions of capitalism are also quick to point out some common weaknesses that have to be addressed.

Hirchman’s Exit vs Voice

This wonderful obituary to Albert Hirschman in the economist, summarizes his voting theory from his most famous book, “Exit, Voice and Loyalty: Responses to Decline in Firms, Organisations and States”. According to the theory, Mr Hirschman argued that people have two different ways of responding to disappointment. They can vote with their feet (exit) or stay put and complain (voice). Mr Hirschman raised some problems with the cult of exit. Sometimes, it entrenches the status quo. Dictators may rule longer if their bravest critics flee abroad (indeed, Cuba uses emigration as a safety valve). Monopolies may have an easier life if their stroppiest customers find an alternative.

So in disappointment, many give up ownership and no longer have influence to change the factors that brought about the disappointment.

Hardin’s Tragedy of the commons

In this well documented phenomenon first postulated by Garret Hardin in the journal science in 1968. Wikipedia summarizes the theory well;

“The metaphor illustrates the argument that free access and unrestricted demand for a finite resource ultimately reduces the resource through over-exploitation, temporarily or permanently. This occurs because the benefits of exploitation accrue to individuals or groups, each of whom is motivated to maximize use of the resource to the point in which they become reliant on it, while the costs of the exploitation are borne by all those to whom the resource is available (which may be a wider class of individuals than those who are exploiting it). This, in turn, causes demand for the resource to increase, which causes the problem to snowball to the point that the resource is depleted (even if it retains a capacity to recover). The rate at which depletion of the resource is realized depends primarily on three factors: the number of users wanting to consume the common in question, the consumptiveness of their uses, and the relative robustness of the common.[18]

In a nutshell, when a common resource has no ownership, there is little or no incentive to manage it.


Externality as defined by Professor Jan Horst Keppler of the University Paris-Dauphine; “Externalities or external effects are goods that have an impact on welfare (positive or negative) that is not taken into account by the agent producing them” – I would have that this impact to cost or benefits are often left out in the transaction of buying and selling.

Often in a negative externality scenario, the market is unable to recognize the true cost of the good sold due to the lack of a feedback mechanism. Examples of this abound in environmental concerns – where the cost of the good does not factor in the cost of pollution or socio economic ills incurred to other anonymous stakeholders affected by this transaction.

So I’ve been thinking that the 3 issues mentioned above we see in capitalism have a common theme of a perversion of ownership. Sometimes what matters is not the same as what is valued in our selfish quest for utility and around incentives. In some parts of the world, culture plays a strong role to mitigate this. If there exist a culture of common ownership, then there will be a non monetary motivation to own and manage that which is subject to the perversion of our selfishness, apathy or greed. Another mitigating factor is information – when we truly understand true cost, or have constructs for collective ownership or a collaborative deep motivation to retain ownership despite disappointment, we can mitigate this natural inclination of the perversion of ownership. In any case, these issues inform me that there will always be a need for government and laissez faire capitalism is but a pipe dream.

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.