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Wheel Of Fortune . . . Or Misfortune

April 5, 2010
by Joe Bormel
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Wheel Of Fortune . . . Or Misfortune
Rolling a Successful Wheel Takes a Committed CEO

I recently visited a hospital that has published “before and after” performance measures on what ARRA and the HIMSS EHR Adoption Model would consider a very modern system (at least relative to the lower 97% of systems). The data therein describe a performance initiative that went live in 2007.

This hospital had both 100 percent CPOE use and 100 percent electronic documentation. Both are, of course, necessities to report perfect or near perfect care under existing performance measures.

The results were inspirational, reflecting what an early adopter of technology can accomplish. Though uncommon when compared to all hospitals at this point in time, such results are not necessarily unique for teaching facilities that have been pushing the HCIT envelop for more than a decade.

While on-site, the chief medical officer shared with me easily a dozen critical success factors. The one that struck me as most profound, and I paraphrase here, was,“ Our hospital CEO was completely behind this project and everyone knew it. I didn't need to point that out to anyone. I cannot stress how powerful that was. Without it, we would have failed."

When I reflect upon the dozens of HCIT projects I've been directly involved with, and the hundreds I've read about, this critical factor is consistent. Successful projects always have the explicit, visible support of the CEO. So is the opposite true. When the CEO abandons a project, or never bonds with it, that spells death. It may be quick, usually concurrent with a general system-level budget shortfall, or a slow death, as if the project were put on minimal life support. I would suspect that you seasoned readers of HCI have experienced both types of “pre-destined to fail” projects, too.

The political and technical chemistry, and physics of the universe will not change with creation of Meaningful Use criteria. Which hospitals will be awarded millions of stimulus dollars and which will enter the fray without hope of success will likely come down to two or three essential factors, CEO support being chief among them.



The CEO of a community hospital with (or without) a large residency program has the issue, but he /she may be at an advantage in so much as the residents are hospital employees. Yet you still want the attendings to use the system for look up even if they push the order entry piece to the residents.

Now in a 'real teaching hospital' (a la University) you can push it off to the med students, although the resident still has to sign the order. The challenge here is you have residents and professors with three different objectives, that of teaching, research, and patient care. Which are not always aligned. There the CIO needs to 'sell' CPOE in a different way to each audience.

In the non-teaching community hospital ...that's the real challenge. Attendings do not make their income standing at a bedside tapping Ipad screens and responding to order conflicts. That is where you could really use a community mandate.

Thanks for your observation. I think the inevitability framework is helpful. A lot of physicians I meet feel that the government endorsement of interoperable EHRs has created such an inevitability.

The ability of a CEO to champion the care transformation required to do HCIT over the time period required is another dimension of this. The CEOs support, over too short of a period of time seems to be embedded in the entire concept of CEO support. Whether retirement, other changes in senior leadership, or temperament issues, CEO factors play one of the major roles. If only to create that air of inevitability.

Dr. Bormel,
Your post expresses what I have thought for quite some time. I know from witnessing the evolution of our EMR that the project would have been shelved long ago had it not been for our CEO. I fact, it may not have come about at all.

There were many skeptics in our hospital, particularly among my fellow physicians opposed to the adoption of CPOE. Others doubted the project because we ed a system that was not developed by one of the top three vendors.

In the end, almost everyone pitched in to make our system work. Not that it was easy, but we're now at about Level 5 and can see the flow of benefits increasing. There were a few who could not support our efforts, some left others were given an opportunity to search for the job they always wanted on a 24-hour basis.

In retrospect, what I found interesting is that those who moved on were almost universally opposed to change. But I have witnessed the implementation of only one system. Do you find this a characteristic of the majority of HCIT nay-sayers? Thank you.

Dr. Ben

Not to be trite, but change is painful. It is slow, it is expensive, it requires personal and institutional effort and during the period of transition it causes errors. It is no wonder that people and organizations are resistant.

If we all think back to our high school chemistry, we will remember something called the reaction coordinate, wherein chemical reactions often required an activation energy to move from reactants to products. The products themselves may have been at a higher or lower engery relative to the reactants, but there was always a barrier to gettting there.

Activation energy could be supplied by collision, vibration, rotation, attraction, repulsion, ejection or absorption. Alternately, activation energy could be lowered by a catalyst or enzyme. This works as a very nice metaphor for change.

All change requires either energy or facilitation to get through the activation energy barrier. That energy can be inevitability, whether generated internally or externally. And that facilitation can be the removal of regulatory, organizational or cultural barriers, perhaps by a CEO or other powerful and motivating champion.

Nice piece, and I have said it many times myself and in fact I do not know anyone that would disagree. But here is the heavy duty question.

How do you get the buy-in /commitment from the CEO? That's the real issue because lets face it if he /she commits time and money he is sticking his neck out and if it doesn't work the Board will be looking for a replacement soon.

In my experience these CEOs are few and far between, most hospitals are run by 'committee' and I've heard a committee referred to nothing more than a group created to disperse accountability and responsibility. Let's face it successfully implementing a mission critical system is a very risky proposition and the CEO that has all the political and organizational pieces in place to weather such a arduous journey is a rarity.

In commercial industry where the CEO is in fact 'THE CEO’…he /she can say: Your either on this train, or you're on the tracks. Not so easy in a community or teaching hospital.

Thank you Doc Benjamin for your comment.

Many of the HCIT nay-sayers that I am aware of are actually not opposed to change. My friend, Dr. Jeff Rose has used the term infobia. He defines it as a combination of two things. One, a fear that one will not be able to learn to use the new technology. And, two, a fear the resulting information technology use will change the balance of power so as to reduce the power (societal, organizational, economic, legal, etc) of the user.

So the opposition to change is very understandable. It is, of course, critical to understand the opposition. The first part of infobia is generally addressable with awareness and training campaigns that match peoples needs. The second part is where a compelling vision, combined with CEO skills of integrating that vision with a talented implementation team make all the difference. Without that skilled CEO, most campaigns are simply the noise before defeat.

I think what you write is true. I might generalize it to the following success factor: inevitability.

When everyone from the housekeeping staff to the CMO believe that opposing the system's rollout is pointless, their efforts get redirected from obstruction and sabotage to either 1) accommodation/negotiation, or 2) looking for another job.

The CEO has enormous influence over whether the outcome is perceived to be inevitable.

Thanks for the kind words. You bring up a central point, is there a community mandate?

When there is, clinical transformation is a prioritization issue for the CEO.

Often in the community hospital level, clinical transformation is a bit of a third rail.

I am surprised that you included teaching hospitals with community hospitals. I suppose your point is that teaching hospitals, historically you can mandate system use, at least amongst the residents.

That's very clear. Thanks for the elaboration, Frank.

Thanks also for using the replies RSS feed. Sometimes it seems that most people dont see replies, and other blog sites often dont offer the replies feed. I appreciate getting your follow-up comment.