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Low level of PM know-how imperils healthcare ITBy Jerry Zeidenberg Hospital IT projects are quickly becoming larger and more complex, but healthcare organizations lack the right project management skills to successfully complete them, a new study by Canadian Healthcare Technology has found. The report concludes that as a result, future IT projects face a higher risk of failure. It strongly recommends that senior managers in healthcare organizations implement training programs in project management techniques. According to the study, to be released this month, hospitals are launching increasingly sophisticated IT projects, such as electronic patient record systems and picture archiving and communication systems (PACS). In many cases, the projects involve multiple hospitals that are dispersed across a region. At the same time, hospital CIOs said their organizations are not using common project management techniques. When asked whether their organizations made use of several standard project progress measures (such as Percent Complete, Earned Value, etc.), it turned out that none were widely used. The point of using these measures is to have a reliable way to gauge the progress of a project from start to finish, anticipate potential problems and take corrective action early in the project. While one can manage projects without either formal training or the use of standard measures and terminology, it is likely that the outcomes will be less desirable than if a more formalized approach is implemented. This is especially true for major projects where the size, duration, cost and effort are simply too big and complicated to be dealt with in an informal manner. The study, titled “IT Project Management in Canadian Hospitals: Challenges and Responses”, was based on a cross-Canada survey of hospital and health-region CIOs and IT directors. The online survey was sent to 262 of these IT leaders, with 70 filling out full questionnaires – a 27 percent completion rate. The poll was conducted in February and March 2004, under the direction of Richard Irving, PhD, a professor of management science at York University, in Toronto. Of the organizations surveyed, nearly 50 percent have 1-4 major IT projects currently under way. At the other end of the scale, about 16 percent or our respondents indicated that they have 17 or more major IT projects currently in progress. This is a relatively high number. For example, in re-engineering projects, most authors recommend no more than 4-5 major projects at once. Sixty (60%) percent of the respondents estimated that 1 percent to 10 percent of their IT projects failed in the last year, while 21 percent estimated that 10 percent to 20 percent failed. Nineteen percent (19%) estimated that more than 20 percent of their IT projects failed. In Project Management, there appears to be a correlation between project size and successful outcomes – the smaller the project, the greater the likelihood of success. This places Canadian hospitals – rather uncomfortably – on the horns of a dilemma, as they are now starting to launch larger, more complex IT projects. As a result, the need for IT Project Management skills will only increase. According to our study, the top hospital IT projects currently under way are: • Picture Archiving and Communication Systems (PACS); • Electronic Patient Record (EPR) Systems; • RIS/PACS integration; • E-learning; • Computer connection to referring physicians; • Integrating disparate systems. All of the above applications can be wide-ranging in nature, and complex to implement and manage. Moreover, organizations like the Canada Health Infoway, Alberta wellnet, and Ontario’s Smart Systems for Health Agency, are promoting the use of system-wide electronic communications and applications. The game is bound to get more challenging for CIOs in hospitals and health regions. When Canadian hospital IT projects failed in the past, what caused the failure? We asked our respondents to rate the relative importance of various factors. The top five factors, said to be inadequate, were: • Levels of funding; • Control of scope changes; • Operational support; • Time; • Senior management support. On the topic of senior management support, there are several shortcomings that are identified by CIOs and IT directors. A majority of the respondents said that senior managers (CEOs, presidents, VPs, etc.) in their organizations fail in the following important areas: • Understanding Project Management processes; • Working with us to make effective use of milestones to monitor project progress; • Supporting an effective project evaluation review process for completed projects; • Supporting effective conflict management processes; • Are willing to make the necessary organizational changes to implement good Project Management practices; • Insist on detailed progress reporting throughout the duration of the project. What are the solutions? Hospital CIOs cannot alter organizational cultures and senior management skills by themselves. If Canadian hospitals are to successfully manage the larger and more complex IT projects that are currently under way, or those which are imminent, they need a coordinated effort between the executive level in the hospital and provincial and federal governments, as well as with the hospital associations. The following recommendations are intended to facilitate this process. • Government-funded projects (either federal or provincial) must require appropriate Project Management processes to be in place as a condition of funding. This goes beyond a project plan and extends to progress measures and project evaluation, as well as appropriate organizational processes. • Any IT project over $1 million Canadian should be broken into independent sub-projects of not more than $200,000 to $400,000 where possible. Funding for the whole project should be contingent upon successful completion of each successive sub-project. • Governments should immediately fund proper Project Management training for senior hospital executives. This training should focus on how to implement PM effectively in a hospital setting rather than on simple scheduling techniques. The complete study, “IT Project Management in Canadian Hospitals: Challenges and Responses”, is available from Canadian Healthcare Technology magazine, at a cost of $495. More details are available at www.canhealth.com.survey04.html BACK TO TOP OF PAGE
Competition only way of rescuing healthcare, say Kirby and KeonMONTREAL – The Institute for Research on Public Policy (IRPP.org) has released a study by senators Michael Kirby and Wilbert Keon entitled, Why Competition is Essential in the Delivery of Publicly Funded Healthcare Services. The authors argue that the only way to stave off a financial crisis in medicare is to increase the cost-effectiveness of healthcare service delivery. They conclude that “the introduction of what are usually called ‘market forces’ is the only effective way to make the healthcare delivery system more efficient and its providers more productive.” Without such incentives, there will be ever-increasing pressure for private financing of healthcare services that would threaten the future of medicare itself. Kirby and Keon contend that associations of healthcare professionals wield “excessive power” in salary and fee negotiations (which generally leave the need for productivity improvements off the table). And scope-of-practice rules, established by the associations, are so rigid that they prevent health professionals from using their full range of skills. The authors call for relaxation of such rules, which would allow more flexibility in deploying medical personnel and lower costs of service delivery. According to the senators, a second area that would benefit from competitive incentives is hospital funding. Rather than the current block-funding model based on historical spending patterns, Kirby and Keon propose a service-based model whereby hospitals would be paid an agreed-upon fee for each service that they actually provide. This would encourage hospitals to improve operating efficiency (since they would keep any savings generated) and create competition among hospitals and smaller specialized clinics. The authors praise medicare’s single-funder structure, which “yields considerably more efficiencies than any multi-funder arrangement” and “must be preserved.” But, they write, assertions that the introduction of competitive incentives in the delivery of health services threatens public funding are “manifestly false” and “without any supporting argument or evidence.” Why Competition is Essential in the Delivery of Publicly Funded Healthcare Services is the latest Policy Matters study to be released as part of the IRPP’s Health and Public Policy series. It is now available on-line in Adobe (.pdf) format on the Institute’s Web site (www.irpp.org). According to senators Keon and Kirby, repeated injections of large amounts of additional money into the healthcare system allows governments to avoid confronting the most important structural weakness in Canada’s healthcare system – its lack of incentive to increase productivity. They assert that the way in which provincial governments currently fund hospitals generates inefficiencies. Today, hospitals have little incentive to enhance the quality and/or accessibility of their services, to contain or reduce costs, to improve their efficiency or to improve their productivity. This is largely because their annual budgets are not based directly on the volume and type of procedures performed in a given year, nor do they reflect the actual cost of providing these services. The key question is: How can the system be changed to drive down excess costs and improve productivity? A key way to encourage competition would be to change from the annual hospital budgeting system to a service-based funding system. This would lead to the establishment of specialized stand-alone facilities that would be able to offer lower prices for procedures such as cataract surgery, some orthopaedic surgeries, diagnostic tests, etc. These facilities would be cheaper to operate because of lower overheads and more flexible job descriptions. As well, greater specialization would lead to improvements in service quality. Finally, competition would encourage hospitals to contract out non-medical services in order to improve productivity and reduce costs. Nothing in the proposals for generating competition requires, or even provides an incentive for, the introduction of for-profit delivery facilities, the senators say. All of the benefits could be achieved regardless of whether service delivery facilities are publicly or privately owned, for-profit or not-for-profit. BACK TO TOP OF PAGE
U of T, Kaiser assess impact of IT on healthcare across North AmericaBy Kevin Leonard, PhD, and Dean Sittig, PhD There is currently very little evidence to support the hypothesis that better information and more efficient information systems (IS) will result in better health outcomes. Our new research project, IMPROVE-IT, intends to create such a body of evidence. (IMPROVE-IT is short for Indices to Measure Performance Relating Outcomes, Value and Expenditure from Information Technology.) It is our objective to demonstrate the link between improved information technology performance and increased effectiveness across a number of health outcomes. Relationship between IT Investment and Improved Health Outcomes: The research hypothesis states that IT investment provides an environment for a new level of care to exist. For example, IT can provide an opportunity to assess trends that formerly took much longer to identify. Improved information access can lead to rapid decision-making. We further hypothesize that the evidence of better information leading to improved care can be demonstrated by improvement in health outcomes. Some such measures are the number of duplicated tests, turnaround time in accessing reports and other patient information, and management access to trend analysis. Better health outcomes may include: • diagnosing patients more accurately, as well as sooner; • complying with patients’ wishes and comforting the family; • reducing the number or severity of errors; • supporting care delivery through better access to information. What, where and when are the benefits? The evaluation of the impact of advanced IT on the healthcare delivery system requires not only the creation of standard measures, but also the demonstration by these measures that the IT adoption caused, or at least helped to cause, the observed clinical outcome. Specifically, one must be able to show a relationship between the use of the IT and the observed measure. In addition, it must be emphasized that state -of-the-art information technology is not a substitute for high-quality clinical care. Rather, it can potentially help clinicians and ancillary personnel to improve the overall care delivery process. These improvements then will not occur unless there is a concerted effort to improve the process. As a result, both the technology and the process improvement must be measured in terms of impact on health outcomes. Ultimately, we wish to show not only that there are benefits from IT investment, but also the importance of the timing of these benefits and when they are expected to occur! In essence, we believe that there are three categories of measures that must be created if we are to analyze IT effectiveness in healthcare. (In the first stage of this research, we limit our measures and analysis to hospitals, as we believe in-patient care has more inherent measurement and IT infrastructure currently in place.) These are: • An accurate measure of total IT spending throughout the hospital; • A detailed measure of the infusion of IT in the organization (where infusion is defined as both the scope and the timing of implementation and adoption); • An array of health outcomes comprised of a small number of existing performance indicators that can be linked to IT and objectively (and easily) calculated. This project will study whether increased IT capabilities, availability, and use lead to improved clinical quality, safety, and effectiveness in the inpatient clinical setting. We will then examine the outcomes as follows: • Investment in IT inherently provides newer and more powerful technology and technological solutions; • This improvement in IT then can generate “better” (more timely, valid, relevant, precise) information; • Increasing the availability and use of IT within the healthcare setting makes it more likely that decision-makers will access this “better” information; • This “better” information allows decision-makers to make “better” decisions (those that improve measurable outcomes across a variety of dimensions). Who is Involved? The IMPROVE-IT project will bring together highly experienced clinical informaticians and healthcare service researchers across North America. The two lead researchers represent a full time academic (University of Toronto) and the director of applied research in medical informatics at a large Health Management Organization (Kaiser Permanente), which aptly merges theory and practice. The member organizations in IMPROVE-IT will include 20 different healthcare delivery systems (i.e., hospitals) throughout Canada and the United States, analyzing clinical and administrative databases (which incorporate over 500,000 inpatient stays per year). In the project, member hospitals will be asked to: • Attend a preliminary meeting (planned for Toronto in November 2004); • Attend annual meetings to report back and improve both the measures and the benchmarking; • Provide measures on their hospital’s performance each quarter over the course of the project to a secured website. In exchange for this commitment, member hospitals will be provided access to the secured website and all of the reported results (prior to publication). These results will be generated quarterly and will present performance measures and comparisons of individual member hospitals to an average “benchmark”, as well as to other unidentified peer group (For more information, see www.improve-it-institute.org.) Kevin Leonard, MBA, Ph.D., CMA, is Professor, Department of Health Policy, Management and Evaluation, with the Faculty of Medicine, University of Toronto. Dean F. Sittig, Ph.D., is Director, Applied Research in Medical Informatics, with Kaiser Permanente, in Portland, Ore. BACK TO TOP OF PAGE
Brantford General obtains benefits by extending PACS hospital-wideBy Jerry Zeidenberg BRANTFORD, ONT. – Earlier this year, the Brantford General Hospital went live with a $2 million Picture Archiving and Communication System from Philips Canada that not only provides radiologists with top-of-the-line digital imaging, but it also extends into the operating rooms, emergency department, orthopedic clinic, critical care unit and other areas of the medical centre. The system has already proved its worth to physicians across the hospital by improving the quality of information used to make decisions, and by speeding up access to images and reports. That’s enabled them to start treating patients sooner, with more confidence in their diagnoses. “We wouldn’t want to go back to the days before the PACS,” said Dr. Gene Jarrell, head of the emergency department, where there are three diagnostic imaging stations, including one in a high-acuity area. He pointed out that by using the PACS, emergency physicians can view images much faster than before, when they had to wait for films from the imaging department. “Now, the first read is often by the ER physician,” said Dr. Jarrell. “We can then send it on to the radiologist for confirmation.” Because the images are computerized, the ER docs can also view the images at the same time as the radiologists, and discuss the patient’s problems with them over the telephone. A feature that Dr. Jarrell really likes: the patient’s previous studies pop-up on the workstation at the same time as the most recent exams. “Before, we never really saw the previous exams, because it would take too long to get the films. Now, all of the images come up chronologically.” Dr. Jarrell said it took about one hour to get trained on the PACS and Web-based system. However, the transition to a computerized solution was phased-in over two months of training and orientation for the ER staff. This enabled them to become adept at using the system, with the comfort factor of film backup, before going completely electronic. He noted there are differences between reading film and electronic images. For example, the lung vasculature has a ‘grainier’ appearance on a computer screen than it does on film. Asked if there were any suggestions for improvements to the system, he replied that the viewing areas could be a bit darker, to obtain even better readings. The PACS has also become popular with the hospital’s Fracture Clinic. “I never anticipated it, but it’s proven to be a massive time-saver,” said orthopedic surgeon Dr. David Pugh. The Fracture Clinic sees about 100 patients each day, and 40 to 60 of them receive X-ray exams, making it one of the busiest parts of the hospital in terms of diagnostic imaging. Clinical workstations have been placed in each of six consultation rooms, where the surgeons make their diagnoses and plan surgical procedures. They can also review the images on-screen and explain procedures to their patients. Dr. Pugh noted that orthopedic surgeons tend to make their own interpretations of X-ray images, without waiting for reports from a radiologist. The fast access to exams, using the PACS at the push of a few buttons, has saved them a good deal of time in diagnosis, review and surgical planning. What’s more, extending the PACS network right into five operating rooms has also been a big help, giving surgeons an effective decision-support tool during procedures. And unlike films, which normally hang from a light-box on the wall, PACS monitors have been brought right to the operating table. “It’s a huge advantage to have the screens on articulated arms, rather than on the wall or a cart,” said Dr. Pugh, explaining that it’s far easier to glance up at the displays during a procedure than to put down instruments and walk over to study images on a lightbox. The articulated arms actually support two monitors, one showing PACS images, while the other displays real-time images from an endoscope. During procedures, the surgeon can compare the two images. Nancy Wheeler, the hospital’s PACS administrator, observed that before the system was implemented in January, “you couldn’t appreciate our multislice images by using film. Now that you can see them digitally, you can even bring 3D and MPR CT images right into the operating rooms.” Physicians have been making good use of the reconstruction imaging software to provide realistic views of organs and structures. The images are gathered using a four-slice CT scanner that was acquired in 2002. Voxar 3D software runs on nine of the hospital’s workstations. Wheeler said many of the physicians have been trained on it, but ENT specialists, orthopedic surgeons and general surgeons have become the heaviest users. Derek Coenen, manager of the diagnostic imaging department, said the hospital first started planning the PACS four years ago. Managers realized that a filmless approach was the way to go, and persuaded administrative officials to visit the Radiological Society of North America (RSNA) convention, in Chicago, to meet with experts and to get a sense of the future of diagnostic imaging. Soon after, everyone agreed with the computerized stratagem, and the hospital foundation was asked to help raise funds for radiology. A campaign for radiology set out to raise $4 million to assist with the costs of going electronic in DI. That included the acquisition of digital modalities and PACS. Brantford General and a satellite facility, the Willett Hospital in nearby Paris, Ont., currently perform some 100,000 diagnostic imaging exams a year. Their modalities include Computed Radiography, Computed Tomography (CT), fluoroscopy, ultrasound, nuclear medicine, mammography, bone mineral density, and interventional radiography. The Brantford General is also awaiting approval for an MRI machine – Brantford and environs are the largest catchment area in Ontario without an MRI scanner. Currently, patients in the area must drive to larger centers for MRI exams. Overall, the strategy is to go filmless and paperless. Hospital managers believe that computerization will lead to improvements in efficiency – resulting in better performance from a business point of view. More importantly, computerization will enhance the quality of care – improving the physicians’ ability to make diagnoses and treatment decisions. The PACS will play a huge role in this plan. Coenen says there is a good deal of built-in capacity for the future, including disk storage of 1.3 terabytes online and 2.7 terabytes of disk storage near-line. As well, there is an additional 4 terabytes of LTO tape-based storage. The expectation is to expand the storage system in two years; like most organizations, Brantford is purchasing storage capacity gradually, as media prices are steadily falling. In the future, the hospital plans to build a Storage Area Network (SAN) that will take care of the storage needs of all departments, including diagnostic imaging. Also in the future, said Colleen Tew, director of diagnostics and project management, the hospital plans to add voice recognition capabilities to assist the radiologists with reporting.
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Low level of PM
know-how imperils healthcare IT