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RHIOs: Making your piece work
Mark Morgan and Rita E. Numerof, for HealthLeaders News, August 21, 2007
Regional Health Information Organizations (RHIOs), which enable the sharing of health information among healthcare professionals and institutions within a geographic area, are intended to be a stepping stone toward a National Health Information Network (NHIN). The ultimate goal of the NHIN is to allow patient records to be seamlessly shared across healthcare providers, reducing delays, slashing costs, and improving patient outcomes.
This is a high-stakes business--with lawmakers lining up behind the idea we could soon see mandatory implementation of information-sharing capabilities. Implementing a system that is incompatible with yet-to-be finalized standards could result in duplicating part, or all, of a rather large and complex IT investment. Failing to come to terms with other participants in the region on issues like cost sharing will leave the RHIO unimplemented, and may result in fines, negative publicity, and organizational headaches.
Appropriately, the majority of advice and commentary has focused on the specific problems of ensuring interoperability of systems and compatibility of data, with another large chunk devoted to how best to negotiate with competitors to achieve spatiotemporally localized cooperation. There is another aspect that needs to be addressed--how best to make your piece of the implementation work. And there are two sides to that question--a technical side (already well covered elsewhere) which we'll leave to the IT professionals, and a non-technical side. It's this non-technological piece that trips up many technically well-executed IT implementations. Getting it right is the difference between a system that ought to work well and one that does.
The softer side of a new system
IT implementations of any sort, but especially those that will have as pervasive an impact as an RHIO, are too complex to be treated as pushbutton operations. They beg to be viewed from a system perspective--and the hardware and software are only half of that system. The other half is the people who use the new IT.
The usual reaction to that statement is "we've got training in place," but training is not enough. Training addresses one of three related issues that are crucial for successful implementation--it addresses "knowing how." The other two are equally vital-- "creating motivation" and "ensuring clear responsibility." They aren't generally the purview of IT leaders, but the failure to adequately address them is so frequent a cause of failure that it is in everyone's best interest for IT leaders to join in championing measures to bring them to heel.
Knowing how…and who
The "knowing how" piece is critical, of course, because if no one knows how to get data in or out of the system, no one will put data in or take it out--which would render the entire investment useless. But there is an additional question--"whom do we train?"--that is important to the efficiency of the implementation (and hence to its ROI), and it is effectively unanswerable unless some serious thought has gone into how people will interact with the system. This means that issues like the capacity to take on extra responsibilities of those filling various roles within the organization become extremely important. If the nurses' current responsibilities make it impractical for them to take the time to make entries into or pull data from the system, the organization shouldn't expect them to do it (and there's no reason to train them to do it)--unless some other priority is dropped or their workload otherwise reduced. Without that, compliance with requirements will be spotty.
So defining who will interact with the system, under what circumstances, and in what ways, is a first step toward ensuring that the role allows them to interact with it, and that the implementation goes smoothly.
Ensuring clear responsibility
That brings us to the issue of ensuring clear responsibility for interacting with the IT infrastructure. Once the "who" and "how" questions are answered, there is a need to ensure that everyone is clear about it. We need to tell the nurses (or whomever) that they will be the ones responsible for various interactions with the system, and precisely what the parameters of that interaction are--how soon after an event that triggers an entry that they need to make the entry, for example. That normally involves explicit role redefinition, not only of those who interact with the system directly, but of those who have the authority to request that these people obtain or enter data, and of these people's managers (who will need to monitor those interactions and correct any deviations from what is appropriate).
This latter point is important, because it is through this monitoring that accountability for interacting with the system is created. Putting the accountability down in writing is one thing, but without an occasional reminder of its importance (in the form of rewards or punishments), human nature dictates that performance will sooner or later begin to degrade. By some means, users must come to see it as in their best interest to make the appropriate entries. Many of today's patient records systems contain glaringly incomplete entries for exactly this reason. No one should underestimate the magnitude of the challenge that data accuracy represents, even under the best of circumstances.
Creating motivation
And that brings us to the final piece--creating motivation. The importance of appropriate interaction with the system needs to be made clear, consistently, over an extended period of time. In other words, it needs to be integrated into the performance management system. Performance management is the primary way to ensure continued motivation (except for activities that are inherently rewarding; interacting with the RHIO IT, as well-designed as it may be, is unlikely to meet that criterion). Even outside of reviews the ongoing monitoring that performance management requires, and the timely reminders this monitoring enables, act to maintain focus on the importance of all the aspects of a role. That includes using the systems that IT worked so hard to implement.
The plan
In most cases, ensuring that the softer side of RHIO implementation goes as well as the technical side begins with persuasion. In an implementation that reaches into every corner of the organization's operations, coordinated and consistent action needs to start at the top. IT leaders need to engage with operational leadership to ensure that the "who" decisions are thought through and made appropriately, that the resources needed to ensure clarity of responsibility are allocated across the organization, and that the proper use of the new system finds its way into performance management.
That's not necessarily easy. There are always other priorities to which to allocate time and resources, and the idea that these issues are critical to optimal implementation is not immediately obvious to many line managers. They are likely to see successful implementation as entirely the responsibility of IT, and it is that perception that needs to be battled.
The task of persuasion requires that IT leaders make a coherent argument that failing to implement appropriate changes on the people side of the system will result in obtaining far less value from the IT investment than would otherwise be the case--and they need to make the case persistently. They need to drive home the potential pitfalls, drawing from their own experiences with suboptimal implementations to bring the negative impacts alive. Ultimately, the resistance will fall, and the enhanced success of the implementation will make the effort well worthwhile.
Mark Morgan, M.S.(R)., is a senior analyst, and Rita E. Numerof, Ph.D., is president of Numerof & Associates, Inc., a strategic management consulting firm located in St. Louis. For more information, contact NAI at 314.997.1587, or info@nai-consulting.com.
This is a high-stakes business--with lawmakers lining up behind the idea we could soon see mandatory implementation of information-sharing capabilities. Implementing a system that is incompatible with yet-to-be finalized standards could result in duplicating part, or all, of a rather large and complex IT investment. Failing to come to terms with other participants in the region on issues like cost sharing will leave the RHIO unimplemented, and may result in fines, negative publicity, and organizational headaches.
Appropriately, the majority of advice and commentary has focused on the specific problems of ensuring interoperability of systems and compatibility of data, with another large chunk devoted to how best to negotiate with competitors to achieve spatiotemporally localized cooperation. There is another aspect that needs to be addressed--how best to make your piece of the implementation work. And there are two sides to that question--a technical side (already well covered elsewhere) which we'll leave to the IT professionals, and a non-technical side. It's this non-technological piece that trips up many technically well-executed IT implementations. Getting it right is the difference between a system that ought to work well and one that does.
The softer side of a new system
IT implementations of any sort, but especially those that will have as pervasive an impact as an RHIO, are too complex to be treated as pushbutton operations. They beg to be viewed from a system perspective--and the hardware and software are only half of that system. The other half is the people who use the new IT.
The usual reaction to that statement is "we've got training in place," but training is not enough. Training addresses one of three related issues that are crucial for successful implementation--it addresses "knowing how." The other two are equally vital-- "creating motivation" and "ensuring clear responsibility." They aren't generally the purview of IT leaders, but the failure to adequately address them is so frequent a cause of failure that it is in everyone's best interest for IT leaders to join in championing measures to bring them to heel.
Knowing how…and who
The "knowing how" piece is critical, of course, because if no one knows how to get data in or out of the system, no one will put data in or take it out--which would render the entire investment useless. But there is an additional question--"whom do we train?"--that is important to the efficiency of the implementation (and hence to its ROI), and it is effectively unanswerable unless some serious thought has gone into how people will interact with the system. This means that issues like the capacity to take on extra responsibilities of those filling various roles within the organization become extremely important. If the nurses' current responsibilities make it impractical for them to take the time to make entries into or pull data from the system, the organization shouldn't expect them to do it (and there's no reason to train them to do it)--unless some other priority is dropped or their workload otherwise reduced. Without that, compliance with requirements will be spotty.
So defining who will interact with the system, under what circumstances, and in what ways, is a first step toward ensuring that the role allows them to interact with it, and that the implementation goes smoothly.
Ensuring clear responsibility
That brings us to the issue of ensuring clear responsibility for interacting with the IT infrastructure. Once the "who" and "how" questions are answered, there is a need to ensure that everyone is clear about it. We need to tell the nurses (or whomever) that they will be the ones responsible for various interactions with the system, and precisely what the parameters of that interaction are--how soon after an event that triggers an entry that they need to make the entry, for example. That normally involves explicit role redefinition, not only of those who interact with the system directly, but of those who have the authority to request that these people obtain or enter data, and of these people's managers (who will need to monitor those interactions and correct any deviations from what is appropriate).
This latter point is important, because it is through this monitoring that accountability for interacting with the system is created. Putting the accountability down in writing is one thing, but without an occasional reminder of its importance (in the form of rewards or punishments), human nature dictates that performance will sooner or later begin to degrade. By some means, users must come to see it as in their best interest to make the appropriate entries. Many of today's patient records systems contain glaringly incomplete entries for exactly this reason. No one should underestimate the magnitude of the challenge that data accuracy represents, even under the best of circumstances.
Creating motivation
And that brings us to the final piece--creating motivation. The importance of appropriate interaction with the system needs to be made clear, consistently, over an extended period of time. In other words, it needs to be integrated into the performance management system. Performance management is the primary way to ensure continued motivation (except for activities that are inherently rewarding; interacting with the RHIO IT, as well-designed as it may be, is unlikely to meet that criterion). Even outside of reviews the ongoing monitoring that performance management requires, and the timely reminders this monitoring enables, act to maintain focus on the importance of all the aspects of a role. That includes using the systems that IT worked so hard to implement.
The plan
In most cases, ensuring that the softer side of RHIO implementation goes as well as the technical side begins with persuasion. In an implementation that reaches into every corner of the organization's operations, coordinated and consistent action needs to start at the top. IT leaders need to engage with operational leadership to ensure that the "who" decisions are thought through and made appropriately, that the resources needed to ensure clarity of responsibility are allocated across the organization, and that the proper use of the new system finds its way into performance management.
That's not necessarily easy. There are always other priorities to which to allocate time and resources, and the idea that these issues are critical to optimal implementation is not immediately obvious to many line managers. They are likely to see successful implementation as entirely the responsibility of IT, and it is that perception that needs to be battled.
The task of persuasion requires that IT leaders make a coherent argument that failing to implement appropriate changes on the people side of the system will result in obtaining far less value from the IT investment than would otherwise be the case--and they need to make the case persistently. They need to drive home the potential pitfalls, drawing from their own experiences with suboptimal implementations to bring the negative impacts alive. Ultimately, the resistance will fall, and the enhanced success of the implementation will make the effort well worthwhile.
Mark Morgan, M.S.(R)., is a senior analyst, and Rita E. Numerof, Ph.D., is president of Numerof & Associates, Inc., a strategic management consulting firm located in St. Louis. For more information, contact NAI at 314.997.1587, or info@nai-consulting.com.
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