Caveats of Health Informatics: Glimpsing Through IT Panels

Health Informatics (HI) is seen worldwide as one of the effective disciplines for enhancing the efficacy of medical procedures and promptly meeting the widening healthcare demands. Moreover, adoption rates of IT systems are exponentially increasing in healthcare sectors across the world. It is also commonly believed that healthcare IT systems improve patients’ satisfaction, enhance clinicians’ efficiency and lessen the impact of human resource shortages in healthcare sectors.


These [IT] systems are mission critical systems and are implemented in dynamic and peculiar environments of hospitals. Therefore, specific issues and actors that shape these environs deserve attention and consistent guidance respectively. The success of implementation process is as important as healthcare IT systems themselves; since these healthcare systems and their integrated applications cause huge risks of failure; and the effect of error is enormous, making these systems completely different from normal IT projects. The risk becomes even larger when such systems are deployed in multiple intra-load sharing hospitals which are scattered over wide areas. From a change management perspective, an interesting job of the project manager is “to get the unwilling to do the impossible for the ungrateful”.


One of the prime slip-ups expected from change managers is assuming the “finish line” at the end of the project. Hence management efforts and resources are restricted till the system implementation stage whereas; one critical stage of healthcare IT system rollout is the monitoring and management of “change” after successful implementation of the IT systems. Organizational change involves heavy risks, as the consequences of change are usually less eminent than the consequences of not changing. In such environments, when there is slight difference between perceptions of current situations and aspiration levels, the need for change is hardly recognized.


During the early stage of implementation, changes in clinician's productivity may require extra staff and to be able to make continuous adjustments. Another important factor during change process is to discern the difference between the organizational noise that comes due to change or reflects real problems, so that the organizational inertia is addressed accordingly. The literature identifies communication in healthcare individuals as often "informal, disorganized and variable". If cooperation is not part of the organizational culture, individuals will not fully participate in cooperative work. Furthermore, the complexities and required inter-dependencies of the medical processes make healthcare IT systems more intricate in their performance outcomes. Therefore, healthcare IT systems are not considered a cost-effective option, due to their complicated development and implementation process; and reduced success rate of acceptance by healthcare users.


Innovative healthcare providers are moving away from focusing heavily on acute care and instead shifting their focus to proactive care which cannot be possible without utilizing IT in healthcare sectors. Devoid of a defined care plan, medical errors often sneak through the cracks of disorganized healthcare IT systems and eventually lean processes fail. Lean, in its simplest terms, is about increasing value by eliminating waste. Untapped abilities and creativity of front line workers is a huge waste in healthcare. One of the challenges, that lean addresses, is the fact that waste is often not where we think it is.


Guiding principles for Health Sector Executives & Change Managers for Seamless Implementation of Health Informatics Projects are: Flexibility. "People believe software to be flexible, and therefore they flex it. They flex it beyond reasonable boundaries." (J. Millar). A related problem for IT projects, also stemming from the intangible nature of software is abuse of the perceived flexibility of software. The inability to visualize the boundaries of what is possible or practical in IT encourages people to change their mind more frequently than they might do for engineering projects where constraints are obvious.


Complexity. Complexity can be a significant obstacle to successful design and delivery of IT projects. As stated by G. Robinson: "On a large software project one is lucky if one person in 50 has anything resembling an overall understanding of the conceptual structure of the project, and divinely blessed if that person has the ability to explain it in lay terms."


Uncertainty. Many complex IT systems seek to undertake or augment tasks previously carried out by people. There can be great difficulty in elucidating clear requirements for such systems, since the outcome of any software project is necessarily uncertain and there is no problem “producing” software – the problem is knowing what to produce.


Software and Failure. "In my experience when things go wrong there is always somebody in the organization who knew they were going to go wrong. The question is how do you create an environment in which those who know it’s going to go wrong feel able to say so and then get a proper hearing?" (G. Robinson). In a software project you don’t finish any task until the whole task is complete. Requirements Management


"Humans are very poor at saying precisely what they do want and extraordinarily talented at recognizing what they don’t want." (M. Lunt). Requirements’ definition is one of the most critical, and most challenging, stage of the project. Many projects fail due to flaws in the elucidation of requirements, others fail because the requirements have become obsolete by the time the project is delivered. "Do not try to achieve everything in the first implementation. Get a working system implemented – the experience of using it generally changes your view of what you want it to do." (P. Haren). Lack of Clarity of Purpose


"Without strict project control mechanisms, projects either never end or end up as camels which should have been horses". (D. Ball). Any project or initiative is destined for trouble if its objectives and purposes are unclear. "Value the experience of failure – you have just spent a fortune on a very expensive lesson." (D. Dalcher).


Inadequate Executive Support. The organization’s leaders may be committed to the undertaking yet not demonstrate that commitment. Tough project decisions may get made in a way that shows the leaders are not as serious as their rhetoric, because when push came to shove, they caved in. Absence of Credence in the Project. At times the objectives are very clear, but the members of the organization are not convinced that the project is worth doing at all. Because the project will change the work life of many members and require that they participate in design and implementation, they need to be sufficiently convinced that the project will improve their lives or is necessary if the organization is to thrive. "If you have an incorrect architecture it does not matter what else you bring to the project, it will probably be doomed to failure." (H. Lilleniit).


Organizational Inertia. Clinical work has been described as mostly "unpredictable and non-routine". Dealing with multiple uncertainties is a challenge for clinicians. Even when the organization is willing to engage in a project, inertia can hinder it. People are busy and stressed; they may imagine that an uncertain outcome cannot be a good outcome.


Recognition & Apposite Reward System. Aspects of organizational policies, incentives, and practices can hinder a project. The organization’s incentive system may not be structured to reward multidisciplinary behaviour. An integrated delivery system may have encouraged its member hospitals to be self-sufficient. As a result, management practices that involve working across hospitals never matured, and the organization does not know how (even if it is willing) to work across hospitals.


Dearth of Forthrightness. Organizations can create environments that do not encourage healthy debate. Such environments can result when leadership is intolerant of being challenged or has an inflated sense of its worth and does not believe that it needs team effort to get things done. Absence of climate that encourages conflict and can manage conflict, means that initiative problems will not get resolved.


Project Complexity. Sometimes complex projects disappear in an organizational mushroom cloud. The complexity overwhelms the organization and causes the project to crash suddenly. Many curves will be thrown the project’s way as the implementation unfolds and people realize their mistakes and understand what they failed to understand initially.


Failure to Respect Uncertainty. Significant organizational change brings a great deal of uncertainty with it. The leadership may be correct in its understanding of where the organization needs to go but the belief that a particular outcome is certain can be a problem in itself. Agility and the ability to detect when a change is not working and to alter its direction are very important.


Initiative Undernourishment. There may be a temptation, particularly as the leadership tries to accomplish as much as it can with obvious constraints. The leadership may believe that such bravado will make the team work extra hard and, through heroic efforts, complete the project in a grand fashion. However, bravado may turn out to be bellicose stupidity. This approach may doom a project, despite the valiant efforts of the team to do the impossible.


Invisible Progress. Sometimes initiatives are launched with great fanfare. Speeches are made outlining the rationale for the initiative. Then nothing seems to be happening. If possible, the project should seek to produce a series of short-term deliverables, even if they are small. Organizational commitment is like a slowly leaking balloon; it must be constantly re-inflated.


Organizational Baggage. Some organizations have no history of competence in making significant organizational change. They never master staying the course over years during the execution of complex agendas. This taints the credibility of newly proposed initiatives and helps ensure that organizational acceptance will be weak.


Failure to Anticipate Short-Term Disruptions. When processes are changed, there is a shakeout period as staff adjusts and learns how to make new processes work well. This can degrade organizational performance and balls will be dropped in many areas. The organization can misinterpret these problems as a sign that the initiative is failing. Listening closely to the issues and suggestions of the front line is essential during this time.



While Implementing HI applications there are embedded and unbounded number of assumptions. Most of which are not decisions that you have taken, but things that you have not thought about. As victor Hugo states: “Nothing is more powerful than an idea whose time has come”.

The writer is MS in Computer Software Engineering & Engineering Project Management from NUST & Melbourne Uni Australia respectively.

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