Sad State of IT In Healthcare And How To Solve It

Once upon a time I worked for a world-renown hospital which had essentially, shockingly to me at that time, an unprofessional IT department, and I was a part of it, for a short period of time. I am not going into details but "unprofessional" is the most generous description of how this outfit functioned.

This wasn't an outlier; no, this was typical for healthcare sector. When I work at healthcare clients I am always struck at how low the quality of the IT services is across the board in healthcare. My experience is in Canada but I think healthcare IT is mostly subpar across the developed countries at least that's the vibe I get from various forums.

Simply put, IT services are generally delivered with delays, cost overruns, low quality software product, poorly tested and then poorly maintained and managed and most importantly, they are duplicated across the healthcare providers. In other words they break most of the basic rules and norms of IT delivery. One has to wonder then how good can the health service itself be if it relies on such a poorly managed key component in the delivery?

When I work for a client I typically work on low level specific issues like design and integration and what I see are low level management issues such as poor or no BA, mismanaged SDLC, non-existent CI/CD, insufficient testing etc., that make the service delivery difficult and in the end well below mediocre. While these issues are important and typically clients are not aware of them, I think there is something more important that precedes these issues. If these issues were strictly local then one would expect wide variations in the quality level across locations from excellent to bad, but there isn't much variation, they are uniformly subpar, some a bit more or less than others.

It's only after I am away from healthcare sector that I can think clearly and holisticlly about these delivery problems. And so I have done some thinking over the last 10 years and I came to the conclusion that essentially the IT delivery structure in healthcare is fundamentally wrong, in other words, the computing model in healthcare is not the right one.

The current as well as historically computing model in healthcare has been that IT is managed and delivered locally at the place of healthcare delivery itself.

Local delivery means in this article roughly the following:

• The IT is essentially led and managed by the healthcare team itself. This applies to family clinics with a single doctor, where it makes sense, as well as a large hospital with hundreds of staff where it makes little sense. In a hospital setting, there will be some professional IT management but it will not be fully in control, it will be controlled by the healthcare professionals.

• With local delivery, usually everything is local: hardware procurement, staff hiring, software selection, vendor selection, installation and maintenance, often software development is done locally even for the core applications, so hospitals often have their own EMRs, EHRs, HISs etc.

• There is some level of oversight and coordination by the government responsible for healthcare but this is usually minimal as the government bureaucracy is afraid to assert its authority and dictate how the IT will be managed locally, let's call it "the fear of the MD" factor.

• The consequences of this almost full "localization" of IT delivery has been very negative including:

  • Poor staff quality since the healthcare management is usually not qualified/have the skill to recognize and hire top staff

  • Top IT people don't want to work in healthcare which doesn't really understand or appreciate IT but still insists on effectively running it

  • It's not just the technical skills that local IT often lacks, even bigger problem is their work attitude (why work if they cannot fire you?)

  • Poor vendor and product selection because neither the management nor the staff is qualified to make long-term strategic decisions about software

  • This leads to homegrown software development, since they are unable to choose, it's safer to create your own, the reasoning goes.

  • But if the staff is not qualified to select its software it's even less qualified to develop it with the obvious consequences, low quality all around.

  • And since larger healthcare organization often develop their own software this leads to proliferation of semi-professional local software addressing the same basic needs over and over again. Remember, each "locality" knows only what it is doing and has no idea what any other "locality" is doing. It never occurs to IT people at hospitals to ask the neighbouring hospital if they can share their EMR.

  • The proliferation of various local software packages leads to the proliferation of the integration requirements because, through the IT service is primarily local ("siloed" as HL7 calls it), it increasingly needs to connect to other services and systems in the sector.

• The only positive has been that if the local IT was involved in software development it could do so in a truly agile way, everything was there just like "agile" methodology prescribes: small, local teams implementing software for local users in small increments. But to be truly agile, you have to be very professional which was typically not the case with these teams as mentioned previously. So even this potential positive didn't actually amount to much in practice.

There are historical reasons for the "local" IT delivery in healthcare and they are not too hard to see.

• In the past decades all IT has been mostly local, because of technology limits, except for mainframe environment which used to offer centralized computing. But only larger companies had the resources to run a mainframe environment and healthcare being chronically strapped for cash was not in that league. And besides, healthcare doesn't actually need much computing it's primarily a data storage and presentation domain, so a mainframe would be mostly a waste in healthcare.

• There are are also 2 cultural reasons for the "local" dominance in IT delivery:

  • Healthcare is a deeply conservative environment and culture that breeds conservative mindset of most healthcare providers. This goes back to the ancient Greece and the Hippocratic oath, I am paraphrasing, "First do no harm...". Hence healthcare professionals by-and-large are cautious, do not follow the latest trends even those trends that could help their patients! I know this first hand, my son is studying to be a doctor and medical researcher and says that it takes often 10+ years for new methods of treatment to be accepted in the clinical environment (by the actual healthcare providers). If the doctors are slow to introduce new treatments you can imagine how little interest they will have in the modern IT technology which they don't understand but feel like they should manage it because "hey, I am an MD and know everything"

  • Doctors and nurses (to some extent) are "arrogant" and think of themselves as being "the smartest people" or alternatively as the most important people in the universe and will not accept advice or ceed control to someone else such as IT professionals. Again, I witnessed this attitude firsthand in a friend of mine. He was a trained doctor but worked for 2 decades in IT. While he was in IT he was a "normal" unassuming guy easy to get along with. Then he decided to go back to medicine and became an unbearable arrogant know-it-all (just by joining healthcare he started to understand educational realm and everything else) a middle-aged smart Alec who refused to take responsibility (in general) for any failures in medicine and always blamed the governments for everything negative in healthcare.

Standards to the rescue

Thus we ended up in the current state: too many low-quality software assets, a lot of them duplicates and even multiplicates of the same functionality spread across the state/province/region, housed and used by local healthcare providers that need to be connected.

In the last few years the governments of all levels responsible for healthcare (federal and provincial in Canada) focused on the integration efforts. And so for the last few years numerous initiatives have been started to create standards so that integration can proceed.

Standards will surely help. They will help integration efforts and they will even raise the quality of the current "substandard" software if it's upgraded to fit one or more standards. But there is a huge downside to standards:

1. They take a long time to develop (often years) as the standards team needs to consult with numerous stakeholders

2. They are difficult and sometimes impossible to implement by the existing software.

3. The standards will do little to alleviate many of the short comings of the "local" delivery, for instance they will not make local IT staff more skilled or work harder though they could potentially raise the quality of their work.

Hence the appropriate question: isn't there a better way to improve the healthcare IT, not instead of, but beyond the standards introduction? Again, it's not the standards that are in question; but are they the best and only solution to the continuing IT healthcare crisis?

I think not. What is needed is a complete overhaul of how IT is delivered in healthcare because the "local" delivery method is now legacy, it never worked well but may have been useful (or not) in the past but is not the way of the future.

A useful exercise at this point would be to see if there are similar industries, economy sectors to healthcare and how they are organized. Let's examine what healthcare is most like:

• Healthcare is not like any other economy sector. It's not a business because most people and vast majority of governments believe that citizens health should not be subject to a profit, US being the outlier. Hence it's up to the governments to fund the healthcare costs and therefore manage healthcare.

• But healthcare is not like other government services either. Most government services are information/data related and can be provided on-line. Not so with healthcare, a patient cannot be diagnosed (until AI comes along) and treated online, it has to be local physical process using healthcare providers.

• Healthcare is most similar to armed forces and this is no accident. They both have the same mission which is national security. Ultimately healthcare is or should be treated as national security issue as was evident during the recent pandemic. If a large portion of country's citizens dies or is sick the country will likely not survive.
  

There are lessons to be learnt in healthcare delivery based on the army model. First of all, the army is the last line of defence, if it fails there is no country left. Therefore, typically, the army is the best organized structure in the government. If we take the example of the armed forces and apply it to healthcare maybe we can come up with a better structure. So how does the army deliver (or not as in Russia) on its mission?

• Central control and command of everything: the gear is procured centrally and delivered locally, the units are commanded centrally through a rigid hierarchy, no local adjustment is allowed unless ordered so.

• From a logical perspective, the army is a single unit fully coordinated from top to bottom.

• But from a battle-field perspective individual units and soldiers matter and they make the difference on the ground and eventually may decide a war. But as the saying goes, one can win a battle but lose the war. So there is a fine balance between local, on-the-ground units and the overall central command, they both must work together to be successful.

The structure and the delivery in the military are simple, they must be, it's a practical necessity, otherwise the whole thing wouldn't work, and the country wouldn't be a country but a province or territory of another country with a better run military.

If we were to extract the best lesson from this setup, it would be very simple, complete top-down approach from command to procurement, to strategy, tactics, everything flows from top to bottom with minimal decision-making left to the units on the ground, the bottom.

If we compare that to healthcare, it's just about the opposite. It's essentially a bottom up structure and environment, local healthcare providers are the real decision-makers for everything. This is not completely wrong because in healthcare unlike in the military it's the troops on the ground that must make life-and-death decisions about their patients, it's a basic law of ethics in medicine. And that's fine and it must be respected, but everything else should be based on central command structure including medical infrastructure procurement and delivery of IT services.

So here is the simple recipe for healthcare to improve its IT quality, assuming it's government-run or controlled:

• Adopt top down approach to managing your healthcare domain, centralize almost everything

• But let local healthcare providers make local healthcare-only decisions, everything else should be the domain of the government

• Procure the best healthcare IT services and share them across the providers

• Don't simply create standards and let private business implement numerous different variations of the standard, this is completely counterproductive. This way the healthcare domain ends up with dozens of different products which may or may not work together. As an example, the army doesn't buy 10 different models of helicopters for the same job, it buys one, the best one. The same should apply to IT in healthcare, there should be a standard and there should be a default reference implementation either free or for minimal cost.

• Centralize all healthcare IT assets as much as possible and let them be shared across the domain at minimal cost to the providers

• Always promote reuse among the providers, this will reduce the need for system integrations significantly and hence lower costs and improve interoperability

• Take responsibility and impose a specific, best of the breed product on the healthcare providers, don't make IT service offering a buffet, where people on the ground with little experience are supposed to pick and choose

• Adopt "cloud" as the primary healthcare IT delivery mechanism because the "cloud" is the definition of centralized IT
  

This should go a long way in solving the common issues in IT delivery, substandard, multi-plicated products and even worse services for the product.