The Culture of HIT Implementation

This entry is part 1 of 2 in the series When Worlds Collide: The Cultural Side of HIT Failure

“An account of technology’s frustrations can start anywhere, but sooner or later it leads to medicine.” – Edward Tenner

In his book, Why Things Bite Back, Edward Tenner thoughtfully articulates what he calls the “revenge effects” – the unintended consequences that so often arise as we continue our relentless Information Technology (IT) adoption. Tenner is a sociologist by training – not a technologist per se – therefore eminently qualified to weigh in on the messy things that happen when people and technology collide.

Few of us would disagree that cultures are a major factor in challenged Health Care Information Technology (HIT) projects. Much is written about managing HIT change by considering and accommodating these cultural issues. Typically, the literature describes how IT leaders and project managers work to overcome the cultural barriers between clinicians (physicians and nurses) and administrators (executives and managers) in a health care delivery organization.

Perhaps another set of cultures creates challenges – conflicting cultures among those responsible for HIT implementations.

HIT projects typically involve multidisciplinary teams with a breadth of knowledge and experience. For example, most organizations use some form of formal project management in their HIT implementations. A Guide to the Project Management Body of Knowledge (PMBOK® Guide) is the best known. A similar skill set comes from those experienced in information technology management as exemplified by various System Development Lifecycle (SDLC) models. More recently, these organizations also employ approaches to change management, sometimes formalized, sometimes not. We have never observed tight integration of these three disciplines in an HIT implementation. The people responsible for each area may work independently from each other and at times at cross-purposes, possibly due to distinct and divergent cultures among members of each group – values and beliefs that may well conflict with the values and beliefs of the other two.

Change Management Culture: Change management culture is about how individuals and groups feel. This is psychology, the human side, involving factors not easily observable. For example, this culture addresses human interactions, how people feel individually and together, whether they feel heard during the decision making process and whether there is mutual trust. Change managers are holistic, attending to all emotions as a key to understanding how we interact with each other.

Project Management Culture: Project management culture is a systematic approach to scoping, scheduling and budgeting. Project managers view success in mathematical, logical terms, e.g., percent of schedule complete and budget remaining, number of defects, number of people trained. This view dovetails with the “hard” sciences: define a task, a resource, a timeframe, the specifications, and then execute the task within those constraints – very black and white. The tools project managers find most useful illustrate these quantitative values and beliefs – Gantt charts, work-breakdown structures, risk analyses. Project management training usually involves learning to apply components of a widely accepted, industry standard like that developed by the Project Management Institute (PMI), breaking project components into finite, discrete and repeatable components that occur in a specific lifecycle.

IT Management Culture: IT management culture revolves around the creation, delivery and maintenance of applications and the physical infrastructure supporting them. Technologists tend to reduce most problems and relationships to an underlying set of binary instructions, i.e., on or off. Many in technology prefer their assignments slipped under the door and returns them the same way. Infatuated with the details, they often fail to see the big picture, including specific plans, deadlines and frequent feedback in groups to review and ensure success. This also often includes difficulty in communicating ideas or answers to a non-technical audience. People acculturated in IT tend to see the world as just the technology. The people – “users” – are often a secondary consideration.

A recent experience with a tribal nation illustrates this cultural conflict. An ambulatory Electronic Heath Record (EHR) implementation in a rural setting for a relatively small organization ran into a number of issues challenging the implementation, some technical, but one set of challenges stood out. It involved cultural differences among those responsible for implementing the EHR, not the usual suspects – clinicians, administrators and IT professionals.

A definite lack of cultural understanding plagued this tribal nation’s ambulatory care EHR implementation. The EHR project was a failure largely due to this key factor. The Project Manager complained to the CIO that during help desk calls, IT insisted reported problems were simply not possible. However, when witnessing the problem first hand, IT found these problems were indeed occurring as reported. Only then could IT solve these problems. This failure to communicate continued despite ongoing complaints. In fact, the CIO felt his staff “did a great job.” The Chief Medical Officer (CMO) received only 30 minutes of one-on-one training and thought that this was sufficient for his needs. He and the Project Manager agreed this same training would suffice for others – so to correct schedule delay and minimize cost and clinician time away from patients, they mandated a 30-minute limit on all clinician training. The Change Manager told the Project Manager that this training was insufficient but met with resistance. The limited training resulted in physician difficulty using the EHR and reduced length and number of patient visits. Not unexpectedly, the volume of technical support calls increased, as did clinician frustration with IT’s lack of understanding.

In short, each culture in this drama fully believed their issues were real and significant – and that the issues of the other cultures were irrelevant or even flat-out wrong. This experience illustrates the well-worn adage “Culture eats planning for lunch.”

It is fair to say that those of us who work in HIT have increasingly come to understand culture as one of the most challenging – and perhaps least appreciated – aspects of implementing HIT. If you have not experienced some form of culture-driven failure in an HIT project, just wait. Your time will come.

This piece first appeared in Journal of Healthcare Information Management (JHIM) Winter 2013 / Volume 27 / Number 1 issue.

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Posted on January 5th, 2013 in Innovating Health Care IT
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