What every CIO, CTO, and healthcare IT professional should know
In 1989, Stephen Covey, a patriarch in motivating individuals and organizations to achieve success in becoming better leaders and even better humans, published a little known book entitled the 7 Habits of Highly Effective People. Of course this powerful guide to achieving one’s best became a best-seller because of its effective principles that could be applied, no matter the individual, to achieve one goal—success in life!
Like Covey’s 7 Habits for effective people, guided principles and a singular focus can be applied to the world of healthcare interoperability. This may seem like a stretch, but like Covey’s 7 Habits, it is essential to become effective in delivering a connected healthcare community. This connected community is often referred to as interoperability.
The demand to connect organizations—clinics, hospitals, labs, radiology practices—as well as medical devices and healthcare software applications is rising exponentially, especially with HITECH and Meaningful Use requirements. Being effective in delivering on the promise of integrated healthcare is critical.
Using the 7 Habits as a guide, we will explore how they can be applied to achieving healthcare interoperability and realizing the vision behind HITECH.
Setting the effective habit stage
Part of the concept in Mr. Covey’s 7 Habits is moving from being dependent to independent to interdependent.
By following the 7 Habits, people or organizations can move up the spectrum. From the beginning, habits 1 through 3 move you from a dependent state to an independent approach. After you have made that transition, the foundation is in place to become interdependent with the people and organizations with whom you will create your connected healthcare community. Habits 4 through 6 guide your interactions towards gaining greater interdependence with key partners. Finally, Habit 7 encourages continuous improvement.
In the world of healthcare interoperability, this paradigmatic model applies well. To achieve healthcare interoperability, healthcare interfaces or integration is a necessary step to move in that direction.
Many healthcare providers (e.g., hospitals, radiology practices, laboratories, clinics, etc.) and vendors are reliant on doing things the same old way. Their solutions are static at best with thoughts like “It’s tough and it’s expensive,” or “It takes too long,” and “We can only send patient data this way,” or “We can only receive patient data that way.”
Whether valid or invalid, these are concerns based out of dependency on old ways. An underlying idea throughout Covey’s 7 Habits is progression—continual forward motion to perform better and achieve more.
When using the 7 habits, the movement from dependence to interdependence can be thought of as a move from integrating healthcare applications within your four walls to connecting healthcare communities. This is a transition from a private to a public victory, and it is opening an integration generation in healthcare like we have not experienced before.
In the healthcare, rather than a private victory and public victory in moving from dependence to interdependence, it is a hospital victory—or put in your specific perspective—moving to a community victory.
In other words, healthcare providers need to integrate their various internal applications together while extending their reach outside the four walls and connect with a healthcare community. This may come in the form of simple patient results (or, patient reports) distribution or connecting with a Health Information Exchange (HIE).
This is the movement occurring today within health IT—enabling a move from dependent to independent to interdependent patient data exchanges.
In practice, to move from a state of healthcare interfacing dependency to healthcare interdependence, Covey’s 7 Habits serves as an excellent guide to make your transition to healthcare interoperability a success.
Habit 1: Be proactive
The proactive habit can be applied in multiple ways to foster healthcare interoperability.
Flexibility in data transformation
First, there are multiple applications or healthcare providers that require patient information to be communicated in a specific data format. Each vendor or provider, of course, believes that their format should be the one followed. Consequently, one could be reactive and just wait for the other vendor or provider to change the way they accept or send patient data; however, doing this results in a stalemate. The better approach would be to act in a flexible manner and transform the data in the middle to the different specifications. An added benefit to this approach is the ability to implement a best-of-breed application approach since the differing data formats can be transformed easily in the middle.
Leveraging integration engine technology
Second, working with other application vendors or medical device manufacturers can be a restraining experience. Waiting for point-to-point interfaces to be developed, delivered, and tied to their queues can be frustrating. Being proactive can be liberating. By leveraging interface engine technology, independence from various vendors can be gained while delivering healthcare interfaces to your customers in a more timely fashion.
State, regional, and community initiatives
Third, there are several state, regional or community based initiatives which are driving HIEs or other healthcare interoperability efforts. Similarly, the Federal government has dedicated resources and issued directives around a more integrated healthcare community. Why do anything? Let the agencies and communities drive it. Although that is a possible approach to take, it is clearly a reactive one and may result in more pain later.
Organizations that take the initiative and are proactive in connecting with their departments or referring physician communities are realizing benefits today. From saving dollars with more efficient processes to increasing revenues by offering a better way to interact, the proactive approach can have a positive impact today while also offering a direction for struggling community initiatives.
Finally, another proactive approach to healthcare interfacing is the way IT service levels are delivered. The reactive approach is to claim ignorance, because the monitoring capabilities are not available. The best proactive approach is to be alerted when an interfacing parameter has not met a defined threshold, and you receive a page or email with the change in status. Essentially, with this approach, you are the first to know and the first to respond.
By being proactive in healthcare integration, the end result is:
- Adaptability being flexible to adapt to the various data requirements
- Independence removing total reliance on others to achieve your objectives
- Satisfaction delivering responsive customer service
With a proactive mindset and approach, the move from being dependent to being interdependent begins.
Habit 2: Begin with an end in mind
What is the end game? Is it streamlined patient data flow? Is it robust, connected healthcare workflows? Is it physician outreach, connecting to practices in an electronic manner? Is it just doing it in a simpler, less costly, and easier to manage way?
Today, HITECH and Meaningful Use are delivering a defined vision. If your organization chooses to pursue the available incentives, then a roadmap is available for you. However, it is a generic definition or plan.
Envisioning what healthcare interoperability means for your organization is important in developing and implementing the right strategy and healthcare IT tactics. You need a target. Like the old adage says, “If you aim at nothing, you’ll hit it every time.” Direct your aim at the end in mind.
If just connecting two applications to each other is the end game, then a point-to-point interface may be the best approach.
If monitoring a point-to-point interface while extending the leverage to other applications, then a mixed approach—point-to-point and interface engine—may be the best approach.
If implementing a best of breed application strategy while connecting to referring physicians, laboratories, and imaging centers is the end game, then an integration platform may be the best approach.
Deciding what you want to achieve for your hospital, radiology practice, laboratory or clinic is important in deciding what integration approach should be taken. Without visualizing the end game, it usually translates into just muddling through. Muddling through costs more, frustrates more, and results in less.
Recently, an executive director at a radiology practice was determining ways to offer better service to their referring physician community. The end game in her mind was delivering better service, and she knew that certain technology investments were necessary to realize that end game plan.
In her words, read the insights about how habits 1 and 2 came into play to move to a more interdependent approach.
“We knew we needed to integrate more technology across our practice. We needed to increase the efficiency of processes associated with billing and diagnostic reporting. In addition, we are receiving an increasing number of requests from referring physicians for HL7 interfaces. We wanted the control to respond quickly to these requests and the flexibility to accommodate all of the different HIS, PMS and EMR systems they might be using.”
With better service as the vision, the elements that needed to be in place in order to make it a reality came into full view.
Habit 3: Put first things first
The patient is first. Delivering high quality patient care in a timely and accurate manner is fundamental.
What helps facilitate putting patients first?
There are many answers to this question. Having the right physicians, nurses, and other personnel is an essential part of the formula. Having the right facilities and equipment is a vital part of the formula. Having the right systems, applications, and ways to connect them is an integral part of the formula.
While the quality of care is largely determined by human hands, an expert mind and caring spirit, the delivery of the care is equally important. Healthcare IT plays a critical role by managing the systems and integrating the data flow. With IT support, the patient care experience becomes seamless through the various workflows.
In healthcare interoperability initiatives, key IT decisions need to be made in order to determine what needs to be put first. Decisions include:
- Defining the integration benchmarks and desired results
- Development cycle time
- Deployment cycle time
- Resource requirements
- Defining the desired turn around times
- Delivering patient reports to referring physicians
- Response time to correct a connection issue
- Re-sending an HL7 message from log files
- Defining the operational cost structure to the integration platform environment
- Resource type required (e.g., Java engineer, IT analyst, etc.)
- Cycle time requirements
- Manageability requirements
These decisions along with others will drive your healthcare integration approach and aid in identifying which principles should come first.
For example, a large hospital used older technology to facilitate their integration efforts. The platform worked, but several issues arose. First, the existing integration platform required skilled Java developers, and these resources can be expensive. Second, the development and deployment cycle times for new interfaces were long and costly. Third, insight into how the interfaces were performing was challenging. On the surface, everything was working fine. Underneath the surface, challenges and issues were brewing, threatening to undermine the vision of delivering first-class patient experience.
Instead of waiting, the IT department took the initiative, explored new integration platforms, and initiated a migration. The result was better manageability of the integration environment and an exponential improvement in cycle times. In fact, over 30 interfaces were developed and deployed within the first six months after one training class.
Although the change was in the IT infrastructure, patient care was positively impacted. Key comments from the IT department included: “…our patients do not experience delays in the services they receive…” and “We are able to deliver high quality patient care… orchestrating the clinical data flow between our healthcare applications.” With patient care coming first, the IT organization aligned itself to deliver.
Getting stuck in the IT issues (e.g., old technology platforms, “we’ve always done it this way,” etc.) keeps organizations in a dependent model. Moving beyond the typical IT issues and focusing on the important mission moves the overall organization beyond dependency.
Another way to look at this is using the two-by-two quadrant below. Where do you spend most of your time?
Unfortunately, many of us are caught in the bottom tier when we should be spending more time focused on Opportunity. There will always projects and actions necessary to complete in order to keep daily operations effective. However, we need spend more time planning the strategic applications required to meet the new healthcare interoperability demands coming both from the referring physician community, the organization’s strategic plan, as well as from new government regulations (e.g., HITECH).
Along with focusing on patient care, this is the essence of putting first things first.
Habit 4: Think win/win
With the first three habits firmly in place, independence is gained, and the transition from dependency to interdependency can begin. What does interdependency mean in healthcare? It means working with external healthcare providers in a seamless, integrated way. It also means facilitating data flow efficiently between different internal applications.
The seamless, productive interaction with external providers in tandem with high quality, effective data flow between internal applications is an interdependent healthcare environment. The end result of an interdependent healthcare community is enhanced patient care, including less frustration because the care experience is connected.
To gain these attributes of an interdependent healthcare environment, the first step is the win/win habit. How can healthcare IT organizations create win/win mindsets with others?
Defining mutually beneficial terms is a start, and it needs to happen at three levels—with departments, external providers, and vendors. Often times, the IT mindset is:
- Departments–“I’ll deal with it later.”
- External providers–“How are we going to handle all these additional connection points?”
- Vendors–“They want how much for one interface? What do you mean it will be six months to get that interface?”
All of these may be valid points, but coming in with that thought process will only push the vision back to one of dependency, not move it forward. The right mindset will help to structure the right approach to continue to move the healthcare interoperability initiatives in the right direction.
For example, a laboratory was doing business as usual. Getting interfaces from their LIS vendor was a long and costly process. At the same time, the CIO saw that many of their referring clinics were beginning to install EMR applications.
With a win/win mindset, the CIO determined what their referring clinics required, and they explored new technologies to gain independence from their LIS vendor. By deploying an interface engine approach, healthcare interoperability happened to over 400 different physician offices. Without the mindset to determine a better approach, this would have been a story of lost business and lost opportunity. Instead, it is one of making a difference in their network of care.
Habit 5: Seek first to understand, then to be understood
Many times, we jump to what we need, rather than listening to what our partners are requesting. A simple question to ask to gain greater understanding should be “What are you going to do with the information that I give you?” By asking this question, it provides greater insight to how what you will deliver will be used. Many times, this will highlight additional information that will be required to deliver either to or above expectations.
Having a conversation without first understanding the other organization’s objectives, drivers, or concerns will be hollow. From one viewpoint, it will seem like one organization is dictating to the other. From another vantage point, it will be one of “they just don’t get it.” It is much easier to be understood when you first understand the other person or organization’s perspective.
As outlined above, there are three primary players in the healthcare interoperability picture, and each have a differing set of requirements. Understanding each, rather than assuming, is imperative.
In hospitals, there are many different ancillary applications that support critical functions for different departments. For example, the emergency room department has unique characteristics that require unique applications to support their activities. This extends to other departments from radiology to laboratory to dietary.
The departments are working diligently to perform their responsibilities in the most cost effective, efficient manner possible. Interoperability is essential for departments in order to gain access to patient information quickly.
What are the key drivers for each department? Understanding the answer to this question will lead to a better understanding. Two key areas to explore include:
- Integration points–What patient information is required? Are all the points of integration internal or are there external points as well?
- Manageability–What level of involvement does the department want in terms of integration? Do they want the flexibility to build their own interfaces? Do they want the insight to know the status of the interface points? Do they want to troubleshoot or resend patient messages if problems occur?
Listening and understanding to what is needed will help craft the right approach.
External providers depend on your perspective. In many cases, it is the physicians who refer patients; the laboratories who conduct the standard or special tests; or the imaging centers who take, read, and analyze detailed images. The key areas to explore include:
- Capabilities–What level of capability do the external providers have to electronically send or receive patient information? What time schedule are they on to be electronically connected with selected hospitals?
- Systems–What systems will accept the information (e.g., EHR, EMR, RIS, HIS, LIS, etc.), and what data format is acceptable (e.g., HL7, CCR, CCD, X12, etc.)?
With vendors, the conversations can sometimes be demanding. Granted, vendors create some of the problems in enabling a cost-effective approach to integrating various applications together. It is like a struggle between countries. Each country has their own interests and wants to protect their boundaries and their sovereignty.
Understanding the perspective of the vendor may be critical to determining the best approach. This will be the toughest challenge for many providers to do, but a vital one.
By understanding the vendor’s approach to integration or interfacing, you will be able to better define your organization’s healthcare interoperability approach.
Habit 6: Synergize
Although the word “synergize” is an overused term in the business world, it is critical to work with people from other departments or organizations with which you are trying to connect. If interdependence is to be achieved, then the sum of all the parts needs to work consistently and effectively with the whole.
What does synergize actually mean? Another term for synergy is alliance. In the healthcare environment, instead of treating each party as a department or vendor, it may be better to treat them as alliances. For alliances to work, everyone involved needs to work together. That is the point of synergy, and it is necessary to make connected healthcare initiatives work.
A few quick points:
- Do you involve other departments in the process of determining the best way to improve the flow of patient data?
- Do you work with your vendors to solve problems?
- Do you work with your referring physician community or reference laboratories or imaging centers to understand their requirements or to solve interoperability issues?
- Are you viewed as an alliance partner with your HIE initiative or in your connected healthcare community? Are you viewed as a “lone ranger”?
- How much can your organization take on? Is there another approach to gain leverage?
The key point—recognize the individual difference but work to build an alliance with all the individual organizations involved. It is not an easy task, but each of the habits provide for a direction to realize this important point.
Examples of building synergy occur within provider organizations as well as vendor organizations. One example of building synergy is offered from a vendor perspective. Many development organizations try to do it all—build the best features for their application, build the best infrastructure platform on which their application is based, build the best way to capture customer requests into new releases, etc. In reality, doing it all internally can stretch resources and can become uneconomical.
One such vendor was in that situation. It was trying to release new features while also attempting to offer a robust integration platform to meet every customer requirement and incorporate every new healthcare standard that came along. Fractures soon began to emerge as the weight of their “do-itall” approach bore down on the development staff. Consequently, the R&D director began to open up the approach and look at alternatives.
One alternative was to create an alliance with another company that could offer the integration platform to meet any client requirement and any healthcare standard. Through a collaborative partnership, focus returned to offering new features to meet growing customer requirements while offering robust integration through a seamless partnership. Growth in features, growth in revenue, and growth in customer satisfaction were happening in tandem. Although different habits were utilized to get to this point, this story illustrates synergy at its best.
Habit 7: Sharpen the saw
If there is only one thing that we can do in our life or in our organizations, it should be to look continuously for ways to improve. Whether it is in our client relationships, the way we solve our problems, or the way that we approach solutions, keeping our eyes open to new ways to do things is a must. This process of renewal will keep progress moving forward.
To achieve healthcare interoperability in our communities, continuous improvement is a must, because—if for no other reason—there are so many changes to which we need to adapt. There is a simple choice—adapt and improve or maintain the status quo and keep the paper flowing.
Improvements can be realized in many different areas including:
- Resources required to build, test, and implement a connected community
- Mindset in working with various constituencies— departments, providers, and vendors, etc.
- Processes or workflows—understanding the desired flow and mapping the right technology to support the vision
- Technology platforms to support healthcare interoperability
The improvements can be realized through many different resources. From workshops and trade shows to case studies, white papers, and blogs, there are many different avenues to continue to grow and adapt.
There also is simple interaction. Talking with people from similar or different organizations to gain their perspectives can open the thought process. Setting aside the time to learn and improve is the first step.
The demands for healthcare interoperability are clearly increasing. How the demands are met will determine your success rate. Stephen Covey provided a timeless, relevant framework to work through most issues and realize most visions. Although it is a practical approach, it is challenging to adopt the habits and make the changes necessary to stop the inherent dependencies and move to a more interdependent environment.
Organizations are achieving varying degrees of success in pursuing an integrated healthcare community. It may be through brute force, new ways, or just luck. Leveraging and using the 7 Habits can make a longer-term impact on the goals and will make the process of getting there