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Time Capsule: Process Anarchy: Why Hospitals Buy Off the Rack, But Expect a Tailor-Made Fit

January 18, 2013 Time Capsule 6 Comments

I wrote weekly editorials for a boutique industry newsletter for several years, anxious for both audience and income. I learned a lot about coming up with ideas for the weekly grind, trying to be simultaneously opinionated and entertaining in a few hundred words, and not sleeping much because I was working all the time. They’re fun to read as a look back at what was important then (and often still important now).


I wrote this piece in May 2008.

Process Anarchy: Why Hospitals Buy Off the Rack, But Expect a Tailor-Made Fit
By Mr. HIStalk


I recently met with a group of employees from one department in a big medical center. So big, in fact, that many of that department’s couple of hundred employees didn’t know each other and had to be introduced. They’re assigned to odd locations, doing highly specialized work, and rarely poke their heads out to see what’s going on anywhere else, even within their own department.

We were talking a software rollout that affected them. That’s where the consensus thing comes into play – how they should use it, what changes they would see, and all the other painful change management stuff that wraps itself around a technology implementation.

Two of them were talking and animatedly gesticulating. It looked like an American tourist trying to get a Moscow local to understand that he’s looking for a restroom by just saying it slower and louder. Finally, one turned around and said (with some combination of wonderment and exasperation), “We work one floor apart, but it’s a completely different world.”

There’s an automation challenge for you. One information system, but two completely opposite groups trying to agree on how it should be configured. From the same department of the same hospital.

That’s a nightmare for healthcare idealists and software developers. In a perfect world, all hospitals would work the same. In a less-perfect world, hospitals might vary, but at least practices within a single hospital would be consistent. In a world that’s in disarray, everyone in a given department would at least follow a single set of rules. And in a world of madness, even small subgroups of individual departments do things their own way, a healthcare version of anarchy.

I’d say most hospitals are somewhere between disarray and madness. That doesn’t even account for IDNs with hospitals from 50 beds to 1,000 beds that face the daunting challenge of getting all of them to agree on a single software setup that reflects their intra-group disarray.

Certain hospital areas are so ruggedly individualistic that nobody else understands them 90 percent of the time (peds, oncology, surgery, ED, and ICU). Experienced nurses who transfer in feel like new grads all over again because everything is different (that’s a big problem right there). They defiantly stick with puzzling practices and dare well-intentioned outsiders (like administrators) to understand what they do, much less change it.

Those practices mimic the medical education of the doctors who work there, which rewards specialization. Each specialty proudly creates its own lingo, methods, and forms. Sometimes they’re necessary extensions, sometimes plainly bizarre and illogical practices used like gang colors – to make sure outsiders know they’re outsiders.

That’s why best-of-breed systems designed for those specialty areas won’t go away in the foreseeable future. That’s also why systems that all areas use, like CPOE and clinical documentation, can turn into an unmanageable stew of configurability options that drive vendors crazy when they’re trying to program and test changes. Instead of delivering strategic new functionality, products keep moving laterally with new options to be chosen once, even though a given client will just set it and forget it without receiving any real benefit.

Vendors have it tough. The respective agendas of current customers vs. prospects are very different. Entire new functionality may interest only a few potential users. The most vocal users are the showcase accounts, like academic medical centers, who demand changes that make no sense to the average hospital. Any resemblance to consensus is accidental.

(And here’s a vendor kudo: what little standardization exists in hospitals can be attributed to three groups: software vendors, the Joint Commission, and professional organizations for specific disciplines.)

Maybe it’s asking too much for vendors to deliver off-the-shelf software that every hospital can not only use, but love. One size doesn’t fit all.

Lip service aside, most hospitals want it their way. Anything less makes them angry. Cost and complexity forces them to buy suits off the rack when, deep down, what they really want is to have a tailor to make them one that fits perfectly.

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Currently there are "6 comments" on this Article:

  1. I would be interested in hearing what other readers think regarding the best of breed vs integrated system debate has changed in the last 5 years since you wrote the article “Why hospitals buy off the rack..”

    It seems like Epic and a few other vendors have been very successful lately in selling customers on not just the idea of using their entire suite of systems (even the immature modules), but also on following a fairly prescribed implementation process that results in system builds that deviate very little from the vendors recommendations. Many of these customers are organizations that are swapping out existing systems and already experienced in these issues you raised. So they are making an informed decision to focus on a single solution, and to build and implement it based on the vendor’s experience and best practices. Furthermore, these customers are reporitng through KLAS and other venues that they feel they are getting their money;s worth.

    Has the industry reached a level of maturation in understanding the workflows and in the develpoment of the core functionality in these deparmtental systems? Is the unique knowledge and functionality of the best of breed vendors really the key differentiator anymore?

    On the customer side our revenues are dropping at the same time we need to deploy solutions to meet an expanding list of requirements that come with the rapidly changing health care landscape. ACO’s, MU, PQRS, ICD-10, are the big initiatives we all know, but their are dozens of other smaller compliance and regulatory changes that have to be dealt with. Meanwhile, there is tremendous pressure to lower IT costs to remain competitive. What I hear from my colleagues at other organizations is an increased acknowledgement that they can no longer afford the cost of managing the interfaces and functionalty of multiple systems or to figure out with each new initiative how they will cobble it all together systems and workflows to meet the requirements.

    With our physicians I hear a real willingness to forgo a best of breed departmental system in favor of an integrated solution that is easier for them to navigate and brings less duplication of work.

    I welcome thoughtful responses. Snarky, condescending comments are of little use.

  2. I’d like to propose the following thought:

    In my world, it appears that the IT side of organizations are playing more and more of a role in the selection of systems. From an IT perspective, I would propose that their primary motivation is to select a system that would allow the highest probability of ‘non failure’. Increased functionality, flexibility, improved patient care, increased revenue, etc., are not their concerns. With this thought in mind, single vendor solutions, with defined, almost restrictive implementation plans seem far more attractive than the alternative.

    If I try to be fair, it is a difficult task from the IT perspective to select systems based upon functionality and of course as systems grow more complex, it’s difficult for non IT personnel such as administrators, clinicians, and other health practitioners to understand the functional differences.

    I believe this is a root cause of the current trends in the industry. I am saddened by it, as I firmly believe innovation primarily comes through the smaller, best of breed companies, albeit I must admit some prejudice in this area.

  3. I think that what you say is playing a role. I see it in my own organization. For decades our HIT division was really ahead of the clinical and operational elements of our organization in understanding and promoting innovation and making our health system a top performer on national QI initiatives. But the complexity of what we had created, which included a significant amount of internal development, caught up with us. We found ourselves with very high IT costs, and a patchwork of systems and worflows that became impossible to respond rapidly to the new requirements of MU, et al.

    Our legacy vendors also couldn’t keep up.

    Now we are in major reorg of not just IT, but our other support divisions as well (HR, Finance, etc.) in effort to streamline. And a major part of that work is using the replacement of our core clinical systems with a single vendor solution, not just to simpify our IT environment, but also as a way to push the necessary clinical and operational standardization.

    Doesn’t this seem like a natural part of the cycle of progress? Periods of innovation and disruption need to be broken up by periods of consolidation and standardization in order to create a stable foundation for successive rounds of innovation.

  4. You’re last paragraph presents an interesting idea and I’d like to think about it some more, but frankly, I”m just not ‘buying it’. Why should that trend exist?

    I would propose that the artificial influx of money from the government has more to do with a single vendor solution than anything else. Think about it. What’s the fastest and easiest way to qualify for all the government money — a single vendor with a standard installation.

    Secondly, realize how difficult the overall task is. Just as I would propose to you that IT people aren’t the best singers in the world, healthcare professionals are not going to be the first group of people to either a. standardize their approach, or b., utilize computer systems. When is the last time you’ve heard a group of IT people have great people skills, for instance?

    As a last note, and somewhat off topic, I’d like to point out how unique healthcare is in this country. Healthcare has been practiced, for far, far too long, with an open pocketbook. Think about this concept. What other product is sold without the consumer knowing what the purchase price is before the transaction is conducted? I think this is relevant to this topic as again what is the motivation for standardization and efficiency?

  5. @HappyLemming:
    “With our physicians I hear a real willingness to forgo a best of breed departmental system in favor of an integrated solution that is easier for them to navigate and brings less duplication of work.”

    I’ll agree with this statement, but not as a positive. Physicians have generally given up on the electronic health record dream and succumbed to the inevitability of functional mediocrity. Whether blame sits with vendors or hospital IT departments, the failure of the “best of breed” model is less a reflection of the superiority of standardization, but more an indication of failure of execution. With pressure from HITECH, there’s no time to tinker and get it right any longer, which is why experienced organizations are abandoning innovation for standardization. The phenomenon you’re experiencing is an artifact of government intervention, not a natural innovation cycle. It doesn’t take long to realize that nobody is really happy – users, IT staff, C-suite, or anybody else – except the small handful of vendors who sell cookie-cutter as a viable alternative to innovative. The success of vendors such as Epic is more an indication of industry-wide failure – imho directly resulting from government intervention in the natural innovation cycle – than of success of the single-suite, standardized implementation model.

  6. “Failure of execution” I like that phrase, and it seems true. It would be interesting to explore the root causes of failing to execute integration of best of breed into a portfolio of solutions. There are a variety of reasons to consider:
    -Lack of a consistent vision from leadership.
    -Cultural issues or problems with organizational structure that lead to conflicting and inconsistent decisions being made.
    -Absent or sporadically implemented standards for interoperability.
    -Or a failure to acknowledge the ture Total Cost of Ownership it takes to create and maintain workflows and dataflow between disparate systems with different user interfaces and data structures.
    -I am sure there are others.

    Implementing a single vanilla system that has decent functionality (even if it is not best of breed in all deparmental areas), and following the vendors scripted implementation methodlogy, is being seen by many as a way to overcome the root causes of failure. And it is easier to jump on the bandwagon when you see signs that over the past decade a number of organizations have been successful with this approach and this vendor. Look at the members of the HIMSS Level 7 adoption club. Read the customer comments in the KLAS surveys. Look at the reports about % of organizations on that vendors system who have qualifed for MU or PQRS.

    I think the government initiatives did accelerate the shake out of the vendor market, and is propelling the consolidaton of health care systems into larger organizations, which is further impacting the market segments for some vendors. But these were trends that were already occurring. And if you look at those initiatives MU, ACO’s, ICD-10, PQRS, HIPAA, etc. you will find that they came ideas already piloted by forward thinking healthcare organizations that were already doing this kind of work and were having successes in managing quality and cost. The government has just incentivized best practices to try to move off the dime.

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