- HIStalk - https://histalk2.com -

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

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.