The current COVID-19 pandemic has placed unprecedented stress on healthcare systems all around the globe. It has also accelerated the adoption of digital technologies, particularly in telemedicine. In so doing, it has elevated the potential of digital technologies for hospitals and it is likely that we will see higher levels of investments in tech than those pre-COVID, particularly in areas such as patient-engagement, care coordination, intelligent automation, remote working and, of course, telehealth. However, the danger is that tech becomes the focus of attention as hospitals accelerate their ambitions to become digital hospitals.
By that I mean, an attitude of let’s throw tech at the problem, whatever that problem might be. And there is no shortage of vendors promoting their solutions or the next tech big thing. Unfortunately, merely deploying technology won’t solve most problems in hospitals and indeed is likely to result in even more complications if not carefully considered. Tech, for example, is a key reason many hospitals are less agile than they would like to be. Tech is why hospitals struggle to share information across siloed specialisms. Tech is a prime cause of stress among medical staff, particularly when working with electronic health record (EHR) systems. I could go on…
Or at least tech is blamed for these situations. The real culprit is actually the lack of thinking and imagination that went into deploying technology in the first instance. The resultant tech solution is merely a manifestation of this. As the old adage goes, automate a mess and it is still a mess! Harnessed appropriately, tech can liberate data; tech can intelligently automate treatment plans; tech can empower employees; tech can augment and enhance the decision-making of clinical staff; tech can improve hospital efficiencies; tech can speed up the diagnosis process; tech can provide opportunities for personalized care, ultimately improving the patient engagement and their experience. The key is getting a firm handle on the raison d'être of tech: information. The quest to become a digital hospital will demand a focus on information and using technology to reimagine healthcare without the constraints imposed by pen and paper. Most hospitals have been optimized for paper as the conduit of information; it is time to architect them with digital technology in mind.
Information is the life blood of a hospital
Let’s park technology for a moment and consider first the critical resource that tech enables a hospital to better capture, store, share, manipulate and present: information. Information has often been described as the “life blood” of an organization; the “glue” that keeps it together. This metaphor should resonate strongly with providers of health care. In the absence of information or with impediments to its free flow, all activity in a hospital soon grinds to a halt. Poor quality information also has a detrimental impact not only on the operations of the hospital but more importantly for patients.
Consider a hospital setting where the absence of a patient record means that relevant information is not available to medical and nursing staff in the provision of care. At the point of delivery of care, the provider is left impotent. Prior medical history, existing conditions or allergies will be unknown to the attending medical staff. Diagnosis will prove difficult to make without these and the results of diagnostic tests such as bloods or scans, themselves become information gathering exercises. Clinicians use information to support and enhance their decisions. Less information means more reliance on judgement than on fact.
Scheduling and administrating tests requires information to flow freely and unimpeded across, what are in reality artificial created organizational boundaries, to safeguard the efficient utilization of resources in their provision. Arranging a procedure in theater requires a similarly seamless flow of information between multiple entities across a hospital. This will include ensuring all relevant staff, inventory and instruments are available when required.
Patient engagement is similarly an exercise in information gathering and sharing. Consider outpatient clinics. Scheduling appointments, ensuring all patient information is available to the consultant during a consultation episode are key ingredients to success. During the consultation itself, the consultant engages in a data collection exercise through probing and questioning the patient; the patient may be sent for further tests in order to provide additional information.
Consultants and medical staff are not just consumers of data, but also collectors; for example, taking and recording a patient’s blood pressure for future recall. For administrators, data is needed on procedures, consultants time, tests conducted, etc. in order to accurately bill patients and payers. The efficient running of an outpatient clinic requires information on who is scheduled to attend, timings, etc. While hospitals may have physical flows of patients (via perhaps care pathways) these will also have accompanying information flows. In fact, the efficiency of patient moving through the hospital system is reliant on these information flows. Similarly, the effective management and optimum utilization of hospital resources, beds, inventories, and staff is dependent on how effectively information is harnessed and utilized in decision making processes.
The digital opportunity
In many ways, the ‘modern’ hospital has been designed and optimized for pen and paper, the prevailing technology when many were founded. When deployed, information technology has generally been accommodated within existing structures, processes and ways of working. It is essentially overlaid on the existing organization, and while it has improved efficiencies, it has not realized its full potential and expected productivity improvements.
Tech has also created additional problems. For example, systems are implemented for particular specialisms (such as cardio vascular or orthopedics) that can reinforce separate silos. Multiple IT systems automating and optimizing their “bit” of the hospital usually results in information being trapped in these silos, inhibiting both its accessibility and free flow. These systems themselves are often incompatible due to different standards rendering their integration difficult and creating a “joined-up hospital” an unrealistic objective. Moreover, many software applications were designed from an administrator perspective and not from the standpoint of the health care professional. Indeed, clinical systems seem more focused on counting ‘Band-Aids’ than on patient safety or clinician effectiveness. This has significant implications at the point of work.
The real dividend from digital is the opportunity to fundamentally rethink the very essence of a hospital and the provision of care. Moreover, technology such as smartphones and sensors, provides the capability to connect directly with the patients and the wider ecosystem, opening up additional opportunities particularly in generating revenue. However, a hospital’s digital strategy must be driven, not from a technology perspective, but from an information (and systems) perspective. The provision of healthcare is a heavily information oriented endeavor.
Clinical practice is based on specialization but patients need a holistic approach. Herein lies a dilemma: patients need health providers to work together and for IT systems to link the operations of the whole health ecosystem (public and private hospitals, GPs, community health workers, etc.). While technology can enable this to happen, information is the foundation. We can see the potential to integrate data from multiple sources, like wearables, imaging, diagnostic labs, etc. on secure and easily accessible data platforms.
Unfortunately, over the years, technology has tended to overwhelm our thinking. There is a tendency to focus on specific systems such as the Patient Administration Systems, the Electronic Patient Record, eProcurement or the Cardio Vascular Information System. We get caught up in the excitement of shiny new technology, forgetting that as amazing as it is, it merely provides particular capabilities. These capabilities are limited to data collection, sharing, storage, manipulation (i.e. processing, search, etc.) and presentation. Organizations are only constrained by the creativity and ingenuity of their people as to how they choose to leverage these capabilities. By harnessing these capabilities, technology permit us to organize for work in fundamentally different ways, ways that are not possible without technology. It also facilitates novel ways of engaging with patients, GPs and the wider ecosystem. Capturing these is the essence of a digital strategy.
Consider outpatient clinics. Virtual outpatient clinics conducted during the current pandemic have shown that for many consultations it is not necessary for the patient to actually come to the hospital setting; relevant information can be collected remotely. In the future, heart rate sensors, exercise trackers, sweat meters and oximeters may also feed information into the process. Those consultations where a presence is required will usually necessitate the collection of data that the patient is unable to provide themselves from their home and where on-premise tests need to be conducted (e.g. bloods, x-ray).
In a clinical environment, patients, nurses and doctors are all mobile. Access to information at the time and place required should be the norm. Making people mobile does not always mean making all devices mobile. Mobility needs to be seen as an outcome: it is people who need to be mobile not necessarily the devices. For example, having a computer at every bedside overcomes the key infection control issues and still provides clinician mobility. The infrastructure can deliver a mobile outcome without itself being mobile.
Patient engagement can also be enhanced and enriched by leveraging technology capabilities. Booking appointments is an information oriented task; patients typically phone a consultant’s secretary requesting a consultation; on reviewing the doctor’s schedule (an information gathering exercise) they will be provided with a list of available dates and timeslots and select an appropriate one. This is recorded by the secretary, again an exercise in information handling. Technology affords patients the opportunity to book appointments from the convenience of their home, by directly accessing the consultant’s diary. Depending on the nature of the visit, artificial intelligence (AI) technology can automatically determine if any tests will be required prior to visiting the consultant, and if so to similarly schedule these. Patients can be reminded of appointments and provided with the opportunity to reschedule. They can view test results from a personal patient portal. They can be provided with additional information about any procedures they might have to undergo and what to expect during the operation (e.g. hip replacement). They can even be connected with other patients who have similar conditions or who have undergone similar procedures – again an exchange of information.
Engagement with the patient’s primary care provider can also be enhanced using digital channels. A doctor’s letter is merely limited information that is currently transmitted in person by the patient on their first visit to the hospital. The ‘discharge letter’ is really a vehicle to transfer relevant information to the patients GP or primary care provider; this information can be communicated more rapidly and accurately using technology.
Consultants and medical staff are not just consumers of information, but also collectors of information; for example, taking and recording a patient’s blood pressure. Historically, patient data was recorded by pen on paper and stored in a folder dedicated to that patient. With legibility problems due of writing as well as a single physical file, paper records have significant deficiencies. More recently, this data has been collected and stored using technology. While tech offers many advantages for digitizing patient information via a patient record (e.g. multiple people can look at same record, it is legible, requires less physical space, etc. as well as identify, for example, potential drug interactions if there is some intelligence built in, and contribute to a repository of data for research and analysis) it can sometimes make data entry much slower for the consultants and medical staff.
However, new capabilities like voice recognition can greatly speed up data entry. Pen-based data entry can also provide consultants with the familiar “look and feel” of the paper-based environment that they are accustomed to. Technology can also aid information retrieval and presentation. Consider the impact that ‘Siri’ or ‘Alexa’ has had for search and information presentation in consumer markets. Emerging AI capabilities can curate information that is presented from a patients file, depending on the context.
But there is also a serious issue to consider. Many IT systems in the Health ecosystem are based on 1980’s architectures – approaches that have long since been dropped by the commercial world. As a consequence, application portfolios are ageing, overly complex, unplanned and poorly integrated. In general, most Health IT portfolios are a ‘House of Cards’ – difficult to manage and risky to change. Change is required, but very difficult to do.
The digital transformation challenge
It would not be an exaggeration to state that all hospitals would like to become digital hospitals. The beneficial consequences for patients and staff are obvious. Payers and society also get considerable benefits. But becoming a digital hospital will require much more than investing in tech. Hospitals are complex ecosystems, with hundreds of clinical and business processes. They contain medial and non-medical staff, familiar working in particular ways. They are typically organized around clinical specialisms, focused on episodic interventions with patients. Most hospital systems and processes have been designed from a bygone era, optimized for pen and paper and manual workflows.
The real opportunity of digital technologies is to re-imaging the hospital and what is being provided to patients, primary care providers, payers and society. There is the opportunity to address head on complexity and to consider possibilities for re-orientation around digitally enabled processes and more information-driven care models. Technology capability provides real opportunities for the efficient delivery of personalized care. New care models and remote technologies give rise to streams of data, including behavioral, environmental and social, that can be integrated with clinical data to provide holistic and personalized care.
But there are also challenges that will need to be addressed. For example, as virtual care is now part of the new normal, integrating telehealth technology with a hospital’s EHR, defining clinical protocols for telehealth ‘visits,’ obtaining reimbursement, and revamping hospital processes to support remote consultations (e.g., what does a virtual waiting room look like?) need to be resolved.
The enormity of the task is way too big to be left to the hospital’s chief information officer (CIO) or chief digital officer (CDO). In fact, as I hope I have demonstrated, it really has little to do with technology but transforming the institution. It will require galvanizing the whole organization behind the ambition. In the end, digital transformation is not about technology but leadership. Let me conclude with a quote from the UK’s Secretary of State for Health and Social Care at a talk he gave in January 2020, stressing the importance of leadership in digital transformation; he expresses what is needed more eloquently and with more authority than I could ever hope to:
“And when I talk about leadership I don’t just mean people with the word ‘information’ on their name badge. Every CEO needs to be comfortable and competent in leading digital transformation, every board needs to know what questions to ask, how to hold their CEO to account, every medical director and chief nurse needs to know how technology is going to transform what their teams do and lead that adoption. If everyone leaves it to the IT department, it will fail. If everyone owns it, if it’s clinically led, if the board and the CEO and the top team all have skin in the game, then, and only then, has it a chance of success.”
Joe Peppard BBS MSc PhD FICS, is Principal Research Scientist at MIT’s Center for Information Systems Research (CISR), Sloan School of Management. He is also an Adjunct Professor at the University of South Australia, the University of Southern Queensland and Visiting Fellow at Durham University (UK). His recent books include; The Strategic Management of Information Systems: Building a Digital Strategy and Taking the Reins as CIO: A Blueprint for Leadership Transitions. Joe is also a Vitro Software board member.
In his consulting, Joe advises large complex organisations on IT and strategy related matters, leveraging information and on how to unlock business value from their IT investments. He also works with several technology companies helping with their strategy, market positioning and growth. A former Irish international athlete, he is a Non-Executive Director of IT Alliance Group, an outsourcing and managed service provider, sits on the Irish Government’s eHealth Committee, and previously served as Chairman of the Board of Fineos Corporation (ASX:FCL), a global provider of innovative software solutions for insurance, bank assurance, and social insurance.