Flawed Human Behavior Could Threaten Success of Stimulus EMR Incentive Program

Reprinted by permission from Healthcare Technology Online As someone involved in the digital document and content management business I have watched the approaching stimulus incentives for EMR (electronic medical records) with a great deal of interest. There’s no question that if implemented correctly the stimulus program can accelerate the adoption of more efficient (computer based) record management, resulting in improved health care and reduced costs. But the ultimate success of stimulus funded electronic medical record systems could be jeopardized by hideous human behavioral flaws that often affect many information technology projects. I’m referring to the irrational and counterproductive tendencies of people to make projects increasingly complicated to the point that chances for a positive return are diminished considerably. I have witnessed this behavior and its’ results many times over the years when seemingly intelligent people pile on layer after layer of system complexity. The fancy and overly complicated result is caused by a condition I call Swiss Army Knife lust. Swiss Army knife infatuation (SAKI for short) is an attraction to does- everything solutions for situations best approached with a scalpel. I would like to go on record right now by saying that I really hope that my tax supported stimulus dollars go towards the funding of scalpels, not Swiss Army knives.   Before discussing why excessive complexity in the stimulus EMR program is not a good thing it’s worth looking at why it is at risk of occurring. What is it that drives the human tendency to over-complicate information technology projects? I can identify a number of seemly logical reasons responsible for this illogical behavior. One reason is that many humans suffer from what I call the finite solution syndrome (FSS). Finite solution syndrome occurs when people approach information technology challenges as static and therefore treatable with one shot. The static thinking results in the flawed rationalization that every conceivable requirement can be foreseen and that adding enough functions and features (complexity) all of them will be addressed. By the launch time all of the functions and features in the one shot cure has become quite a cocktail capable of producing quite a hangover.     In the real world medical information and technology are both dynamic and forever changing. People suffering from FSS fail to recognize change and by continually adding complexity they often end up chasing their tails. FSS victims simply don’t understand that once they ‘bake the cake’ it is not possible to change the ingredients later. A lot of cakes are baked in the world of information and technology (particularly in medicine), but some end up like the one in MacAurthur park, “out in the rain”.      FSS is a compounding behavioral problem. People often recall the last round of technology projects currently requiring extensive upgrading and even replacement (often a painful procedure). Naturally everyone would like to not have to repeat the process again in several years so they go in search of the ‘this time forever’ killer solution. But when they exercise static thinking they can end up feeding a project of spiraling complexity, expense, and diminished pay back, and still (unless the chain of FSS thinking is broken), the need for future system replacement may be almost guaranteed. FSS can be especially debilitating given the severe shortage of accurate long range crystal balls available to accurately predict the future beyond a year or two.     Swiss Army knife infatuation is often associated with people suffering from FSS. SAKI behavior in people is understandable. Swiss Army knives are shiny and flashy, and they have attachments for everything. Who isn’t infatuated by the thought of becoming MacGyver with a solution in your pocket that does everything? But there is a huge difference between what is implied in the phrase ‘does everything’ and what can actually be done. I personally have three fancy brand new Swiss Army knives (all gifts) that have collected under my socks in a dresser drawer at home. None of these shiny bobbles has ever seen the inside of my pocket. I also have a simple single bladed lock-back pocket knife with a broken tip and cracked handle that has worn more holes in more jeans than I can count. I keep that old knife whetted and wouldn’t trade it for all of the red-handled jobs Swiss knives in China (sorry gift givers). The fact is that for working around up in the pole barn that single bladed knife is the right tool for the job.     People afflicted with SAKI will often insist that complex and multi-functioned systems are inherently superior solutions because they incorporate all of the required (and very many extra) functions and tools in one. They use this path of logic as a compelling reason to go Swiss and fail to see that a correct set of scalpels functioning in harmony can perform successful operations that could never be performed with one flashy red handled knife. People from the Swiss camp also often claim that Swiss Army knives save money over purchasing a variety of individual scalpels. When considering costs there is at least some chance they could be right. But a good deal on the wrong tool is certainly not a good way to guarantee a positive return on your investment. More likely is the chance that you end up buying a lot more gadgets than you need. In fact, there’s a good chance that the fancy seventeen bladed knife ends up too expensive for your budget.   Even the best intentioned people can fall victim to the siren song of FSS and SAKI. The best defense is to accept that even the most complex projects can be broken into simpler, less expensive, and direct phases that can be prioritized and deployed sensibly. Understanding and acknowledging that there will never be an end-all does-all finite solution provides people the freedom to work in a phased approach. Phased approaches can be budgeted, deployed, and validated over a period of time. This approach is also much less disruptive to functioning practices or clinics. I’m not implying here that you should ignore the long term objectives. In fact, by dividing the big project into phases you can often get launched sooner. Prioritizing allows you to select and implement the phases that offer the best return on investment (the low hanging fruit) first. The scalability, flexibility, affordability, and effectiveness of phased implementations are all things that should appeal to the common sense in all of us.   Another human behavioral factor to threaten the stimulus EMR incentives is greed. In case you never noticed, greed often thrives in overly complicated technology environments like germs in a petri dish. It’s no secrete that many solution providers stand to make nice fat profits from stimulus EMR, especially if they can keep qualifying systems and services really complicated. In short, the more complicated it is to understand and meet regulations, the more money they can extract from their customers. While I don’t think anyone would begrudge system and services providers from earning well deserved profits, I do see something wrong when providers and special interest groups deliberately promote increasing layers of complexity for self-serving purposes.   Government regulations are infamous for creating and perpetuating mountains of red tape. But before you criticize the government for creating complicated standards peek over their shoulders and see the companies and special interest groups cruising shark-like in the background and ‘helpfully’ contributing their complicating recommendations. Words like simple, flexible, affordable, and optional are not often a part of their vocabulary. Obviously, not all solution providers fit the prior description. But for too many of them there’s lots of money to be made by promoting fluff and complexity.     OK. We’ve discussed how quickly complexity can burden good intentions. I can already hear screaming and yelling that EMR (electronic medical records) is not a simple concept, nor is it solvable by a simple system. I agree. In fact, I suggest that EMR solutions ultimately will be more far-reaching than most people might initially realize. It is also reasonable to assume that there will be a number of twists and turns between now and when EMR is a mature (and hopefully) functional nationwide system. That is exactly why the last thing we should do is seek Swiss Army knife style solutions when establishing what will and won’t quality for stimulus money. Let’s not mandate the deployment of expensive and complicated systems at a time when we don’t know exactly where the future will lead. As anyone that works in the information technology industry will tell you, nothing changes faster than original standards (have you tried to load information from a 5.25” floppy diskette lately?). A successful EMR deployment will never be as simple as throwing a switch, so let’s set soft goals for stimulus EMR incentives that allow the technology adopters (even small practices and clinics) to harvest rewards along the way to a future final goal.   I hope that when the standards for eligible EMR systems are finalized they reflect the true stimulus spirit by promoting systems that are scalable, flexible, easy to install and use, and able to provide a rapid return on investment based on their own merits. Specifically, the system(s) that come to mind are digital medical record management systems. While it is not necessary to limit systems at this level, I think it is very important to consider them (when properly configured and utilized) as a qualifying solution. Digital medical record management systems I am referring to here are document imaging systems on steroids. While these document and content management systems don’t necessarily offer a full EMR solution, they do represent the sweetest and ripest low hanging fruit.     Digital record systems have some very strong features and benefits to recommend them as an ideal first phase on the road to full blown EMR. First, they address one of the most immediate challenges faced by everyone in the medical industry – that is managing existing paper-based medical records. Systems for scanning, storing, and managing medical records can stand alone, exist as part of a larger and more comprehensive EMR system, or can be integrated to a comprehensive EMR system in the future. The systems are very easy to install and train, and they can be up and functional in as little as a day or two, without great interruption to daily routines. Digital record management systems can also be very flexible and scalable, making them very affordable for any clinic or practice, and they can be expanded and modified to accommodate future needs. These systems also provide a way of linking old and current medical records to new electronic ones in the future, while providing the ability to manage any type of unstructured information. And, unlike ERM solutions based on still emerging standards, digital record management systems are based on proven and mature technologies and software.     I don’t think it is possible to overemphasize the importance of a fast investment payback achievable with a well designed and implemented digital record management system. What better way is there to create stimulus and momentum for EMR than by encouraging the adoption of a system that addresses existing problems and quickly earns a return? And even if smaller sized clinics and practices never expand beyond a first phase system, they (and everyone) still benefit from the implementation and use of it. Fast and positive pay back, easy to install and use, flexible for future needs, now that’s what I call stimulating!   In the end creating the forthcoming standards and qualifications for stimulus EMR incentives is no place for people suffering complexity issues such as FSS and SAKI. I sincerely hope that the Certification Commission for Healthcare Information Technology (CCHIT) charged with creating the forthcoming standards possesses the wisdom to resist fancy and complicated in favor of simple and effective. I also hope that they recognize stand-alone digital record management systems as a qualifying solution. For the sake of all (even the smallest) clinics and practices, as well as for everyone served by the medical industry, it is to keep this easy to understand and comply with. Let the stimulus program fulfill its intended purpose by promoting an important and effective first step toward increased efficiency. Let’s harvest the low hanging fruit. There will be plenty of time and opportunity to refine and direct the program in future phases as long as the first phase lands on its feet instead of on its face.       Footnotes:     At the time of this article final decisions regarding exactly what will and won’t qualify for stimulus EMR incentives have not been finalized. There are indications that the CCHIT has recently relaxed proposed guidelines from a ‘one system, one solution’ approach. However, there is still a lot that can (and should) be done to ensure the simplicity and effectiveness of the stimulus program – particularly as it applies to smaller practices and clinics.     Jeff Nelson is vice-president of BOLT Document Management with 20 year of experience in computer systems and 12 years in document management. He provides document and content management system consulting and design to medical, government, manufacturing, and defense industries. He can be reached at jnelson@getbolt.com.

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