by Claire Hutkins Seda, Writer, Migrant Clinicians Network, Managing Editor, Streamline
[Editor's note: This article is part of a series onthe lives of members of Migrant CliniciansNetwork's External Advisory Board. Learn moreabout the board at http://www.migrantclinician.org/about/external-advisory-board.html.]
Biomedical informatics should be a simple tool to improve health care: just design, develop, and implement IT-based innovations into the Electronic Health Record (EHR) and other processes, and the delivery, management, and planning of health care will improve. Right?
“It’s not always the case,” admitted Philip J. Kroth, MD, MS, Director for Biomedical Informatics, Research, Training, and Scholarship at the University of New Mexico Health Sciences Library and Informatics Center, and Associate Professor at the University of New Mexico School of Medicine. He pointed to a well-known incident at the University of Pittsburgh’s neonatal intensive care unit, where a new software system caused patient mortality to double because the workflow was disrupted. “A number of changes that came about because of the EHR actually caused process breakdown -- and their mortality rate went up,” said Kroth. The case is a stark reminder that the technology on its own may not be capable of the big changes that technology promises to deliver. But Dr. Kroth, through trial and error, has learned ways to avoid such serious implementation blunders -- and it’s more about the people than the technology.
Dr. Kroth brings a unique perspective to the world of biomedical informatics; he has a degree in computer engineering and worked for four years in the field before returning to school to study medicine. Consequently, he has always had a sharp eye and keen interest in the ways information technology can improve the delivery of health services. For migrant agricultural worker patients, the potential may be great. Changes to an EHR may assist front desk staff and clinicians in properly identifying workers, which in turn aids clinicians in making proper diagnoses of environmental and occupational injuries. Clinicians may be prompted to provide information and resources to the worker on the health risks associated with their employment. But before the benefits of a new informatics system can be reaped, it must be developed with technology, policies and procedures, and workplace culture and workflow in mind.
Technology, Policies and Procedures, and Culture
Dr. Kroth is board certified in internal medicine as well as in clinical informatics. To receive the latter certification, which was first offered just three years ago, a practitioner may be board certified in any of the medical specialties or sub-specialties, which results in a very diverse “polydisciplinary” program, he noted, necessary “because informatics affects the whole spectrum” of medical professions, just as technology affects all processes, not just one branch of medicine.
Although technology was the magnet that drew him to informatics, Dr. Kroth quickly found the human relation and workflow pieces in implementing a new informatics system were just as essential. “Imagine a pie chart: one third is technology. It’s what most people focus on,” he said, even if the other two pieces are equally relevant. “The second part is policies and procedures,” like assigning a practitioner a username and password to the system, and then assuring that the practitioner doesn’t share it, so the security of the system won’t be compromised, he offered: “If you write your password on the table, you can have the most bullet-proof security system in the world and it just went right out the window!” The technology often comes before the policy and procedure part, as implementation often exposes exactly where those policies are needed, Dr. Kroth noted, so spending time to anticipate those pieces is important to protect patient information.
“The third part of the pie that is very often overlooked is the culture, what people are willing to do,” Dr. Kroth explained. “When you bring in a new system, you have to involve the end users… Not only are they in the trenches and have the best knowledge on those processes that are unknown” and unwritten, like how a primary care team functions in real time, “but they are more invested in the system that you are getting.”
Unfortunately, “that’s a very difficult sell for management,” he noted, because of the time and effort required to build relationships between end users and programmers, and the patience and persistence needed to accomplish input and buy-in from those who will eventually use the technology. He hopes that the new informatics board certification -- which gives attention to all three parts of the pie -- can deliver the full suite of tools and knowledge that health centers and hospitals need to best implement a new technology -- because in the end, it’s not really the technology that gums up the works. “Technology is the minority of what you deal with,” Dr. Kroth explained. “Most of the time, this is a people problem.”
End users are the experts
Dr. Kroth learned this lesson early in his career during his fellowship, when he was troubleshooting a new system that automatically registered a patient’s bedside vital signs. The system, implemented on just one floor of a hospital, had serious kinks -- all the computers needed to be rebooted regularly or else they’d shut off -- Dr. Kroth had trouble determining how to scale up the system to the rest of the hospital. And, he wasn’t getting buy-in from the nurses on that floor, who were frustrated that the computers would regularly go out without the reboot. One night, however, a nurse mentioned to Dr. Kroth that the nurses could really use a report to keep track of diabetic patients and their schedule of finger stick blood sugar results. The tech team easily created a quick fix report for that problem and implemented the report -- and the nurses responded very positively. “It totally blew me away -- it was their idea, and I had done it. Even though it seemed insignificant to me, it really mattered to them. And then I asked, ‘How are the computers doing?’ and they said... “Oh, we just unplug them and plug them back in and they work fine.’” Suddenly, he no longer got resistance from the nurses in helping to implement the larger system.
“There were other issues that people were ignoring that were important too, and when I solved one of them, almost by accident, it built trust,” he explained. When he troubleshooted the problem, he told his tech collaborators, “I’m going to go to the nurses and have them design it, determine how they want it to look,” designing it alongside them, so they have ownership over the piece when implementation finally comes.
“Of course you have to know about the technology… but you really have to...recognize the people systems that are in place,” Dr. Kroth said he learned. “It’s about developing the relationships for the long term and recognizing that the people in the trenches are the experts.”
Dr. Kroth’s expertise in technology is just one area that he lends to Migrant Clinicians Network through his participation in MCN’s External Advisory Board (EAB), a peer technical and scientific committee established to promote cross-disciplinary collaboration, and to give expert advice on community-based participatory research and the development and expansion of MCN programs. He came to the EAB through his longtime professional relationship with MCN’s Ileana Ponce-Gonzalez, MD, MPCH, CNC, Senior Advisor for Scientific and Strategic Planning, whom Dr. Kroth has known for many years. MCN is greatly involved in the future of informatics, both within Health Network, our bridge case management system that assists mobile patients, and in the wider world of regional and national health information exchanges, which could potentially be a boon for migrant patients who traditionally have had limited ability to transfer their medical information as they move. Similarly to the internal problems of a hospital implementing a new system, Dr. Kroth sees the stumbling blocks that are slowing down national health information exchange issues as primarily cultural and political issues, and less technological.
But Dr. Kroth has hope that further study and training can transform technology implementation from an exercise in institutional foot-dragging to a collaborative initiative to better our delivery of health care. “We’re in a Golden Age,” Dr. Kroth emphasized. “And we’re just getting started.”