With all of the discussions of rising health care costs, technology is often cited as being a major potential factor for reversing this crippling trend. Electronic medical records are predicted to save billions of dollars per year through increased efficiency and availability of information.
Despite these optimistic predictions, health care process improvement practitioners often see something different when working with health care organizations. Projects often fall into two categories: (1) organizations immediately assume that a technological intervention is “the solution” to their perceived problem, or (2) they are struggling with a technological implementation that didn’t result in the anticipated improvements (or made processes worse) and they need help just to get back to where they were before the technology was implemented.
Hospitals regularly struggle with implementing one EMR system and spend potentially hundreds of millions of dollars on a system, but then decide to start over with another EMR system after they “give up” on the first one—a step which assumes that the particular EMR that they chose was the problem to begin with. Staff end up having to keep track of 15 different user-names and passwords that they must change every 3 months due to security protocols. Therefore, from the “front lines” of hospitals, there seems to be a different reality to technology in health care than what the public is led to believe. This perspective is corroborated by research by the Henry J. Kaiser Foundation in 2007 which is summarized below:
“The particularly rapid increases in health insurance premiums over the last few years have focused the health policy community on the issues of cost containment and health insurance affordability. A key question from policymakers is why spending on health care consistently rises more rapidly than spending on other goods and services. Health care experts point to the development and diffusion of medical technology as primary factors in explaining the persistent difference between health spending and overall economic growth, with some arguing that new medical technology may account for about one-half or more of real long-term spending growth. ”
The “promise” of health care technology is that it would drive down the costs, not increase them, so this begs the question of “why?” If these investments were actually driving down the cost of health care, then there would begin to be a net reduction in U.S. health care costs. The reality is that the U.S. spends more per-capita on health care than any other country, and outcomes (in terms of life expectancy and other similar measures) are far from demonstrating a big payoff from this investment. Therefore, there seems to be a large divide between the potential capabilities of health care technology and what health care organizations are able to realize in their actual operations and care provided to patients.
This should lead one to ask the following questions: “Is health care technology inherently ineffective?” or, “Is the way we select, deploy, and integrate technology in health care ineffective?” When one looks at a hospital or any health care system, it is largely a “people-based” system. This leads to a very dynamic and fluid environment, and the effectiveness of the technology is dependent on how it interfaces and relates to staff that use the technology. Therefore, there is no simple way to “plug and play” technology in a dynamic health care environment. There must be an effective approach to integrate the technology with the staff and environment. This is contrary to the way that most technology is deployed in health care where it is essentially “dropped” into their area with minimal training or an approach to truly integrate it with the rest of their work. Also, these technological interventions are often based on a perceived need, and this technology is an “educated guess,” at best, to meeting this need.
As a Lean health care practitioner, none of these disconnects seem surprising. One of the fundamental tenents of Lean is that of “A3 Thinking,” which is an approach to developing staff to think about problems in a different way. An A3 is a single-sided, roughly 11”x17” (A3 sized) paper form that is used for teaching this different way of thinking. Without going into too much detail, there are essentially two sides of the form: the left and right hand side. The divide between these two sides are great, and significant to this discussion. The left hand side of the form is for carefully investigating, defining, and determining root causes for the problem.
Only after this left-hand side has been completed should one proceed to the “right hand side” of the form. On the right hand side of the form is the implementation, testing and evaluation, and sustainment of the improvement. When we teach classes on this approach, probably about 1/3 of teams “jump” to the right hand side prematurely and begin developing solutions to problems that they didn’t clearly define and without identified root causes (this would be almost 100 percent of the teams if we didn’t strongly encourage them to linger and “struggle” with the left hand side of the form). The teams that prematurely “jump” always struggle with the right hand side and then have to return to the left-hand side of the form to further refine their understanding of the problem. Once they have struggled through this, they then return to the right-hand side of the form and have a much easier time developing a plan based on a clearly understood problem.
Many of these teams that prematurely “jump” to the right-hand side were fixated on a pre-determined solution, often involving a particular piece of technology. There is something almost “genetic” about the human tendency to jump to solutions without clearly defining or understanding the problem. This is really the focus of the people development side of Lean processes.
If one were to take this same approach and insight and apply it to hospitals or health care organizations, the implications are significant. A health care organization is full of individuals that think the same way as those class participants who “jump to the right hand side” of the A3 form. This then leads to large organizations that “jump” immediately to the right-hand-side of the A3 form (implementation) and never return to the left hand side of the form to more clearly understand the problem. The embedded assumption is that the problem is the technology, not their understanding of the underlying problems or what is truly missing. Managers and leaders are often encouraged and rewarded for being “decisive,” and this can manifest itself as jumping to solutions to ill-defined problems and throwing resources at a perceived problem.
Technology/IT vendors are more than happy to offer a wide range of potentially great solutions to problems, but if the decision makers haven’t taken the time to clearly understand their problems or develop or support their staff in thinking in a different way, the technological investments will be implemented without any approach or capability to truly integrate them. Also, how does one solve a problem that they don’t truly understand?
The best examples that we have seen of technology truly addressing the needs of a health care organization involved a team of staff in the work area of the perceived problem deeply studying and understanding the problem, doing small scale experimentation with the simplest and most cost-effective technologies available, and testing these technologies in their effectiveness to impact their process numerically.
When they take this approach, they are directly addressing the root causes of the problem and developing integrated systems that provide better and more efficient care for their patients. Therefore, they are not making “guesses” but are only using technology to address an actual problem. This also results in the greatest benefit to the organization: the people are developed and become better problem solvers who are able to continually problem solve, integrate new technology, and provide better care to patients.
As mentioned earlier, health care is largely a “people-based system,” and the greatest gap in the current health care system is that the primary focus is on developing our technology and not developing our people. This gap is manifested by the lack of positive impact from technological investment in U.S. health care, as the leaders and staff don’t think in a way that enables them to improve their own processes and effectively apply, integrate and maintain new technology. The U.S. health care system contains some of the most highly educated workforce in the country, but the system we have developed neglects its greatest resource – its people. Toyota has been able to harness the resource of its staff greater than any company in the world, and has risen to dominance in the auto industry through this approach, not through having the highest level of technology.
If the health care system can learn this lesson from Toyota and develop its staff in a similar way, then the potential benefits of technology will be realized. If it doesn’t, then costs are likely to continue to spiral out of control. This therefore illustrates the “double edged sword” of technology in health care. It can either help us or hurt us, but this depends on how we develop our people to think and operate in a different way.