(International) White Collar Healthcare

I visited Peru a few weeks ago to present a hospital-wide HIS and EHR to three hospitals. Over the past three years, I’ve presented EHRs and HISs in half a dozen countries including Peru, Canada, the UK, Saudi Arabia, Iraq, and Malaysia.

I am worried for these staff at international hospitals. I thought EHR implementations were difficult in the US. It’s going to be nearly impossible abroad. They are going to make a lot of terrible mistakes on the path to health IT success.

I’ve argued before that mistakes are good, but these folks abroad will make far more mistakes than they should. I see two fundamental problems: an expectation problem and an executional ability problem. Both are rooted in a lack of modern white collar organization and skills.

The first and perhaps most glaring problem is contract structure. Many international governments don’t actually understand what they’re purchasing. They look at EHRs as an isolated bubble. They structure the tender as if the EHR is a physical product. The vendor must commit to a hard timeline, and if the timeline is missed for any reason, the vendor is penalized.

The governments do not budget for deployment costs, training, or support, but expect a "warranty" on the software. They will not pay for deployment or training expenses as they occur. Perhaps most egregiously, the hospitals will not pay their vendors a penny until the hospital issues a seal of approval on the final, delivered product. They have adopted a hardware contract — for example, a contract for a hospital bed — and applied it to an organizational-wide process change. This is a recipe for disaster.

US industry veterans know that this is untenable. No vendor would ever agree to those terms. EHR vendors have performed dozens if not hundreds of deployments, but for the employees at each hospital, it’s usually the first time. No vendor would take on employee incompetence risk like that, especially across language and cultural boundaries. And of course no vendor would incur the enormous costs of an entire deployment without compensation. That’s absurd.

Given the contract structures, it appears that hospital management abroad simply doesn’t understand what they’re purchasing. Hospital EHR vendors are not software companies, but services companies.

In Peru, our demo was scheduled from 10:30-12:00, and we provided free lunch afterwards. We had requested 1.5 – 2 full days just as we usually do in the US. The hospital informed us that 1.5 hours would be sufficient to present the entire application to all departments in one room together (including translation time) despite our strong suggestions to the contrary. Perhaps I could’ve done it if I rapped the demo at 344 words / minute. Shame on me, I guess.

We arrived an hour early to ensure we’d have adequate time to set up and test the projector — you never know what kind of IT infrastructure you’ll find in international hospitals. Three nurses were already in the presentation room. We thought there might have been another brief presentation scheduled before ours. There wasn’t. They had been told to show up at that time, and we had no clue why. Most of the rest showed up on approximately on time.

The rest filed in over the first 30 minutes of the demo. Two were actually talking on their cellphones as they walked into the room. Although we told them that I would pause for questions every five minutes, they constantly interrupted. Each was far too concerned with their very specific, totally-out-of-context questions, with no regard for the their 39 colleagues in the room.

I didn’t really even give a demo. I just answered sporadic questions from people in rapid succession. Most of the time they didn’t even want to see how the software accommodate their request, they just wanted to know if it could it. Clearly they haven’t been burned by software salesmen before.

Coordinating thousands of people to effectively manage large volumes of clinical and administrative data in a 24/7 environment is extremely complicated. Each employee only sees and understands a small piece of the system, and yet their decisions impact dozens of other people throughout the organization. EHR deployments require sophisticated white-collar organization. People need to show up on time, do their jobs, learn to compromise, and work with others in a fast-paced, dynamic environment.

Healthcare as a profession has never promoted or fostered white collar organization and teamwork until very recently, and only in the US because of the Meaningful Use push. Historically, healthcare delivery has centered around a single individual, traditionally the physician. But modern medicine is collaborative by nature. People need to know how to work in teams across multiple projects, disciplines, and managers.

Most American clinical professionals have struggled with this over the past few years. In Peru and most other countries, computer literacy is measurably worse. I estimate that 80-90 percent of the population has never used a computer in a significant fashion. In the US, it’s probably inverted: 80-90 percent are computer literate. There’s no way an organization can make the transition when 80 percent of people are struggling to use a mouse and keyboard.

Looking forward, I hope medical schools incorporate more white collar, team-based project management training. The vast majority of the content of medical, nursing, and therapy schools is, in technology terms, "memorizing a big database." The medical training schools teach the art of working with patients, extracting information, and other soft skills, but the fact remains that there’s a reason students are staying up all night studying: they have to memorize lots of clinical stuff. Stuff that computers already know. Medical schools should teach students how to work with each other and with the tools of the future so they can provide the best collaborative care.


Kyle Samani is a technology enthusiast who is passionate about healthcare and technology startups.

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