Healthcare IT as strategic a collaboration edge

Thornton A. May had a piece in the Jan 22 Computerworld, on "Why Don't More CIOs become CEOs?'

As he said in I T May have become too Invisible, (Computerworld, May 2005) "The challenge for the discipline is that most of the executives currently involved in such activities don't think of IT as being able to contribute much in the transformation and innovation arena. What's worse, the people who will take those executives' places don't really think about IT people at all."

Public Health shares one major problem with enterprise IT - when it works perfectly, it's perfectly invisible. So we have the "baffling" situation where politicians complain loudly about the total health care bill ($1.7 trillion this year), while ignoring the fact that we currently spend under 2% of that on prevention, and over 98% on heroic repair. The prevention, like a clean water supply, is invisible and taken for granted. The heroic repair garners huge headlines and grateful recipients funding new buildings.

A second problem is one of image. Computing professionals today are concerned about many issues ranging from social dynamics to algorithms for collaboration to design of safe and high-reliable systems, knowledge representation, library science, etc. But the mental image many people have of it is somewhere between "payroll system" and "those people who store my data for me." It's the Rodney Dangerfield phenomenon, and it "don't get no respect" for what it is today, not what it was 30 years ago. The same thing is true in public health - tremendous advances in understanding social dynamics are invisible and public health is viewed as "insurance for poor people."

The orphan of both worlds, health care information technology, is in even a worse boat,
almost completely misunderstood and downplayed by the corporate world, by hospitals,
by public health, and invisible to patients, except when it breaks.

The fairly certain idea that increasing prevention to, say, 5% of the budget would cut downstream repair costs by 50% has close to zero traction. People evolved to be locally-oriented animals, and this "distal causality" concept apparently has no internal template or neural wiring to hang its hat on. People look at it, nod "yes", then go back to what they were doing unchanged.

Many business leaders share the "IT Doesn't Matter" mindset May quoted coming from Harvard's B-School in your June 2003 article " Harvard Flunks IT."



So, here's some thoughts.

First, yes, there's a serious visibility problem for enterprise IT. A perfectly done migration of a thousand servers from Oracle 9 to Oracle 10G will involve a huge amount of effort, and be 100% invisible to the users. The better it's done, the more invisible it is. There is about zero appreciation of how much scurrying under the covers it takes to keep on patching and migrating every component while keeping the visible surface rock solid, stable, and level. There is even less appreciation of long-range planning that avoids problems ever coming to the forefront in the first place.

Second, May said in the Harvard IT piece, "What Carr doesn't seem to understand is that the future is all about the evolution and blurring of the interface between people and our machines." I guess I agree that the entity that is evolving on a global scale now is a hybrid of human and digital components, which are co-evolving and increasingly hard to disentangle.

IT is increasingly shifting on the socio-technical axis from the "technical" end to the "social" end. That has several consequences. When IT attempts to deal with enterprise issues such as privacy, or a decision about what email system to use, the dysfunctions of the social structure are projected onto IT and IT is blamed for the resulting visible problems (see the
Oxford University example below).

Conversely, many people hope to totally avoid having to deal with social dysfunctions in their organizations and hope that somehow, with magic, putting in a new software application will cause their social problems to evaporate. If anything, the reverse is probably true, as people who were comfortable in separate silos of specialty areas suddenly now are force to deal with each other over common lexicons and applications.

Oxford is one step beyond Harvard in the model of many "ships on their own bottoms" (or "silos" in health care), each doing their own thing and refusing to cooperate, almost on general principle. I was looking at Oxford to see, OK, if we were to let academics rule the world, what would it be like?

Oxford University's IT planning documents are on line. Here's the Corporate Plan and the
Draft ICT plan .

Oxford's budget is about $200 million in the hole, each year, and sinking fast. They have heated debates but can't agree on what email system or calendar to use. But, hey, they've only had 1,100 years to sort out how to collaborate. Maybe they should get a 1 year extension on the due date for their paper.

So, it's actually then worse than invisible - IT is selectively visible only when it forces unpleasant and unacceptable social dysfunctions to become visible. Or, in evolutionary terms, IT is slowly applying an evolutionary fitness pressure on the humans to learn how to cooperate and collaborate.

And, if we believe many researchers at B-Schools who I do, in fact, agree with, these changes in culture are pivotal to creating dynamic, productive, high-performance, high-reliability organizations. The literature is becoming quite solid on the crucial role of culture in any organization that wants to produce reliable output under stress, which is pretty much all of us.

So, the large-scale, slowly changing IT infrastructure tends to become invisible to the rapidly changing, short-time-horizon CEO's.

I think one major opportunity here is to revitalize the definition of "IT" to make it much more of a socio-technical endeavor, with much more emphasis on the "socio" part.

In fact, we know that most IT projects fail, and that most of them fail over social dysfunctions in the organizational information gathering, model building, and decision-making processes. An increasing amount of academic research is revealing the distinction between legacy applications that had many individual users, and new applications, such as email or EHR, that require groups of users. All of our hard-won intuition about how single user software, such as tax preparation or a spreadsheet works, doesn't carry over into how mulitple-collaborating-user software operates or crashes and burns. This type of field is studied by Professor Gary Olson's course here at the School of Information in "Technology Mediated Collaboration", ( see http://www.si.umich.edu/research/area.htm?AreaID=3 )

But the electronic health record isn't some passive database, is the problem - it's a matrix that facilitates and forces cooperation and collaboration between doctors in different specialty areas who don't like to work with each other. It's all about what Technorati's Sifry calls "the conversation". This is new generation software where either everyone agrees on how to use it, or it won't work. And there's the new stumbling block that people aren't

But, because mentally, systems such as CPOE (Computerized Physician Order Entry) are viewed as technical challenges, not as socio-technical challenges, the design and development teams don't include cognitive psychologists, social psychologists, or anthropologists, and the social problems that tend to crash such deployment are not only unseen, but almost impossible from that perspective.

It's not one company's fault. The whole US and much of Western Civilization is caught up in the craze, as blazoned on the cover of Time magazine repeatedly, that "Our Technology is What will Save Us!" As I've noted before, this is actually more like what T. S. Eliot noted, in Choruses from The Rock (1934):

They constantly try to escape
From the darkness outside and within
By dreaming of systems so perfect that no one will need to be good.
But the man that is shall shadow
The man that pretends to be.

Top Business schools, such as the University of Michigan's Ross School of Business, are now discovering the "new" concept that human emotions and psychology and even character and integrity are the keystones around which a solid bottom-line is delivered to shareholders.

The point is that humans are not actually primarily "rational actors" and getting them to all go the same direction is, indeed, worse than "herding cats." Top-down directives by "Deciders" such as Bush don't result in everyone (even the military) saluting and going that way.

Worse, even if humans do try their best to listen, obey, and comply with top-down orders, unless there is room for them to grow as human beings, the experience is more like becoming a member of Star Trek's "Borg" than joining a winning sports team. Unless the heart is engaged, having the mind try to comply doesn't actually work in the long run. Humans are not computers. Feelings matter. "Soft" social factors matter. Virtue affects the bottom line.

Now it's becoming very clear that cooperation and collaboration and high-performance teams are keys to corporate bottom-line success, more so than an internal culture of adversity and competitiveness. Glimmers of this show up in the new "agile" project managment techniques.

But, everywhere, we see the need for small-team support. The Institute of Medicine's key document "Crossing the Quality Chasm" focuses on "microsystems" as the appropriate unit to focus organizational change on - that is, small teams of people who work together to deliver a product or care for a patient. Again, design of systems to facilitate small-group small-team feedback and self-management, smaller-scale dashboards than enterprise size ones, is crucial.

And, yes, virtue drives the bottom line. There's a limit to how high a management pyramid one can build out of self-serving individuals and have the whole thing still function as a healthy unit. If the people are bonded to each other, we can build soaring structures, but if the people basically cut themselves off from each other emotionally and spiritually, we get just a big sand pile that collapses under its own weight.

The serious academic literature is beginning to support that fact, and it's a fact that technology,
by itself, if not socio-technical, cannot cure. There's a corner here we have to recognize and decide, are we a "train" company or are we a "transportation" company -- are we going to fight air travel, or start providing it? Are we going to fight social factor engineering as part of the IT core competencies for the new century, or are we going to embrace it as our new wings?

This is getting way more into Web 2.0 and interactive participation than ever before, and all the power of that, which should be part of "IT", is so far missing from the equation.

What's all that say. It says that the way upwards for CIO's is to move IT back into the strategic core of the business, visibly, by bringing in a new component under the IT banner of IT as the supporting web for social collaboration, small-team functioning, agile programming, etc. That means embracing Web 2.0 participatory interactions, which involves breaking the grip of tight, top-down, theory-X management styles.

This is the same battle agile techniques are fighting from within - to be free to grow and be facilitated, not squashed, squelched, and stomped out. There's a very deep top-down hierarchy legacy history this has to overcome, like any paradigm change. There are also very real examples of where "soft" social factors are fluff, and need to be ignored, that opponents of the new paradigm can rally behind. A solid case needs to be build, slowly, reducing the heated debate.

So, it comes down to a redefinition of the field, as train companies, faced with the arrival of airplanes, had to decide if they were really train companies, or transportation companies.
For health care IT to become strategic, it has to get out of the basement and start demonstrating power at cutting big chunks, on the order of 30% or more, out of the
nation's health care bill.

IT, in my view, is at that juncture. If the field is viewed as "data processing", yes, strategically, it is a commodity. If the field is view as "electronic facilitation through feedback-based shaping of high-performance culture", it moves back into the limelight.

Too many people's mental models of projects such as the CPOE are 95% technical, and 5%, afterthought, social. IT leadership, true leadership, will see that reversed. The job is primarily social re-engineering, changing the conversation, through the leverage handles available surrounding an "IT project".

That's using the hybrid (human and digital) tools at our disposal in the most productive fashion. In my reading, that's what needs to be changed to bring IT back into the leadership circle, and get a new lease on life that's central to evolution of the man-machine hybrid culture ahead of us.