Sustainable change requires meaningful adoption

The thesis for this article is that only when we achieve meaningful adoption of advanced ICTs in healthcare will we see the type of change that justifies the investment we have made, and indeed need to perpetuate.

We hear a lot of talk of driving change, or accelerating change. My view is that we will only get that change when we see adoption take off. Perhaps that is a statement of the obvious, but I think we sometimes look too simplistically at the challenge of driving change. And especially when we consider the challenge of sustaining the change and making the new world the norm.

Change only occurs when the uncertainty of the future is less daunting than the reality of continuing with the present. So how do we create such an environment in healthcare?

Today in Canada, and elsewhere, we have all the fiscal pressures we need to recognize a looming crisis for healthcare. For sure that provides an impetus, but as yet has proven insufficient to drive the type of lasting change we desire.

Secondly we have great examples of healthcare ICT adoption and change in process and practice that show us what is possible. The benefits of such initiatives are well documented, again in Canada and elsewhere in the world. I refer to ePrescribing projects in FHTs in Ontario, shared EMRs for team-based care in PCNs in Alberta, home health monitoring and care coordination in Quebec, and many more.

So why haven`t these successes been readily replicated? That is a good question.

I submit that these are the classic early adopters, but they don’t as yet represent the tipping point.

Perhaps therein lies the first challenge. We have a tendency to fund lots of good ideas and pilot projects, but are unprepared to be brutal in our assessment of successes and failures. The essential core of innovation is to “let a thousand flowers bloom” (with apologies to Chairman Mao). However to maximize the chance of success we must follow that with a rigorous evaluation of which ones have the potential to grow. Jim Collins refers to this approach as “bullets followed by cannonballs”. The process by definition must be selective. Some initiatives, while good and valid ideas, must be curtailed and without shame as they have served their purpose. The ones where we see the greatest chance of uptake are the ones we must plough significant resources into.

My second line of thinking around driving adoption is that of creating a future that is less daunting than the present. I heard it said that a pen is the most dangerous weapon in a physician’s tool bag. This referring to the risks of paper prescriptions. Here is an example of a situation where it ahs been proven that continuing with paper scripts is more dangerous than moving to ePrescribing. We have so many examples of medication errors that could have been prevented with electronic transmission of scripts and/or drug-drug interaction checking. Yet this seems insufficient to drive ePrescribing. Why not?

Well there is definitely the issue of workflow for physicians and pharmacists alike. While there is no question that early attempts were clumsy, we have moved beyond that now. Hence the pockets of successful implementation we can see across the country.

Then there is a capital necessary to build large, province-wide drug information systems. Not only do we not have the capital but the likelihood of success, especially in any time soon, is low. Perhaps the very concept here is wrong. If we look to our neighbours to the south we see Prescription Exchanges that are privately funded and operated, with their return based on the processing of an eScript.
Here is an example of leveraging private funds and paying based on adoption.

Then there are incentives. Why must we continue to pay for inputs? For example paying doctors to implement EMRs. Some argue this was necessary to get the ball rolling. Perhaps it was, but it is clear that the approach is insufficient to keep it rolling and achieve perpetual motion, so to speak. Now we need new tools.

The colleges could regulate the use of electronic tools as best and safest practice – who can argue that the use of an EMR or ePrescription is more safe than not?

We could shift to paying for results/ outcomes or even as simple as paying for things a physician can only do with the eRecord, but would be impossible or impractical with paper records. Things like proactively managing populations of chronically ill patients, or self-monitoring of same. We know the protocol for managing diabetics for example. With eTools, test reminders can be easily generated, and blood glucose levels can be taken at home and monitored by the care team. So why is this not a national standard, where we pay based on a physician’s management of their diabetic population?

One definition of insanity is doing the same things in the same way and expecting a different result. We have many tools available to us to change this equation. Do we have the will to accept the reality of what has worked and what hasn’t? And then to focus our increasingly limited resources on those initiatives with the best chance of taking off?

Only then will we be on a path to meaningful adoption, and hence sustained change.

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