The commentary below hit my inbox today. There have been almost two weeks of constant media coverage over the supposed scandal at the Ontario Government’s E-Health agency. All of the media coverage, and this commentary, miss the point in my opinion. It does so badly.
First, let me say that I do not know Sarah Kramer or Alan Hudson. I also don’t know David Caplan. As always, in my view, the focus on the media is in personalities, instead of the underlying root causes for affairs like this. As a species, we just love the allure of gossip and speculation.
My own view of why Kramer and Hudson failed has little to do with the things that have received so much time in the media. I believe that they were simply not qualified to this job. I also believe that the people who put them in these positions did not really understand what competencies are required in the successful leaders for e-health implementation.
The current Ontario E-Health strategy is clear. It has real targets with associated measurables. Kramer and Hudson, and everyone else associated with its creation, deserve to be complimented for their willingness to be concrete and tactical in formulating their plans.(see http://www.ehealthontario.on.ca/pdfs/About/eHealthStrategy.pdf)
Lots and lots of money has been spent on information technology in health in Ontario over the past ten years. International collaboration over many years has lead to architectures such as Health Level 7 (http://www.hl-7.org/). It is not a question of inventing new IT architectures. Technical innovation is necessary. But it is no longer the key.
The implementation of a strategy is not the same thing as the formulation of it. Implementing technically based change strategies is especially difficult. The implementers must accept and recognize that they are changing a culture , not just implementing technology. Success at cultural change requires many things, including an ability to understand the secondary benefits of that the current culture has for people. Without a willingness to go beyond the surface level, and deal with this aspect of cultural change, failure is inevitable.
Kramer’s and Hudson’s tale is about the failure to recognize that E-health is a deep cultural change. On the surface, they came across to me as individuals who are technical specialists, insensitive to cultural nuances. Their attitude to the governmental culture in which they were working is my best evidence for this. In fact, in listening to Kramer on TV and radio, I often got the sense that she was somewhat contemptuous of it. This struck me as a bad sign about someone who was going to lead a major cultural change.
As I listened to the media coverage of this affair over the weeks, I became more and more sad. We need successful e-health badly. It has great promise for reducing the unit costs of health care delivery, as well as improving the lot of individual patients. But it is not going to succeed if we keep pretending that e-health is a MEDICAL TECHNOLOGY and INFORMATION TECHNOLOGY issue. These aspects of the problem are secondary to the cultural change issues involved. The currently ongoing belief on the part of our senior politicians that e-health can only achieved by leaders who have medically related information technology expertise is not helping the situation.
Successful implementation of e-health means convincing doctors to change a fair number of their personal practices. Even more importantly, it means getting their office assistants to change theirs. They do a fair deal of the record keeping and administrative work in doctor’s offices and in hospitals. That will not be easy.
Lots of information technology implementations have failed over the years, in many industries. People need to change the way they do things to successfully use new information technology. Achieving this is not easy in the “command and control” culture that characterizes financial services and manufacturing.
Medicine has far less of “command and culture” in its culture. Effective collaboration between relatively independent professionals who use a common infrastructure is a far better description of its culture. Cultural change is this environment is more difficult than culture change in “command and control” that characterizes many of commercial organizations in our society.
The successful implementation of e-health is first and foremost a cultural change issue. It needs short term tactics such as the one spelled out in the E-Health strategy document. But it also needs a much broader social vision in its leaders. It needs leaders who can work with existing colleges and universities to change the medical education curriculum so that we start producing doctors, nurses, medical technicians and administrators who look forward to using e-health approaches. It needs leaders who will collaborate with medical professional bodies to incorporate e-health exposure into on-going professional education programs. It needs leaders who are respectful of the huge contribution to medical record keeping that is made by office assistants and hospital administrators. It needs leaders who recognize that the first step in changing a culture is respect for it, and the people who live it.
What it does not need is leaders who so convinced of their own superiority that they feel justified in ignoring the simple and straight forward rules of procedure that have served government agencies well for years. Kramer and Hudson failed in their leadership. The people who put them in their positions failed to appreciate that e-health is not about techniques first, and people second.
E-health is about the convincing independently minded professionals to undergo the personal change needed to use new e-health technologies. When the leaders of Ontario’s E-Health Agency demonstrate that they understand how to undertake such cross institutional cultural change, we may begin to benefit from the technology underlying e-health. When the politicians who have the ultimate responsibility for the delivery of health care in our society recognize that implementing e-health needs cultural wisdom more than its needs technical prowess, we may begin to succeed.
Maybe we will get lucky and such leaders will emerge without deeper insightful on the part of politicians and media commentators. But I doubt it. I suspect that I will have more reason to be sad in future.
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Here is the link to the article that I am commenting on … …
http://www.chmonline.ca/news/article.jsp?content=20090618_162815_7368
