Picture an orchestra – not just any orchestra, one made up of classically trained musicians, jazz soloists, traditional pop instrumentalists and a few hip-hop artists thrown in for good measure. Now, imagine you’re the conductor of that orchestra and it’s your job to put on a concert (nothing too difficult – say, Wagner’s Ring Cycle) and make it a hit with all involved: the producers, the critics, the musicians, and of course the concert-going public. If you can’t quite get your head around the above challenge, here’s one that may resonate a little more with you. Imagine the task facing Sarah Kramer, CIO of Cancer Care Ontario. Three years ago, she found herself at the head of an ambitious initiative to reduce hospital wait times for Ontario adults in five critical areas: cancer surgery, cardiac revascularization procedures, cataract surgery, hip and knee joint replacements, and MRI and CT scans. The project required a major feat of orchestration involving a large and diverse group of stakeholders, including about 1500 surgeons, and the CEOs, CIOs, and CFOs of Ontario’s 52 hospitals.
Kramer was no stranger to large projects involving multiple stakeholders. As CIO for the Department of Health in Nova Scotia, she implemented an electronic health record connecting every hospital in the province. And at Cancer Care Ontario she implemented a computerized physician order-entry system now used in 11 hospitals.
But even for this healthcare IT veteran, the Wait Time Information System project was a huge step up in complexity and scope. Announced by the Ontario Minister of Health in November, 2004, WTIS would capture wait times electronically, in near real time, from surgeons’ offices, diagnostic imaging departments, and hospital information systems throughout the province. By capturing this information, patients would effectively have their wait times put on a clock, which would start ticking at the moment their treatment decision was made.
As there was a perceived need to have the leadership of the WTIS project be somewhat outside of government, Kramer got the nod to head the technical side of the initiative. She works closely with business leads Dr. Alan Hudson, ‘Wait-Time’ Advisor to the Minister of Health, and Dr. Terry Sullivan, CEO of Cancer Care Ontario.
“They understand that CIOs are part of the strategy-forming group of an organization, and that they need to be there when strategic decisions are made, not just brought in when someone brings up a technology issue,” said Kramer. “I push for that myself, but I don’t have to push very hard with these two individuals.”
A CIO TAKES THE LEAD
Kramer went into the project armed with many levers to help do the job. One of them was strong project management – a rigorous, transparent approach to understanding what the risks were, where everyone was on any given issue, and when and if something needed to be escalated. And if something did need escalating, each person knew what they had to do to get the issue resolved.
“That has worked very well for us,” said Kramer. “When you’re talking about fifty basically standalone organizations who really don’t have to do what someone on University Avenue tells them to do, you need to look at that kind of tool to make sure there’s a level of trust and coherence in the project to get the work done.”
In January of 2005, Kramer began assembling an expert panel of advisors, which included CIOs within each of the province’s 14 Local Health Integration Networks (LHINs), physicans, and CEOs. The panel also included a few thought leaders in the use of health information generally.
“I wanted people who had the ear and the trust of their colleagues. And while they’re not representing an organization, I didn’t want them to have to apologize for what they did afterwards,” she said. “I also wanted people who could provide really constructive feedback on issues that I didn’t know the answers to myself. And the panel is very effective in that respect. They actively advise on how these things will fly in the field.”
Kramer used her own judgment when picking the CIOs for the panel, choosing those who she thought were the emerging leaders locally as well as provincially. That wasn’t hard to do, she noted. She also wanted to get two top CEOs who understood the importance of technology in the business of healthcare. And in the end she was successful, choosing Pat Campbell of Gray Bruce Health Services, and Janice Skot of Royal Victoria Hospital.
LAUNCHING THE INITIATIVE
In the early stages of the initiative, the focus was on creating an information strategy to solve the high-level informational issues associated with reducing wait times. The first step was to do a deep dive into what an effective strategy would look like. The normal environmental scans were done, but the biggest challenge was simply getting everyone who would have an impact on the work in the (virtual) room. And though the project leads didn’t agree with all the advice they received, they did listen to it all and came out with decisions that could definitely be justified in light of the advice received.
“The big step was to be really transparent about the decisions being taken, and to float that information around to everyone,” said Kramer. “We wanted people to be clear on what was going to happen and why.”
Within the strategy were benefits for every stakeholder. Hospital administrators were going to have a much better sense of what was going on in their own hospitals. Surgeons were going to have more time to perform surgery. Hospital CIOs were going to get key software that was on their wish list. And government was going to be able to show significant progress on the wait time issue.
Not to say that implementing the WTIS wouldn’t give some stakeholders a case of heartburn. To paraphrase a quote attributed to Abe Lincoln, You can please some of the stakeholders all of the time, and all of the stakeholders some of the time, but you can’t please all of the stakeholders all of the time.
OF CARROTS AND STICKS
Two critical groups to get onside were hospital CIOs and surgeons.
Most of Kramer’s dealings with CIOs she described as “a real pleasure”, but she added that sometimes there was friction, and, on occasion, plenty of it. It was a situation not unfamiliar to many CIOs trying to introduce standards, especially in the public sector: everybody wants there to be a single information system, and they are happy to agree to it, so long as it doesn’t affect them. This was something Kramer and her team bumped up against quite a bit.
Fortunately, Kramer had a couple of tools at her disposal that were very effective. One was the ‘carrot’ of providing CIOs with a provincial electronic master patient index – a linking tool which serves to match and link Ontario citizens who are registered in many systems, including the Ontario Health Insurance Plan and the registration systems from hospitals. Its purpose is to uniquely identify the individual seeking health services from multiple healthcare providers so information can be shared securely and seamlessly.
It took nine months for all components of the patient registry to get a ‘thumbs up’ from the Ontario government, but considering the labyrinthine approval process it had to go through, that time frame was a remarkable accomplishment.
Another tool Kramer took advantage of was peer pressure.
“We had some regional leaders on side who would talk to their peers and figure out ways to move around problems,” she said. “The project wasn’t that difficult from a technical perspective, but for some very small places even a minor technical implementation is a big deal. So if there were issues on how to do it, we pushed out lots of resources to help people do the work.”
Those resources included site leads who were responsible for three or four hospitals, providing them with leadership and knowledge about the larger context of the work. Site leads acted as a single point of reference so that help could be provided quickly when needed.
Each hospital had a project manager that coordinated all of the work locally and was responsible for the local implementation. As well, rigorous toolkits were provided, containing model project plans, communication templates, and various other tools that could be populated and used locally.
Kramer had one other tool that she could rely on, and it was a very effective one. Because the project was tied to reducing wait times, each hospital had agreed in writing to put the system in when they got the additional money to do more surgical cases. That gave Kramer the option of saying: If you don’t put the information system in that’s fine, just give us our money back, please.
“It’s a pretty big stick, and we use it very judiciously; but I have to say, when I talk with my colleagues across the country working on similar problems, they all envy me that stick,” she said.
A CHALLENGING SURGICAL OPERATION
Kramer and the WTIS team faced a different set of challenges when dealing with another key group of stakeholders, the surgeons.
“About fifty percent of the fourteen hundred surgeons we were dealing with didn’t have a computer that could launch Internet Explorer. That’s what we were starting with,” said Kramer. “And it floored me, because I’d been working in healthcare for some time and had assumed that surgeons, being most closely tied to hospitals, would be more computerized than that.”
So a big side benefit of the project – one that helped sell it to the CEOs and CIOs – was that it gave surgeons the ability to communicate by email and brought them into the loop on some other things that the hospitals were trying to do electronically, such as Operating Room booking.
“Many hospitals are really pushing forward on bringing more technology into the every day management of healthcare, and they struggle sometimes with the autonomous physician and the lack of ability to influence them,” said Kramer. “So they’re using the WTIS as an opportunity to do other things. That, so far, has worked quite well for many of them.”
Overcoming surgeon resistance was a big challenge, and again, Kramer used many tools to move the initiative forward, including the financial “stick”. The money actually goes to the hospitals to do extra cases, but the surgeons have the incentive of ultimately getting to do more of what they like best: performing operations.
“Surgeons don’t want to sit around waiting for the OR to open up. They want to get their patients through,” she said. “So we were able to convince most of them of two things. First, that this is a bit of quid pro quo – you’re getting your extra cases, but you have to take a little medicine with that sugar. The second and more important message is that over the course of the next year, you’ll be better able to understand what’s going on in your own practice and your partners’ practices. And you can look at getting shorter waits for patients, because you’ll know that you can refer a patient who must wait six months to see you to a colleague who has only a one-month waiting list.”
Kramer added that the WTIS team is really pushing for the realization of that capability in the coming year – where people understand what they have and actually use it to improve the process that they put in place.
ROLLING OUT THE PROJECT
In the summer of 2005, the team began figuring out which hospitals would be the beta sites. The goal was to have 20 percent of Ontario hospitals implemented by the following spring.
“The question was, which hospitals would it be? What did we want to look at? What did we want to make sure we tested?” said Kramer.
“I recognized up front that the important criteria were things like CIO leadership, CEO commitment and leadership, a mix of community and a mix of types of issues that we thought we would face,” she explained. “The first two, I think, were the most important, because being a beta is not easy. I needed to have CIOs that I really trusted and knew could withstand some hot times.”
In the end, she got some of her strongest colleagues to agree to tackle beta testing. Why did they do it? Two reasons: because they were people who liked to do interesting things and because they would get much more input into what the product would look like than people in the next round.
“We started at the beginning of March 2006 and rolled out to the end of that month. And we did it ourselves, so we could get a deep knowledge of what it actually takes to do this in the field,” said Kramer. “We went out with 80 percent of the product and then developed and refined it over the course of last summer.”
As betas go, this one went pretty smoothly. The surgeons were reasonably pleased with the product, which was the desired benchmark for the first implementation. And beta sites began producing good data, which has improved over time as kinks have been worked out.
One of the biggest learnings from the beta testing was the need to get in front of the surgeons much earlier in the process – let them air any complaints about the system, walk them through it and help them figure how to adopt it successfully.
UP AND RUNNING
Rollout of the WTIS has proceeded on schedule. By the end of 2006, 90 percent of the WTIS funded cases had been put on a single wait time system. In total, 1,400 surgeons are using the system, entering priority ranking scores for their wait time cases. By the summer of this year, it is expected that all hospitals funded through the strategy will report wait time data through the WTIS, representing over 255,000 surgical cases.
At this point a system of metrics has not been devised to gauge how much the system is responsible for reducing wait times in Ontario.
“The government wanted to move on the whole file quickly and they did a full-court press on all of those different fronts, so it’s very difficult to discern which piece has had the most affect,” said Kramer. “But anecdotally, we definitely are hearing that this has had a huge effect.”
One notable effect is that Premier Dalton McGinty is investing 100 million more dollars in funding, resulting from the increased confidence inspired by the data now starting to come off the system.
Eventually, the WTIS will likely be rolled out for all types of surgery. Planning has already begun on that implementation.
“My hope for the future is that there will be the capacity to lead provincial implementations like this on a regular basis without having to borrow from other people to get the work done,” concluded Kramer. “You need someone to be doing this kind of work as their day job.”
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David Carey is a veteran journalist specializing in information technology and IT management. Based in Toronto, he is editor of CIO Canada.
SIDEBAR:
What the Wait Time
Information System does
The WTIS has two main purposes. The first is public reporting. The system is a data collection mechanism that shows what is happening with wait times and whether or not the government is meeting its promise to bring wait times down. Another aspect of public reporting is to obtain information that will improve over time, and enable patients and their family doctors to make informed decisions about where they should go to get the kind of care they need. Towards that end, a Web site is now up and running (www.ontariowaittimes.com) that does just that.
Secondly, in order to fix the wait time problem, there needs to be good information about what is going on in the healthcare system. The WTIS will give surgeons, hospital administrators and funders good, deep information about such things as who is waiting, how long they’re waiting, and why they’re waiting. The WTIS currently doesn’t address the total wait, which for a patient would be from the time she feels sick until the time she is better. It starts from the time the surgeon and patient decide a procedure is necessary until the time that procedure is performed. The patient is entered into the system from the surgeon’s office through a Web application. Registration starts with some basic information about what procedure the patient is waiting for and the level of urgency, established by the clinical expert panel. The doctor has tools to manage the list and can sort by urgency and by how long people have waited. Flags and alerts appear when a patient is within 20 percent of the target time for the procedure, as determined by a relevant clinical expert panel. That way, patients don’t get ‘lost’ in the system.
Ultimately the system will help identify bottlenecks, but that capability is not presently available.
SIDEBAR:
Sarah Kramer’s ‘lessons learned’
CIO Sarah Kramer identified five key lessons learned on the WTIS initiative. Here they are, in her own words:
- It isn’t necessary to have all your ducks in a row before you go out the door. If you have momentum behind you and the only way to keep it is by going out the door quickly, then the risk of not knowing everything is outweighed by the benefit of moving things forward and getting things done.
- Be realistic about potential problems. The WTIS project was ‘yellow’ all the way along, just because of the speed, and I’ve been fully up front about that. One of the problems we all have is to say everything is ‘green’ all the time, until it’s in flames, as opposed to understanding where the risks are and attacking them. An important lesson learned for me was to be very transparent about that and having everybody agree that a red is a red and what are we going to do about it?
- Bring experts in early and often. And take their advice – that’s another critical thing.
- Have a big tool kit with lots of levers – positive and negative – in place. The most important positive lever is building relationships where there is some faith and some trust. But having the stick in the background is very useful. People will entertain your conversations if they know that you have some authority to take some money away.
- It’s not about putting in pipes and wires. You can’t talk about it that way. The issue is improved health care – that’s the reason for doing it. That’s not so much of a lesson learned as it is a principle reinforced.
