ElectronicHealthcare, 2(2) May 2003: 3-4

The Editor's Focus: Amnesic Déjà Vu: The feeling that you have forgotten this before.

Michael Guerriere


When I first heard this humorous definition, I couldn't help but think of our healthcare system as it tries to implement electronic health records. Over and over again, the same tactical and strategic errors have been repeated across the country. Somehow, the health system does not seem to retain lessons learned in an effective way. Certainly we would progress more quickly down the EHR path if we learned more effectively from the mistakes and successes of others. So what is it that keeps us from learning and remembering our collective past experiences? Several factors contribute to the health system's memory impairment. Leadership turnover is one. According to CIHI, the average term of office for key health system positions (minister, deputy minister, CIO, etc.) is less than two years. This rapid attrition rate results in a constant stream of new players who have no health information experience and hence come to their positions without the benefit of knowledge about what has been done before. Key success factors that have been shown to be essential for success in the past are overlooked due to the loss of institutional memory. As a system, what was once collective wisdom is lost when the key players change.

Another impediment to sound recollection is the irrational belief that one's circumstances are so unique that wisdom gained in other settings is not applicable locally. This characteristically adolescent view that the experiences of others are not relevant dooms many to repeat the mistakes of others. I often wonder why this is so common in the Canadian healthcare system. Perhaps the lack of competition between organizations in the health industry makes the actions and experiences of others seem irrelevant. In a competitive environment, organizations are obsessive about watching their peers to discern any emerging competitive advantage. Another possibility is that the consequences of failure in our public sector system are not great enough to stimulate a rigorous approach to project planning and the research required to do it well. Either way, going it alone is a commonly observed behaviour that is very costly to the system.

Finally, there has been a paucity of good venues for exchanging experiences gained in the field and documenting them for future use. Although there have been many publications devoted to health informatics over the years, there has been a publication bias toward reporting successes and good news stories. Without a balancing number of articles discussing failures and lessons learned, this has made it difficult to distill key success factors from the published literature.

Fortunately, there seems to be significant movement on addressing the deficiency in effective knowledge management on a number of fronts.

We launched this journal as a vehicle for exchanging experiences gained in the field. Our editorial policy is to seek real-life experiences and to document them in enough detail to learn something about what worked and what did not. Articles about successes and failures are welcome; both have great learning value. The key is to include details about what was actually done and what were the outcomes. Articles of this type will have the most value and relevance, even for experienced health information leaders trying to navigate the minefield of implementing an EHR.

The Protti-Johansen article is an excellent example of this. Not only does it address the technical issues involved in large scale EHR projects, but it also outlines the details of compensation, implementation approach, governance, etc. that are so essential in successful change management. It is the interplay between the technology, operations, clinical process, culture and incentives that determines the degree of success that a project enjoys. This article provides insights into the mix of factors that made the EHR implementation in primary care such a success in Denmark.

This article is also notable for the utilization metrics it reports. Bringing a system live is only one milestone in a much longer implementation effort. All too often, the go-live is considered the project endpoint. In reality, an EHR project is not complete until clinicians embrace the technology and alter their daily routines to take advantage of it. Good utilization metrics are the key to measuring implementation progress over time. MedCom used the percentage of total transactions performed electronically (such as "% prescriptions written through the electronic system") as their key metrics. This is an excellent choice, because the degree of penetration of the system (and buy-in from clinicians) is very easy to discern from their graphs. This type of metric is essential in understanding how far down the path of the EHR an organization has progressed.

This issue also includes two articles describing the information strategies for the cancer agencies in B.C. and Ontario. Although the information needs of the two agencies are similar, they are taking very different approaches to developing their clinical systems. Given their different service delivery mandates, environmental context, legacy environments and numbers of cancer centres, it is not surprising that they are taking different approaches to addressing similar information needs. It will be instructive to follow their progress in the coming years to compare the merits and weaknesses of their approaches.

And yet, a journal such as ElectronicHealthcare is insufficient to solve the knowledge management needs of the Canadian health informatics community. Fortunately, Canada Health Infoway has recognized this. Infoway is launching its knowledge management portal to dramatically enhance the exchange and storage of information related to EHRs. Not only will it organize and index journal articles and other relevant information sources, it will also offer virtual discussion capabilities to communities of interest that want to share information on a particular topic. By creating and storing information about successes and failures, we will hopefully improve the ability of the health informatics community to learn from each other's experiences.

Of course, no portal, journal or conference will offer any knowledge management advantage unless those of us working in the field take the time to document our experiences. As a guide, the projects worth documenting are those that have taught us something new or have challenged our capabilities to the limit. Let us all resolve to allocate a few hours per quarter to share what we have learned with others in the community by documenting our experiences both good and bad. We will all be the better for it. Perhaps if we diligently make regular deposits in the knowledge bases available to us, our institutional memory will improve.



Michelle Purdon wrote:

Posted 2011/05/10 at 12:21 PM EDT

This is a great reminder that the practice of change and learning comes from our actions and sharing of what worked and what didn't work, rather than the finish line or a binder on the shelf to identify completeness. I have been amazed of how many practices are currently in clinical areas across Canada such as utilization of different skill mixes such as RN's and LPN with scant amount of literature in this area.


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