Harvard: Computers in Hospitals Do Not Reduce Administrative or Overall Costs

Harvard researchers recently released the study Hospital Computing and the Costs and Quality of Care: A National Study, which examined computerization’s cost and quality impacts at 4,000 hospitals in the U.S over a four-year period.

The researchers concluded that the immense cost of installing and running hospital IT systems is greater than any expected cost savings. Much of the software being written for use in clinics is aimed at administrators, not doctors, nurses and lab workers. Additionally, as currently implemented, hospital computing might modestly improve process measures of quality but does not reduce administrative or overall costs.

The researchers also found no reliable data support claims of cost savings or dramatic quality improvement from electronic medical records.

The researchers did acknowledge that the modest quality advantages associated with computerization were difficult to interpret since the quality scores reflect processes of care rather than outcomes. Access to more information technology may merely improve scores without actually improving care by facilitating documentation of allowable exceptions.

From the paper:

"We used a variety of analytic strategies to search for evidence that computerization might be cost-saving. In cross-sectional analyses, we examined whether more computerized hospitals had lower costs or more efficient administration in any of the 5 years. We also looked for lagged effects, that is, whether cost-savings might emerge after the implementation of computerized systems. We looked for subgroups of computer applications, as well as individual applications, that might result in savings. None of these hypotheses were borne out. Even the select group of hospitals at the cutting edge of computerization showed neither cost nor efficiency advantages. Our longitudinal analysis suggests that computerization may actually increase administrative costs, at least in the near term."

Himmelstein, D., Wright, A., & Woolhandler, S. (2009). Hospital Computing and the Costs and Quality of Care: A National Study The American Journal of Medicine DOI: 10.1016/j.amjmed.2009.09.004 Sphere: Related Content

OSUL2013: Agile Organizational Development?

Over the past year I have been involved in a grassroots effort to create a roadmap for organizational change at The Ohio State University Libraries, known as OSUL2013. The purpose of the effort is to help the organization adapt to the changing information, educational, and environmental landscapes.

What has been unique about this process is that while it has been supported by library administration it has been entirely motivated and guided by Libraries staff. For their part, the administration has been actively encouraging staff to participate. I have been impressed by the growing participation considering the timing of the initiative coincided with the Library's move back into it's newly renovated building.

The process began with a full-day workshop on April 1, 2008, attended by 35 OSUL faculty and staff, including myself. The primary outcome of that event was the creation of five task forces, which worked through the summer of 2008 to investigate and create reports on the topics of:

• Assessment
• Collaboration
• Innovation (which I chaired)
• Scholarly Communication
• Ubiquity
  

Each of the reports define the topic, provides case studies, outlines a Blue Sky vision, and identifies "quick hits." The quick hits were important since they were seen as small scale projects and efforts which could help lead the organization towards each Blue Sky vision.

To continue the process, the task forces recommended an Implementation Phase. This phase began late last fall and concluded at the end of May. The Implementation Phase focused on a handful of quick hit projects projects and was managed by an Implementation Team, on which I served. An Implementation Community (made up of nearly 30 staff volunteers) was created to serve as a very important support unit. They acted as a sounding board and a source of new ideas. Community members were also active participants in several brainstorming sessions. Many also served on project teams.

The Implementation Phase final report (found here) summarizes the process, the projects, and recommended a new group be identified to continuation of the process. It calls for the creation of a working group starting in August '09 and continue through the fiscal year. That group would have several roles:

• serve as a peer source of information and support for staff and faculty interested in pursuing innovative projects;
• test and promote an appreciative model for group-based work based on facilitation, encouragement, and constructive feedback;
• assess the progress toward the goals;
• propose the next phase of the 2013 process

The activities associated with the next phase of OSUL2013 would be built from five high-level goals:

• Library as Commons: Provide physical and virtual space for collaboration and communication
  
• Empowered Staff and Focused Leadership: Encourage staff and faculty to take initiative to assess and to innovate
  
• User-Centered Organization
• One Library System: Facilitate and encourage communication and collaboration between individuals and units
  
• Leadership in Scholarly Communications: Lead innovative efforts in the creation, distribution, and management of scholarship in all formats.

So, what does the title of this post come into play? As I was finishing up this summary I began to realize that the process that we have been unknowingly using could be characterized as being agile organizational development. We have been moving from phase to phase with only a half-baked notion of what we were going to do next. Each phase was an iteration on the previous with mid-process corrections being made based on our experiences and feedback.

While our report recommends that the next phase should last until next June, I have been thinking as I write this that it should last only until the end of the calendar year. We could squeeze two iterative phases in during that time period rather than just one.

Participating in OSUL2013 has been interesting experience for me, considering that I work in the Health Sciences Library which is technically not a part of OSUL. Not only has the OSUL organization embraced my involvement, but HSL leadership has been very supportive and encouraging. I will continue to be involved in the process going forward, but I haven't decided at which level of participation. Sphere: Related Content

Is a Green Ocean Strategy Needed for Libraries?

Our medical center leadership has embraced the Blue Ocean Strategy as introduced by  W. Chan Kim and Renée Mauborgne. As a result, our library has also begun to use the metaphor presented in the book in our planning processes. 

Red oceans represent all the products and services in existence today - the known market space. In red oceans, boundaries are defined and accepted, and the competitive rules of the game are well understood. Organizations try to outperform their competition in order to grab a greater share of existing demand. As the space gets more and more crowded, products turn into commodities, and increasing competition turns the water bloody. Picture sharks in the water.

Blue oceans represent all the products and services not in existence today - the unknown market space. In blue oceans, demand is created rather than fought over. There are two ways to create blue oceans. In a few cases, organizations can give rise to completely new products and services. But in most cases, a blue ocean is created from within a red ocean when a company alters the boundaries of an existing product or service. Blue ocean strategy is all about doing business where there is no competitor. 

For generations, libraries existed in blue ocean space. I would argue that many of the services that libraries provide now exist in the red ocean.

Let's say that a library creates a product or service in blue ocean space. For example, traditional reference services. For generations, reference librarians were alone in this information space. Along came the Internet. The tides shifted this service from the blue ocean into the red ocean. Traditional reference services now have to compete with Google in this space. The Blue Ocean Strategy suggests that organizations need move away from red oceans and should identify new service and product spaces. This approach is also consistent with Clayton Christensen's disruptive technology theory.

However, I believe that the greatest challenge facing libraries may not be in identifying new blue ocean strategies. Yes, that is a difficult task in itself. The much more difficult task may be the ability to identify when a product and service that was in blue ocean space is starting to drift into the red ocean. The problem is that while the red ocean is easy to enter, it is hard to survive. What an organization needs to either avoid, or knowingly enter, the red ocean is what I call the Green Ocean Strategy.

(NOTE 1: OK. Yes, I know. Red and blue make purple. I went with green to conjure up an image of murky, algae infested waters. This color wheel inconsistency aside, I have never seen naturally occurring purple waterways, but have seen green. NOTE 2: This concept is not even half-baked, so I am interested in feedback. NOTE 3: This is a different concept than the similarly named environmental approach also derived from the book) 

Perhaps the hardest thing an organization can do is to spot when the tidal shift between the blue and red oceans is underway. The ability to navigate through these waters requires the organization to make hard decisions. Does it complete in the red ocean, pull out of the waterway, or does it modify the product or service so that it is back in the blue ocean?

Making such decisions is complicated by the fact that significant resources and investments have been made to get into the blue ocean space.The decision to reallocate resources or eliminating products and services after significant investments have been made becomes extremely difficult to do. However, a Green Ocean Strategy would appear to be required to help guide the transition and prepared the organization to make those very hard decisions about whether when a service/product is ready to jump the shark.  

A complicating factor is that the Green Ocean has relatively calm waters. There are no rapids to alert the organization that a tidal shift has begun. The service or product simply drifts slowly into the red ocean until the organization wakes up one day, surprised, and surrounded by sharks. The organization may become paralyzed and unable to make a quick enough decision to get them back into the blue ocean.   

Lastly, sometimes an organization wears colored glasses which tricks itself into believing that they are still in the blue ocean when they are really in the red. They become so emotionally attached to the service or product they they do not see, or simply ignore the sharks. The auto industry is learning this nautical lesson the hard way. When you look at their situation, what they lacked was an effective Green Ocean Strategy.

Are libraries simply allowing too many services to drift into the red ocean and land up spending too many resources fighting off the sharks?  Instead, should we be spending more time coming up with a Green Ocean Strategy that includes concepts such as planned obsolescence or service life-cycles that acknowledges the perils of living in the red ocean? 

Sphere: Related Content

Moving Towards an Innovative Library

I have been working for a couple months on a graphic that represents the elements of innovative library organizations. The one I came up with was inspired by that which appeared in The Game Changer.

The graphic below depicts a continuum of six concepts which are vital to building a more innovative organization.

Inspiring Leadership

In trying to determine where the continuum in the above model begins, I decided it begins with leadership. Leadership sets the tone for everything that a library does. Innovation is all about change. During times of change an organization will be unstable, characterized by confusion, fear, a temporary loss of direction, reduced personal productivity, and a general lack of clarity about the organization's direction and mandates. A time of change can be a period filled with emotion, with employees focusing on what is changing and being lost and therefore unable to look into beyond the present and into the future. Employees not only need to have confidence in their leadership so they have someone to look to during times of change, they need to be inspired by them.

While a director or formal management group may be the most visible leaders, most library organizations have leaders throughout. Innovative organizations would also seem to have a higher number of change agents and idea champions. As Helene Blowers points out, Innovation starts with 'I.' The challenge is identifying innovation leaders, cultivating their potential, and empowering them to act. While these individuals may not be leaders in the hierarchical sense, they are extremely important leaders in building staff buy-in and moving ideas ahead. It therefore takes inspiring leadership to spot and cultivate organizational leaders.

Courageous Culture

If leadership is the starting point of the innovative continuum, then creating a courageous culture is the foundation. A climate and culture that conducive to innovation will generally be open to change, willing to take risks, tolerant of debate and disagreement, playful, will stress flexibility, adaptability, and celebrate both individual and group achievements and failures.

When it comes to implementing innovative change, there is an inevitable resistance as individuals discover that they may be giving something up. In many organizations, simply suggesting a change is often met with a negative attitude. Nothing is more deadening to the innovative process than having idea shot down even before it has a chance. A change in culture, behavior patterns and how change is approached are critical to moving towards an innovative organization.

Training and Development

Sir Francis Bacon is quoted as saying "Knowledge is Power." Indeed, innovative organizations have knowledgeable staff equipped with the skills they need to innovate and perform. An organization looking to become more innovative should expect, no, require that it's staff advances their understanding and broaden their point of view beyond their individual responsibilities.

To that end, many library organizations are moving towards a competency-based assessment system which recognizes individualized learning styles and methods. In this model, every employee and their supervisor should be accountable for continuous learning with training goals spelled out in annual performance reviews. Exploring and refining new skills, ideally outside of their area of expertise, should be of high value to the organization.

Enabling Organizational Structures

Most mature organizations, and libraries certainly are that, reach a sustaining level where the focus is on efficiency. Employees are slotted into specialized roles and are gathered together in social groups based on those roles and the resulting processes. Therefore, each employee's web of social connections mirrors the way their work is organized. As Chris Trimble points out, most social connections are made with others with closely related specialties, which share similar perspectives, and are shaped by the demands of the same customers.

Being a part of a particular social network for a prolonged period of time does influence individuals in significant ways, such as internalizing the "ways of thinking" (groupthink) of that network. Yet, innovation initiatives are often most successful when there is an unusual interaction between employees. How do many brainstorming or strategic planning sessions start off? By counting off and creating new groups. Otherwise, people tend to organize into the same social groups.

Organizations that are unstable, or responding to instability, are also more likely to innovate. A constant of slight discomfort gets individuals out of their comfort zones, gets them talking to one another, and can create new connections where none previously existed. Trimble states:

"Breaking networks is the only way to prepare an organization to take innovation efforts beyond mere ideas. You can train an individual about what an innovation is and why it demands different behavior, but you can't retrain an organization simply by training the individuals within it. The individuals may acquire knowledge, but organizations are more powerful than individuals..."

Streamlined Processes

Andrew Van De Ven observes that people and organizations are largely designed to focus on, harvest, and protect existing practices than paying attention to developing new ideas. The more successful an organization is, the more difficult this becomes. Clayton Christensen echoes this theory. While the process of conceiving an idea may be an individual activity, innovation is a collective achievement of pushing and riding those ideas.

Transforming innovation into practice involves so many individuals that those involved may lose sight of the big picture. Innovation transforms the structure and practices of an organization. The challenge is creating a culture where process does not get in the way of innovation.

Resource Reallocation

Many innovative ideas die simply due to limited resources. While resources are often equated with dollars, resources also refers to the reallocation of time, people, materials, existing equipment, and assistance. To become more innovative, inspired library leaders need to reposition staff to support innovative projects and programs, through new hires and reassignments where appropriate.

The efforts of staff that develop successful systems should also be rewarded. Innovation activities need to be recognized when decisions are made about merit increases, promotions, and even tenure decisions. If such rewards exist, then more staff will be interested in engaging in innovative activities. In the end, participation in the development of innovative solutions needs to become a vital part of the librarian's career track, and as such, should be reflected in how the librarians work, and resulting scholarship, is defined and evaluated.

Sphere: Related Content

Journal Of Access Services Jumps the Shark

I may be in the minority that feels that (tenure track) librarians need to change how we define scholarship. Until there is a paradigm / culture shift, the peer-reviewed journal will remain one of the gold standards. However, the integrity of the entire system is built upon maintaining the quality of our journals.  

It is of great concern when I see a refereed journal, either intentionally or inadvertently, set aside their standards. This appears to have happened with Haworth’s Journal of Access Services. The journal's editor recently decided to dedicate all of Vol 5(4) to  a series of essays written by an 'anonymous' blogger. [I refuse to acknowledge this person by pseudonym]

[For the purpose of full disclosure, I am unable to independently assess the quality of the issue's content since the electronic version title is currently embargoed. Doing so would be like reviewing a movie without screening it. However, I am not focusing on the content but the editor's decision.]

When I put on my hats as both a scholar and the the Chair of our promotion and tenure committee, the decision by the editor and publisher creates a crack in the foundation of our profession's scholarly communication. It is as if the editor of the American Psychologist decided to dedicate an issue to the essays of Dr. Phil.   

There are so many problems with this decision that I do not know where to start. I think I will let others highlight them for me.

Chadwick Seagraves observes: (make sure to read his entire post!)

Ponder this. This Journal now gives legitimacy to an anonymous writer, in a professionally sanctioned and sponsored serial...You know, you come to expect some level of authority from peer reviewed journals. Does this mean I can submit articles under my own pseudonyms and be potentially accepted for publication in the Journal of Access Services? Apparently it does...the beginning of the end of the authority of peer review is now here

Rudilibrarian notes:

Has scholarship in librarianship grown so weak that AL is now the best of what’s out there? Is this what passes for reasoned argument? Is Access Services so devoid of smart people doing interesting work that this is the best the journal could find to publish? It seems like one of the premier publishing houses in the field of LIS thinks so.

 Mary Carmen Chimato comments:

I would like to take a moment to thank the Journal of Access Services for driving home the point that the work we do here in access services is ripe for the mocking

From Colleen Harris:

You have just admitted that you are not a scholarly journal to be taken seriously. And as someone moving back over to Access after a long stint away, I'll be certain to send my work to the Journal of Library Administration, the Journal of Academic Librarianship, or hell, even to that cute little kid 'zine Highlights before I let my professional work be associated with you.

Karen Glover is saddened: 

I assumed this was a joke but am slowing beginning to realize the seriousness of it. I will not begin to complain about what this does to scholarship. I will, however, complain about what this does to Access Services... I am left feeling like the butt of a library joke. It saddens me that the one avenue of thoughtful discussion on subjects in my area is reduced to an extended tirade

At least one of the editorial board members was even unaware that this decision was made before seeing the issue themselves. 

My guess is that that the editor a) decided to take advantage of the recent attention given to the 'guest' author to promote their journal; or b) was duped; or c) seriously thinks the author offers a fresh voice.  The impact this decision could have on the state of our scholarly communication could be profound, assuming anyone notices, or even cares.  It makes our 'profession' more amateurish. 

Lastly, I applaud the bloggers quoted above for not hiding their opinions behind the veil of anonymity (although it took digging to identify Rudy Leon).   

Sphere: Related Content

Personal Health Records Need MARC/AACR Approach, I Think

I attended an IT Innovation in Healthcare conference in town today. Practically the entire morning was spent talking about the personal health record (PHR) and related electronic medical record (EMR). While the EMR is information about your health compiled by your health care providers, the PHR is maintained by you.  The ideal PHR would  gather data from many sources and making this information accessible online to anyone who has the necessary electronic credentials to view it.

The discussion centered around the fact that it is very difficult to move information between systems. The challenge is the lack of standards. The various PHR and EMR systems don't talk to one another. This got me thinking. The health care industry needs to take some lessons from the library community and establish some data standards.  

Libraries got over the hump from a paper-based to an electronic catalog in part since we had two tools to work from; AACR and MARC. AACR covers the description of, and the provision of access points for, all library materials. MARC provides the protocol by which computers exchange, use, and interpret bibliographic information and is responsible for the foundation of the online catalogs we have today. Add on top of this Z39.50 like functionality and we have a basis for a PHR system which could do what it is envisioned to do; harvest and syndicate content between other records systems. 

There is, however, a bigger challenge. As I bounced this concept off of a CIO of a major academic medical center, they said those standards are in place. They have SNOMED. 

The librarians out there will immediately see the problem with the response.  For the CIOs out there, well, please have your librarian explain it to you. 

Sphere: Related Content

Does the Innovation-Decision Process Impact Library Innovation?

It occurs to me that while libraries DO want to innovate our service development lifecycles are way too long to be really innovative. We wait until a technology has emerged before we even start learning about it. We then investigate possible service applications of a technology only when a majority of the staff are comfortable. Adding onto the lifecycle is the need to build consensus during the planning process and making sure the service is perfect before releasing it. 

So, the question I keep asking colleagues is if libraries could speed up the service development lifecycle if we were more proactive in providing awareness and how-to knowledge about innovative / disruptive technologies / services as they were emerging, rather than waiting until they emerged? 

The latest book on innovation I have opened up is Rogers' Diffusion of Innovations.  One section jumped out at me since it was a mashup of the innovation theme with library decision making process. Or, as defined by Rogers, the innovation-decision process:

The innovation-decision process is essentially an information-seeking information-processing activity in which the individual is motivated to reduce uncertainty about the advantages and disadvantages of an innovation. This is a social process involving talking to others.

Rogers describes three types of innovation related knowledge. 

Awareness-knowledge is simply information that the innovation exists. This information simply motivates than individual to seek out  How-To Knowledge, which consists of how to use the innovation 'properly.'  This is an essential type since rejection may occur if the amount of information relative to the complexity of the innovation is inadequate.  Principles-knowledge consists of information about the underlying functionality of how the innovation works.

What I instinctively liked about the Learning 2.0 approach, and what I now understand,  is that its success may be because it contains all three knowledge areas. Participants are made aware of various online tools, are provided and a hands on / how to  opportunity to play with each, and by the end the participants should have a conceptual understanding of the underlying principles of Web 2.0 / the social web. 

So, it makes sense to me that if a library creates a participatory technology learning environment it would create a more active innovation-decision process, which would then speed up the service development lifecycle.

Sphere: Related Content

Consensus Building Cripples Library Innovation

I am not a fan of consensus building, an approach that is common in many, if not most, library organizations. While such an approach can be effective for small groups it has a number of shortcomings in larger groups, or if used to manage an organization.

One of the problems I have with consensus building is that an individual or a small minority can effectively block agreement to a proposal or idea. It unfairly tips the decision-making scales towards a staff member who may simply like the existing conditions, which may continue to exist long after the majority would like the conditions changed. Consensus building has the potential to reward the least accommodating group or staff members while punishing those trying to innovate. 

By giving all group or staff members the right to block any idea or proposal, an organization can essentially be held hostage to an inflexible minority or an individual. The impact this has on a library's ability to create innovative library services can be significant since creative or alternative ideas can be blocked or slowed by a small minority.

Consensus building also focuses on the need to discuss the topic ad nauseam and the need to seek the input of anyone would could possibly be affected.  This turns decision making into a very time-consuming process. This poses a liability to organizations trying to become more innovative since decisions often need to be made quickly. Since innovative process often result in half -baked solutions, it is simply not feasible to incorporate the opinions of everyone who could be affected in a reasonable period of time.

 
Library organizations probably migrate to consensus building since they generally want to work towards agreement, not disagreement. Yet, innovative organizations more often create atmospheres in which there is a great deal of disagreement and debate. Staff in innovative organizations learn how to disagree and build up a tolerance for disagreement. In such organizations, everyone is encouraged to act based on their individual motivations, and are rewarded simply for acting, rather than for success or failure. If libraries wish to create a culture innovation, we must 'allow' staff with the desire and energy to act on their own vision. This means that libraries must also empower staff to act by changing the system of rewards and support non-consensus decision-making processes.

Throughout history the most innovative ideas have been in opposition of the consensus opinion. According to Robert S. Root-Bernstein, the decision to go forward with an innovative idea should not be made because everyone agreed that it would work, but instead on different set of criteria: 

• that it was controversial, striking at the heart of the field. (Libraries tend to want to avoid controversy) 
• that it hasn’t been tried before and was therefore likely to yield new knowledge regardless of the outcome. (Libraries tend to wait until 'someone else' does it first and publishes it in the literature. And if it fails nobody will ever forget it did.)
• that it was designed in such a way that it would easily be seen whether it worked or not (Libraries tend to over-think solutions and make things more complex then they need to be)
• that the research was relatively inexpensive compared with the possible pay-off if success were to occur. (See above)
• that the idea had a champion (or leader) who was willing and eager to risk his or her time and effort to implement the program. (Libraries support this notion, but there also needed to be a task force or committee with full representation and, oh, there still needs to be a consensus) 

Sphere: Related Content