Zombie ECM

ECM: not alive and not dead, walking towards sounds and smells. On autopilot to get to the next big event. What do you have with information management that does not have adequate quality? You have zombie ECM systems marching toward something.

We like to think this something is for the greater good. A place where healthcare can find their data and get paid, where financial institutions can store their signatures, where pharma can follow the regulations. Without more information quality checks and balances, this greater good looks more like zombie land where we only do what the standards and regulations say, nothing more. We trudge along and wait for the next upgrade, for the next event, the next big thing.

Does everyone feel that they are doing the best quality work on implementing their systems? What would be a better way of designing ECM? How can you improve on how your process works, how solutions get implemented? Why doesn't Gartner have an info quality quadrant their ECM leaders?

“One Patient, One Record”

This healthcare IT tagline has been around for a while. Software vendors and healthcare provider IT groups, touting this slogan, are definitely aware that it over simplifies a patient’s information trail. There are many unknowns that could splinter that “one record” goal. For example, what if a patient goes to a different hospital? What if the patient’s insurance changes, what if any number of issues could happen to the many systems used to keep track of a patient’s registration, appointments, orders, results, ED visits, discharges, etc.

Patient is a person not a chip

Patients being human can inadvertently cause havoc on their own information. It could be as easy as changing your baby’s name or moving to a different healthcare provider. The information that follows the patient me get split into two separate buckets, orphaned by glitches in the systems. Regional information exchanges can help, but typically do not house all of a patient’s record, only the current, actionable data. What happens when patients move and then return to the same hospital years later? I can tell you that merging patient information can be very tricky.

Release of Information—can you be specific?

When a patient requests all of their health record data, do you really think all of it is collected? If so, how is this verified? Are there any regulations that state this type of request has to be complied with fully? Essentially, the patient has to fill out a form and select which information he/she wants, with an “other” line for her to fill out. This could leave many documents behind because the patient has no idea how many types of documents are in a healthcare ECM system: hundreds, if not thousands.

Every Visit to the Doctor’s Office

Every visit to a provider generates thousands of records. There is the registration which gathers insurance information, signatures for consent, appointments. There’s the nurse who enters current information about allergies, weight, body temperature, blood pressure, etc. He may or may not have paper forms as well for the doctor. The doctor opens another form on the computer, shows test results maybe, enters in clinical notes, writes a script, enters in a diagnosis code, and so on. Many of these entries are split up and branch to other systems for further processing.

From One Record to Many

A patient’s healthcare record will never be “one” record, it will always be a tree of information, or many trees of information, connected by one or many medical record numbers. A regional exchange will hopefully help to cull a patient’s information trees together. Maybe a national register would help as well, but this is way in the future. Sharing health information transparently would lower healthcare costs, however it would lower profits, so there will be lots of feet dragging before “One” record is achieved…

Hallway Chat Projects

With all of our productivity tools we use to communicate and make decisions on projects, hallway conversions can still drive the everyday decisions and information sharing. The problem is that there’s no way to forward a decision or share information beyond the folks that have the conversation.

Sometimes the conversation is summarized, but usually it turns into action and surprises other team members. It’s the surprise that is a sign that the vehicles of communication of a large company are still not being used. The small company mentality is still there.

Small businesses that grow to large ones slowly have this issue more than ones that grow quickly. The slow growth makes it possible for the relationships and behaviors to stay the way they were without too much change. Fast growth usually brings in MBAs who have learned the structure and designs of past organizations that have “worked”. The case study of fast growth breaks up the old patterns of hallway communications.

So, applying this to IT projects and large project communication, you can experience the symptoms of this hallway phenomenon as the tasks progress beyond the planning stage. When the doers are engaged in the discussions, the scope of the project is usually torn apart. The hallway decisions are fast and furious. The project starts with members shaking their heads. The more experienced team members follow along, but secretly see the gaps. If they speak up, the project manager, who by this time has had a hallway agreement on the deadline, overrides their concerns and pledges to consider them.

The final result of hallway projects is that the project manager moves onto to a new position. The implementation of the project is done, but the fixes and stabilization are painful and disruptive. 

From Allscripts to OnBase: A Migration Story

In healthcare, it’s about the patient’s chart, tests, and results, which all starts in the quality of the information extraction from Allscripts. Of course, when you move from one solution to another, people tend to get in the way. What I mean by this is that there usually needs to be a consultant to broker between each sides of the transfer.

Information

Requirements gathering is only as good as the person’s experience who’s managing it. A third may boast many years of experience, however, chances are good that there are a few key internal architects that need to be involved and listened to from the get-go. The mapping of patient data, doc types, and workflows are all fundamental to the success of the migration. The sizing parameters will have to be detailed, such as, number of files, average file size.

Execution logistics

As the “what” questions are answered, inevitably, new ones come up, such as “What transfer batch size should we use?”, “How long will it take to transfer each batch?” and “When will we shut down access to Allscripts?”, etc. A “who/what/when/where/how” matrix will help sort out the details. The transfer batch will depend on how many document pages are extracted and will entail multiple folders and file naming convention.

Testing

Testing and its organization are a litmus test of how well the project is managed. Hopefully all of the application’s SMEs are involved and designated Users are scheduled to test. Testing ADT scenarios and OnBase scanning and indexing are essential. Also, testing the backfill of accounts and demographics has to be done at least twice to get all of the pieces validated.

Extract

The Allscripts extract index will be delimited and should have all of the metadata needed to import into OnBase. It should have a pointer to the scanned files. These files will most likely be extracted pages, so there will need to be a unique number to be able to build the document before importing into OnBase. You’ll need the following:

Patient Demographics – enough information to validate and tie back to the ADT patient record.

Master Patient Index – the corporate medical record number to identify the extract as it is imported to OnBase

Document types – each type must go through HIM for validation. If Allscripts was used for ambulatory sites, chances are good that the naming of doc types will reflect this. You may want to just keep all the source names and prefix them with a value that allows for easy recognition. These should also be set up in a new doc type group if there are a lot of them. The “go forward” strategy of scanning should include only the unique doc types that were not already in the Onbase system.

Document formats – there may be some formats that surprise you. Import formats have to be identified and set in the OnBase import process.

List of file pointers – this list tells OnBase the page’s file system locations. If there are thousands of pages, the pointer will most likely have a folder in it that changes as the batches are imported. The filing naming convention will have to be unique and could be extracted from Allscripts’ unique file naming.

Data Manipulation

Between any focused information management system there are bound to be idiosyncrasies. For example, the patient medical record numbering scheme will be different, the rules around naming conventions of metadata, and many other conventions specific to the infrastructure of the source system.

Registration, EMR and interface

With different naming conventions of patient metadata between the source and target systems, the issues of data integrity could be compounded. During testing all sorts of issues can come up from ADT messages not having correct patient data, to patient corporate numbers being duplicates. Quality control and validation as a separate can help fix issues before they go into the target system.

Import

As we know the quality of the import starts with quality of the extract. As the patient data issues get mapped and fixed, the actual importing will have to be achieved through a third party tool or customization. Every difference that is not accounted for in the design or development will definitely show up as errors during testing of this process. Using the tool to look up values in the target system based on source values should be part of the tools requirements. The tool should be able to handle errors gracefully by logging them and queueing them for reimporting.

People

The human factor cannot be overlooked with any migrations. Both sides will have feelings though they may be hidden behind professional facades: some were comfortable with the old system and others are not happy about the new responsibilities of the new one. These feelings will show themselves with delays in development, or show stopper issues during testing. If everyone is complaining about the project manager then you know the culture is old school in that the walls of knowledge continue to be fortified, that sharing only occurs when show stoppers force everyone to open up and help each other if only for just that moment…

ECM Matures Beyond the Models

Gartner’s ECM Maturity model from 2012 shows the simplified journey of an ECM implementation into a company through time. The trail followed is well worn into the trained minds of solution providers. What typically happens with this methodology mantra is that it infiltrates and pervades, then when fully dependent upon the software solution that touted it, the company buys more modules, more licenses, more storage, etc.

How mature is mature?

ECM implementations reach the goals put forth be the company’s director in charge of operations. Each time a “nice to have” is overlooked or pushed to further phase, it may reach a dead end. These dead ends accumulate, but are not factored into the overall implementation; they fester and show up again when the next cycle of solutions/consolidations/open source evangelists sweep in.

It’s easy to win with a Model

I’ve seen original solution documentation show this maturity model from the beginning. The instructions are outlined, budgeted, and milestones are set. All you have to do is do what it says to do and you will succeed. Any movement forward is seen as a win. Plus, you executed on the plan, never mind that dead ends were left along the way. You can’t please everyone!

The model is the model

The model’s steps of “Initial, Opportunistic, Organized, Enterprise, and Transformative” are exactly what happened to this model. It is an artifact of solution execution, but in the end it is just another way to sell product suites and Gartner products. This model matured. A new one is coming.

Implementation’s long tail

If you are looking at models make sure the last half the curve looks like a thick long tail. This shows the correct long term implementation of ECM. It takes mature team of people to fully realize its potential beyond initial expectations and bouts of disillusionment. Over time, if you are lucky there will be enough focus on the quality of information and its benefit to productivity.

ECM Moving Across the Silos of Information Management in Healthcare

Information silos are commonplace in every industry. They tend grow around concentrations of knowledge/experience collectors and “best of breed” applications. Because enterprise content management usually spans across these silos, we as ECM solution providers get a unique insight into how work.

Take scanning solutions in Healthcare for example, you get exposure into not only financial and HR applications, but EMR, interface, and lab apps. Once you have gained trust among the managers of these applications and have implemented ECM across them, you will begin to see the potential synergies. One potential synergy could be to combine Informatics, HIM, and ECM under one director to be able to fully realize the full patient information potential.

Let’s say for this example that Informatics is underfunded, HIM is well funded, and ECM is okay. By combining budgets and focusing on common goals, the patient as well as the hospital’s image will undoubtedly benefit. By providing ECM with a direction base on requirements coming from what patients need, the emphasis and objectives will be clear and hopefully funding will be well justified and measurable. 

Post ECM Modern New New

When John Newton, Alfresco CTO, talks about the “Modernization of ECM” he takes the biggest, most pervasive view possible of ECM at an organization. The issue I have with this view is that most solutions are point solutions which may be expanding into other departments, but are mainly focused on specific solutions, not necessarily solutions that impact the enterprise. He wants everyone to think big with “millennials” using “mobile” phones “collaboratively”, “sharing docs”, using “Instagram”, and “Snapchat”, etc.

Ok, great, CIOs think big, I get it, but what happens during the implementation? Did the big idea get implemented well, or are we blaming Users for “poor adoption”?  John says, “Employees don’t buy in because the systems are cumbersome, non-intuitive, or lack support for B2B sharing and remote access.” That type of statement side steps the many bad implementations made by his previous company’s professionals. You can’t leave a company, build a better solution, and then blame the old software for being inferior. For those of us who have seen their share of implementations, we know that ECM was first CM at many of these companies. The “E” depended on the professional services as much as the software.

The “extended enterprise” beyond the firewall concept has been around for over a decade. The issues of security and sharing information are evolving and involve way more than an ECM solution’s capacity and technology. The larger enterprise is under the gun here, not the content management system.

With the “Explosion of Digital Content” as quoted from IDC sources, the “big data” issue of finding and contextualizing content will always be an issue. The point should be that the “crap in, crap out” adage is the real issue, not the system. If you don’t take the time to add context to your content on the way in, the search results later, regardless of how heuristically brilliant the algorithm, will not be as accurate as you want or need.

There’s no doubt Alfresco has a head start with open technology, integrations, and UI simplicity. I just find it hard to believe that they still think ECM is everything to everyone when it comes to content. All applications have evolved to deal with content and metadata. ECM can help patch the holes and connect the dots, and even be everything to a small/medium sized company, but with large enterprises it takes many software solutions to deal with its content and information. Whether it be financial, human resources, healthcare, pharma, registration, etc., in each case there are specialty professional services and software solutions to fit the requirements. What ECM promises is to patch the hole when a leak occurs because a leak in the other solutions will eventually occur.