Marion Ball, Ed.D., is a fellow at the IBM Research Center for Healthcare Management and professor at the Johns Hopkins University School of Nursing (both are based in Baltimore). She is also co-chair of the executive committee for the Technology Informatics Guiding Education Reform (TIGER) Initiative, which was formed in 2004 to bring together nursing stakeholders to develop a shared vision, strategies, and specific actions for improving nursing practice, education, and the delivery of patient care through the use of health IT. A highly respected expert in the field of healthcare IT, Ball has authored several pieces, including an article in Methods of Information in Medicine that examined why clinical information systems are failing. Recently, Associate Editor Kate H. Gamble spoke with Ball, who is also a member of the Healthcare Informatics Editorial Board, about the report’s findings, the mission of the TIGER Initiative, why IT adoption is still low, and the importance of involving clinicians in the planning, development and implementation of IT systems.
KG: And this is where initiatives like TIGER come into play.
MB: Right, I’m a big advocate of the TIGER Initiative for technology. We need to have trained healthcare professionals who can effectively communicate with the well-meaning IT people and vendors. They themselves are going to be using the technology, and we need to train them to know what’s available.
Take for example someone who was living in Europe in the 1940s, and all they knew about cereal was that they had oatmeal for breakfast. Well, if you take them to the cereal aisle at A&P or another a big store in the U.S., they’ll see 200 or 300 different kinds of cereals. Now you see that there are other options, and other ways they can look at this. The bottom line is, if you don’t even know something exists, you can’t try it. You can’t see whether this option is going to be better, and it’s the same thing with nursing. We don’t even give them that kind of exposure.
So that’s why I feel that new training methods are needed in nursing schools, pharmacy schools and dental schools, where the young people already know about enabling technologies and can learn how to apply them. Even more important, the average age of a nurse is 48. And if you’re 48, you just had maybe the beginnings of computing when you were going to professional school. How are we going to retrain what I call the foot soldiers of the healthcare delivery system? There are 3 million registered nurses, and if you add the aids and the LPNs (licensed practical nurses), you’ve got another 3 million, and that’s 6 million of your foot soldiers who don’t have the weapons to fight the war.
That’s when I get on my high horse and preach like a zealot. But that’s why we wrote that paper on failure — to provide clinicians with the useful systems that they need. We’ve got to jump over what we’re doing now. A leapfrog example would be what we talked about: the smart room and voice documentation with clinicians.
KG: Ultimately, what does TIGER hope to accomplish, and what message would you like to send out to hospital leaders about the initiative?
MB: You can’t do anything unless you recognize the problem. So the first thing is to realize that the medium is not the message. It’s not about technology; it’s about how do we change behavior and processes and thought flow to be able to transform the way we practice, and then use the enabling technologies to transform healthcare. That’s what it’s all about.
TIGER stands for Technology Informatics Guiding Educational Reform. We’ve got to retrain the entire workforce and make them basically computer-literate. Teach them basic competencies and provide opportunities for virtual demonstration centers so that people can have the chance to go to the store and see all of the cereals, or see what nurses are doing in other locations that is transforming the way they practice.
We need to be able to get involved with changing legislation. There is very little research, money and support for nursing, and yet nurses are the ones who are taking care of all the sick people and we’re all going to need them when we get older. And we’ve got enormous workflow problems. In Maryland, for every five nurses that retire, we’re bringing one more in the system. That’s scary.
So what TIGER is saying is, let’s empower the nursing profession to begin with. It’s really not just for nurses. It’s just that I want to attack where we can do the most good, because that’s the army. But we’ve got to also get the deans of schools of nursing, the chief nursing officers and other leaders at least receptive to saying, let us come in and make sure your people have the minimum competencies included into your training programs — not only in the university settings and in the community colleges, but in the in-service training. These are the things that need to be done. Know what we can do with consumer advocacy; know what we can do with the personal health record; how can we better consult and give information to our patients during the discharge process and tell them how to find information on the Web. You have to even know that these things exist.
KG: And the goal is for this to happen before all of the money starts flowing in from the stimulus package?
MB: Absolutely. There’s a wonderful quote from Albert Einstein that says, the definition of insanity is doing the same thing and expecting different outcomes. For the last 40 years, we’ve had 18 percent clinician adoption. If we think that because we’re going to pour the ARRA money into what we’ve been doing, that it’s going to be more successful, that makes us insane. It’s just going to speed up chaos.
These are the kinds of questions we should be asking. Is it going to make any difference if we put more money into what we’ve been doing, or do we need to look at a whole disruptive innovation to seeing how we can use different ways to skin the cat, so to speak. And one way is to address the issue of what the clinician needs at the point of care.
How are we going to use enabling technologies as we move into the medical home concepts, using primary care physicians, using nurse practitioners, looking at how do we provide care — not only in the emergency rooms, but at Wal-Mart and at drug stores. These are all disruptive innovations, each of which will also need the information component and some enablement by technology. But it’s 90 percent transforming and change management, and 10 percent technology. Changing behavior is more difficult than anything and anyone ever wants to admit to.
KG: So it all comes back to the idea that technology needs to adapt to users and not the other way around?
MB: Yes. But also, the technology and the vision that we have needs to be platform-independent, it’s got to be ubiquitous access. When you look at a clinician, that person is a mobile individual. He or she is not in one place for more than one minute. And the systems they use were designed by brilliant computer scientists and information scientists who are sitting at their desks.
And the problem is, how do I get the information I need on my Blackberry? How do I get it on my tablet? How do I get it in my office when I’m on my PC? I’m going to three hospitals and each hospital has a different system — one is Cerner, one is McKesson, one is Epic. I want to be able to have my Blackberry or iPhone give me the same information so that when I walk into the hospital, I don’t have to put in 20 or 30 passwords. And that can be done. I want to know who my patients are, I want to know who is most sick, and I want to know what the latest lab results are. So the whole idea is, give me less, but give me what’s relevant to my practice. And that, I can assure you, we are not doing.
KG: One of the key points in your paper is that if clinicians find that technology eases their work, they will adopt it, just as they have with technologies like cell phones. I think that’s a very good point. It’s such a simple premise, but it makes complete sense.MB: They will embrace it. A good example is as soon as radiologists saw what you can do with 3-dimensional images, with PET scans and CAT scans, within 18 months, most hospitals in the country had those tools because the physicians said, ‘This is making my practice better. I can do a much better job in diagnosing patients.’ It was instantaneous because it made a difference. We’ve been doing this for 40 years — we have to learn that something isn’t right. Look at the disasters you’re seeing now in England with all of the money going into the Cerner systems. Big business doesn’t want to hear that because they’ve got a lot invested. In my opinion, the worst thing we can do with the stimulus money is to put it into things that we know haven’t been successful to the degree that they should have been in the past.