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When Projects Fail, Should We Fault the Technology?

April 6, 2011

Last weekend, I saw the film “Up In The Air.”  Ok, so I am a few months behind in my movie viewing.  That is what the Netflix lifestyle does for you.  There is an interesting connected health analogy running through the film and I want to explore it with you in this post.

George Clooney plays the lead character and he spends a lot of time on airplanes.  His company outsources corporate downsizing and his job is to travel the country showing up at a firm to give the bad news to the employees that are being let go.  A much younger woman, who is up and coming at his company, comes up with the brilliant idea of communicating to each individual losing his/her job by videoconference (in the movie, it looks quite a bit like Skype).  The idea is to save on travel costs by having folks like Clooney communicate by video all over the world without leaving their desks.

We first watch Clooney’s character object to the idea.  He believes the idea will never work, claiming that there is a fine art to firing people and you can’t do it over the Internet.  We then watch them perform pilot tests (they are on site at a company being downsized, but do the firings from a different room via video).  In the end, it does not work.   The last scene of the movie is about him being told he must get back on an airplane and travel to a site to practice his craft.  Video just doesn’t cut it when you are getting fired.

Those of you who have been part of connected health program adoption will see the obvious parallels.

The initial protests from Clooney remind me of the old days when doctors and nurses said telemedicine would ‘never work.’  Clooney’s character is tied to a business model that meets his personal needs and he has difficulty moving beyond that to see the change ahead. We see this in all industries and health care is certainly no exception.

The most profound parallel, however, emerged when we learned that the experiment was deemed a failure and that face-to-face meetings are necessary for the delivery of such emotionally charged news.

When a health care technology pilot fails, it is often because the architects of the pilot either choose the wrong use case (as is illustrated here) or execute the project in a flawed manner.    Rather than determining whether or not the circumstance or execution was flawed, the entire concept is determined as flawed.  Too often we blame good technology for poor planning and execution.

I’ve often said that there are certain interactions that a clinician and patient should have face to face because of the clinical or emotional complexity.  Getting fired is akin to hearing for the first time that you have cancer.  I would never recommend that we do Skype visits to inform patients of their initial diagnosis of cancer.

It’s a funny thing though, as technologies mature and go mainstream, people start to ask why these technologies are NOT used in certain circumstances.  Recently a number of mental health professionals in our network have begun to Skype with their patients. It solves a number of problems quite nicely.  Most of these patients must travel from far away for a brief medication assessment visit with their psychiatrist.  They expend lots of effort for a brief, standardized encounter.  In fact some of them are so stressed from the effort that their illness is negatively affected.  Skype visits are convenient for them.  They can see their psychiatrist in their own environment and the psychiatrist gets a more natural look at the state of their mental illness. While this use of Skype is only investigational right now, it has a lot of promise.  It will be especially relevant as we enter the realm of accountable care, the patient centered medical home, bundled payments and the like.

I guess the moral of the story, for now anyway, is chose your technology wisely to match the clinical need.  I doubt in my lifetime I’ll feel comfortable that Skype is a good tool to communicate that someone has lost his or her job, or to inform a patient of a surprise diagnosis of a dread disease.  However, there are many instances in healthcare where we mandate that a clinician and patient must get together in a physical space and allocate time to perform a routine task of low emotional value.  These instances are ideal for both synchronous (like Skype) and asynchronous (like email) communications technologies.

24 Comments leave one →
  1. April 7, 2011 2:22 am

    Great post – and common sense 😉 Low acuity symptoms, Rx Refills, chronic disease management – lots of these really can and should be handled by remote convenience – for both sides. Similar question came up last year on Quora where someone asked about legal liability of dispensing medical advice over the internet. My reply was about the same:

    “Not an attorney – but it stands to reason that there are legal risks with doctors dispensing medical advice over the internet. What’s harder to determine is how much greater is the risk of dispensing medical advice over the internet versus in an office (or ambulatory) setting. As the cost of healthcare escalates – I believe this will become an important mechanism for low-acuity, chronic symptoms where the doctor/patient relationship is already well established. The doctor can always advise “better that I see you on this one.””

    http://b.qr.ae/fNBUfT

  2. April 11, 2011 4:20 am

    Joe, Another nail, hit squarely on the head.

    I spent a week in February touring parts of northern Sweden to look at the way they make use of their digital access networks. The middle of February is not the most obvious time to head up into the arctic circle – night-time temperatures lower than minus 35C and daytime peaked at about minus 25C. But these ice-clad communities really rammed home the headline in their health network’s brochure – ‘Ideas are born where they are needed most’.

    When travelling is this difficult, where distances are vast, where communities are scattered and where there is a well-developed level of interdependence , it is not surprising that a great deal of thought goes into deploying technologies that are properly ‘fit for purpose’. And at the heart of that planning you find the challenges of basic infrastructure – the connectivity and the information records.

    As commercial, regulatory and political battles rage over how better access networks should be provided it is rare to see anyone championing the cause of ‘Fibre to the Car Park’ – see the mobile mammography van at: http://www.groupe-intellex.com/editorials/18-gi-global/271-ideas-are-born-where-they-are-needed-most.html

    The experience of IT Norrbotten shows that video is not just useful for consultations and diagnosis – we saw remote instruction in physio-therapy exercises following joint replacement and and a great range of after-care services including family and health professional gatherings to plan care regimes for elderly relatives. When you stretch the imagination it rarely goes back to its original shape.

    • April 11, 2011 9:28 am

      thanks David for your on-point thoughts and for sharing your experience.

  3. April 12, 2011 12:38 pm

    Joe,

    I, too, missed “Up in the Air” when it came out and unfortunately watched it on pay-per-view while on a business trip — a regrettable choice. And I am again slow to the game when it comes to responding to your post, but it demanded that I think about it a while before responding.

    I have an idea that I’d love to discuss with you (and anyone else who wants to join in): What can the internet do? What can’t it do? In other words, when is a certain technology the right tool for the job?

    Andrew Schorr recently wrote about a man who was experiencing a heart attack and took the time to Google his symptoms instead of just rushing to the hospital:
    http://blog.patientpower.info/2011/03/30/when-you-should-use-the-web-and-when-you-shouldn%E2%80%99t/

    Andrew’s point was that a Google search was the wrong tool for that job.

    Contrast that with this tweet I saw on 3/31:

    @aliciabloom priceless moment of the day: patient’s spouse (in his 80s) tells our #palliative care team, “i google’ed you & am ready to talk.”

    Clearly in that case, in that person’s opinion, a Google search was the right tool for the job.

    Going back to the topic of heart attacks, check out this lovely post:

    Why we keep telling – and re-telling – our heart attack stories
    http://myheartsisters.org/2011/01/21/retelling-heart-attack-story/

    Blogging may be the right tool for that job, as are many other social tools which allow people to tell stories.

    I’ll be thinking about this more, so if anyone wants to join me, please leave a comment here or find me online: http://www.pewinternet.org/Experts/Susannah-Fox.aspx

  4. April 12, 2011 2:33 pm

    so, provocative, and I appreciate it. As an information resource, the Internet can do only so much, but as a communication tool, I’d say the possibilities are endless. Though today’s version of consumer video communication applications (Skype, FaceTime, iChat) don’t carry enough emotional connection to justify the tough conversations i alluded to, Cisco’s telepresence does and i fully suspect someday we’ll be able to have that high quality, ‘just as if you were there’ kind of communication using the Internet.

  5. akroundtree permalink
    April 12, 2011 3:51 pm

    Joe and Susannah:

    Really interesting post. It brings to my mind a couple of issues.

    First, it got me thinking about the phenomenon of publication bias, where journals tend to report only good news or groundbreaking findings, as if there isn’t as much to be learned from finding nothing or having you hypothesis contradicted.

    Second, the post makes me realize how important it is to take seriously evidence-based design in crafting new media interventions. We need more researchers and designers reporting more results–successes and failures. We need more, rigorous, longitudinal studies measuring meaningful outcomes (be they behavioral–e.g., measuring treatment adherence–or rhetorical–e.g., changing attitudes, sentiment re: care). Then we need systematic reviews, meta-analyses to aggregate and assess those findings and inform our design.

    In the case of technology for health communication, there’s a lot more to learn about social and new media before we abandon any certain application or technology completely. Failures are just as important as successes to know/consider in tailoring new media to suit specific needs and audiences. We shouldn’t fault technology when research and intervention design matters, and when we can’t be sure that one failed intervention (and its design) represents all or most others like it.

    Aimee
    Twitter: @akroundtree

  6. April 12, 2011 8:24 pm

    I agree. wish there was an a better way to publish failures in an academic environment.

    • Ayesha permalink
      May 2, 2011 5:48 pm

      I would completely agree with Aimee, may be it is possible to survey the patient, what factors led them to a behavior that resulted in failure of the pilot, perhaps that would be publishable?

      In a clinic/hospital setting the physician has psychological influence and the patients go there after making up their mind to follow the advice.
      In asynchronus method, or mails, patients has the power to read or not read the mail and has lead/ dominance over the advice, i.e., to follow or even to read or not. Also the physician’s mails are not distinct from other mails (except sender name) to add a level of preference to the medical advice.
      The patient may say after seeing the mail, “what pestering mails” if the patient is not overtly conscious about their health (non-participatory behavior), if they are not looking forward to Preventive treatment and just joined in because of less cost.
      Telehealth would be successful depending on patient behavior so as Aimee pointed out more research is needed in those directions first, especially w.r.t. what causes the success of face to face visits rather than Tele-health.

      Last thought, my teacher found in his study that people wont own and follow a service no matter how much they have to pay for it, but they would care a lot if there was some physical effort involved, then they would not let a project fail. perhaps that causes success of hospital visits.

  7. April 28, 2011 11:49 am

    Joe – the “Up in the Air” analogy is so helpful; thanks. In reflecting on your post, I think we are challenged by the lack of evaluation models in healthcare that successfully tease out the important aspects of three seperate but inexorably linked domains: technology, execution (implementation), and business model. In the “real world” of healthcare, like the “real world” of the movie, when something doesn’t work, it is really hard to tease out which of the three domains is to blame. I think that technology is usually the scapegoat because it is the easiest to identify, and is usually described as the variable in the evaluation.

    We are not very good in healthcare on evaluating the potential failings of execution or the adverse behavioral impact of flawed incentive structures. A “systems” approach is required. Maybe we need to look outside of healthcare for evaluation models that give us the needed insights rather than assuming, as you correctly point out, that technology is to blame.

  8. April 28, 2011 11:58 am

    These comments go to the very heart of the healthcare technology ‘crisis’ today. Is there enough money to make care more efficient? Yes! Are the people involved smart enough to make projects successful? Yes! Does the technology exist today? Yes, again! So what’s the problem here? Too much governmental interference, in my opinion. As one who has been in healthcare automation for nearly twenty years now, and having been involved in the automation of the Retail and Distribution sectors, I can unequivocally state that without the burden of local, state and federal requirements, as they exist today, far more projects would be successful and healthcare would be a much more ‘connected’ environment than it is today. In most situations I get the feeling that there’s just not enough time for departmental and I/T staff to do their jobs. In one project, even after nearly two years of meetings and presentations the hospital team still didn’t know enough about what they were trying to accomplish to even construct a list of requirements or a proposed workflow diagram.

    This wouldn’t happen in any other business, but it continues to happen in healthcare daily.

    • April 30, 2011 5:32 pm

      Regulations and laws often seem to get in the way, but of course they serve a purpose too – to protect society. Witness the approach that the FDA has taken to mHealth – very hands on and not stall apologetic.

  9. Mark VanderWerf permalink
    April 29, 2011 8:37 am

    Joe, Thank you for your post. Even as a person who has driven technology for years, I am the first to say “It is not the technology”. Technology is just a tool … and there are a great variety of tools to choose from.

    A few years ago I lead a study of what made telemedicine programs were successful, which programs failed and what were the factors that caused each. We found that ot the 10 factors only one was technology. Still, most of the early telemedicine and telehealth programs I have observed, lead with the technology. The technology selection process was detailed, most of the budget was aimed at technology and most of the preparations focussed on the technical aspects. The selection of cases and patients, the creation of processes and measures took a back seat. Many of these early telemedicine prograsm did not succeed. But if you look at the programs that are overwelmingly successful, the applications, the cases, the selection of patients, the processes and training, the measurements and management were stressed. Further, if you also look at programs like the VA and others who have tried a variety of technologies, you will find found that many of the technologies, although different, produced substantially the same result. Technology is just a tool set. Figuring out what you want to accomplish and what you need to be successful along with the processes to prepare for and measure your success is the key. After that, knowing what you need in a tool becomes easy. I contend that choosing a quality tool is still essential but not as essential as chooing the “right” tool for the task. Selecting (and getting too excited about) the tool first is a good way to fail.

    Mark

    • April 30, 2011 5:35 pm

      Well spoken. I think people lead with technology so often because they, as evangelists, are truly excited about what it can do. Those who need to have work flow changed or who are inconvenienced in other ways are not so enthusiastic.

  10. April 29, 2011 9:03 pm

    Joe – This topic could not be more timely. The government has poured $27B into hospital systems across the country to stimulate them to implement the EHR (Electronic Health Record ). There is also a stick beyond this carrot. They will get penalized if they don’t install such a system. The results are starting to come in. In a large portion of the projects, the hospital systems are reporting large financial losses using the new systems – numbers like 25% of revenue. And how do they explain this? Of course! They are blaming it on the technology.

    But I’ve been here before. I was CTO for an electronic healthcare startup back in ’96. Most of the hospital systems, following the old mantra “this is medicine. who better than docs to manage it”, don’t have a clue what they are doing. And this strong criticism is not just a sound bite. They truly don’t have the experience or training to understand what they are up against. So the implementation fails drastically. This is not to say that there isn’t fault on the supplier side. Again it’s NOT the technology. Because of the large effort to install these systems, the suppliers have hired people who have never done a major software install in medicine. So the “consultants” don’t know what they’re doing either. AND, to be sure, the existing technology is not up to the expectations that people have for it.

    The important point I want to make is that, if people who have the credibility to bring up the true explanations for all the failures don’t speak up, and do so soon, then the failures will be written off for the wrong reasons, and the next time we try this, we still won’t get it right.

  11. April 30, 2011 1:11 pm

    I like to say that you have to choose the right technology for the right purpose and the right audience. However, it isn’t the technology’s fault if it doesn’t work. It is the result of poor or misguided planning.

    My kids saw the movie, but I didn’t. I’ll have to add it to Netflix so I can watch it now. Thanks for the great perspective and new resource!

    • April 30, 2011 5:38 pm

      Yes, many factors can lead to poor outcomes even if the technology is a good fit.

  12. April 30, 2011 5:09 pm

    It’s an interesting analogy. I saw the movie, but never made the leap. I think you hit on a good point. I often make this in pharmacy. The first few times that you fill your prescription are critical. That is when you need information about side effects. That is when you need consultation. That is when you need the cognitive services that are often best served over the counter. After the initial fills and once the patient has titrated, it is possible to move to mail order or to some type of tele-pharmacy kiosk.

    George

    • April 30, 2011 5:39 pm

      Thanks, George. I had not thought of the pharmacy analogy.

  13. Larry Heimlich permalink
    May 2, 2011 6:07 pm

    Great post Joe. I thought you drew some interesting parallels between Up In The Air and technology failure. Audio and two dimensional visual communications only utilize two of our five senses limiting our ability to communicate. Ultimately, for things that truly matter, we need to develop trust between the parties and that becomes difficult without the other three senses.

    The observation that “Too often we blame good technology for poor planning and execution” accounts for the great number of failed start-ups and innovations. How many of these fail because of the lack of non-technology related resources? The most important are the right people. It’s not enough to build a better mousetrap. You need to find people who have a passion for killing mice.

    Larry Heimlich

  14. Ayesha Masood permalink
    August 24, 2011 4:35 pm

    Sir
    The same project pilot, conducted in a less educated and ‘frugal’ neighborhood , may give the opposite results.
    There are people who prefer skype over facebook, mostly older people from different regions of the world.
    Connected health may become the only healthcare option in far flung areas where it takes a long time to reach a doctor.

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