We’re all used to reports of EMR project delays and cost overruns. In fact, being over-budget and over-time now appears to be the norm for such initiatives.
But if these accounts are unsurprising they’re also unfortunate and unfair. Unfortunate because negative views of EMR projects lead to depriving patients and providers of healthcare information systems that are our only path to increased efficiency and quality of care (see this post on our Failure to fund eHealth innovation and investment). And unfair because we have evidence that EMR project delays and budgetary excesses are inevitable.
To understand the inevitability, consider first what we know about cost and schedule overruns in public construction projects. As an example, the findings and background literature review from this Journal of Construction Engineering article show that overruns are proportional to the size and length of the project: the larger and/or longer the project, the more likely it is to miss meeting our original expectations.
Of course, healthcare’s primary construction projects are hospitals. However, I could find no evidence that building a hospital is particularly prone to delays and cost overruns, which suggests that healthcare is no worse than other industries when it comes to construction project management.
But compared to an EMR project, hospital construction is a low risk undertaking; it’s very unusual for building failings to lead to patient harm. Yes, the failing might hurt capital spending or ongoing maintenance and operating budgets, but it’s rare for it to dangerously compromise care.
In contrast, EMR projects must work with patient information, which requires us to stringently assure confidentiality, integrity and availability (CIA). Getting that right trumps budgetary and time considerations. And that makes EMR project delays and cost overruns an almost unavoidable reality.
Sadly, most critics of eHealth fail to recognize this reality. Their narrative is also founded upon inevitability, but instead of it being about the inescapable challenge of building safe systems they frame it as another example of incompetence and waste in public spending.
Fortunately, we can easily refute that argument if we look at the aerospace industry.
I often turn to civil aviation and the design, building and maintenance of commercial airliners to inform how we should be thinking about eHealth. That’s because, like healthcare, aviation is safety-critical: do things carelessly and people needlessly die.
At present there are four major plane manufacturers: Airbus, Boeing, Bombardier and Embraer. And over the past decade, three of the four have run a new product development project with huge cost overruns and delays:
• Airbus A380 – entered service in 2007, two years late and with a program cost at least $6 billion above its initial $18 billion budget. It also weighed more than planned, reducing fuel efficiency by 3-4%.
• Boeing 787 Dreamliner – cost an estimated $12 billion, more than double its original $5 billion project estimate. In addition, it entered service three years late.
• Bombardier C Series – now expects to deliver its first plane in early 2016, three years overdue and with a program cost of at least $5.5 billion, about 60% more than the $3.5 billion expected cost.
In each case, the extra time and money needed to complete the project was a result of software and hardware innovation that was more difficult to get right than planners anticipated. Components had to reworked or replaced in order to meet exacting specifications. And each announcement of another postponement provoked concern about whether the project could be successfully completed.
While all the major aircraft companies receive forms of government support that support isn’t especially different from the favourable treatment granted to any industry from agriculture to pharmaceuticals. More important, all of the aerospace companies are publicly traded corporations whose stock price and enterprise value rises and falls based on how the market evaluates their business.
The final point is key: these major missteps are occurring in the private sector, not in the public. And they demonstrate that the private sector’s corporate leadership is no better at dealing with the challenges of large projects in a safety-critical industry than are managers in public sector healthcare.
As we approach 2016, perhaps saddened and demoralized by how little progress we’ve made in eHealth over the first 15 years of this century, we should remember that accounts of EMR project delays and cost overruns aren’t signs of shortcomings that are specific to our domain. Rather, they’re testimony to prejudices and unrealistic expectations that we’ll have to aggressively manage if we want to accelerate the journey to safer and more affordable care.