Probably no task challenges today's behavioral healthcare leaders more than selecting and implementing information systems, especially electronic health records (EHRs). In the January/February 2004 edition of this column (in one of Behavioral Healthcare's predecessors, Behavioral Health Management), William R. Connors, MSW, and Michael Bütz, PhD, discuss the importance of executive involvement in EHR implementation.1 They stress that despite the temptation to avoid involvement in EHR implementations, senior managers must be more involved, and the authors provide excellent suggestions about how to do so.
This issue warrants continued attention because many CEOs remain intimidated by technology. This reluctance to become involved in IT decisions means leaders are not providing the type and level of leadership their organizations need.
Initially, many leaders are challenged by the technology itself. Technology can be overwhelming, with discussions about hardware, software, and the “bits and bytes” of it all. Likewise, negotiating highly technical contracts with vendors is daunting. Thus, an unwillingness to get involved is understandable, since many of us—perhaps most of us—were not prepared professionally for these types of decisions. CEOs aren't information technology specialists, but they are accountable for decisions surrounding technology implementation.
Community mental health executives faced a similar bind with the financial changes of the 1970s and 1980s. Most CMHCs had been grant funded, but as funding resources changed, organizations needed to learn how to secure funding from insurers and other third parties. Controllers became CFOs, and executive directors expanded their knowledge beyond grants to billing, collections, and accounts receivable.
Technology has caused a similar revolution in community mental healthcare organizations. Managers of data processing are now chief information officers, and CEOs must know more about technology if they are to succeed. Yet the technology change has been more difficult for most than the earlier financial change. The financial change required CEOs to modify their knowledge about money management and accounting—skills they already had. The technology change, on the other hand, requires the adoption and understanding of a new body of knowledge—one that many find perplexing.
Technology itself might be challenging, but it pales in comparison to the difficult organizational and personnel changes required to successfully implement technology, especially EHRs. In most cases, successful EHR implementation requires the entire organization, with no exceptions, to make the change from paper documentation to a computerized record.
An EHR implementation can provide huge improvements in patient care—but only if work processes change significantly and completely. For example, imagine if some clerical staff were allowed to continue using typewriters and carbon paper while their peers used computers. Or what if your CFO still liked entering financials by hand on green ledger sheets instead of using a spreadsheet software program? We might chuckle at such absurd examples, but when it comes to standardizing and changing processes, we make similar decisions by allowing some employees to define their own work processes that do not use the technology.
Managers need to be leaders and make tough decisions. For example, a CEO might have to insist that technology-averse, hard-to-recruit physicians use EHR systems even if it means losing some of them. EHR adoption requires leaders to be fairly inflexible on this point. All employees must be willing to change and adopt the new technology.
Leadership during times of change is among the most important jobs of a leader. One of the earliest examples of an effective change manager was Moses, leading Israelites out of Egypt to their promised land. Today's leaders would do well to note two important points about Moses’ experience: (1) For this change to occur successfully, he had to endure a period of disorientation and chaos (wandering through the desert), and (2) he did not say, “Since some of you want to stay in Egypt, we will support two promised lands.” Instead, everyone left Egypt, and despite the confusion and fear of wandering around in the desert, all agreed that the end result was worth it. So it is with EHR implementations. (Naturally, one hopes EHR implementation takes fewer than the 40 years it took Moses to cross the desert).
This is tough leadership. Leaders sometimes back away on the basis of clinical, financial or, more commonly, personnel reasons. In some instances, recruitment issues will end up taking precedence over 100% staff EHR adoption. However, this is often a rationalization for not confronting strong people in the organization. Compromising will lead to multiple systems in the organization, creating workarounds that promote inefficiencies and reinforce poor personnel-management procedures.
Remember that the next generation of leaders is watching us to learn how to lead. If they see us compromising on tough management decisions, how will they handle similar decisions? Clinical staff, too, look for examples of good decision making—skills they'll need as they are held more accountable for their clinical decisions and as more, and perhaps competing, evidence-based practices become available.
Our employees look to us for many things, but the most important, and arguably the most difficult, is leadership.
Author and leadership expert Warren Bennis, PhD, says managers are people who do things right, and leaders are people who do the right thing. Effective EHR adoption ultimately will not be accomplished by management. It requires leadership.