Frankenstein Consolidation In Health IT: Does It Have A Pulse?

By Florent Saint-Clair

In Mary Shelley’s Frankenstein, the main character, Victor is convinced he’s found the secret of life and spends months stitching a creature out of old body parts, which eventually becomes “alive.” However, when he looks at the monstrosity he has created, the sight horrifies him. This is not uncommon from what happens in the healthcare industry when a merger or consolidation occurs. Often what’s left behind is a “monster” of disparate systems, duplicate software, and looming questions of what lies beneath in the hospital’s data center. That, in conjunction with missing knowledge of older solutions or interfaces, guessing games of who owns the data, and wondering if the stitched system will operate effectively, or at all? 

A few years ago, we compared Radiology to an Archaeology Dig noting that if Indiana Jones and McGyver ever had a love-child, he or she would probably be tempted by a career in Health IT. In 2021, not much has changed, in fact, the complexity of the Health IT industry continues to grow, with not only consolidation, but a Gold Rush of new technology, particularly AI applications. Given this information, where do we go from here? Healthcare consolidation is bound to continue as it follows the lead of other industries (airlines, hotels, technology). Knowing this, what types of protocols need to be put into place to ensure a successful merger from a systems and infrastructure standpoint? Just like Human Resources has an onboarding process. How can we mitigate the “Frankensteins” in Health IT consolidation?

Consolidation Poses Challenges for IT Professionals

IT professionals who are tasked with implementing a restructuring within a newly merged organization face a daunting challenge. Much like an iceberg, for the 20% of the project that’s in plain view, 80% of unknown factors lurk below the surface. Merging IT organizations must be approached much like a heart transplant, ensuring that the patient care continuum is uninterrupted throughout the project. As Donald Rumsfeld once famously paraphrased, “there are known unknowns, and there are unknown unknowns.” In other words, any experienced transition IT team should be ready for what they don’t know they don’t know.

Discovery is the single most important part of any such project, and it should begin as early as possible during technical due diligence, before a merger is consummated. Some of the most thorough discovery processes and procedures can mitigate disastrous operational disruptions, but they cannot mitigate them 100%. For every well-documented IT asset, ten other assets are poorly documented. For every well-documented interface, twenty more interfaces have no documentation at all. Compounding the problem is that in the real world, people routinely move on, get promoted, fired or reassigned. With less than perfect knowledge transfer, knowledge of an interface created years ago gets lost along the way. However, some mergers are announced and consummated on an accelerated timeline that does not allow for an orderly or thorough discovery process, thereby putting the IT group on the defensive from the beginning.

Lack of Documentation Calls For A McGyver Approach

Health IT professionals are often put in the undesirable position of a “McGyver” character, improvising along the way, doing their best to preserve their meager budgets to maintain the continuum of care. Improvisation inevitably leads to corner cutting, which leads to undocumented, unsanctioned bandaid solutions. As long as patient care is preserved, the incentive to go back and retroactively document a fix is often diminished. The path of least resistance is usually the most desirable one. When the discovery process hits a wall, the level of risk-taking increases. 

In the absence of proper documentation, it isn’t uncommon for the advanced discovery team to resort to unplugging mystery servers in order to empirically discover their purpose within the IT ecosystem. If no complaint or anomaly appears, the server is presumed to be a vestigial asset that no longer serves a purpose and can be safely removed from the production environment. However, if the unplugging of the server results in a ripple effect that propagates throughout the enterprise, mitigating the fallout could be a stressful firefight for the team. This becomes more complicated if the organization has low throughput workflow, as issues may lay dormant for a long period of time and problems may not be correlated to the mystery systems easily because it was removed  “awhile back.” Detailed change control is an important factor and keeping the unplugged system in standby mode for certain periods of time helps to avoid the disasters that may arise.

Health IT Consolidation Shows No Signs Of Slowing Down

According to a report, hospitals acquired 5,000 physician practices from July 2015 to July 2016 alone. A separate analysis from PricewaterhouseCoopers revealed that there were 255 healthcare merger and acquisition deals in Q2 of 2018. Mergers between radiology groups are also on the rise. This consolidation, like any merger (or marriage) has supporters and opponents. So why are hospital mergers on the rise? As value-based reimbursement places financial pressure on providers, healthcare organizations are striving for efficiency, cost control, and sustainability. Healthcare consolidation is often an increasingly popular strategy for fulfilling these goals. Another trend: economies of scale, as shared in a teleradiology webinar with Gautam Agrawal, M.D, CIO and co-founder of Vision Radiology.

The benefits of consolidation in the healthcare industry include:

• Increased care coordination
• Reduced duplication of clinical services
• Improved clinical integration and management
• Reduced operating costs of 15−30% for acquired hospitals
• Increased local access to acute care services
• Reduced administrative costs

Opponents of consolidation cite the following disadvantages:

• Increased average price of hospital services by 6−18%
• Reduced competition
• No measured impact on quality
• Limited patient benefits
• Higher health insurance premiums

Healthcare Consolidation and The Impact on Radiology

Frost & Sullivan predicts that the enterprise imaging IT space will drive up to $2 billion in investments toward imaging workflow efficiency, interoperability and analytics in 2021. Budgets will be focused on imaging-IT infrastructure upgrades and teleradiology to manage workflow optimization and reduction of unnecessary examinations. Consolidation of traditional IT infrastructure, picture archiving and communication systems and vendor-neutral archives is expected to improve the efficiency and quality of outcomes without wasting resources. 

When hospitals and physician groups merge, radiologists may find themselves practicing in new clinical and operational environments. The factors contributing to these changes include a higher degree of clinical management oversight of their decision-making, the emergence of artificial intelligence and machine learning tools, and policy and payment changes. Often, this translates into new performance expectations and increased pressure to reduce turnaround times (TAT) on studies. At the same time, radiologists may be facing competition from remote-read services in the United States as well as India, in addition to the demands by the public and payers to bring down radiological charges and costs. Another new demand on the radiologists’ time is the expectation to participate in clinical and resource-utilization peer review.

What Consolidation Means for Radiology Workflows

Consolidation affects not just the administrative aspects of hospital operations, but their enterprise imaging systems as well. Imagine moving in with your significant other and showing up with your mismatched furniture that doesn’t even fit into your new house. That’s what imaging sometimes looks like: studies may be located in multiple PACS/MIMPS, specialty department imaging systems, or even CDs or legacy archives. How can you enable your imaging workflow to run smoothly while ensuring secure patient-centric access to images and reports, whenever and by whoever necessary?

Mitigating the “Frankensteins” in Health IT Consolidation

Although blunders will occur when it comes to Health IT consolidation, for enterprise imaging, there are ways to ensure the integration goes smoothly with minimum impact for the end user. This requires due diligence and vendor neutral archive (VNA) software.
(PACS) neutral software. In many cases consolidation leads to replacing most of the components and introducing new ones. In reality some of the legacy components become permanent  for a long period of time until the next consolidation.

IT due diligence is the single most important step in a successful infrastructure consolidation. Meticulous discovery and documentation of both sides of the merger enables IT professionals to gauge the relative redundancies that may exist between the two organizations, and to plan out the transition appropriately.

The discovery stage doesn’t end with IT asset inventory. This critical stage also gives clinical workflow experts an opportunity to interview end-users of software solutions on both ends to determine which solutions should survive the consolidation and which components can be safely eliminated without impacting live clinical workflows.

Due diligence prior to health system integration is a multi-dimensional exercise that must involve many types of professionals beyond IT expertise, to cover all financial, legal, operational and regulatory matters. 

1. Discovery 
2. IT asset cataloging and documentation
3. Infrastructure review (on-prem and cloud)
4. Ensure vendor-neutral software
5. Human capital and impact analysis
6. Licensing and contract reviews
7. HIPAA risk assessment
8. Infosec risk assessment

Conclusion

Health IT ecosystems are highly complex in nature. They encompass new clinical solutions that may have been deployed last month, mixed with solutions that have been embedded in the infrastructure for several decades. New innovations and research in the field of health IT, especially the advent of machine learning algorithms, are placing enormous pressure on IT professionals to not only maintain the precarious balance they have kept in their respective ecosystems, while preserving the integrity of privacy and security policies, but also to provide enough flexibility in their framework for progress and innovation to be possible.

It should be noted that not all IT consolidations are ultimately successful, or even the result of a merger between two entities. Health systems don’t necessarily need to be parties to a merger in order to gain economies of scale from IT consolidation—joint ventures come to mind. Several large health systems have, in the past, attempted to consolidate their supply chains and IT infrastructures. The best of intentions cannot always counterbalance the politics involved with bringing two large and complex organizations together. One side may feel more entitled to call the shots than another and therefore may feel that their IT ecosystem should be the surviving model going forward. Unresolved political considerations can ultimately cause a well-intentioned and desirable consolidation to fail.

Healthcare consolidations emanate from the best of intentions. Whether those intentions are tied to shareholder ROI, market dominance, operational efficiency or the best interest of patients, a minefield of unintended consequences can emerge from consolidations. From staff elimination to infrastructural transformation, the inevitable decisions that must be made during integration will have real human impact, whether intended or not.

Frankenstein’s creation was born out of scientific curiosity mixed with the outsized ego of its creator. While Health IT integration doesn’t present a direct risk of blindly hunting down its proponents (as far as we know), the combination of two large and complex organizations’ IT assets and solutions can be a scary prospect. Ultimately, there is no substitute for experience in these projects. IT leaders who are tasked with executing these tumultuous projects should be seasoned experts who have the battle scars to prove it.