Call to digital health leaders: test and leverage this guideline to support health information technology implementation in practice

Introduction

Globally, there is an increasing pressure to implement health information technology (HIT) to transform health systems.1 Some evidence suggests that HIT implementation can improve healthcare quality and safety,2 while other research shows many HIT implementation efforts fail, with few achieving sustainability in practice.3

Health systems’ complexity makes HIT implementation non-linear and unpredictable.4 Managers and leaders are crucial in ensuring successful HIT implementation by aligning factors associated with success.5 No guidelines exist to support managers or leaders to navigate uncertainty and leverage the factors associated with implementation success. Models, theories and frameworks vary in terms of terminology, generality and purpose, with no approach identifying the range of processes, or contextual or evaluative activities associated with HIT implementation success.6

The first author conducted a master’s research study to answer the question: ‘What are the factors deemed important for leading a successful implementation of HIT within healthcare organisations?’ The outcome was a guideline to assist managers/leaders achieve HIT implementation success. The first author graduated in 2018 and worked for a consultancy organisation, providing implementation services to various health services. The specific focus of this article is the first author’s experience leveraging the guidelines in a national programme leadership role in the New Zealand (NZ) Health System Reform. The question for this manuscript is ‘How did the guideline and framework perform in practice?’

Methods

Four steps were used to develop and test the guideline and the associated Broad Implementation Framework for HIT (BIFHIT).

1. Literature review to identify existing conceptual theories, frameworks and models in the implementation science literature and develop a draft framework.8

2. A set of semistructured interviews with senior health information system managers and leaders in NZ, to discuss the draft framework and add missing components, refine existing components, and discuss adjustments.8

3. The data were analysed thematically with the addition of memos as the researcher synthesised and developed the guideline and the BIFHIT.9

4. The first author tested the application of the BIFHIT framework and associated guideline in a national programme leadership role from July 2021 to June 2022. She used the BIFHIT guideline and table 1 as a memory aid throughout the process (see online supplemental file).

Results

The literature review identified eight key themes within conceptual theories, frameworks and models, namely, clinical leadership, executive commitment, relationships and communication, vision, evaluation and measurement, funding constraints, human factors, and an Agile approach. Through the interview process, these themes were refined and updated. This formed the basis of the BIFHIT conceptual framework (see online supplemental file).

From the refined BIFHIT, the first author thematically drew out five key action areas, which form the basis of the guideline. Each action item has questions for health service managers/leaders (HSMLs) to systematically check to support the congruence of factors associated with HIT implementation success (see online supplemental file).

The five actions are as follows:

1. Involve and develop positive relationships between stakeholders early within implementation processes.

2. Establish and ensure a consistent vision for HIT success within the organisation.

3. Consider the attributes of the HIT system.

4. Ensure evaluation and feedback are iterative in approach.

5. Create a learning culture for implementation activities.

Table 1 highlights the links between key action areas and the BIFHIT.

Specific reflections of the first author in her national leadership role are as follows:

• Action 1: The implementation of large-scale digital transformation is dependent on bringing together various stakeholders to redefine the future collectively. HSMLs must have strong skills to build relationships, cocreate and execute HIT implementation across a mosaic of stakeholder groups. Leading relationally and including relevant voices early in conversations reduced regrettable decisions and created buy-in to the cocreated vision.

• Action 2: Vision is critically important to implementation success. It was vital to articulate the minimum ‘must-do’ actions to satisfy the collective vision. This prioritised the focus onto action and minimised the noise that inevitably arises from a large transformation effort. Communicating the vision and key updates was the most important thing to get right, but was challenging to continually ensure stakeholders had timely and relevant information. Communication is critical to retaining and attracting talent, as teams will feel particularly vulnerable during times of change.

• Action 3: Attributes of data and digital technology are crucial for successful implementation. Leaders needed to ensure that new technology procured was modern, adaptive and aligned with the strategic direction of HNZ. Cost considerations of the technologies (both capex and opex) were also vital. Proactive engagement with other business units and go-live contingency planning is vital to identify requirements early and manage risk.

• Action 4: Early and iterative feedback mechanisms are vital to ensuring the implementation effort remains true to the cocreated vision, while enabling timely responses to factors that may later inhibit implementation success. Agile methodologies can support this approach.

• Action 5: Embracing the opportunity to learn and grow through change is vital at all professional levels. HSMLs play a crucial role in developing this learning climate, namely one that tolerates failure, challenges the status quo, supports collaborative working and enables the exploration of innovative solutions.

Discussion

The purpose of this article was to investigate how the guideline and framework performed in practice, leveraging the first author’s experience in a leadership role in the NZ health reform. Her experience re-enforced the utility of the BIFHIT framework to bring awareness to the range of factors associated with implementation success, with the guideline and associated checklist supporting action-oriented application in practice.

A common theme through these reflections is that the success of digital implementation efforts has less to do with technology and more to do with people. For successful transformation at scale, HSMLs must have a learning mindset, extend outside their comfort zone and use skills to build relationships, cocreate a shared vision and execute across a mosaic of stakeholder groups. These findings are supported in the literature,6 10 with Tagscherer and Carbon stating that digital transformation success depends on leaders who are visionary, embrace change and risk, and continually promote collaboration, relationship-building and teamwork.10

Conclusion

The BIFHIT framework brought awareness of the range of factors associated with implementation success, and the guideline enabled action-oriented application in practice. HSMLs are invited to test and leverage this guideline as a tool to navigate the uncertainty associated with HIT implementation and improve the congruence of factors associated with success.