Sue Lani Madsen: Why it’s hard to pull the plug

The problem was obvious and the cure seemed simple in 2008. Electronic health records were becoming ubiquitous in both public and private health care, but on a variety of platforms which couldn’t speak to each other. Mustering out of service under DoD care meant physically carrying a stack of paper records to the VA to scan into their system. The Department of Defense and the VA each had their own EHR systems, and relied on the pre-Internet “tennis shoe network” to communicate.

The federal government could have just picked one of the two electronic systems. It had a choice between DoD’s AHTLA, cited in a July 2010 Military Medicine report as the “number one professional frustration among clinicians,” or the VA’s older and more user-friendly VistA record system. The federal government could have developed objective criteria for selection, valued practical usability by medical personnel and patients, and picked one.

That didn’t happen.

Recent reporting by The Spokesman-Review covered the timeline in depth. DoD and VA were mandated by Congress in 2008 to cooperate on a fully interoperable system. After four years of unproductive trench warfare, they abandoned the effort in 2013. The awkward handoff between the military and the VA was still causing problems for constituents, and Congress stepped in with a second mandate telling the DoD and VA to “do something.” With every mandate and every budget, more good money has been poured down what rapidly became an IT sinkhole. Billions of dollars and another eight years later, the project is undermining VA health care.

Who should have seen this coming? And why is it so hard to pull the plug?

There’s no shortage of candidates for scapegoat in a project spanning three presidential administrations and two dozen sessions of Congress. Finding a “who” to blame misses the systemic problems in decision-making between the client and the end user.

“Big Data” projects have a notoriously high failure rate, according to numerous business sources. Failure to pull the plug is not a new problem. As a Harvard Business Review article from 1987 puts it, “at times some managers, and even entire organizations, seem almost programmed to follow a dying cause.” And yet we keep making the same mistakes in project management because of both systemic and very human factors.

Knowing when to stop is one of the recommendations in a Forbes Technology Council article published Oct. 12, 2020, listing “16 Signs It’s Time To Pull The Plug On A Tech Project.” It requires “the setting of start, stop and continue criteria” at the very beginning. It’s tough to start a project by discussing how you will know when to stop, and that happens too rarely.

In holistic management decision-making, the same concept is described as assuming any plan is flawed and monitoring for early signs of failure. Monitoring for failure comes naturally in health care, if not in EHR system development. Vital signs in the normal range are of no particular interest. You wouldn’t go back to a doctor who dismissed a failed blood glucose test because your blood pressure was under control. Early detection of a temperature too high or oxygen saturation too low allows time for effective treatment to get back on track.

The managers in charge of this project from 2013 to 2021 should have been monitoring whether veterans could actually use the portal and checking the morale of VA staff. And now we now have VA Secretary Denis McDonough reaffirming his commitment to a top-down system that doesn’t meet user need, regardless of whatever glowing reports of future potential are submitted by Pentagon contractors bidding for projects.

Progress reports back to Congress, DoD and the VA over the past eight years have undoubtedly focused on signs of project success. Among the factors at play in IT project failures, the Harvard Business Review cites the psychological tendency for individuals on both sides of those reports to avoid admitting failure. Pulling the plug is a tough call in a culture which correlates persistence with leadership. Then there’s the organizational tendency to administrative inertia which makes stopping harder than continuing, especially when billions of dollars have already been poured down the sinkhole.

What Congress wanted was satisfied constituents. What veterans wanted was a way to transfer records without hassle. What doctors wanted was a system supporting good patient care. And frankly, it all could have happened in 2013 if the organizational egos in the Department of Defense had admitted the VA had a better system.

Maybe it’s time to pull the plug.

Contact Sue Lani Madsen at rulingpen@gmail.com.