This fourth chapter of our “Reducing Complexity in Healthcare IT” examines the concept of technical debt within the Healthcare IT environment.  Be sure to catch Part 1, Part 2, and Part 3 of this series in case you missed it!

In order to fully understand and begin to counteract the lifecycle and root causes behind technical debt, it is important to comprehend what is commonly referred to as the Technical Debt Quadrant.  Martin Fowler illustrates this concept from a software development lifecycle perspective by categorizing technical debt into the following quadrants using a matrix of the following adjectives:  Reckless, Prudent, Inadvertent, and Deliberate.

Reckless & Deliberate

Perhaps the most lethal cocktail in terms of spawning overwhelming layers of technical debt (and chaos in general) are the actions of the deliberately reckless.  The common comparison here might be forcing a square peg in a round hole simply to create the illusion of an immediate result.  In Healthcare IT this happens more than one might anticipate or would care to think about.  With impending Meaningful Use-driven penalties, a push to acquire and consolidate, and risk-based reimbursement models becoming a reality, there are times when the only solution is to step on the gas despite knowing what the long terms consequences could be.

Common Root Causes:

• Abandonment or lack of design, implementation, testing, and validation standards
• Poor decision making during the implementation process due to lack of proper oversight, process, and quality standards
  • Using “stop gap” solutions to support interface design where core functionality is lacking
  • Inadequate testing and validation of integration points (patient portals, interface design, data conversions) that result in ineffective use of FTE’s and general support overhead

Prudent & Deliberate

The combination of prudent and deliberate based technical debt is just that….a deliberately calculated business decision supported by a full understanding of the potential consequences of moving forward.  These characteristics tend to highlight both sound solution designers and decision making leaders who adhere to a consistent approach for delivering quality projects outcomes.  Strong, self-sufficient organizations, with a proven method for doing business often are able to make these tough decisions and deal with the consequences.

Common Root Causes:

• Committing and executing a timeline (initiative) for which the risks of abandoning or re-working do not outweigh the forecasted technical debt
  • The need to implement and attest for Meaningful Use to avoid penalty
  • The need to absorb and/or acquire additional physician practices on a fixed timeline
  • The need to execute a Healthcare IT initiative due to budget allocation constraints

Inadvertent

Inadvertent technical debt is most commonly laced with good intentions and the willingness to learn and improve. The goal in these situations is of course delivering business value, recognizing there is always a better way to do things, and then completing the feedback loop by reinvesting lessons learned into future initiative and implementation standards.

Common Root Causes:

• Trying to keep up with the curve of changes in industry and/or implementation standards
  • Keeping up with clinical and electronic processes due to industry changes
    • ICD9 and ICD10
    • Meaningful Use Stage 1 and Stage 2
  • Taking on projects, initiatives, and standards in a domain that is new to an organization
    • Late adoption of risk-based modeling and bundled payments
    • Implementing net new clinical service lines such as Home Health, Nursing Homes, and/or other continuity of care-based services

What is interesting about the concept of technical debt is that is isn’t something that is necessarily tangible (such as a broken server or even a trend of financial losses that shows itself on a quarterly balance sheet).  Like monetary interest it builds up over time and eventually works its way into the core functionality and culture of the business.  The impacts to an organization’s cost of doing business, culture, and morale become appreciable and result in unmanageable roadblocks to an organization’s business objectives over time.

Perhaps its most devastating intangible impact is its ability to drag down innovation!

Looking for information or for ways that Galen can help pay back your organization’s technical debt?  Read more on our website or contact us!

References

“TechnicalDebtQuadrant,” Martin Fowler.  www.martinfowler.com