It was the "go live" gone wrong.
"We turned on our new system and it immediately crashed," said Alexander Towbin, MD, associate chief of clinical operations and informatics at Cincinnati Children's Hospital. The system was down for a week.
The informatics department at Cincinnati Children's had planned to implement a new picture archiving and communication system (PACS) and a new electronic medical system on the same day.
Towbin and his team had done their testing, and had even done a "soft" live launch ahead of time. They had, however, overlooked an important factor: they had load tested the system in the radiology department — with its 100-person database — without thinking about the 15,000 people in the overall hospital database. The company providing the PACS software had never tested it on such a substantial number of users before, and Towbin's team had failed to ask if they had. It turned out to be too many users for the system to handle.
It was not a good day for Towbin. He was the person who had to explain to hospital administrators what had happened, what the contingency plan was, and provide updates throughout the week as they fixed the problem.
Ten years later, Towbin hopes others can learn from his mistake. He shared his story with a roomful of radiologists at a seminar titled, "Radiology Informatics Mistakes and War Stories from the Physician Front Lines" held at the Radiological Society of North America (RSNA) 2019 Annual Meeting in Chicago.
He was not alone in acknowledging missteps and using the lessons he learned from them to help others. "Our goal is to help folks with common things that go wrong that might not be taught in the books or the lectures," said seminar moderator Peter Sachs, MD, vice chair of the Department of Radiology at the University of Colorado School of Medicine in Aurora. "We also realize this is extremely complicated stuff, so everybody's going to make mistakes. You learn as you go."
Digital technology and informatics are constantly changing. In order to remain innovative and offer patients state-of-the-art treatment, informaticists are required to adapt and change practices frequently. And things often go wrong when implementing new processes, upgrading technology, or trying new systems, he explained. But the biggest mistakes are often human-error ones, not technical.
"A lot of what we do depends on human interactions and processes," said Sachs. "Those are sometimes more complex and more difficult to teach or manage. They depend on real world experience."
Mistakes usually "have to do with leadership training, change management, negotiations, communications, or following some kind of business process," said Nabile Safdar, MD, MPH, associate chief medical information officer at Emory Healthcare in Atlanta, Georgia. "And, frankly, most of us are not trained in those types of things."
When CTRL+ALT+Delete Won't Work
Safdar's presentation, "When CTRL+ALT+Delete Won't Work," focused on what happens when you implement new healthcare technologies, systems, or digital solutions without considering the human element.
He told the story of the time he agreed to install recording devices in the hospital suites where patients were imaged and underwent procedures with the aim of better understanding, improving, and optimizing workflow. Although he followed the appropriate rules, he neglected to consider the staff who — it turned out — strongly opposed being on camera while they worked. In the end, the project was scrapped.
Money and hard feelings would have been saved had he initially consulted the staff, Safdar told Medscape Medical News.
He learned the hard way how important is it to carefully consider how projects and changes affect people. Communicating openly with everyone involved goes a long way toward successful implementation of new systems and processes, he said.
Including this seminar in the RSNA program was important, said Chris Roth, MD, MMCi, vice chair of Radiology for Information Technology and Clinical Informatics at Duke University School of Medicine in Durham, North Carolina, and organizer of the conference's informatics program. "We're all human and we can learn from each other's mistakes."
Roth's mistake was introducing a new image-sharing application to a number of large academic and private centers in North Carolina without fully understanding if it would work for all imaging use cases. It didn't. The number one lesson he learned was the importance of outreach and clear communication, he told Medscape Medical News.
Was he glad to have learned this lesson? "Heck, no," he said. "I could have learned from someone else making mistakes. It was hard on my family, hard on me, and it caused high blood pressure for some people in the organization."
Hence the importance of sharing these stories, said Roth.
"Even leaders in healthcare who've been trying to bring the best, innovative technology solutions into their healthcare environments have tried and failed," said Safdar. "In order to succeed, we have to be willing to accept and recognize our failure, and pick up and say, 'Let's figure out how we can make this better.' "
Radiological Society of North America (RSNA) 2019 Annual Meeting: Seminar RCC32. Presented December 3, 2019.
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Cite this: Leadership Gaffes and How Their Worst Day at Work Can Help - Medscape - Dec 12, 2019.