Getting the most benefit from information systems consultants.

Consultants are usually well-meaning people who enjoy the variety of organizations and problems they face in their work. Most do not like to get bogged down in fruitless and wasteful consulting engagements any more than managers of health care organizations like to supervise them, but at least the consultants are paid for their time. The health care organization that defines a project poorly, does not know what it wants from consultants, or does not direct consultants will pay the price in increasingly scarce resources squandered. The tips in the following article for managing an information systems consulting engagement apply to most consulting engagements and to the use of other expensive advisers, such as attorneys and engineers. But information systems is a field particularly foreign, and often threatening, to most administrators and physician executives, so the risk of wasting money on unsuccessful consulting engagements is high.

Why use consultants? What role do they play in society, in general, and in information systems planning and procurement, specifically? hi general, the U.S. business world is more complex than ever before, in terms of politics, economics, regulations, human resources, and technologies. Information systems fall into the technology category, where new technologies, new vendors, and new functions appear every day. Most general managers need help in planning for, and implementing, information and communication systems often costing multiple millions of dollars and affecting every employee and every customer of the organization. Consultants can reduce the time required to make a good decision and implement systems less expensively than the organization could accomplish on its own because consultants know more about strengths and weakness of current technologies and vendors than most managers do. But they do not know your company as well as you do, and they probably don't know your business and your industry as well as you do, so you need to stay very involved to make certain that what they recommend, and help you implement, is what your organization really needs. Most of the problems organizations have with consultants derive from the managers themselves, who are not as involved in the process of defining requirements for information and communication systems and in implementation decisions as they need to be.

Consultants should transfer some of their skills to the organization that has retained them in the course of their engagement. They need to leverage their knowledge of technologies, vendors, and business requirements to help the organization obtain a good result faster and cheaper than it could on its own. They need to promote constructive change in the organization and to insist that the work rules and habits of employees change to get the best results from the new technology. Consultants worth their salt, and billings, need to push the organization to take full advantage of the technologies it acquires. If that means reassigning employees, giving some new duties, or even relieving some of their duties, the organization should do so. Consultants with guts to disagree with those who retain them will be more valuable to you than those who passively follow your orders. If you have all the answers, you ought not have hired a consultant in the first place.

You will find that the simple tips below have much more to do with the governance of the organization seeking consulting advice than with the consultants themselves.

* Know What You Want to Do. Take the time to define your requirements for information systems, and your requirements for a consultant, as specifically as you can. Don't avoid starting for fear of making a mistake, or neglecting something important. The exercise of first defining specifically what you want is invaluable, before you call in outsiders to tell you what they think you want. Most health care leaders know what they want to do, but, when it comes to information systems, they may be less certain, because they probably do not understand the capabilities, and limitations, of the technologies available for licensing. This problem is compounded by health care managers who do not know anything about clinical care, or medical records, but persist in trying to control the acquisition of clinical information systems they think will reduce the operating costs of their facilities. An example is the manager who decrees that a hospital will have a computer-based patient record (CPR), because with it he thinks he can automate clinical pathways and make the medical staff adhere to them. He probably does not understand the functions of CPRs that appeal to physicians, or that his facility lacks basic, standardized feeder systems required by any CPR to make it useful to clinicians.

* Have a Strategic Plan for the Organization That Defines the Functional Needs for Information Technologies. Many, and maybe most, health care organization lack specific, detailed strategic and operating plans. The reason may be that most are tax-exempt and their leaders do not want to distress or alarm any of their many and varied constituencies by making detailed and explicit how they intend to spend their capital in the future. They do not want to admit which, or how many, insurers they will try to contact, or with which, and how many, physicians they will partner to form PHOs or HMOs, or which medical groups they will try to acquire. They want to be all things to all people. That is the way with tax-exempt, "charitable" institutions, but it leads to squandering much time and effort on committee meetings to build consensus about each management issue facing them. Consequently, it is difficult for them to plan successfully for their information systems needs. Information needs must be tied directly to explicit needs and wants of the organization, defined in a strategic plan. Without an organizational strategic plan, one cannot produce a specific organizational strategic information systems plan that will direct the staff of information systems to allocate capital effectively. Yet, most IS directors are told to plan for information systems, not knowing what the organization truly wants. For instance, imagine planning for a hospital information system not knowing if the hospital leaders will emphasize or de-emphasize managed care, or PHO development, or acquisition of group practices, or sharing clinical and financial data among member institutions, or marketing centers of excellence, or promoting specific clinical "product lines," or even whether they intend to sell hospitals and move into the HMO business.

* Have an Organizational Structure That Indicates Who Is in Charge, and How Much Capital He or She Can Spend on Any Information Systems Projects. Information systems projects cost a lot of money, often tens of millions of dollars for a major new information system in a large hospital or a group practice with hundreds of physicians. Too often, planning projects for information systems start de novo, without clear responsibility for planning or for authority to spend the money to procure a system once they have defined their requirements and chosen a process for satisfying them. Many organizations have multiple planning groups working simultaneously on projects that will affect each others' plans, but without any coordination or clear authority. For instance, I know of one system that allowed three hospitals each to plan for digital storage systems for medical records, but no planning occurred to make certain those three hospitals (in one system) adopted the same vendor's product, or that the images from the system would be legible on workstations attached to the wide-area network of the organization. I know of another organization that had three committees working simultaneously, one on an information systems plan (without a corporate strategic plan, by the way), one on the procurement of a computer-based patient record for some (but not all) of the system's facilities (this committee was led by administrators, not physicians), and one on the physicians' workstation. Those committees were doomed to failure because they were not coordinated, and they had no corporate commitment, the form of a strategic plan, a strategic information systems plan, or a budget to support their efforts or give their recommendations authority.

* Do Not Be Afraid to Interview Fellow Managers and Physician Leaders Yourself. So much of the early work of consultants is spent in interviewing people in the organization to find out what they want, and expect, from information systems. These interviews cost a lot of money, because the consulting firms usually charge more than $1,000 per day for relatively young and inexperienced junior employees to perform the interviews, and they separate the managers who hired the consultants from their own constituents. I believe the interviews need to be done by information systems staff themselves, with notes from those interviews transcribed into a document that fairly summarizes the answers and opinions of those interviewed. The interviews need to be with a broad segment of the people likely to be affected by a proposed information system. If the interviews are meant to help the organization define its strategic information systems plan, the people interviewed should have read the latest detailed, explicit organizational strategic plan. If the organization does not have a detailed, explicit strategic plan, do not waste time and money organizing interviews to find out what senior managers and physicians want from information systems. Use the interviews to start the process of creating the organizational strategic plan.

* If You Must Hire Consultants to Write the Strategic Information Systems Plan for Your Organization, Hire Them Carefully. Consultants can twist whatever they hear in their interviews inside the organization into a list of preferences (functional requirements) that lead to exactly the sort of information systems they understand. Worse, some consultants will lead their clients to select those information systems they know how to implement and install. So, by hiring a certain consulting firm, it may be a self-fulfilling prophecy that several years later the organization will install those same systems the consulting firm already knows best. Still worse, some firms with large staffs trained for systems development are much more likely to recommend software development, because no vendor will meet the precise needs of the client organization. Software development usually is much more expensive in time and money than the client organization ever expects when it signs up to create a system. Agree to software development as a last resort, after you are certain no vendors will meet your needs, and your needs are so pressing and strategically important that meeting them justifies the expense and risk of development. Generally, it is much more prudent for an organization to license existing software from a reputable vendor and to contract with that vendor to enhance its systems in specific ways than to take on the very uncertain task of creating an entirely new system. Talk to many references on any consultants you are considering hiring, especially if you will entrust your strategic information systems plan to them and you suspect they may lead you toward custom development.

* Define Functional Requirements in as Specific a Way as Possible. Here consultants may be very helpful, because they should have on file detailed reports of functional requirements by type of business requiring automation. If they don't have such reports, or want to create a new set of reports for your organization, consider switching consultants to one who has faced, and managed well, a similar project for another health care organization. You want to pay for as little on-the-job training of neophyte consultants as you can. Let other organizations with money to bum do that.

* Know How Consultants Differ from One Another and Hire a Firm that Fits Your Requirements. Consultants vary in their skills, of course. Learn about the strengths of the various firms you consider. Some specialize in "strategy," and those firms would worry me if they do not also have strong expertise in application programs, telecommunications, and implementation. Strategy is a safe haven for the young firm without extensive resources, but you might find them naive about the details of your business or about the vendors you eventually consider. After all, God and the devil are in the details.

Some consultants specialize in one type of information system, such as patient accounting applications for hospitals, general ledger systems, telecommunication networks, laboratory systems, or group practice accounting systems. Hire a firm that understands your needs well, and don't hire a firm your organization knows and likes if the project you want them to consult on is outside of its expertise. Some are skilled in contract negotiation with vendors, and promise to more than cover their fees in the savings they can negotiate for you with vendors. Be wary of them if you want a consultant to find a suitable vendor for your organization, because they might lead you to vendors who they know charge exorbitant prices initially and discount generously in negotiations.

Selecting a system requires knowing the industry you are in, and your needs, and not which vendor will give the largest discounts. Separate the selection of a vendor and product from negotiation of contract terms with that vendor. Some consultants really are not interested in procurement of vendors' systems, because they want to build systems from scratch. Selecting such a consultant for your procurement may lead you down the primrose path to software development. Be wary, and ask consultants about all their projects, what they do, and what they prefer to do, and what they have done, for whom. Then call their clients.

Some consultants are far more technical, and do good work of installing software, while others do better work helping the organization create a detailed information systems plan. Again, ask in detail about what they do, and where their expertise lies. If they say they can do it all, if you retain them, study them closely to make certain your organization is not paying $1,000-$1,500 per day for junior members of the firm to learn to do "it all" the first time at your site.

* Make Certain You Know Before You Contract with a Consultant Who Will Be the Day-to-Day Manager of Your Consulting Engagement. Too often, firms fly in their very best presenters, with the most knowledge of your industry, and perhaps of your firm and your competitors, and they list those luminaries as members of the consulting team to work on your project. Once their firm wins the contract, you see those luminaries little, if ever, again, because they are off presenting at other potential clients, and your project is managed by someone much younger and less experienced in your business, and your requirements, than you are. You need to be comfortable that the day-to-day manager of your engagement knows what he, or she, is doing, because that person will be your contact with the luminaries of the firm and he, or she, will be the eyes and ears of the entire firm at your site. Consequently, if the consultant does not see or hear something important to your organization's eventual success with an information systems project because of lack of experience or expertise, your project, your organization, and you suffer.

* Be as Specific as Possible in Defining the Work Plan for a Consultant, and Do Not Let the Consultant Write It. Consultants know far better than you do how they make money on engagements, what their strengths and weaknesses are, and who will or won't be assigned to your project. They want you to be specific in your requirements for information systems. They do not necessarily want you to be specific in your requirements of them. If you do not specify in detail what you expect from them, how will you know when the engagement is done? How will you know when you have received your money's worth from them? Make certain you define your expectations in detail, including the depth of detail expected in any document they produce for you. If consultants are building a system for you, make certain it is well documented, so you can continue to work on the system with employees after the consultants have left your organization. Too often, consultants cobble together software that is poorly documented, so you need to use them to continue the project.

* In Summary, It Pays to Know What You Want and What You Expect From Consultants. Good consultants will want the same thing, because they don't want to waste their time in frustrating engagements that accomplish nothing because the organization did not have its priorities sorted out ahead of the engagement. Good consultants are so busy that they want clearly defined engagements so they can succeed, earn their money, and leave a satisfied client behind to produce good references.

RELATED ARTICLE: The Informatics Institute Off and Running

The Informatics Institute taught its first class in February 1995 in Falls Church, Va. The Institute currently is offering 17 separate two-day courses, scheduled in more than 40 sessions in 1995 in the Education and Conference Center of Inova Health System. Inova Health System promotes attendance at the Institute courses to all its senior managers and affiliated physicians. Inova will send some 200 people through the Institute's courses this year. The Informatics Institute training facility includes a lecture hall and computer training rooms adjacent to it.

Courses have been scheduled so that most students will be able to attend in the same week two courses that logically go together. For instance, "Introduction to Informatics" is followed by "Hands-On Tutorial for Personal Computers" in four separate weeks in 1995. "Introduction to Informatics for Teams" is followed by "Decision Support Systems for Teams" in four weeks of the year, for teams of physicians, nurses, and others interested in developing informatics expertise in continuous quality improvement work. "Assessing Your Information Needs," a case-based study of the methodologies available for information systems planning, procurement, and implementation, follows "Informatics for Group Practices" once, "Informatics for Integrated Health Care Systems" twice, and "Advances in Information Technologies" once. "Outcomes Management and Informatics" follows "Managerial and Clinical Databases for Decision Support" twice.

The faculty for The Informatics Institute come from institute staff and experts around the nation. Leading experts in hands-on PC training, integrated information systems, group practices, managed care organizations, outcomes management and clinical quality improvement, computer-based patient records, telemedicine, and nursing informatics have joined the full-time faculty of The Informatics Institute to make the courses as relevant and useful to our students as possible.

The Informatics Institute will begin offering classes in San Francisco in 1996. Several large health care organizations have suggested an affiliation of Learning Laboratories with The Informatics Institute, so the former may cosponsor training sessions at its facility there, just as Inova Health System is promoting the work of The Informatics Institute on the East Coast.

The schedule of courses for 1996 will be released in the summer of 1995. It is already known that there will be a course on the Internet and the Information Superhighway, including extensive hands-on training on the Internet; a four-day course for indepth experience with personal computers; and a four-day course on Data Analysis for Clinical Quality Improvement projects.

Marshall Ruffin, MD, MPH, MBA, FACPE, is President and CEO of The Informatics Institute. He is also Clinical Information Officer, INOVA Health Systems, Falls Church, Va.