Marion, it's great to have you back again. It's always a pleasure to speak with you and to hear about the stories that you have from the many decades of experience in the field of health informatics. It's so wonderful that you've brought with you just a handful of the many publications. Many of the books that you've published and what I want to do now is talk to you a bit. You and I have talked about John Kotter a lot. His seminal work on developing his Eight-Step Model for Change after researching hundreds of organizations. I want to start with step one now and this issue of creating a sense of urgency and how important that can be in order to successfully lead organizational change. Can you share with us an example of a time where that been important for you. Okay. Well, I guess first we have to remember nobody wants to change. Yeah. You're happy where you are in your fat and happiness. So, if you want to bring about a change how do we bring it about and that's what you [inaudible] , and I think just from a global perspective, you can see when we had the Y2K crisis, that was an urgency. That change in centuries was going to happen whether we liked it or not. Yeah. So, that created a sense of urgency for all people who are running computing centers and everybody had to buckle up and say, hey listen, we're going to have to look it up [inaudible]. So, a lot of it and as because the urgency was created, it really went very smoothly. If nobody would've, seconds, they would've had crashes, we would've had computer crashes. This might even crashes because systems wouldn't have worked. So, that urgency forced the whole computer industry to really get their act together and to prepare for the change that was inevitable and that was going to come. For students that might be younger, Y2K. Yeah. What's funny is it was in my first year of college. You're just a spring chicken, young lady. Yeah. So, I do recall flying home. I did my undergrad at Stanford where Dr. Leeman trained as well, and I remember flying home for New Year's Eve to be with my family in Arizona, and we were turning from 1999 to the year 2000. So, what's the issue with Y2K that Dr. Ball is referring to. So, when you go from 1999 to the year 2000, all of the systems weren't designed to handle that 00 from the 99. So, there was a huge amount of urgency, and that's an impetus to force people to re-evaluate the way they've designed their system. Exactly. Yeah. So what they actually did in those case in many computing centers, they realized that their all systems couldn't even handle it. They brought in new systems. They had new programs, and that was then successful, and that they were very minimal problems because of that. But that's one, that's true, I would say everybody remembers that, but here you, you're right. These kids and even younger than you are. But anyway that was an example of creating, it was an urgency that was created by the inevitable. Inevitable. Yeah. Okay. Now, we're going to talk about an urgency in the healthcare area, particularly. This goes back since you asked In my experience, I was a professor and Chief Information Officer which wasn't even a term. I was director of computing at Temple University, and for many years from 1969 till 1985 when my husband was given a position at the University of Maryland, so we moved here, and I was very fortunate that the time to be hired at the University of Maryland because they had just put in and received a grant from the National Library of Medicine which was called an IAIMS grant, the integrated advanced information management system. Which meant that their university which was a silo of of schools: the nursing school, the medical school, the dental school, the school of law, the social work. So, in other words they had all of the different schools each doing their own thing and each operating on their own bottom, so to say. Right, plenty of redundancy and waste in that system. Universities is a nice comparison to the way healthcare has been with the silos. Yes, exactly. I know that's a that's a very good interesting point. Exactly. So, the proposal that they'd already gotten a grant to see if they could put a plan together, and so it was a planning grant that was funded by the National Library of Medicine now in 1984. So, we know going back, and it was why many universities competed for it, and only four got the grant, and that was the University of Maryland, it was Columbia University, University of Utah, and Georgetown. So, those were the four institutions that got it, which already gave them a lot of status. So, finish you see first of all you have to feel, you've got something that the others don't have. So, you're already set up a certain amount of willingness to maybe go an extra mile to keep the momentum. Right. Anyway, so that was the beginning of the whole thing. So, now we have to bring about the change in honoring the proposal that was granted and the next step that NL, National Library of Medicine required was that, now the next step was to put together a model program that you would begin to start implementing in a small way. Okay. So that meant, how could we bring together the deans of all of the diverse schools to work towards seeing how could we bring a integrated advanced information management systems together, that's what IAIMS stood for. IAIMS, yeah. So, we looked at what do all of these schools have in common where they could not necessarily disagree. They all use the library, and as primitive as it might have been at that time they all did use the computing center. So, those were the two areas that you could say research Spanish parking, any other question you would have there would be a lot of arguments. So, the first thing was to see where could you find something that they could possibly. A common need, yes. And agreement. So, that was a big step forward that you said okay. So, one of the things that I was brought into I was as I said at Temple University and then came here and I was made the director of Health Science Computing at University of Maryland. So, what we did first of all we said given the fact that we've got a resource here, which we can combine that every school would be willing to use and agree upon. We got funding from the state to build actually little bit later on, but we'll work towards the second largest health sciences library in the United States, which is here at the University of Maryland, and it's a regional medical library and that's one of the reasons we at Hopkins are a member of the regional library. Okay. So, what you're describing is this movement towards a shared service model? Everything, yeah, exactly, and also to see how do we combine, they're still separate the Library and Information Services, I mean there are two complete. So, my job was to see how do we do that and we designed the building, so that they would be in the same space. So, the important is if you in proximity and you have breakfast together, and you see each other, there's a certain kind of bonding that happens almost automatically. So, as you said, how do we stress? How do we set change to come about? So, the plan really was that even the building itself that are the outside windows would be where the offices would be, both librarians. We even thought about that already calling them Informationist, which we're now starting to do 25 years later. Anyway, to say they're not really just librarians, they are using the computer systems already then. In those days Med Line, you had to pay for, but the thing is we were able to get that part of it together. So then, we started to see, we say okay. Now, how do we get all of the schools to agree, for example, on a common e-mail system, very basic things. So, now we bring about the change of voicemail, just at that time, Unisys which was a company that's almost not even in existence anymore. We were able to get 20 lines of a voicemail, so that the dean could then or the Vice President for Information, vice president of the University, which was a guy by the name is Dr. Ed Brandt, who had been Secretary of Health, was at the University of Maryland. We've got 20 of these lines as a gift. Now, how do we motivate them to use the voicemail? I don't like to use the phone. If I want to see somebody, you can come to my office, and the dean, and the president said, look I want to be able to put one message out that everybody can hear, and you're not going to hear it unless you get a voicemail system. We'll teach you how to use it, and so the urgency was set up by the fact that, all the deans didn't want to be left out on the call. They wanted to be sure end of the day again, have to have support from the top. If you don't have, he was the one who said I'm not the only way you're going to get that as if you get on that phone. Yeah. When we talk about organizational readiness for change, it's interesting. If you don't get that support. The management support. So, that's number one, if you don't have the top support and they are not supporting you, forget it. I'm going to take you one step back though in Million, when you talk about the IAIMS project and what was the reason for NLM? Granting this award to the four different institutions. What was there, I want the students to hear about the role of the National Library of Medicine. Well, mainly, the National Library of Medicine, is an incredible organization, you should just know it. It is in my opinion, the jewel in the crown of the National Institutes of Health. It is really the United States gift to the world, because it's the only medical library worldwide. There are other libraries, the British Library, they have within their libraries, sections, but this library is only dedicated to health. It's all it is, we get over a million hits a day. You have, I've been fortunate, I served on the Board of Regents for over 11 years. So, I was really lucky to be on the BRC. I've had a 30-year love affair, so to say, with the National Library site. I say, I know I've a certain prejudice to the way, but I feel it's such an incredible organization with databases for pharmaceutical products for emergency. I mean, it's not just books, in every aspect of being able to get information when way you need it, you can get through the National Library of Medicine, just not PubMed, and Medline, and all that, but you can get aging projects. You can get visual help. I think there are like 60 different databases that people aren't even aware of, but the whole library was saying, how did this- and of course, the University of Maryland was a regional medical library. They have regions all over the country. We have the northeastern region here. But anyway, their motivation was to say, ''Look, how do we get the best dissemination of information to the healthcare professionals?'' Which means, you have to communicate with each other. They are also the ones that fund as you know, training programs for medical informatics for the last 30 years. The big training programs. We would not be in medical informatics if it weren't for the National Library of Medicine. So, they have realized how technology can be a binder and bring together all of the various healthcare professions, and have put their money where their mouth is, so to say. So, that's- Yeah. Aims Project was a great success. They also realized not every one of the four institutions I talked about, did it the same way. Now, that would give all other academic health centers an opportunity to emulate either one of the four, and they did. So, part of what we are now is as a result of the IMs Project, which is now 30 years old. But anyway- One thing I was going to say about that is, it's interesting the students learned about data, information, knowledge, wisdom, DIKW pyramid, and what we're really talking about here is the NLM saw that there were these disparate disconnected sources of information, and providers needed the latest. They needed to have access to all of this information. So, there was that sense of urgency as the- Well put - the amount of- Yes. -knowledge, and the amount of research, and the rapid speed, picked up over the past several decades, and the NLM saw that okay, there's a lot of redundant work going on and a lot of good information that's being published, but it's not being disseminated. Like you said, Exactly. It's really great that institutions like yours, and in the role that you were in, applied for this and recognized the opportunity that existed to really have a huge legacy with the IMs project. Let me tell you. Those of us who wanted to bring about that change, it sounds like a great idea, who wouldn't buy into it? A lot of resistance, a lot of arrows in the back. I'm just going to give you one little example, because it is a case study, and I think I've told you this story before. But, just look at the one project, there were many. We're going to look at, how do we now bring these 20 telephone- these telephones, into a family of voicemail so that the president of a university, the chancellor he was called at the time, could communicate at one moment with all of them? So they were all-. Which is so funny, because this must sound so antiquity for some but we're talking in the 1980s? Yeah. We're talking 1980s. We're talking 1989, let's say. Yeah. Okay. So, we hired somebody to come and help us to implement these 20 phone calls which meant to individually go to the deans, convinced them and the chairman of the department, because we had more than just the chief chairman to do that. So, one case, and there were many, not quite as drastic like this one but I'm going to give you the drastic one. So, we went to the dean, I did, to the dean of that, because I didn't put- we knew this was going to be a difficult person. So, when you are a good director, you take the hard ones, and give your people like the light ones. So, the Dean of the School of Social Work, we won't mention any names, was an older lady, did a lovely job as Dean of School of Social Work. The first thing that we realized that some of the deans had rotary telephones, which you guys don't even know about it, the touch tone telephones. So, we knew that we needed to first get this dean a touch-tone telephone. So, I figured out when it was her birthday, try to be nice, and the importance of building rapports by the way, with people, that's so crucial. In any case- Can't emphasized that enough. Yeah, can't emphasize it enough. I mean, I have a nice rapport with her, and I said, ''Look, it's your birthday, and I even put a pink bow on it. She opens this thing, and she says, ''What in God's name is this?'' I said, ''Dean, this is going to be your newest. I'm giving you a gift, that's just your new telephone because we're going to replace your rotary phone, because we're going to install a voicemail system so that you can leave messages, and you can listen to the weekly reports, and the daily reports that transfer would like to share with all of the deans and all of the deans are invited.'' She took that phone, and she threw it at me. Just to give you an idea. Different human resource policies back then. I figured, I guess she's not interested in this, and I figured, this is lucky, I'm a good catcher, I did catch the thing. I figure I better go right to the transfer and tell him what's happening. Because before- There was a little bit of resistance to change Mr. Chancellor. Yeah. The bottom line is, this particular dean never used that phone, she resigned a year later. When they say, mode of change comes about through death and taxes, believe me, this was an example of it. She was not an early adopter. That's for sure. She was not. She was not an adopter at all. Some of the other ones that were doing, were also very angry and just say, ''Well, I guess I have to. I'm going to do it, but I don't like it, and made it very unpleasant for the person.'' So, the urgency of change was, you're not going to get any information from your transfer, if you don't get onto that voicemail system. It was not complicated, but it was a change and people don't like change, resistance to change, just a good example. Huge. Yeah. Now, I think that's fantastic, it's going to wrap it up. It's a true story. Right. I know, and I think it's a great example of something so simple as switching from a rotary phone, whereas nowadays we all want the newest technology. But I think as you're learning about provider resistance, initially to Computerized Provider Order Entry, or as we're talking about provider resistance to accepting patient-generated health data or in incorporating data from wearables, or patient reported outcomes, or using population health management registries, think about that rotary phone example, and the resistance from that social work dean. I was going to wrap up this segment by reading, the students have access on the website to a 2,000 Jamie article, Managing Change, by Nancy Lorenzi and Robert Riley, and what they say is, ''It has become apparent in recent years that successfully introducing major information systems into complex health care organizations, requires an effective blend of good technical and good organizational skills. A technically best system can be brought to its knees by people who have low psychological ownership in the system, and who vigorously resist its implementation. The leader who knows how to manage the organizational impact of information systems, can sharply reduce the behavioral resistance to change including to new systems and technology to achieve a more rapid and productive introduction of information technology.'' End quote. Even if that means going in with the present and a pink bow, whatever's needed right? I just wanted to say Nancy Lorenzi is one of the most incredible people who just doesn't work and change management. She's also got two books in our series, this is a series, this is the springer series on healthcare informatics. Nancy has been primarily responsible for very successful implementations at Vanderbilt University. That book she wrote about, I think, it's in the third or fourth edition, about started at 20 years ago. Yeah. Fantastic. She's a great change agent. You're lucky to have all these resources. We didn't have them 30 years ago. Thanks so much. Thank you
