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Observations From the Field
Building Consensus for Common Action


 By Patricia Dodgen & Dale Emerson

 

 

Observations From the Field Background

When we first began working in Health Information Exchange (HIE), we looked carefully at the work of the eHealth Initiative. The 2007 study, Blueprint.: Building Consensus for Common Action offered a "guide to enhancing health and healthcare improvement strategies through the use of health IT and health information exchange". This paper uses that document as a baseline for our observations about HIE, its history, its progress and its future.

For past eighteen (18) months we have been working across the United States, studying the HIE environment and working with a variety of Regional Health Information Exchanges (RHIOs). As a result of these experiences, we have a number of observations concerning the progress of HIE. These observations are intended to provide insights for policy makers and others interested in building RHIOs and furthering the establishment of HIE.

Our work has taken us into both rural communities and urban areas. We have presented our ideas about RHIO development and creation to over 30 different groups, facilitated over 40 meetings about RHIOs and worked with over 250 healthcare practitioners. We have interviewed the senior staff of over 30 hospitals and clinics. We have attended three statewide conferences on HIE. In addition, we have carefully analyzed and/or responded to Requests for Information and Requests for Proposals from eight different states. Finally, we have actual, hands-on experience in facilitating the development of RHIOs in three states.

Our observations will focus on what we believe are the six primary challenges and five critical needs where help in implementing HIE is required in communities across the country. Not all communities face all six of the challenges, but we found that every community has all five needs.

The six challenges we observed include:

o Lack of a state and/or national compelling vision for HIE

o Internal organizational issues that need resolution before participating in HIE

o Failure to identify the value propositions for each participating stakeholder

o Lack of a believable business case for each participating stakeholder

o Leading with technology instead of using technology as a solution for most HIE issues

o Change is difficult

The five areas where help is needed to move forward include:

o Providing the tools necessary to help with the change process

o Building the skills and competencies needed for HIE at the state and local level

o Finding the outside, neutral assistance needed to bring disparate local groups together

o Outlining the options available to local communities for each critical component of HIE

o Designing the business case framework for stakeholders to use in determining their value in joining an HIE effort

Using case examples from various stakeholders implementing HIE in the field, we will identify how HIE is struggling and specify the help that is needed. To protect the privacy of the groups dong this work we will not identify actual RHIOs by name; however, each example is taken for our own client experience base. We presume the reader has a solid working knowledge of basic HIE concepts.

Six Key Challenges to HIE Adoption

􀂃 Lack of a state and/or national, compelling vision for HIE

Significant efforts have been undertaken at the national level to help generate interest in HIE. Even before the Bush Executive Order of 2004 many efforts have been sponsored and funded by the federal government. Several states have completed "roadmaps" outlining their strategy for achieving HIE. Various national organizations have completed studies and pilot projects to demonstrate the value of HIE. Unfortunately, there is still no compelling national vision that captures why HIE is important to consumers/patients.

President Bush’s Executive Order outlines the "what", but not the "why" for HIE. It clearly outlines an outcome and timeframe - we will have personal health records by 2014. It doesn’t offer any reason as to why this is valuable and important to each of us. There are various mission statements about HIE from federal agencies, as well as from several states. Most of the writings about HIE presume it to be valuable and move directly to the "what" and "how" of HIE. What is missing is the compelling vision , e.g. "I have a dream that my four little children will one day live in a nation where they will not be judged by the color of their skin, but by the content of their character." - that truly connects with people and enlists them in the effort to make HIE a national priority.

A clear and compelling HIE vision provides the reason for each of us to change our behavior and processes around collecting, sharing, and using personal healthcare information. Without a compelling vision, people are left to try and figure out on their own why they need HIE. Knowing the "what" without the "why" leads to uncertainty and limits the ability of HIE leaders to effect the massive changes in required for the implementation of any new program. Therefore, the personal behavioral changes needed for HIE to be adopted quickly occur more slowly and painfully, thereby inhibiting progress.

If HIE is to have any chance of achieving the 2014 deadline, the pace needs to quicken dramatically. The only catalyst that can accomplish this goal relatively quickly is the development of a national compelling vision for HIE. As we have met with groups across the country seeking to implement HIE, we have been using our own company vision and it has been well received. Our vision is "to have my health information available to me and my provider, for it to be complete, accurate, and secure, when and where I need it so I can receive the best possible care". While this is only one suggestion, we believe it connects with each of us directly and gives all of us a vision for why we need HIE.

􀂃 Internal organizational issues that need resolution before participating in HIE

Almost every hospital and physician we interviewed told a very similar story. They are currently focused on their internal operations and felt a strong need to be able to exchange data internally before they were ready to engage in a community discussion of HIE. Many of the attendees at the meetings we conducted were reluctant to state any position publicly. However, many of them made comments to us after our meeting and expressed similar sentiments. The most common comment we heard was "I need to get my own house in order before I open up to others. I don’t want to be embarrassed by our own lack of technology or interoperability".

Based on our observations and interviews, it is our belief that many hospitals may need another year or two before they may be ready to comfortably engage in a community discussion about HIE. They may attend stakeholder meetings and they may even encourage HIE, but they will remain reluctant to move very quickly to exchange any real data. They simply do not want their competitors or the public to discover their internal limitations.

The good news is that almost all of the hospitals we interviewed were in the process of internal integration. Some of them were fairly far along and had clear plans for where they were going and when they would arrive. They had carefully considered the governance structure, privacy and security issues and operational financing. Others were just beginning the process and were still developing their strategies.

Physicians were somewhat further behind in both recognition of the need for HIE as well updating their internal operations. Fewer of them acknowledged the need for HIE and those who did were just beginning to address their internal issues. Return on investment is the most often cited reason for not moving faster. Disruption to their business is the second most cited reason. However, more and more practices are beginning to recognize the value of HIE. In a program in Tampa, over 900 physician practices recently signed up for a funding program to receive software that will lead to HIE compatibility.

􀂃 Failure to identify the value propositions for each participating stakeholder

Each stakeholder group has its own unique value proposition and motivation for joining an HIE effort. Unfortunately, most HIE groups fail to recognize these differences and behave as if one value proposition works for all stakeholders or across each category of stakeholders. Usually the presumed value proposition revolves around improved healthcare outcomes. While this is certainly a part of the motivation for all stakeholders it is hardly the universally most compelling factor for everyone.

If HIE is to be broadly successful, a clear understanding of the value proposition that connects with each stakeholder group (hospital, physician, lab, payer, consumer, pharmacy, etc.) to any regional effort is important. In our work we have identified the following value propositions:

o Improved consumer healthcare outcomes

o Cost savings/avoidance

o Ability to serve more patients

o Higher quality patient interactions

o Increased revenues – Higher profitability

o Lower personal risk related to malpractice

o Enhanced competitive advantage

o Economic competitiveness

o Lower healthcare costs

o Healthier, more productive employees

o Better responsiveness to broad healthcare crisis

o Others to be discovered

Any or all of these value propositions may factor into a stakeholder group’s decision to join an HIE effort. In addition, each value proposition may be relatively more or less important to each stakeholder group and it may vary by community.

While each stakeholder group can identify with one or more of these value propositions, individual stakeholders within the group may vary on the relative importance of each one. Therefore, a regional HIE effort can encounter a complex array of value propositions for each stakeholder in their group. Determining the value proposition for each stakeholder is critical to enrolling them in the effort. Until an HIE can directly connect with and show value to each stakeholder, the necessary long-term commitment will be difficult to achieve.

For a number of reasons, determining the true value proposition for each stakeholder is difficult. It is important to be able to gain the trust of each stakeholder in order to coax them to share their underlying issues and problems that are the basis for their true value proposition for joining an HIE. Sometimes they simply haven’t thought through the issue or assume it is one thing when it may be another. Taking the time to get to the real motivation is critical to long-term success. In one major HIE project with which we are familiar, this process has taken nearly four years and required the assistance of a trusted outside third party to help facilitate these discussions. Each stakeholder completed multiple iterations before arriving at their real value propositions. It was a process of testing and retesting until they were all comfortable that they understood the value they would receive from the HIE.

The final challenge is reconciling different stakeholder value propositions when the stakeholders believe that they are competing with one another. We have seen several cases where stakeholders clearly want very different and sometimes competing results form the HIE. In one particular case the economic priorities of the community as a whole conflicted directly with the desire of the HIE stakeholders to provide better healthcare outcomes. After two years of hard work and hard feelings, the stakeholders had to stop, bring in an outside third party, take the time to rebuild trust, and then start fresh.

􀂃 Lack of a believable business case for each participating stakeholder

Long-term sustainability requires a business and financial model that generates sufficient revenues from ongoing operations to generate positive cash flow. Many of the HIE efforts we have examined ignore this fundamental requirement and attempt to build an HIE business based solely on "improving healthcare". While this is a desirable outcome, the HIE effort will suffer if the basic business case that all stakeholders can agree upon is not developed. The business case needs to detail at a minimum the following elements:

o Stakeholder trust

o Stakeholder value propositions

o Governance structure

o Products and services offered

o Markets served

o Realistic revenue and expense projections

o Marketing/Communications plan

o Community education plan

o Stakeholder training plan

o Practice transformation plan

o Others as may be required

The challenge for most HIEs is there is no national model for creating a robust business plan. Some attempts have been made and numerous studies have been completed. However, most of the studies provide a macro view of the potential costs savings and there is a limited amount of data available for a local or regional HIE. Many of the stakeholders interested in starting an HIE are professionals from the clinical or technical areas of healthcare and accordingly have very little training or experiences in business plan development. In many cases stakeholders don’t know what questions to ask, what data to collect, how to analyze the data they do collect, or how to present it so their organizations and the HIE as a whole can make sound business judgments and decisions.

One of the RHIOs we have studied has taken over three years to collect, analyze and present their business model and financial projections. They very carefully created a process where the stakeholders submitted their confidential operational data in a way that fed the requirements of the business model and still maintained the confidentially of the data. Most stakeholders will not wish to publicly release their detailed operational data, even when they completely trust the other stakeholders. Therefore, it becomes important to build a business and financial model that protects everyone’s data but still shows the short- and long-term impacts of various business decisions of the RHIO. Having a model that protects confidentially while permitting the HIE to model various projections is the one critical key to success for this RHIO.

Another key challenge in the development of the business model is that HIE participation will likely create a significant change to the stakeholders internal business model. For example, if the reduction of redundant lab tests is a way to reduce overall costs, some participants in the HIE may experience a decrease in their revenue because they will no longer perform the same volume of tests. Even if the tests eliminated are truly redundant and therefore the HIE and community benefits from reducing this duplication of effort and expense, someone loses revenue unless that revenue is offset in other ways. When doing the business and financial modeling for the HIE, it is critical that these variations in revenue are understood and accounted for in the holistic model. This will very likely require several iterations and testing of various financial assumptions and some very frank discussions before a suitable resolution may be found and agreed upon. This process takes time and can explain why some HIE’s have taken years to get their agreements in place.

􀂃 Leading with technology instead of using technology as a solution for most HIE issues

Hardware, software, and network companies have thousands of sales representatives traveling the length and breadth of the country promising that they have the comprehensive HIE solution.

There have been very few voices in the marketplace, including our own that say that HIE is not fundamentally about the technology. In fact, buying technology before you have a well defined business and financial plan that clearly defines and documents the technical requirements is completely backwards.

Every potential participant in HIE is short on time, money and resources, Consequently, everyone is looking for the simple solution that requires limited effort and focuses on technology as if it was the "silver bullet" for HIE. However, there is no simple answer. Technology is only one of the tools required to make an HIE sustainable over time. Fortunately, more and more people are beginning to recognize this fact. Recently we responded to a statewide RFI and presented these ideas about the proper strategic course. To our delight, the state in question acknowledged that nearly everyone who presented to them told the same story, "don’t lead with technology!"

However, one of the many reasons stakeholders tend to lead with technology is because the CIO is either assuming the organizational responsibility for HIE or is given this responsibility by the CEO. All too often, the CIO is the only executive at the HIE meeting representing the participating stakeholder organization and CIO’s tend to see problems from a technology point of view. We rarely see other "C level" executives in attendance or actively involved in HIE efforts. For HIE to be successful, the full support of the executive team and some level of active involvement by several key executives is necessary.. Stakeholders must be represented by multiple decision makers because implementing HIE impacts the entire organization. It is in the best interests of the "C level" executives to not only be aware but to also be involved.

􀂃 Change is difficult

HIE requires fundamental changes in the operations of all stakeholders. In his recent book "Change or Die" 3, Alan Deutschman provides evidence that if people are given a choice of changing their behavior or dying earlier, the scientific odds are nine to one against an individual successfully changing his or her own behavior, even when his or her life is at stake. This is important for three reasons. First, HIE can require changing some clinical behaviors with over 100 years of acceptance within the carefully regulated field of medicine. Second, it is important because if we don’t clearly understand the root problems solved by HIE, we are not likely to be able to affect the changes in human behavior required to make HIE work. Finally, it is important because implementing change is hard work and understanding the natural barriers people put up to resist change will help us find solutions to overcome these problems.

We have observed three primary inhibitors to the acceptance of the change necessary to create HIE in many cases across the country. The first inhibitor is a general lack of HIE knowledge at the state and local level. In discussions with people charged with implementing HIE in various communities, we have been struck by their overall lack of knowledge. In reviewing several statewide RFP’s, this lack of knowledge is evident. It is evident in the continued focus on technology, in the lack of emphasis on the necessity for building stakeholder trust. and in a failure to understand the need to change behaviors. For example, one state recently issued an RFP that in part called for a complete inventory of HIE technology in hospitals, clinics and physician practices across the state, which is a large geographic region. The committee work that identified the need to do the inventory for the state was at least a year old when the RFP was issued. We calculated it would take at least another year to complete the inventory. If we assumed the state would take another year to review the results and make any decisions, most of the applications and hardware would have been replaced and/or upgraded. Therefore, the whole exercise would have wasted taxpayer funds and delayed HIE development across the state while local efforts waited for state guidance.

Another change inhibitor is a phenomenon we refer to as the "fog bank" effect. In a fog bank, it is easy to get lost and disoriented. Some people who are resistant to the changes required in a successful HIE have discovered the best way to curtail any HIE discussion is to lead potential stakeholders into the fog bank. Privacy and security and return on investment (ROI) represent the two primary fog banks. Whenever someone wants to derail a productive conversation about HIE, they often simply lead the participants into one of these fog banks where definitive and complete answers are impossible. We have seen the same philosophical dialogue about certain privacy and security issues repeated over and over without any satisfactory resolution. The inhibitors of change can always find some aspect or permutation of a problem without solution and will argue, therefore, that all efforts are doomed. We believe those who worry and fear change are content to keep these two discussions in the fog.

Five Key Areas Where Help is Needed at the State and Local Level

Where does HIE go from here? In the first section of this paper we outlined six challenge areas inhibiting the progress of HIE. While these issues are important and need resolution, we do see many hopeful signs. There are several successful HIE efforts underway and more are coming. The industry is generally now beginning to move in the right direction and we are optimistic about the future, although concerned about the timeframe.

In order to accelerate the movement towards HIE, we believe there are five areas where help is needed that will provide the best opportunity for enhancing success in the next few years. From our direct observations, these areas are frequently ignored, skipped or given too little time to be dealt with properly. Sometimes in the rush to exchange clinical data, critical activities are overlooked, leading to less than satisfactory outcomes. The result is either the demise of a local HIE effort and/or lost time as the stakeholders are forced to regroup and address or re-address the elements necessary for success. Below are five areas that are critically important to building a successful HIE where states and local stakeholders lack either the knowledge or the tools they need for success.

􀂃 Providing the tools necessary to help with the change process

Changing people’s behavior is a process that takes time and effort. It is often difficult, never glamorous, and usually difficult to measure. In spite of these challenges the change process itself is critically important and should be recognized as a top priority in any HIE effort. What is needed in the field are tools to help local and regional HIE efforts deal with the complexities of changing human behavior.

For example, many of the federal agencies and national organizations have presented numerous presentations on what is happening at the national level and how they are working to help HIE move forward. Even though these presentations are useful in terms of information, they are not practical to the participants in HIE. We applaud eHI in its ongoing efforts to provide hands-on, usable guidance. We strongly advocate the approach that conveys the 7, 10 or 14 really useful ideas that individual HIE’s have derived from their work. This information should be distilled from the perspective of the specific state where the HIE is located, in order to take into consideration the specific legislative and legal context of that state, as well as any state roadmap considerations that should be overlaid.

This is what the HIE participants in the field want and need. They are repeatedly asking for practical and useful ideas, methods, tools, and solutions to problems similar to the ones they face but don’t understand how to resolve. They need guidance first and foremost on changing people’s behavior and easy to understand and use tools, with updates about national and state policy and thought leadership taking a back seat.

􀂃 Building the skills and competencies needed for HIE at the state and local level

In addition to the ideas, methods, tools and solutions, people in the field need skills development. Building an HIE is similar to starting a new business. Many of the stakeholders are highly skilled medical professionals and extremely intelligent people. However, the majority of them lack some of the basic entrepreneurial skills – business case development, visioning and strategic planning, marketing, financial modeling, business operations, education and training – that are required to start up a new business. They need the skills that can help them start their new HIE business.

They also sometimes lack skills necessary to bring disparate groups together to reach consensus decisions on difficult governance, privacy and security, technology, and various financial issues. We are not remotely suggesting that they are at fault. Within their profession they simply haven’t been trained or given the experience necessary to effectively accomplish this difficult task. They need help in learning how to oversee this new work. However, it can’t totally be delivered by an on-line training course, a white paper, or a workbook. They also need an experienced facilitator or designee to help guide them through the business development process.

􀂃 Finding the outside, neutral assistance needed to bring disparate local groups together

Every white paper we have read, every study we have reviewed, and every group we have talked to evaluate trust as the one key requirements for making HIE work. Trust is the fundamental building block for success. Without it, nothing productive will happen. Even with it progress is not ensured. However, the probability of success is certainly much higher with trust than without it. Developing trust is the beginning point and maintaining trust over time is the ultimate goal.

The question is where to start? In our experience, it can be extremely useful to obtain outside assistance from a neutral third party. A person or entity with no bias or particular allegiance to any of the participating stakeholders is ideal. This facilitator or mediator might be a college professor with expertise in change management, or the local or regional economic development agency who is interested in seeing the community prosper, or an outside consultant who has successfully done this type of work with others. They can sometimes even be an individual from within one of the stakeholder organizations. Whoever is chosen, they must be viewed by all of the stakeholders as someone they can all trust and someone who is viewed as capable and competent. This is vitally important in order to motivate all of the stakeholders to do all of the many things necessary to create a viable HIE.

One aspect of trust often overlooked is internal to each stakeholder organization. We repeatedly see organizations looking outward when many of their trust issues are internal. Frequently the work to build internal trust is more difficult then the effort to build external trust. Internal histories are longer, internal violations of trust are perceived as more egregious and overcoming them can be much more problematic. However, if you can’t trust your own team, trusting other stakeholders will be more difficult.

Through our work we have identified seven behavioral keys for building trust. Establishing these boundaries upfront and maintaining them over time is important to all HIE efforts.

o Transparency and openness – An HIE demands an open process where all of the stakeholders are upfront and honest with each. This is no place for hidden agendas.

o Positive communications – Communicating all of the information, activities, actions and decisions of the HIE is key to transparency and openness. Communicating these in a positive way makes the messages easier to hear, understand and internalize.

o Respect for self and others – All of the stakeholders must feel they and the other participants enjoy a sense of mutual respect.

o Clear expectations – Establish clear expectations at the beginning and keep them updated as events unfold and ensure they are regularly communicated to all participants. Each stakeholder needs to know exactly what is expected of them and of everyone else associated with the project.

o Agreed upon behaviors – Define upfront how all of the stakeholders will interact with each other with specificity.

o Model the right behaviors – Once the behaviors are defined, it is important for all of the stakeholder participants to model the agreed upon behaviors, both within the HIE working group, but within his or her own organization where the HIE is concerned.

o Accountability – Ownership of actions and activities, delivery of promised results and acceptance of individual responsibility are essential to success.

􀂃 Outlining the options available to local communities for each critical component of HIE

People working at the local and regional levels are looking to eHI and other state and national organizations about guidance on how to build an HIE. What they find are numerous studies, reports, books, white papers, and other documents that present a multitude of issues. While offering valuable information, many of these documents present HIE as a complex and complicated undertaking with many issues to be considered.

We don’t believe HIE is as complex as it is frequently presented. We see seven major capability areas for any HIE to be successful – 1) Stakeholder trust and commitment; 2) Governance, including privacy and security; 3) Financial sustainability; 4) Structure; 5) Technology; 6) Education and training; and 7) Practice transformation. Within each of these capabilities, there are numerous factors to be considered. For example, consider the simple case of structure. One of the decisions to be made is what type of entity will be created. The initial decision can be separated into two major alternatives – a for-profit legal structure or a not-for-profit legal structure. Each alternative then has a limited number of options for consideration. If the stakeholders want to consider a for-profit model, then the choices are probably limited to a partnership, an LLC, or a C Corporation. Each option has certain benefits and drawbacks that can be easily presented for discussion. In addition, each option has certain short- and long-term costs that can also be identified and analyzed.

We clearly recognize that each of the options identified above could generate lengthy discussions. Consensus decisions may take time and will need to be agreed to by all of the stakeholders. However, we shouldn’t confuse different points of view with complexity. In our view, most of the decisions factors required to form an HIE can be identified and presented relatively simply. What is desperately needed in the field, and something we are currently working to develop, is a decision framework tool. This would be a framework where all of the options about building an HIE, with pros and cons and corresponding costs and benefits, are presented in a simple and straight forward manner. All of this needs to be presented in a logical way that allows local and regional developers of HIE to understand and make solid business decisions about the construction of their HIE.

􀂃 Designing the business case framework for stakeholders to use in determining their specific value proposition from joining an HIE effort

Organizations need concrete reasons for joining an HIE. In order to provide motivation to engage and work towards a common HIE goal, the HIE must identify and quantify each stakeholder’s value proposition with as much specificity as possible as early as possible in the process. Identifying the measurable outcomes and returns related to active participation in the HIE is key to getting and keeping stakeholders engaged.

Our work has identified three areas that tend to serve as motivators for organizations to join in an HIE effort. Stakeholders may be motivated by overlapping interests in multiple areas and the HIE needs to actively capture their interest very early in the process. These three motivational areas include:

o Improved clinical interactions

- More time per patient

- Quicker access to patient information

- More patient information accessible

o Reduced medical risk

- Fewer avoidable medical errors

o Improved use of resources

- Lower costs

- Higher revenues

- Increased productivity

Various types of operational considerations factor into determining the return any stakeholder may receive from participating in an HIE. In some cases, the operational factors will be easy to determine. For example, using the amount of time spent per clinician per patient or the number of patients seen per day as simple metrics to calculate and correlate to the motivational area of improved clinical interactions. Increasing the productivity of the staff or measuring improvements in staff utilization are more difficult to determine but can be done. In any case, all operational factors for every type of stakeholder, can be established and measured over time. This simply requires the desire to measure progress, to connect with the value of the HIE and to demonstrate an ROI for the stakeholder, and the discipline to capture the data.

The final step in designing the business case framework is to get stakeholder buy-in. Even if the HIE can collect and measure direct returns for each value proposition, it is important for each stakeholder to satisfy and agree to its own specific goals and measures in participating in the HIE as they related to their operational needs and considerations. Keeping the stakeholders engaged throughout the process and continually verifying their agreement with the measures becomes critical. Providing ample opportunity for each stakeholder to understand the HIE’s business and financial models, as well as the opportunity to get internal buy-in will strengthen the entire HIE effort.

Summary

Progress has been made in HIE development over the past 2 - 3 years. However, that progress has been somewhat limited because of the challenges and needs identified in this paper. Over the next 12 to 24 month cycle, as an industry we should focus strongly on providing the specific tools that HIE efforts need to be successful, as well as the support, knowledge sharing and advocacy necessary to move to a critical mass of HIE participation by 2010. We believe this is not only achievable, but necessary.

Patricia Dodgen, CPHIMS is a Fellow of The Business Forum Institute.  Patti holds a BS, Financial Management (Cum Laude), Clemson University, 1977 and has broad experience as a senior executive in financial, technical, and operational management for various industries. She has specialized consulting experience in the telecommunications, broadcasting, print media, and computer technology fields. Currently, Patti is working on a national project to redesign the fundraising activities of a major non-profit client.  Her approach to business strategy and development evolved during her years with Dun & Bradstreet as a senior business analyst and with Digital Equipment Corporation (DEC), as a senior financial manager. At Dun & Bradstreet, Patti had the opportunity to closely examine and analyze the financial and operational successes and failures of a vast assortment of businesses of varying size within many industries. As a key senior analyst, she investigated, analyzed and developed conclusive responses to business questions for firms such as RJ Reynolds, Belk Store Services, Nucor and Bernhardt Industries. Patti is a frequent speaker at national conferences on the topics of complex change management, strategic positioning and "managing by the numbers". 

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