When Choosing Agile or Waterfall Development for Healthcare, Take a Pragmatic Approach

When Choosing Agile or Waterfall
Development for Healthcare, Take
a Pragmatic Approach

© 2014 Health Catalyst
www.healthcatalyst.com
Proprietary. Feel free to share but we would appreciate a Health Catalyst citation.
Waterfall vs. Agile Development
It may not be the epic rivalry
proportions of Pepsi vs. Coke,
iPhone vs. Android, or Chevy vs.
Ford, but if you want to watch a
group of developers (healthcare
or otherwise) get intense, bring
up the topic of Waterfall vs. Agile
development.
Each side has its ardent advocates and evangelists, and
as a rule they rarely, if ever, cross the aisle.
At Health Catalyst, we often find ourselves caught up in
the same debate.

A quick review of our
Knowledge Center would
have you believe that we
want everyone to become
Agile in healthcare.
It’s what we talk about and
promote the most.
For much of what we do for
our clients, it is the superior
choice.
It was specifically designed
to overcome issues in the
Waterfall development that
preceded it.

The reality is Waterfall versus
Agile isn’t an either/or, all-in
choice. Both development
methodologies have their
benefits and drawbacks.
What’s important is under-
standing the circumstances
where each works best and
then apply the methodology
most appropriate for the job
at hand.
In other words, understand
the principles and be prag-
matic in their application.

Navigating the Whitewater of Waterfall
Waterfall works very well
when there is a clear vision
and understanding of what the
end product should look like.
It’s well suited to projects
which follow a known path,
and has very little need for
variation or creative deviation.

Waterfall development is also
valuable when the tolerance for
imperfection is very low.
It may be the preferred method
when the benefit of risk
mitigation justifies the cost of
extensive upfront planning.
In many ways it’s like
performing surgery.
You want know exactly what
you’ll do at each step to
produce the desired outcome.

A great example of where this works well with the work we
do at Health Catalyst is in the implementation of a Late-
Binding™ enterprise data warehouse (EDW).
We have years of
experience and vast
knowledge about what
steps are needed to
establish a robust and
well-performing data
warehouse.

The EDW has a core set of
capabilities that maximize the
value of the data assets in
driving outcomes improvement.
Analytic solutions are best
derived from an environment of
iterative learning, which leads to
early and frequent value.
Waterfall development requires
all contingencies be considered
upfront, so it is ill-suited for this
type of work.

Think of attempting to develop an
analytics application to improve
throughput in the emergency
department (ED).
No matter how hard the team
works up front to determine all the
steps required, there will always
be variances.
One new regulation or software
tool alone could disrupt the entire
workflow. In this case, using
Waterfall development will likely
lead to frustration and failure.

Getting Agile
Situations such as the emergency
example on the previous slide are
exactly why Agile methodologies
were created.
With Agile, the organization
doesn’t need to know everything
about everything up front.
It just needs to have a general
idea of where it wants to go and
how it wants to get there.

Getting Agile
Some business intelligence groups
believe that they can anticipate and
plan the design before they are
even requested.
If clairvoyance is your strength then
it might be possible to deliver a
nice, pristine, finished product.
But this thinking underestimates the
importance of front-line involvement
in the successful adoption of the
end product.

Getting Agile
It is far more effective to have
those closest to the problem
provide constant feedback in
iterative cycles to ensure that
value is delivered frequently and
on target.
This methodology enables an
organization to hypothesize and
develop solutions, test and make
adjustments, and take iterative
steps until the desired outcome
of improvement is achieved.

Getting Agile
Consider this real-world example:
A group of young men ages 14-
18 were planning a five-day, fifty-
mile wilderness adventure on the
Appalachian Trail.
The adult leader determined it
would not be very effective to
hold a series of meetings to
discuss everything they would
need to pack, and then send
them on the trail for five days.

Getting Agile
Instead, they held a meeting,
discussed what was needed
and then took an overnight
camping trip.
Afterward, they met again to
discuss what they forgot as
well as what they brought, but
didn’t use.
They did a series of these short
meeting/trip combinations over
the next four weeks.

Getting Agile
By the time they went on the
long trip they knew from
experience how to be prepared
and be self-sufficient.
Despite not knowing everything
they needed to know in the
beginning, the trip down the
Appalachian Trail was a huge
success.
They attribute this success to the
short preparatory camping trips.

Getting Agile
This sort of agility is important
in any business intelligence.
But in the rapidly-changing
world of healthcare, where
new discoveries are being
made and introduced daily,
and with constantly shifting
regulations, it is highly critical.

Getting Agile
A common misperception of
Agile development is that it
doesn’t require documentation
or advanced planning. That is
simply not true.
Regardless of methodology,
there must be a plan. But,
instead of comprehensive, up-
front documentation and
planning, Agile methodology
calls for documentation and
planning in each iterative step.

Getting Agile
Quality control and all the
other rigors of development
must also be included if Agile
is being applied properly.
In a sense, the Agile
development methodology
incorporates the exact same
steps and elements of
Waterfall development, it
simply applies them in small
bite-size chunks.

Blending the Two Development Styles
In our experience, the best
solution to an organization’s
issues requires a blending of
both methodologies.
We will use Waterfall to ensure
rapid implementation of the
EDW to aggregate data from
all the disparate systems.
We will then use Agile
methodologies to create the
analytics themselves.

Replace “Sides” with Pragmatism
Clearly, what’s called for is a
change in thinking.
Rather than continuing the Holy
War over which methodology
works best, or being tied to any
particular dogma, we believe
pragmatism should rule the day.
Organizations can take a best
practices approach to every-
thing they do and select the
methodology that’s most
appropriate for their challenge.

More about this topic
The 4 Clinical Teams Needed to Drive Sustainable Improvement
Susan Easton, Kathleen Merkley, Tracy Vayo and Kirstin Scott
Getting the Best Business-Intelligence Solution for Healthcare (Executive Report)
Mike Doyle – Vice President
4 Options for Choosing the Best Healthcare Analytics Solutions (Executive Report)
Dale Sanders – Senior Vice President, Strategy
Data Warehouse Tools: Faster Time-to-Value for Your Healthcare Data Warehouse
Doug Adamson – Vice President of Architecture
Link to original article for a more in-depth discussion.
When Choosing Agile or Waterfall Development for Healthcare, Take a
Pragmatic Approach

For more information:

Dan LeSueur has been developing and implementing the core products and
services of Health Catalyst since February of 2011. He started as a data architect,
moved into a technical director role and is now a Vice President of Client and
Technical Operations. Prior to joining Health Catalyst, Dan owned and operated a
management consultancy for five years that assisted ambulatory practices in the
implementation of electronic health records and data-driven management
methodologies. In this venture he served as data architect, business-intelligence
developer, and strategic advisor to physicians and practice owners in the strategic management and
growth of their practices. Dan holds Master’s degrees in Business Administration and Health-Sector
Management from Arizona State University and a Bachelor of Arts degree in Economics from
Brigham Young University.
Other Clinical Quality Improvement Resources
Click to read additional information at www.healthcatalyst.com

When Choosing Agile or Waterfall Development for Healthcare, Take a Pragmatic Approach

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