Trends in Informatics Case Study
believe the general principles and recommendations provided in this chapter should be equally applicable to other health- care settings, such as small and medium-sized healthcare organizations and postacute facilities.
HEALTH INFORMATION TECHNOLOGY GOVERNANCE: NEED AND CORE COMPONENTS Given that healthcare is an information-intensive endeavor, health IT represents a core pillar that enables and supports a modernhealthcareorganization’sabilitytoachieveitsstrategic and operational objectives. Indeed, health IT encompasses vir- tually all aspects of a healthcare organization’s clinical and business activities, including clinical care delivery, billing, human resource management, staffing, financial manage- ment, population health management, research, education, andthetrackingandimprovementofcarevalue.Inlargerorga- nizations, the numbers of systems and applications can be in the hundreds. Given the broad and deep involvement of health IT in all aspects of an organization’s mission and operations, healthcare organizations must ensure that their health IT efforts are aligned with their key objectives. Moreover, a healthcare organization’s strategic and operational initiatives often require health IT resources to be optimally effective. Whether it is care pathway implementation, population health management, or medication safety, it is rare for a key health- care initiative to not require health IT support. Thus the need for health IT resources (e.g., analysts and software developers) will often significantly exceed the available capacity of such resources. The critical nature of effective health IT governance then arises from the following fundamental interrelated needs:
1. The need to ensure alignment of health IT resources with institutional priorities
2. The need to effectively prioritize the use of health IT resources in the face of numerous competing demands for these limited resources
Healthcare enterprises are often recognized as being one of the most complex of all organizational structures. Consequently, when one speaks of “institutional priorities,” the list is often long and generated from multiple sources. Historically, beyond priorities established by senior leadership, requests for health IT resources are received from researchers, the finance and quality departments, specialists who are refining clinical processes or investigating clinical variances, and so forth. More recently, increasing requests from institutional stakeholders are being submitted as they work on emerging areas of priority in healthcare, such as payment reform,
personalized medicine, and more sophisticated costing meth- odologies. In summary, the demand for health IT resources and expertise is growing rapidly, the requests are coming from a broader group of constituencies, and the institutional priorities are becoming much less clear. Without effective gov- ernance, key stakeholders—including healthcare providers— will be frustrated by delayed or inadequate IT support and a resource allocation rationale they do not understand. More- over, the overall resource allocation is likely to be suboptimal for addressing institutional strategic priorities, and organiza- tions may even be supporting conflicting and overlapping projects.
The role of health IT governance is to help clarify priori- ties, allocate resources and, if necessary, approve the funding to support the expansion of available health IT resources. Health IT governance should also be accountable to track and monitor the benefits of these investments.
To meet these needs, effective health IT governance must include the following components:
• Organizational structures responsible for clearly defin- ing institutional priorities. Typically, this function is primarily the responsibility of the board of directors and senior leadership of a healthcare organization.
• Organizational structures responsible for ensuring that health IT efforts are aligned with institutional priorities and used optimally.
• Accompanying processes to operationalize the gover- nance. For example, health IT governance typically incorporates the processes in Box 29.1.
Establishing such operational processes is much more straightforward compared to establishing a governance struc- ture that appropriately owns and uses these processes; there- fore the remainder of the chapter will focus on health IT governance structure rather than on the processes used to operationalize the governance.
A sample health IT governance structure, adapted from recommendations by Hoehn, is as follows:
• Board of directors and executive management, respon- sible for setting the overall health IT strategy and clear expectations within the context of institutional priorities
• Clinical IT governance committee, including chief med- ical officer, chief nursing officer, chief medical informat- ics officer, chief nursing informatics officer, chief information officer, other relevant operational execu- tives (e.g., chief operating officer, chief financial officer), and appropriate clinical and administrative department chairs, responsible for establishing and overseeing the implementation of the health IT strategic plan
BOX 29.1 Health Information Technology Governance Activities and Processes • Formal processes for proposing new projects requiring health
IT resources (e.g., formal submission templates outlining major aspects of a project such as purpose, scope, estimated timelines, and resources; see Chapter 17 for details about pro- ject management)
• Planning future directions and investments
• Evaluating and prioritizing potential projects; evaluating, approving, and prioritizing changes to the EHR system (e.g., the introduction of new clinical decision support alerts and reminders)
• Approving funding • Monitoring return on investment for projects
493CHAPTER 29 Health Information Technology Governance
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• Various committees reporting to clinical IT governance committee, responsible for overseeing operational exe- cution of clinical IT initiatives consistent with institu- tional priorities and the health IT strategic plan2
Fig. 29.1 shows an example of an organizational chart dem- onstrating this kind of health IT governance structure. The figure shows one of many potential approaches an institution may take to create IT governance. Each institution may need to adapt this governance structure to incorporate other com- mittees with overlapping responsibilities. The next section discusses this and other relevant issues that should be consid- ered in establishing any health IT governance.
KEY INSIGHTS Respect Current Decision-Making Structures In establishing a health IT governance, strong consideration and respect should be given to the governance structures and decision-making processes that are already in place within the organization. For example, if the culture is for clin- ical department chairs to have a strong voice in institutional decisions, then the health IT governance should ensure ade- quate representation of such chairpersons. Furthermore, it is important that strong alignment be demonstrated between the initiatives of the broader organization and the focus of the health IT program. For example, if understanding and improving care value is a key focus of the institution, then supporting the measurement and improvement of value (ver- sus only profit) should be a key priority of the health IT pro- gram. If a health IT governance model does not demonstrate this alignment between organizational priorities and the pri- orities of the health IT program, barriers to effective commu- nication could be erected needlessly.
Time invested in determining who “owns” health IT gov- ernance is time well spent. In some fortunate cases, an existing committee can be modified to embrace the requirements for health IT governance. A much more likely scenario is that the topic has not been addressed. In those situations, the health IT team typically responds to “he who yells the loudest is best
heard.” Clearly the governance structure needs to be tightly aligned with the position within the organization that is per- ceived to be “ highest in the food chain” when it comes to health IT priorities and resource allocation.
Shift in Organizational Mindset For several decades, healthcare organizations focused on developing IT infrastructure and implementing a plethora of applications. The latter have consisted primarily of transaction-based applications that support the revenue cycle, back-office functions such as payroll, and the delivery of clin- ical care (e.g., EHRs). More recently data warehouses with an array of decision support and reporting tools developed by both vendors and in-house resources have emerged. These allow analysis across specialty systems—for example, robust queries can be made across clinical, financial, and staffing systems to more accurately understand the value of care delivered (i.e., outcomes achieved in relation to costs incurred). The increasing sophistication of the IT environ- ment has enabled both clinical and administrative leaders to leverage data in support of their programs and services, while also increasing the expectations that such leaders have on their colleagues in IT. For example, an institution could conduct analyses about a new warfarin clinic and its impact on patient outcomes as well as its associated operational costs to the institution for staffing, supplies, and manage- ment. Litigation avoidance costs could be also considered in these analyses.
Almost in lockstep, the emergence of the internet in the early 1990s led to customer expectations that information about all topics should be at the fingertips of both clinicians and customers (often with little consideration being given as to whether the information is accurate or can be trusted). As a result, patients and families have new expectations in terms of both access to and transparency of data from their caregivers, with the expectations of patients, families, and other health- care consumers often exceeding that of healthcare providers and institutions.
More recently, the era of Meaningful Use and health reform has brought regulatory mandates and incentives, as well as new market pressures, to the forefront. For example, healthcare is increasingly being reimbursed for the value pro- vided to patients, rather than simply on the volume of services rendered. To effectively respond to these changes, organiza- tions have had to commit significant capital to health IT while requiring ever more sophisticated data analyses to refine clin- ical care delivery processes and improve outcomes.
These internal and external forces are causing organiza- tions to rethink their priorities and how both capital and operational and human resources are focused. This requires a change in health IT governance for which many organiza- tional leaders are not prepared. Information has become a strategic asset that is essential to survival within the current healthcare context, and the demands on those with health IT expertise are expanding quickly. As the demands rapidly outstrip the internal capacity to meet the need, prioritiza- tion of projects becomes imperative. This is the role of governance.
Clinical IT Governance Committee
Board of directors and executive management
Inpatient IT Oversight Committee
Ambulatory IT Oversight Committee
Ambulatory IT project teams (e.g., for eprescribing)
Inpatient IT project teams (e.g., for Bar Code Medication Administration)
FIG 29.1 Sample health IT governance structure. IT, informa- tion technology.
494 UNIT 6 Governance Structures, Legal, and Regulatory Issues in Health Informatics
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