Wrap Up

Chapter 14 Health IT Leadership Case Studies

Case 1: Population Health Management in Action Although the integration of patient-centered medical homes and accountable care organizations into the health system is still emerging—as are best practices and key learnings from these early efforts—there have been myriad examples demonstrating encouraging returns and improvement in quality of care. The Patient-Centered Primary Care Collaborative recently profiled several organizations that have adopted patient health management (PHM) tools and strategies to address the preventive and chronic care needs of their patient populations.

Bon Secours Virginia Medical Group Richmond, VA Provider Type: Multispecialty group practice Locations: 140 Patients: 25,000 (Virginia) A pioneer in implementing medical home and accountable care initiatives, Bon Secours has dedicated itself to executing a sustainable care delivery model that is in alignment with health care reform across its providers and locations. Bon Secours's transformation into an organization that embraces PHM is the result of a systematic strategy to reengineer primary care practices, integrate new technologies into care team workflows, and engage patients in their care.

Bon Secours took a leap of faith in implementing these changes, acting on the belief that payers would come to them if they built a viable model. And payers did. The organization was selected as an early participant in the Medicare Shared Savings Program. It has also signed value-based contracts with two commercial payers—CIGNA and Anthem—and is in negotiations with several more. These contracts provide a financial mechanism to expand and scale the medical home initiative and support ACO models. This case study examines in more detail Bon Secours's approach to position itself to achieve quality outcomes and financial success in the changing health care environment.

Bon Secours's Care Team Model The foundation of Bon Secours's strategy for value-based care is its medical home initiative—the Advanced Medical Home Project. The project began as a pilot five years ago. Since that time, eleven practices have earned NCQA recognition as patient-centered medical homes. One of the most significant objectives of the Advanced Medical Home Project is to improve capacity—making it possible for care teams to double the size of their patient panel without overburdening themselves or sacrificing quality of care.

At the heart of this medical home strategy is the effort to reengineer practices by creating high-performance physician-led care teams, which requires changes in workflow, new care coordination activities, and designed delegation of clinical responsibilities across the care team. To facilitate this process, Bon Secours has invested significantly in embedding care managers

into the primary care team. These nurse navigators are registered nurses (RNs) who are either board-certified case managers or actively working toward certification.

Each nurse navigator is assigned a panel of approximately 150 high-risk patients. He or she cultivates a personal relationship with these patients, usually through repeated phone contacts. Although most outreach is telephonic, navigators have the skill to assess which patients require face-to-face intervention. And because they are embedded in the practice, they can spend time with these patients doing assessments, care planning, and education.

Bon Secours's eHealth Strategies An important aspect of Bon Secours's strategy is implementing health information technology that empowers the care team to efficiently manage the health of their populations. They consider this technology—standardized across the medical group—as the key to enable them to scale their system for value-based care. As a first step, Bon Secours implemented an EHR and all its modules in every practice within the system. This gave them a strong foundation for documenting care and accessing health records across the enterprise. Risk stratification. They were able to build a registry that could identify high-risk and high-utilization patients based on data such as number of medications or frequent visits to the emergency department. However, the organization recognized the need for a more robust, scalable registry that would drive efficient population health workflows in their practices and enable analytics and predictive modeling across multiple clinical conditions.

Integrating their EHR with a PHM platform, Bon Secours is able to aggregate all source data into a population-wide registry that enables the organization to implement multiple quality-improvement programs simultaneously. The registry stratifies the population by risk—providing a total population view while enabling each care team to drill down to the data they need about cohorts and individual patients. The system enables care teams within the practice to monitor their patients' health status and take action by delivering timely and appropriate care interventions. Because the system automates these interventions, care teams are able to communicate with many patients at once.

Automated outreach. A significant priority for Bon Secours has been preventing thirty-day readmissions. The medical group uses an automated outreach system to identify discharged patients, link them to a primary care provider (PCP), and pinpoint those who are at high risk for readmission. Flagged patients are then called within twenty-four to seventy-two hours to reinforce discharge instructions, make sure their medications are reconciled, and set up an appointment with the primary care team within five to ten days of discharge. Bon Secours will soon implement a readmissions solution to automate the process of calling discharged patients, asking them to complete a short assessment, and escalating cases as needed based on their feedback.

Personal health records. Another strategy for patient engagement is activating patients on an electronic personal health record (PHR), which allows patients to view clinical results and communicate conveniently with their caregivers via e-mail. Bon Secours works to gain

physician consensus on policies that drive the use of PHR: physicians agreed to allow automatic release of normal results to the PHR, but abnormal results are held for 24 hours to enable the care team to contact the patient. The organization is relying on physicians and staff members to get patients active on the PHR to help them sign up on the spot in the exam room.

Challenges and Lessons Learned Gaining physician buy-in for reengineering practice workflow. The concept of the care team can be difficult for some physicians because they see themselves as the clinician and the rest of the team as support staff members. To help physicians embrace the care team and delegate patient-care tasks, Bon Secours placed tremendous emphasis on physician education. The organization also allows physicians to adjust some of the standardized care team protocols to meet the needs of their practice, which fosters ownership of the process and assures physicians that they remain in control.

Paying for the transition to value-based care. As mentioned previously, Bon Secours implemented its medical home model with the hope that payers would come to them if they built a viable program. CIGNA currently gives the organization a per-member per-month (PMPM) adjustment for care coordination. Anthem, the group's biggest payer, pays a care coordination fee and will change to PMPM in the coming year. Several more commercial payers are lined up to sign contracts with the group. However, this payer involvement is a relatively new development. For the first few years of the project, Bon Secours shouldered the expense. The organization is now poised to reap the rewards of its investment.

Bon Secours is also demonstrating significant progress managing its CIGNA population. In the first six months of their value-based contract, they have achieved a 27 percent reduction in readmissions and are $1.8 million below their projected spend. They have hit many of their care quality metrics and need to improve their gap-in-care metrics only slightly to achieve the index necessary to qualify for gain sharing with CIGNA—a development that will bring a projected annual savings of $4 million.

Bon Secours's mantra for the future is “health care without walls.” The organization is aggressively pursuing remote, noninvasive monitoring for highly acute case management. Their vision is to bring care outside the four walls of the hospital into the patient's home using technology. They are operationalizing a geriatric medical home that will enable patients to age in place with home visits for preventive and acute management. They are also expanding their implementation of the PHM platform to include performance measurement at the group, site, and provider levels; feedback to providers on variance in care; and quality reporting. This added functionality for analytics and insight on the clinical and administrative levels will help the organization ensure that it is meeting the triple aim (to improve the patient experience of care, including quality and satisfaction; to improve the health of populations; and to reduce the per capita cost of health care).

nnovation Impact Thirty-day readmission rate for medical home patients was < 2 percent for two years.

Patient engagement scores were in the 97th percentile. Patient outreach efforts generated approximately forty thousand unique patient visits for preventive, follow-up, or acute care, leading to $7 million increased revenue. Source: Shaljian, M., & Nielsen, M. (2013). Managing populations, maximizing technology: Population health management in the medical neighborhood. Patient-Centered Primary Care Collaborative. Retrieved from https://pcpcc.org/resource/managing-populations-maximizing-technology. Used with permission.

Case 2: Registries and Disease Management in the PCMH Union Health Center (UHC) New York, NY Provider Type: Community Health Center Medical Home NCQA Level 3 Patients: 11,000 Office Visits: 55,000 UHC's Care Team Model Union Health Center (UHC) embraced the patient-centered care team model very early on, which helped ease the transition to new workflows, processes, and features that are critical to change management and quality improvement. UHC clinicians and staff members are assigned to clinical care teams, composed of physicians, nurse practitioners, physician assistants, nurses, medical assistants, and administrative staff members. The practice uses a full capitation model with standard fee-for-service and a fee-for-service plus care management payment model.

Ten years ago, UHC instituted the California Health Care Foundation's Ambulatory Intensive Caring Unit (AICU) model, which emphasizes intensive education and self-management strategies for chronic disease patients. The model relies heavily on the role of medical assistants (called patient care assistants or PCAs) and health coaches. Working closely with other members of the care team, PCAs and health coaches review and update patient information in the record, conducting personal outreach and self-management support, and providing certain clinical tasks. For instance, all PCAs have been trained to review measures (e.g., HgbA1C, blood pressure, and LDL cholesterol), provide disease education, and set and review patient health goals. A subset of higher-trained health coaches works more intensely with recently diagnosed diabetic patients or those patients whose condition is not well managed.

UHC's eHealth Strategies Patient registries. UHC uses patient registries to identify patients with specific conditions to ensure that those patients receive the right care, in the right place, at the right time. In some instances, they use registries to target cases for chart reviews and assess disease management strategies. For example, patients with uncontrolled hypertension are reviewed to help identify treatment patterns, reveal any need for more provider engagement, and may indicate the need for care team workflow changes. In the future, UHC would like to construct queries that combine diagnosis groups with control groups and stratify patients by risk group.

For example, care teams could pull a report of all patients over the age of sixty-five with multiple chronic conditions or recent emergency room admissions.

Maximizing time and expertise. UHC uses technology such as custom EHR templates to support PCAs and free up clinicians for more specialized tasks and complex patients. For example, a PCA or health coach taking the blood pressure of a high-risk diabetic patient has been trained to determine whether or not BP is controlled. If it is not controlled, the health coach checks the electronic chart for standard instructions on how to proceed and may carry out instructions noted in the record. Or, if no information is available he or she will consult with another provider to adjust and complete the note. Following all visits with PCAs or health coaches, the patient's record is electronically flagged for review and signed by the primary care physician.

Working with medical neighbors. The teams also collaborate with on-site specialists, pharmacists, social workers, physical therapists, psychologists, and nutritionists to enhance care coordination and whole-patient care. UHC has also adopted curbside consultations and e-consults to reduce specialty office visits. For example, if a hypertensive patient has uncontrolled blood pressure, the record is flagged by the PCA for further follow-up with a physician or nurse practitioner, who may opt for an e-consult with the nephrologist to discuss recommendations. UHC also has a specialty coordination team—composed of two primary care physicians, one registered nurse, one PCA, and one health coach—which functions as a liaison between primary and specialty providers.

Customized reporting. With their most recent upgrade to a Meaningful Use–certified version of their EHR, UHC will have the capacity to generate standardized Meaningful Use reports. UHC intends to construct queries that generate reports that group diagnosis groups with control groups and identify and manage subgroups of high-risk patients (or risk stratification). For example, care teams can run a report of all patients with diabetes that have an elevated LDL and have not been prescribed a statin.

Challenges and Lessons Learned Recruiting staff members with IT and clinical informatics expertise. Over the years, UHC has faced challenges in identifying and recruiting staff members with the right mix of IT and clinical informatics skills. Although effective in troubleshooting routine issues and hardware maintenance, UHC felt there was a clinical data analysis gap. To resolve this, UHC works closely with an IT consultant and also recruited a clinical informatics professional to work with providers and performance improvement staff members.

Consistent data entry. UHC's lack of consistent data entry rules and structured data fields led to several challenges in producing reports and tracking patient subgroups. The problem stems from UHC's lack of internal data entry policies as well as the record's design. For instance, UHC cannot run reports on patients taking aspirin because this information may have been entered inconsistently across patient records. Moving forward, UHC will be implementing data entry rules and working closely with their vendor to maximize data capture.

Real-time data capture. UHC realized that by the time data reach the team, they may no longer be current. As a workaround they considered disseminating raw reports to clinical teams in real time, followed by tabulated, reformatted data. They are exploring the possibility of purchasing report writing software to streamline the process.

Managing multiple data sources. Similar to many practices, UHC pulls data from its billing system and clinical records, causing issues with data extraction. For example, pulling by billing codes does not provide the most accurate data when it comes to clinical conditions, health status, or population demographics. UHC recognized that to reduce errors in identifying patients and subgroups this will require custom reports.

Innovation Impact Forty-six percent reduction in overall annual health costs Eighteen percent reduction in total cost of care Significant decline in emergency room visits, hospitalizations, and diagnostic services Significant improvements in clinical indicators for diabetic patients Source: Shaljian, M., & Nielsen, M. (2013). Managing populations, maximizing technology: Population health management in the medical neighborhood. Patient-Centered Primary Care Collaborative. Retrieved from https://pcpcc.org/resource/managing-populations-maximizing-technology. Used with permission

Case 3: Implementing a Capacity Management Information System Doctors' Hospital is a 162-bed, acute care facility located in a small city in the southeastern United States. The organization had a major financial upheaval six years ago that resulted in the establishment of a new governing structure. The new governing body consists of an eleven-member authority board. The senior management of Doctors' Hospital includes the CEO, three senior vice presidents, and one vice president. During the restructuring, the CIO was changed from a full-time staff position to a part-time contract position. The CIO spends two days every two weeks at Doctors' Hospital.

Doctors' Hospital is currently in Phase 1 of a three-phase construction project. In Phase 2 the hospital will build a new emergency department (ED) and surgical pavilion, which are scheduled to be completed in eleven months.

Information Systems Challenge The current ED and outpatient surgery department have experienced tremendous growth in the past several years. ED visits have increased by 50 percent, and similar increases have been seen in outpatient surgery. Management has identified that inefficient patient flow processes, particularly patient transfers and discharges, have resulted in backlogs in the ED and outpatient areas. The new construction will only exacerbate the current problem.

Nearly a year ago Doctors' Hospital made a commitment to purchase a capacity management software suite to reduce the inefficiencies that have been identified in patient flow processes.

The original timeline was to have the new system pilot-tested prior to the opening of the new ED and surgical pavilion. However, with the competing priorities its members face as they deal with major construction, the original project steering committee has stalled. At its last meeting nearly six months ago, the steering committee identified the vendor and product suite. Budgets and timelines for implementation were proposed but not finalized. No other steps have been taken.

Case 4: Implementing a Telemedicine Solution Grand Hospital is located in a somewhat rural area of a Midwestern state. It is a 209-bed, community, not-for-profit entity offering a broad range of inpatient and outpatient services. Employing approximately 1,600 individuals (1,250 full-time equivalent personnel) and having a medical staff of more than 225 practitioners, Grand has an annual operating budget that exceeds $130 million, possesses net assets of more than $150 million, and is one of only a small number of organizations in this market with an A credit rating from Moody's, Standard & Poor's, and Fitch Ratings. Operating in a remarkably competitive market (there are roughly one hundred hospitals within seventy-five minutes' driving time of Grand), the organization is one of the few in the region—proprietary or not-for-profit—that has consistently realized positive operating margins. Grand attends on an annual basis to the health care needs of more than 11,000 inpatients and 160,000 outpatients, addressing more than 36 percent of its primary service area's consumption of hospital services. In expansion mode and currently in the midst of $57 million in construction and renovation projects, the hospital is struggling to recruit physicians to meet the health care needs of the expanding population of the service area and to succeed retiring physicians.

Grand has been an early adopter of health care information systems and currently employs a proprietary health care information system that provides (among other components) these services:

Patient registration and revenue management EHRs with computerized physician order entry Imaging via a PACS Laboratory management Pharmacy management Information Systems Challenge Since 1995, Grand Hospital has transitioned from being an institution that consistently received many more inquiries than could be accommodated concerning physician practice opportunities to a hospital at which the average age of the medical staff members has increased by eight years. There is a widespread perception among physicians that because of such factors as high malpractice insurance costs, an absence of substantive tort reform, and the comparatively unfavorable rates of reimbursement being paid physician specialists by the region's major health insurer, this region constitutes a “physician-unfriendly” venue in which to establish a practice. Consequently, a need exists for Grand to investigate and evaluate creative approaches to enhancing its physician coverage for certain specialty services. These potential approaches include the effective implementation of IT solutions.

The findings and conclusions of a medical staff development plan, which has been endorsed and accepted by Grand's medical executive committee and board of trustees, have indicated that because of needs and circumstances specific to the institution, the first areas of medical practice on which Grand should focus in approaching this challenge are radiology, behavioral health crisis intervention services, and intensivist physician services. In the area of radiology, Grand needs qualified and appropriately credentialed radiologists available to interpret studies twenty-four hours per day, seven days per week. Similarly, it needs qualified and appropriately credentialed psychiatrists available on a 24/7 basis to assess whether behavioral health patients who present in the hospital's emergency room are a danger to themselves or to others, as defined by state statute, and whether these patients should be released or committed against their will for further assessment on an inpatient basis. Finally, inasmuch as Grand is a community hospital that relies on its voluntary medical staff members to attend to the needs of patients admitted by staff members such as some ED personnel, it also needs to have intensivist physicians available around the clock to assist in assessing and treating patients during times when members of the voluntary attending staff members are not present within or immediately available to the intensive care unit.

The leadership at Grand Hospital is investigating the potential application of telemedicine technologies to address the organization's need for enhanced physician coverage in radiology, behavioral health, and critical care medicine.

Case 5: Selecting an EHR for Dermatology Practice Suppose you've just been hired as the practice administrator of an eight-physician dermatology practice. After several years of contemplation and serious deliberations, the physicians have made the strategic decision to invest in the selection and implementation of a facility-wide EHR system. They also want to replace their practice management system (which includes patient scheduling and billing). It's an older system that is rather clunky. Ideally, they'd like to find an integrated practice management system that has an EHR component.

Dan Brown, the current CEO of the physician organization, has very little knowledge of information systems technology. He has been reluctant to move toward an EHR system for many years, primarily because he heard stories from a few his colleagues in other specialty areas who have implemented EHRs in their practices and have found the systems to be highly cumbersome and disruptive to the patient care process. One of his best friends claims he “spends an extra hour or two a night in the office because of the additional time demands of the EHR. He claims the system never seemed to work right.” Brown is convinced that there are not any great dermatology-related EHR products on the market, but with value-based payment looming, and the opportunity to improve quality of patient care, he's open to taking another look. In addition, one of their newest partners, Pam Martin, just finished her residency program where EHRs were an integral part of her training. She is a big champion of the effort to select and implement an EHR. She has offered to help lead the effort. One of the other partners, John Harris, came back from a conference impressed with the vendor presentation from Allscripts and convinced it's the way the practice ought to go. The other physicians are nearing retirement and a little nervous about the possible disruption to the office.

Information Systems Challenge Even though the patient records at the dermatology practice are paper-based, the practice has been using computerized practice management systems for patient scheduling and billing for years. Six months ago, they started to have a nurse enter physician-dictated notes into the paper record while in the examination room with the patient. The physician then reviews the notes at the end of the visit or day and signs off on them. This is in an effort to decrease the dictation and transcription that the practice had historically done and to get the nurses and physicians ready for the EHR. The expectation is that nurses will do the bulk of the data entry in the exam room while the physicians are seeing the patients. However, the physicians will have to review the documentation and sign off on all entries.

The practice currently has approximately four thousand patient visits per month, including 40 percent Medicare and 10 percent Medicaid.

Case 6: Watson's Ambulatory EHR Transition Primary care physicians play a key role in the US health care delivery system. These providers integrate internal and external information with their clinical knowledge to determine the patient's treatment options. An effective ambulatory EHR is critical to supply physicians with the information they need to provide quality care and maximize their efficiency. This case involves the decision-making process to replace an inadequate EHR system in a primary care network owned by a community hospital. The IT challenge reviewed in this case will be the decision-making process that optimizes provider support for the new EHR while addressing the strategic plan requirements of data integration, clinical application, and practice management functionality.

Watson Community Association is a private, not-for-profit corporation that operates Watson Community Hospital (WCH), a two hundred–bed acute care facility located in Arizona. WCH has pursued a strategy of employing primary care physicians in their primary service area to provide convenient points of access for patients and to secure a primary care base for the specialists who use the hospital. WCH employs thirty-six physicians and seven mid-level providers in eight clinics, specializing in internal medicine, family practice, infectious disease, and gynecology.

Several years ago, the WCH board of directors adopted a plan to implement a system-wide EHR to, among other things, improve patient safety, integrate information from ancillary systems, and provide access to patient information for all WCH caregivers. In addition, the plan calls for an evaluation of the effectiveness of the WCH physician clinic organization's EHR.

The WCH clinics currently use the XYZ Data Systems Integrated EHR and Practice Management System. This system has been operational for four years. The XYZ system was chosen because of its compatibility with the hospital's Meditech platform. Physician needs and application functionality were secondary considerations. As a result, physician system adoption and support has been poor. Under prior leadership, the hospital IT department provided limited support for the XYZ EHR. The clinic organization was left to develop its own internal IT

capabilities to manage the XYZ system and, as a result, the system has not been routinely updated.

The hospital has decided to stay with the Meditech platform to address the IT strategic plan for an integrated EHR. The clinic organization must now evaluate whether it is in their best interest to stay with the XYZ system, with strong Meditech compatibility, or move to a different EHR platform. The path of least resistance from the IT perspective would be to upgrade the XYZ system. This option offers the greatest integration and could be implemented much sooner. A new platform would require an evaluation and selection process and a significant conversion. With either scenario, physician support will be critical to a successful transition.

EHR Project Plan The following sections detail a description of the planning process developed by the leadership team to transition to a replacement EHR. Read and critique the plan by answering the questions that follow it.

Project Organization The organizational phase of the project will involve establishing a project steering committee and identifying the leadership members who will ensure the project's success. WCH operates eight separate clinics, each with their unique teams and EHR experience. By necessity, the steering committee will need representation from each of these clinics. The project steering committee will likely have twenty to twenty-five members. In addition to provider representatives, the steering committee will also include nurses, medical assistants, and office managers from each clinic. IT representation is critical to the success of the project, and because the department provided poor IT support in the past, the CIO will play an active role on the steering committee. A representative from finance should also participate on the committee, given the importance of billing and collections and other practice management issues.

The leadership of the steering committee will ensure that the committee addresses key steps in the process and does so in a timely fashion. Ideally, the committee should be chaired by a provider who is respected within the group, is objective, and is a supporter of EHR technology. Although the clinic organization does not have a provider who meets all of these criteria, a physician with strong peer support and credibility will be selected to cochair the steering committee. To complement the clinical leadership, the CIO will serve as a cochair for the committee, providing technical expertise. This individual has implemented other EHR systems and will bring a structured process to the committee to ensure a thorough evaluation process. Committee Development Organizations often overlook the importance of understanding the emotional climate of a medical practice when implementing an EHR. Therefore, although the first task of the steering committee will be to define the project objectives, the existing concerns about an EHR transition require that a fair amount of time be devoted to addressing the emotional needs of the participants. Listening to practitioners and empathizing with their concerns will be critical to establish trust and overcome resistance during the EHR conversion.

To address this important issue, a series of discussion exercises will be used to encourage open dialogue and participant engagement. The first exercise will break the large group into teams of four to five members, and each team will discuss the lessons learned from the XYZ implementation that took place four years previously. Team leaders will be handpicked for their facilitation skills and ability to listen. The group discussions will address the “change readiness” and will surface the major issues associated with the implementation. It will also enable the group members to get to know each other in a less formal setting than the large group. The larger committee will reconvene to discuss their findings and prepare a master list of implementation lessons learned.

Although this exercise may raise a number of issues related to implementation, it is also important to openly discuss the current issues with the existing EHR. Once again, small groups will be asked to discuss these issues to ensure participation by all members of the steering committee. Small groups will report out to the large group, and a summary of issues will be developed. This list, as well as the list of implementation issues, will set the stage for a later discussion regarding the scope of the project.

Project Scope and Objectives Once the group has had the opportunity to express personal concerns and key issues have been identified, the group can turn its attention to defining the project objectives. Anxious committee members are often tempted to begin discussing whether the steering committee should upgrade this system or consider alternatives. When this occurs, discussions and conclusions are usually based on the emotional attachment to or disappointment with the current system. A more systematic review process will help frame this discussion to ensure the conclusion is based on facts and the needs of the clinic organization.

The leadership must guide the committee in developing project objectives that are based on the needs of the organization, not individuals. Returning to the list of implementation and current issues, the group will be asked to prioritize the concerns that were raised. This prioritization will focus the committee on the most pressing issues that must be addressed. With this background work, the committee will be positioned to articulate the goals of the committee. It will also define the scope of the project by determining what the project is and isn't intended to address. Invariably, users will raise issues that may not be solved by an EHR application. It is important that the end users review all issues, even though some of those issues may not prove to be within the scope of the project. Users with unrealistic expectations can end up frustrated and disengaged as the process unfolds. Defining the scope and the objectives clarifies expectations before options are considered.

Communication The steering committee will need to establish plans to communicate with the larger audience of clinic users and stakeholders. A plan will be developed that provides this audience with regular updates. The plan must also address how the committee can solicit feedback from stakeholders during the evaluation and selection process. Regular minutes establish the record of the committee's work and provide a means for communicating with stakeholders. Special meetings

with individual clinic groups will also be necessary to address rumors or provide more detailed information regarding the process. The steering committee must communicate regularly to ensure information is flowing to individuals.

Plan of Work Once project objectives are established, the committee will prepare a plan of work. This plan will outline the specific action steps required to achieve the project objectives and the timeline for their completion. The plan of work focuses on the decision to upgrade the existing XYZ application and remain with a Meditech platform or move to a different software solution. The plan of work provides the steering committee with the road map to achieve its goals.

The key steps in the plan of work are identifying possible vendors, establishing system requirements, and completing a request-for-proposal (RFP) process. Vendor identification can occur simultaneously with establishing the project goals. This is a reasonable assertion because it will save time and will engage the clinic representatives in the process. The steering committee will select individuals to attend trade shows to maximize exposure to EHR products. IT staff members will also participate in this review process to address technical requirements and issues.

Establishing system requirements is a critical step in the EHR decision-making process. The system requirements identify the needs of the organization and are the basis for the vendor evaluation process. The implementation and current issues lists developed by the committee will be used to develop the system requirements. Each clinic employee will receive a summary of these lists, and staff members will be asked to provide additional input to steering committee representatives. In addition, the IT department will conduct a thorough evaluation of new advancements in EHRs and regulatory requirements that may affect the EMR choice. The first draft of the system requirements will be preliminary. As the steering committee begins to interact with vendors and complete site visits, additional functionality may be added to the requirements. It would not be prudent to submit RFPs to all vendors who claim to have a functional EHR. The steering committee will need to determine the top five to seven vendors, judging by the initial survey of qualified vendors, trade shows, and market information.

Well-defined system requirements will need to be established and included in the RFPs. Packaging the system requirements in a format that provides structure for vendor responses and steering committee evaluations of vendor responses will be important, as will establishing a record of documentation throughout the acquisition process. The RFP document will provide the following:

Instructions for vendors Organizational objectives Organization background information System goals and requirements The vendors will be required to submit the following:

Vendor qualifications Proposed solutions Criteria for evaluating proposals Contractual requirements Pricing and support The vendor review process will also encompass technical calls, vendor fairs, reference checks, site visits, and vendor presentations. These elements of the review process are designed to ensure that sufficient information is gathered to augment the proposals submitted by the vendors. It will not be feasible for all steering committee members to participate in these activities; therefore, individuals will be appointed to participate on their behalf.

Prior to reviewing the vendor proposals, the steering committee will develop vendor criteria that can be used to evaluate the proposals. Each member of the steering committee will be asked to score the proposals based on the criteria, and a summary score report will be developed. The WCH CEO will give the final approval to proceed with the conversion based on the report and recommendation from the steering committee. However, the final recommendation of the committee will not be based solely on the score report. Ideally, the final deliberations will involve a robust dialogue based on the mutual trust that has developed over time. Ultimately, the committee will balance its objective assessment of options with its intuition and considerable knowledge of the clinic organization.

Conclusion The WCH clinic organization will undergo a significant EHR transition if they upgrade the XYZ system or purchase another product. The process that is outlined in this plan provides the organization the best opportunity to make the right decision for the organization and establish support with key stakeholders for an EHR conversion. A good IT decision-making process requires discipline and objectivity. The structural elements of the process involve leadership, committee structure, system requirements, and a thorough RFP and evaluation process.

Case 7: Concerns and Workarounds with a Clinical Documentation System Garrison Children's Hospital is a 225-bed hospital. Its seventy-seven-bed neonatal intensive care unit (NICU) provides care to the most fragile patients, premature and critically ill neonates. The twenty-eight-bed pediatric intensive care unit (PICU) cares for critically ill children from birth to eighteen years of age. Patients in this unit include those with life-threatening conditions that are acquired (trauma, child abuse, burns, surgical complications, and so forth) or congenital (congenital heart defects, craniofacial malformations, genetic disorders, inborn errors of metabolism, and so forth).

Garrison is part of Premier Health Care, an academic medical center complex located in the Southeast. Premier Health Care also includes an adult hospital, a psychiatric hospital, and a full spectrum of adult and pediatric outpatient clinics. Within the past six months or so, Premier has implemented an electronic clinical documentation system in its adult hospital. More recently the same clinical documentation system has been implemented at Garrison in pediatric medical and surgery units and intensive care units. Electronic scheduling is to be implemented next.

The adult hospital drives the decisions for the pediatric hospital, a circumstance that led to the adult hospital's CPOE vendor being chosen as the documentation vendor for both hospitals. A CPOE system was implemented at Garrison Children's Hospital several years prior to implementation of the electronic clinical documentation system.

Information Systems Challenge A pressing challenge facing Garrison Children's Hospital is that nurses are very concerned and dissatisfied with the new clinical documentation system. They have voiced concerns formally to several nurse managers, and one nurse went directly to the chief nursing officer (CNO) stating that the flow sheets on the new system are grossly inadequate and she fears using them could lead to patient safety issues. Lunchroom conversations among nurses tend to center on their having no clear understanding of why the organization is automating clinical documentation or what it hopes to achieve. Nurses in the NICU and PICU seem to be most vocal about their concerns. They claim there is inconsistency in what is being documented and a lack of standardization of content. The computer workstations are located outside the patients' rooms, so nurses generally document their notes on paper and then enter the data at the end of the shift or when they have time.

The system support team, consisting of nurses as well as technology specialists, began the workflow analysis, system installation, staff training, and go-live first with a small number of units in the adult hospital and the children's hospital beginning in January. The NICU and PICU did not implement the system until May and June of that year. System support personnel moved rapidly through each unit, working to train and manage questions. The timeline for each unit implementation was based on the number of beds in the unit and the number of staff members to be trained. No consideration was given to staff members' prior experience with computers and keyboarding skills or to complexity of documentation and existing work processes.

Although there are similarities between the adult and pediatric settings, there are also many differences in terms of unit design, computer resources (hardware), level of computer literacy, information documented, and work processes, not to mention patient populations. Little time was spent evaluating or planning for these differences and completing a thorough workflow analysis. After the initial units went live, less and less time was spent on training and addressing unit-specific needs because of the demands placed on training staff members to stay on the timeline in preparation for the next system implementation involving electronic scheduling.

The clinical documentation system was implemented to the great consternation and dissatisfaction of the end users (physicians, nurses, social workers, and so forth) at Garrison, yet the Premier clinicians are happy with it. Many Garrison physicians and nurses initially refused to use the system, stating it was “unsafe,” “added to workload,” and was not intuitive. A decision to stop using the system and return to the paper documentation process was not then and is not now an option. Physician “champions” were encouraged to work with those who were recalcitrant, and nursing staff members were encouraged to “stick it out” with the hope that system use would “get easier.”

As a result, with their concerns and complaints essentially forced underground, Garrison clinical staff members developed workarounds, morale was negatively affected, and the expectation that everyone would eventually “get it” and adapt has not become a reality. Instead, staff members are writing on a self-created paper system and then translating those notes to the computer system; physicians are unable to retrieve important, timely patient information; and the time team members spend trying to retrieve pertinent patient information has increased. There have been clear instances when patient safety has been affected because of the problems with the appropriate use of this system.

Case 8: Conversion to an EHR Messaging System Goodwill Health Care Clinic is the clinical arm of Jefferson Health Sciences Center in a large Southern city. The clinic was founded in the early 1950s as a place for faculty physicians to engage in clinical practice. Over the years the clinic has grown to nine hundred faculty physicians and two thousand employees, with over one million patient visits per year. Clinic services are spread across eleven primary care and specialty care units. Each unit operates somewhat independently but shares a common medical record numbering system that enables consolidation of all documentation across units. Paper charts were used until two years ago, when the clinic adopted an EHR system.

Goodwill Health Care Clinic uses a centralized call center to receive all patient calls. Patients call a central switchboard to schedule appointments, request medication refills, or speak to anyone in any of the eleven units. Call center staff members are responsible for tracking all calls to ensure that each is dealt with appropriately. Currently the call center uses a customized Lotus Notes system that can be accessed by anyone in the system who needs to process messages. Messages can be tracked and then closed when the appropriate action has been taken. Notes created from closed messages are printed and filed in the appropriate patients' paper records. These notes cannot be accessed via the EHR.

Clinic staff members are very comfortable with the current Lotus Notes system, and it is used routinely by all units.

Information Systems Challenge Goodwill Health Care Clinic requires all medication lists and refill information to be kept up-to-date in the EHR. Therefore, the existence of the current Lotus Notes system means that the same information must be documented in two locations—first in the call center note and then in the EHR. This leads to duplication of effort and documentation errors. The potential for serious error is present. Physicians and other health care providers look in the EHR for the most up-to-date medication information.

Although the adoption of the EHR has been fairly successful, not all units use all of the available components of the EHR. A companion paper record is needed for miscellaneous notes, messages, and so forth. All units are recording office visits into the EHR, but not all have activated the lab results or the prescription writing features. Several units have been experiencing physician resistance to adding more EHR functions.

The EHR system has a messaging component that works similar to a closed e-mail system. Messages can be sent, received, and stored by EHR-authenticated users. Pertinent patient care messages are automatically stored in the correct patient record. In addition, the EHR messaging system works seamlessly with the prescription writing module, which includes patient safety checks such as allergy checks and drug interactions.

The challenge for Goodwill Health Care Clinic is to implement the messaging feature and prescription writing component (where it is not currently being used) of their current EHR in the call center and the clinical units, replacing the existing Lotus Notes system and improving the quality of the documentation, not only of medication refills but also of all patient-related calls. The long-term goal is to add a patient portal feature where patients can schedule appointments, send messages to their providers, and refill prescriptions electronically.

Case 9: Strategies for Implementing CPOE Health Matters is a newly formed nonprofit health system comprising two community hospitals (Cooper Memorial Hospital and Ashley Valley Hospital), nine ambulatory care clinics, and three imaging centers. Since its inception two years ago, the information services (IS) department has merged and consolidated all computer systems under one umbrella. Each of the facilities within the health system is connected electronically with the others through a fiber optic network. The organizational structure of the two hospitals is such that each has its own executive leadership team and board.

Seven years ago, the leadership team at Cooper Memorial Hospital made the strategic decision to choose Meditech as the vendor of choice for its clinical and financial applications. The philosophy of the leadership team was to solicit a single-vendor solution so that the hospital could minimize the number of disparate systems and interfaces. Since then, Meditech has been deployed throughout the health system and applications have been kept current with the latest releases. Most nursing and clinical ancillary documentation is electronic, as is the medication administration record. Health Matters does have several ancillary systems that interface with Meditech; these include a picture archiving and communication system (PACS), a fully automated laboratory system, an emergency department tracking board, and an electronic bed board system. The leadership team at Ashley Valley Hospital chose to select non-Meditech products, because at the time Meditech did not offer these applications or its products were considered inadequate by clinicians. However, the current sentiment among the leadership team is to continue to go with one predominant vendor, in this case, Meditech, for any upgrades, new functionality, or new products.

The IS group at Health Matters consists of a director of information systems (who reports to the chief financial officer) and fifteen staff members. The IS staff members are highly skilled in networking and computer operations but have only moderate skills as program analysts and project managers. The CEO, Steve Forthright, plans to hire a CIO to provide senior-level leadership in developing and implementing a strategic IS plan that is congruent with the strategic goals of Health Matters.

Currently, the senior leadership team at Health Matters has identified the following as the organization's top three IS challenges. The current director of IS has been somewhat involved in discussions related to the establishment of these priorities.

To implement successfully computerized provider order entry (CPOE) To increase the variety and availability of computing devices (workstations or handheld devices) at each nursing station To implement successfully medication administration using bar-coding technology

Information Systems Challenge The most pressing IS challenge is to move forward with the implementation of CPOE. The decision has already been made to implement the Meditech CPOE application. Several internal and external driving forces are at play. Internally, the physician leaders believe that CPOE will further reduce medication errors and promote patient safety. The board has established patient safety as a strategic goal for the organization. Externally groups such as Leapfrog and the Pacific Business Group on Health have strongly encouraged CPOE implementation. CEO Steve Forthright has concerns, however, because Health Matters does not yet have a CIO on board and he feels the CIO should play a pivotal role. Much of Steve's concern stems from his experience with CPOE implementation at another institution, with a different vendor and product. Steve had organized a project implementation committee, established an appropriate governance structure, and the senior leadership team thought it had “covered the bases.” However, according to Steve, “The surgeons embraced the new CPOE system, largely because they felt the postoperative order sets were easy to use, but the internists and hospitalists rebelled. The CPOE project stalled and the system was never fully implemented.” Steve is not the only person reeling from a failed implementation. The clinical information committee at Health Matters is chaired by Mary White, who was involved in a failed CPOE rollout at another hospital several years ago. She was a strong supporter of the system at the time, but she now speaks of the risks and challenges associated with getting physician buy-in and support throughout the health system.

Members of the medical staff at Cooper Memorial Hospital have access to laboratory and radiology results electronically. They have access through workstations in the hospital; most physicians also access clinical results remotely through smartphones. An estimated 35 percent of the physicians take full advantage of the system's capabilities. Almost all active physicians use the PACS to view images, and most use a computer to look up lab values. Fewer than half of the physicians use electronic signatures to sign transcribed reports.

Case 10: Implementing a Syndromic Surveillance System Syndromic surveillance systems collect and analyze pre-diagnostic and nonclinical disease indicators, drawing on preexisting electronic data that can be found in systems such as EHRs, school absenteeism records, and pharmacy systems. These surveillance systems are intended to identify specific symptoms within a population that may indicate a public health event or emergency. For example, the data being collected by a surveillance system might reveal a

sharp increase in diarrhea in a community and that could signal an outbreak of an infectious disease.

The infectious disease epidemiology section of a state's public health agency has been given the task of implementing the Early Aberration Reporting System of the Centers for Disease Control and Prevention. The agency views this system as significantly improving its ability to monitor and respond to potentially problematic bioterrorism, food poisoning, and infectious disease outbreaks.

The implementation of the system is also seen as a vehicle for improving collaboration among the agency, health care providers, IT vendors, researchers, and the business community.

Information Systems Challenge The agency and its infectious disease epidemiology section face several major challenges.

First, the necessary data must be collected largely from hospitals and in particular emergency rooms. Developing and supporting necessary interfaces to the applications in a large number of hospitals is very challenging. These hospitals have different application vendors, diverse data standards, and uneven willingness to divert IT staff members and budget to the implementation of these interfaces.

To help address this challenge, the section will acquire a commercial package or build the needed software to ease the integration challenge. In addition, the section will provide each hospital with information it can use to assess its own mix of patients and their presenting problems. The agency is also contemplating the development of regulations that would require the hospitals to report the necessary data.

Second, the system must be designed so that patient privacy is protected and the system is secure.

Third, the implementation and support of the system will be funded initially through federal grants. The agency will need to develop strategies for ensuring the financial sustainability of the application and related analysis capabilities, should federal funding end.

Fourth, the agency needs to ensure that the section has the staff members and tools necessary to appropriately analyze the data. Distinguishing true problems from the noise of a normal increase in colds during the winter, for example, can be very difficult. The agency could damage the public's confidence in the system if it overreacts or underreacts to the data it collects.

Case 11: Planning an EHR Implementation The Leonard Williams Medical Center (LWMC) is a 240-bed, community acute care hospital operating in a small urban area in upstate New York. The medical center offers tertiary services and has a captive professional corporation, Williams Medical Services (WMS). WMS is a multispecialty group employing approximately fifty primary care and specialty physicians.

WMS has its own board, made up of representatives of the employed physicians. The WMS board nominations for members and officers are subject to the approval of the medical center board. The capital and operating budgets of WMS are reviewed and approved during the LWMC budget process. The WMS board is responsible for governing the day-to-day operations of the group. LWMC serves a population of approximately 215,000. There are five other hospitals in the region. One of these, aligned with a large clinic, is viewed as the primary competitor.

In its most recent fiscal year, LWMC had an operating margin of 0.4 percent. LWMC has $40 million in investments and has a long-term debt-to-equity ratio of 25 percent.

Information Systems Challenge LWMC has been very effective in its IT efforts. It was the first hospital in its region to have a clinical information system. Bedside computing has been available on the inpatient units since the 1990s. The CIO and IT department are highly regarded. LWMC has received several industry recognitions for its efforts.

The LWMC information systems steering committee recently approved the acquisition and implementation of a CPOE system. This decision followed a thorough analysis of organizational strategies, the efforts of other hospitals, and the vendor offerings. LWMC is poised to begin this major initiative. During a recent steering committee meeting, it was learned that the WMS physicians were anxious to acquire an EHR system. Two years ago a rival physician group had purchased an EHR system. WMS, concerned about a competitive threat, obtained approval of $300,000 to acquire its own EHR. The rival group has since encountered serious difficulties with implementation and has de-installed the system. This troubled path caused WMS to slow down its efforts.

Now WMS has decided to return to its plans to implement a certified EHR. The physicians have begun to look at vendor offerings but have not involved the LWMC CIO and IT staff members. The physicians have ignored the CIO's technical and integration advice and requirements during their EHR search.

The CEO is concerned about the EHR process and its disconnect from the medical center's IT plans.

Case 12: Replacing a Practice Management System University Physician Group (UPG) is a multispecialty group practice plan associated with the College of Osteopathic Medicine (COM). UPG employs 90 physicians and 340 clinical and business support personnel.

UPG has recently been profitable (with revenue from operations this fiscal year of $32 million and a retained profit of $500,000 from operations). However, prior year losses make UPG a break-even organization.

Management and the physicians are focusing on strengthening the fiscal position of the organization. This focus has led to plans to restructure physician compensation, establish a self-insurance trust for professional liability, and improve the financial budgeting and reporting processes.

UPG has entered into a preliminary agreement to merge with Northern Affiliated Medical Group (NAMG). NAMG is a 150-physician multispecialty group located in the same city as UPG. NAMG holds a contract with the local county hospital to provide indigent care and serve as the faculty for the graduate medical education programs in family medicine.

Both organizations believe that the merged organization would be able to reduce expenses through the elimination of redundant functions and, because of greater geographical coverage and size, would improve their ability to obtain more favorable payer contracts.

Information Systems Challenge For many years UPG has obtained practice management systems from Gleason Solutions (GS). The applications are hosted in a GS data center, reducing UPG's need for IT staff members.

Prior to the merger, UPG was in the process of examining replacements for GS. UPG had become displeased because of the GS application failure to incorporate new technologies and application features, limited ability to generate reports, and inflexible integration approaches to other applications.

Despite its displeasure, UPG now appears to be on the path to renewing the GS contract. GS executives have effectively lobbied several important physicians and administrators, and UPG's limited cash position makes the GS low-cost financial proposal attractive.

NAMG uses the GS applications and has also been examining replacing the system. NAMG has a strong IT department and will be providing IT support to the newly merged organization. After examining the market, NAMG has identified four potential vendors, including GS.

Case 13: Implementing Tele-Psychiatry in a Community Hospital Emergency Department Westend Hospital is a midsize, not-for-profit, community hospital in the Southeast. Each year, the hospital provides care to more than twelve thousand inpatients and sixty thousand emergency department (ED) patients. Over the past decade, the hospital has seen increasing numbers of patients with mental illness in the ED, largely because of the implementation of the state's mental health reform act, which shifted care for patients with mental illness from state psychiatric hospitals to community hospitals and outpatient facilities. Westend ED has in essence become a safety net for many individuals living in the community who need mental health services.

Largely considered a farming community, Westend County has a population of 120,000. Westend Hospital is the third largest employer in the county. However, Westend is not the only hospital in the county. The state still operates one of three psychiatric facilities in the county. Within a five-mile radius of Westend Hospital is a 270-bed inpatient psychiatric hospital, Morton Hospital. Morton Hospital serves the citizens of thirty-eight counties in the eastern part of the state.

Westend Hospital is fiscally strong with a stable management team. Anika Lewis has served as president-CEO for the past fifteen years. The remainder of the senior management team has been employed with Westend for eight to thirteen years. There are more than 150 active or affiliate members of the organized hospital medical staff and approximately 1,600 employees. The hospital has partnered with six outside management companies for services when the expertise is not easily found locally, including HighTech for assistance with IT services.

In terms of its information systems, Westend Hospital has used Meditech since the 1990s, including for nursing documentation, order entry, and diagnostic results. The nursing staff members use bar-coding technology for medication administration and have done so for years. CPOE was implemented in the ED four years ago and hospital-wide two years ago along with a certified EHR system.

The Challenge Westend Hospital has seen increasing numbers of mental health patients in the ED over the past decade. For the past three years, the ED has averaged one hundred mental health patients per month. Depending on the level of patient acuity and availability of state- or community-operated behavioral health beds, the patient may be held in the ED from two hours to eight days before a safe disposition plan can be implemented.

The ED mental health caseload is also rapidly growing in acuity. Between 20 percent and 25 percent of the behavioral health patients are arriving under court order (involuntary commitment). The involuntary commitment patients are the most difficult in terms of developing a safe plan for disposition from the ED. The Westend Hospital's inpatient behavioral health unit is currently an adult, voluntary admission unit and does not admit involuntary commitment patients. The length of stay for involuntary commitment patients in the ED can be quite long. In some cases, it may take three to four days to stabilize the patient on medication (while in the ED) before the patient meets criteria for discharge to outpatient care. Approximately 40 percent of the mental health patients in the ED, both involuntary commitment and voluntary, are discharged either to home or outpatient treatment.

The psychiatrists and the emergency medicine physicians have met multiple times during the past six years to develop plans to improve the care of the mental health patients in the ED. Defining the criteria for an appropriate Westend psychiatrist consultation remains a challenge. The daily care needs of the mental health patients boarding in the ED are complex. The physicians have not been able to reach an agreement on this topic. Senior leaders have suggested that tele-psychiatry may be a partial solution to address this challenge.

Tele-psychiatry as a Strategy Westend Hospital has chosen to consider contracting with a tele-psychiatry hospital network to provide tele-psychiatry services in the ED. The network has demonstrated good patient outcomes and is considered financially feasible at a rate of $4,500 per month. This fee includes the equipment, management fees, and physician fees. The director of tele-psychiatry in the hospital network has verbally committed to work very closely with the Westend Hospital team to ensure a smooth implementation.

Technology to support tele-psychiatry uses two-way, real-time, interactive audio and video through a secure encrypted wireless network. The patient and the psychiatric provider interact in the same manner as if the provider were physically present. The provider performing the patient consultation uses a desktop video conferencing system in the psychiatric office.

Tele-psychiatry as a solution to the mental health crisis in the ED was not immediately embraced by the medical staff members. They did agree to the implementation of tele-radiology four years previously. However, the most recent revision of the medical staff bylaws to support telemedicine explicitly states that the medical executive committee must approve, by a two-thirds vote, any additional telemedicine programs that may be introduced at the hospital. The medical staff leaders wanted to preserve their ability to maintain a financially viable medical practice in the community as well as protect the quality of care.

The idea of tele-psychiatry was introduced to portions of the medical staff. The psychiatrists realized that tele-psychiatry could relieve them of the burden of daily rounds in the ED for boarding patients. They were also concerned about their workload when tele-psychiatry was not available.

The emergency medicine physicians immediately verbalized their disapproval on several levels. First, they were concerned about the reliability of the technology based on their experiences over the past several years with video remote interpreting. Then, the emergency medicine physicians were skeptical about the continued support from the psychiatrists when an in-person consultation might be clinically necessary.

Physicians outside of the ED and psychiatry could not understand why the current psychiatrists could not meet the needs of the ED. The barriers to adoption of tele-psychiatry crossed three arenas: financial, behavioral, and technical. Subsequently, many conversations were conducted. Eventually, the medical executive committee approved tele-psychiatry as a new patient care service on June 25 of this year.

Implementation Plan The CEO appointed the vice president of patient services as the executive sponsor. The implementation team includes the IT hardware and networking specialist, IT interface specialists, nursing informatics analyst, ED nurse director, behavioral health nurse director, assistant vice president patient services, physician clinical systems analyst, and the medical staff services coordinator. These individuals represent the major activities for implementation:

provider credentialing, physician documentation, equipment and technical support, and patient care activities. Because of competing projects and psychiatry subject matter expertise, the executive sponsor will also serve as the project manager.

The mental health crisis affecting the ED is the focal driver for change. Patient safety is at risk. Barriers to implement tele-psychiatry have been well documented. The strategies to overcome the barriers include defining the new role for the Westend psychiatrists, developing a process for ease of access and reliability of equipment for the ED physicians, and development of a plan when the tele-psychiatry program is not available.

An unexpected barrier has been recently identified. On initiation of the tele-psychiatry provider credentialing process, the medical staff services coordinator discovered that the bylaws do not have a provision for credentialing of physician extenders in the telemedicine category. The tele-psychiatry providers include six board-certified psychiatrists and twelve mental health–trained nurse practitioners. The medical executive committee has agreed to ask the medical staff bylaws committee to convene and revise the bylaws accordingly. The original go-live date of September has been changed to December.

The executive sponsor along with the implementation team will be responsible for managing the organizational changes necessary to support the introduction of technology and new patient care flow processes. Managing organizational change will be essential to the success of this project. Some items in the project will be viewed as incremental change and other items will be viewed as step-shift change. Communication strategies will be developed to support the change.

Case 14: Assessing the Value and Impact of CPOE The University Health Care System is an academic medical center with more than 1,200 licensed beds and more than 9,000 employees. The system comprises the University Hospital, Winston Geriatric Hospital, Jefferson Rehabilitation Hospital, and two outpatient centers in the metropolitan area. The system has a history of being a patriarchal, physician-driven organization. When University Health Care first started taking patients, it was viewed as a mecca to which community physicians throughout the South referred difficult-to-treat patients. That referral mentality persisted for decades, so physicians within the system had a difficult time making the transition to an organization that had to compete for patients with other health care entities in the region.

In recent years, University Health Care System has evolved and has given physicians proportionately more clout in decision making, in part because the health care leadership team has not stepped forward. Creating a balance between clinician providers and administrative leadership is a real issue. In the midst of the difficulty, both groups have agreed to embark on the EHR journey. Currently about 55 percent of the system's patient record is electronic; the remainder is on paper. The physicians as a whole, however, have embraced technology and view the EHR as the right road to take in achieving the organization's goal of providing high-quality, safe, cost-effective patient care.

Information Systems Challenge Currently, the University Health Care System is in the midst of rolling out the CPOE portion of the EHR project. A multidisciplinary decision-making project was established before beginning the initiative, and leaders and clinicians tried to educate themselves on what the CPOE project would entail. They were familiar with cases such as one at Cedars-Sinai in which CPOE was halted after physician uproar over the time it took to use it and patient safety concerns. To help ensure this did not happen at the University Health Care System, the leadership team decided to take a slower, phased-in approach. Team members visited similar organizations that had implemented CPOE, attended vendor user-group conferences, consulted with colleagues from across the nation, and articulated the following project goals:

Optimize patient safety. Improve quality outcomes and reduce variation in practice through the use of evidence-based practice guidelines. Reduce risk for errors. Accommodate regulatory standards expectations. Enhance patient satisfaction. Standardize processes. Improve efficiency. The board has made it very clear that it wants regular updates on the progress of the project and expects to see what the return on the investment has been.

Case 15: Assessing the Value of Health IT Investment Five years ago, senior leadership at the Southeast Medical Center made the decision to embark on the implementation of a host of new clinical applications in the inpatient units enterprise-wide. The four hospitals that comprise Southeast Medical Center include the Main Adult Hospital, the Children's Hospital, McKinsey Hospital, and the Institute of Psychiatry. They contracted with McKesson to implement the following applications:

ED tracking system Replacement pharmacy information system Clinical documentation system (for all nurses and ancillary personnel; does not include physician notes) Medication administration using bar-coding technology Computerized provider order entry (CPOE) In addition, several administrative applications were implemented, including a new operative scheduling system and materials management system. They also upgraded their clinical data repository viewer (referred to as Oacis). All applications are now operational.

Most recently, the board of trustees has approved replacement of Southeast's ambulatory care EHR. A system known as EasyDoc (a McKesson product) has been in use for years. However, the system was viewed by clinicians and IT staff members as antiquated and cumbersome to navigate. It is also very difficult to retrieve aggregate data from the system. Much of this is

apparently because of its underlying database architecture and structure. EasyDoc also did not interface with the hospital clinical applications, and leaders were concerned that the system was not going to enable Southeast to achieve meaningful use criteria.

Clinicians have also been frustrated that Southeast has been using two different EHR systems, one for inpatient and another for outpatient, and the two don't interface or give a complete picture of the patient's health record. With payment reform and the need to be able to more effectively manage patient care quality and outcomes, senior leaders recommended, and the board approved, replacement of the EasyDoc EHR with Epic ambulatory care EHR. The patient registration and billing system used in ambulatory care will also be replaced with Epic's practice management application. Long-term plans are to eventually replace the McKesson clinical applications with Epic in the inpatient sector as well.

The total cost of ownership for the replacement ambulatory EHR and practice management system is approximately $30 million. Included in this estimate are not only the software and hardware upgrades but also the staff members needed to implement and support the new applications. Replacing the McKesson clinical products with Epic inpatient EHR will cost an additional $90 million. Again, this is an estimated total cost of ownership.

The primary purpose of the Epic EHR project is to provide clinicians with access to a single, complete EHR that spans the patient's continuum of care and improves collaboration and coordination of care. Community providers and patients will have access to the system. Community partners (such as primary care providers) will be able to retrieve important patient information. Currently a local HIE exists that provides ED visit information to all local hospitals. This is to be expanded to include continuity of care documents (CCDs) and other relevant health information. Patients will be given access to their health information such as lab tests, X-ray results, and medications. They will also be able to schedule appointments and pay their bills online through a patient portal known as MyChart. Southeast physician leaders view patients as partners in their own care and are pleased to provide them access to information electronically.

Southeast providers treat a large population of patients with multiple chronic conditions. Managing chronic diseases using evidence-based, real-time support is considered essential. In addition, Southeast Medical Center has available a secure data warehouse of patient data that researchers and clinicians will be using more fully in the future to ensure that clinical research drives best care.

Case 16: The Admitting System Crashes Jones Regional Medical Center is a large academic health center. With nine hundred beds, Jones had forty-seven thousand admissions last year. Jones frequently has occupancy in excess of 100 percent, requiring diversion of ambulances. In addition, Jones had 1,300,000 ambulatory and emergency room visits in the past three years.

Jones is internationally renowned for its research and teaching programs. The IT staff members at Jones are highly regarded. They support more than three hundred applications and twelve thousand workstations.

The admitting system at Jones is provided by the vendor Technology Med (TechMed). The TechMed system supports the master patient index; registration; inpatient charge and payment entry; medical records abstracting and coding; hospital billing and patient accounting; reporting; and admission, discharge, and transfer capabilities.

The TechMed system was implemented twelve years ago and uses now-obsolete technology, including a rudimentary database management system. The organization is concerned about the fragility of the application and has begun plans to replace the TechMed system two years from now.

Information Systems Challenge On December 20, the link between the main data center (where the TechMed servers were housed) and the disaster recovery center was taken down to conduct performance testing.

On December 21, power was lost to the disaster recovery center, but emergency power was instantly put in place. However, as a precaution, a backup of the TechMed database was performed.

During the afternoon of December 21, the TechMed system became sluggish and then unresponsive. Database corruption was discovered. The backup performed earlier in the day was also corrupt. The link to the disaster recovery data center had not been restored following the performance testing.

Because there was no viable backup copy of the database, the Jones IT and hospital staff members began the arduous process of a full database recovery from journaled transactions. This process was completed the evening of December 22.

The loss of the TechMed system for more than thirty-six hours and the failure during that time of registration transactions to update patient care and ancillary department systems resulted in a wide variety of operational problems. The patient census had to be maintained manually. Reports of results were delayed. Paper orders were needed for patients who were admitted on December 21 and 22. Charge collection lagged.

Once the TechMed system was restored, additional hospital staff members were brought in to enter, into multiple systems, the data that had been manually captured during the outage. By December 25, normal hospital operations were restored. No patient care incidents are believed to have resulted.

Case 17: Breaching the Security of an Internet Patient Portal

Kaiser Permanente is an integrated health delivery system that serves more than eight million members in nine states and the District of Columbia. In the late 1990s, Kaiser Permanente introduced an Internet patient portal, Kaiser Permanente Online (also known as KP Online). Members can use KP Online to request appointments, request prescription refills, obtain health care service information, seek clinical advice, and participate in patient forums.

Information Systems Challenge In August, there was a serious breach in the security of the KP Online pharmacy refill application. Programmers wrote a flawed script that actually concatenated over eight hundred individual e-mail messages containing individually identifiable patient information, instead of separating them as intended. As a result, nineteen members received e-mail messages with private information about multiple other members. Kaiser became aware of the problem when two members notified the organization that they had received the concatenated e-mail messages. Kaiser leadership considered this incident a significant breach of confidentiality and security. The organization immediately took steps to investigate and to offer apologies to those affected.

On the same day the first member notified Kaiser about receiving the problem e-mail, a crisis team was formed. The crisis team began a root cause analysis and a mitigation assessment process. Three days later Kaiser began notifying its members and issued a press release.

The investigation of the cause of the breach uncovered issues at the technical, individual, group, and organizational levels. At the technical level, Kaiser was using new web-based tools, applications, and processes. The pharmacy module had been evaluated in a test environment that was not equivalent to the production environment. At the individual level, two programmers, one from the e-mail group and one from the development group, working together for the first time in a new environment and working under intense pressure to quickly fix a serious problem, failed to adequately test code they produced as a patch for the pharmacy application. Three groups within Kaiser had responsibilities for KP Online: operations, e-mail, and development. Traditionally these groups worked independently and had distinct missions and organizational cultures. The breach revealed the differences in the way groups approached priorities. For example, the development group often let meeting deadlines dictate priorities. At the organizational level, Kaiser IT had a very complex organizational structure, leading to what Collmann and Cooper (2007, p. 239) call “compartmentalized sensemaking.” Each IT group “developed highly localized definitions of a situation, which created the possibility for failure when integrated in a common infrastructure.”

Case 18: The Decision to Develop an IT Strategic Plan Meadow Hills Hospital is a 211-bed acute care hospital with four hundred members on its medical staff. Meadow serves a population of three hundred thousand. There are three other similarly sized hospitals in the region. As an organization, Meadow Hills is very well run. It has a good reputation in the community and is considered to be technically advanced based on its investments in imaging technology. The organization is also in a strong financial position, with $238 million in reserves. Meadow Hills has never had an IT strategic plan.

Information Systems Challenge The IT function reports to the Meadow Hills chief financial officer (CFO). The CEO and other members of the senior leadership team have largely left IT decisions up to the CFO. As a result, the organization's financial systems are very well developed. Computerized provider order entry (CPOE), an EHR system, and a PACS have not been implemented. IT support for departments such as nursing, pharmacy, laboratory, imaging, and risk management is limited.

The Meadow Hills IT team is well regarded and the limited IT support for clinical processes has not drawn complaints from the nursing or medical staff. The organization does not currently have a CIO.

The CEO has never felt the need to pay attention to IT. However, he is worried that reimbursement based on care quality will arrive at Meadow Hills soon. He also believes that the Meadow Hills Clinical Laboratory and Imaging Center would be more competitive if it had stronger IT support; rival labs and imaging centers are able to offer electronic access to test results. And he suspects that the lack of IT support may eventually lead to nurses and physicians choosing to practice elsewhere.

Case 19: Selection of a Patient Safety Strategy Langley Mason Health (LMH) is located in North Reno County, the largest public health care district in the state of Nevada, serving an 850-square-mile area encompassing seven distinctly different communities. The health district was founded in 1937 by a registered nurse and dietician who opened a small medical facility on a former poultry farm. Today the health system comprises Langley Medical Center, a 317-bed tertiary medical center and level II trauma center; Mason Hospital, a 107-bed community hospital; and Mason Continuing Care Center and Villa Langley, two part-skilled nursing facilities (SNFs); a home care division; an ambulatory surgery center; and an outpatient behavioral medicine center.

In anticipation of expected population growth in North Reno County and to meet the state-mandated seismic requirements, LMH developed an aggressive facilities master plan (FMP) that includes plans to build a state-of-the-art 453-bed replacement hospital for its Langley Medical Center campus, double the size of its Mason Hospital, and build satellite clinics in four of its outlying communities. The cost associated with actualizing this FMP is estimated to be $1 billion. Several years ago, LMH undertook and successfully passed the largest health care bond measure in the state's history and in so doing secured $496 million in general obligation bonds to help fund its massive facilities expansion project. The remaining funds must come from revenue bonds, growth strategies, philanthropic efforts, and strong operational performance over the next ten years. Additionally, $5 million of routine capital funds will be diverted every fiscal year for the next five years to help offset the huge capital outlay that will be necessary to equip the new facilities. That leaves LMH with only $10 million per year to spend on routine maintenance, equipment, and technology for all its facilities. LMH is committed to patient safety and is building what the leadership team hopes will be one of the safest hospital-of-the-future facilities. The

challenge is to provide for patient safety and safe medication practices given the minimal capital dollars available to spend today.

LMH developed an IT strategic plan and identified the following ten goals:

Empower health consumers and physicians. Transform data into information. Support the expansion of clinical services. Expand e-business opportunities. Realize the benefits of innovation. Maximize the value of IT. Improve project outcomes. Prepare for the unexpected. Deploy a robust and agile technical architecture. Digitally enable new facilities, including the new hospital. Information Systems Challenge LMH has implemented Phase 1—an enterprise-wide EHR system developed by Cerner Corporation at a cost of $20 million. Phase 2 of the project is to implement CPOE with decision-support capabilities. This phase was to have been completed previously, but has been delayed because of the many challenges associated with Phase 1, which still must be stabilized and optimized. LMH does have a fully automated pharmacy information system, albeit older technology, and Pyxis medication-dispensing systems on all units in the acute care hospitals. Computerized discharge prescriptions and instructions are available only for patients seen and discharged from the LMH emergency departments.

Currently, the pharmacy and nursing staff members at LMH have been working closely on the selection of a smart IV pump to replace all of the health system's aging pumps and have put forth a proposal to spend $4.9 million in the next fiscal year. Smart pumps have been shown to significantly reduce medication administration errors, thus reducing patient harm. This expenditure would consume roughly half of all of the available capital dollars for that fiscal year.

The CIO, Marilyn Chen, understands the pharmacists' and nurses' desire to purchase smart IV pumps but believes the implementation of this technology should not be considered in isolation. She sees the smart pumps as one facet of an overall medication management capital purchase and patient safety strategic plan. Marilyn Chen suggests that the pharmacy and nursing leadership team lead a medication management strategic planning process and evaluate a suite of available technologies that taken together could optimize medication safety (for example, CPOE, electronic medication administration records [e-mar], robots, automated pharmacy systems, bar coding, computerized discharge prescriptions and instructions, and smart IV pumps), the costs associated with implementing these technologies, and the organization's readiness to embrace these technologies. Paul Robinson, the director of pharmacy, appreciates Marilyn Chen's suggestion but feels that smart IV pumps are critical to patient safety and that LMH doesn't have time to go through a long, drawn-out planning process that could take years to implement and the process of gaining board support. Others argue that all new proposals

should be placed on hold until CPOE is up and running. They argue there are too many other pressing issues at hand to invest in yet another new technology.

Case 20: Strategic IS Planning for the Hospital ED Founded in 1900, Newcastle Hospital today is a 375-bed, not-for-profit community hospital that serves more than two hundred thousand residents of Newcastle County, New York. The hospital is approximately thirty miles from midtown Manhattan. It provides a full range of primary and secondary medical and surgical services and is an affiliate of one of the large New York City hospital systems for tertiary referrals and select residency programs. Newcastle Hospital has an independent governing body with 25 trustees, 604 active physicians, and 1,121 full-time equivalent (FTE) staff members. Revenues of approximately $130 million per year come from 15,600 inpatient admissions, 71,000 outpatient visits, and 65,000 home care visits. Newcastle Hospital operates in a difficult environment characterized by relatively poor reimbursement and severe competition. There is one other acute care hospital in the county and a total of thirty-five others within a twenty-mile radius.

The sentinel event in the hospital's recent history occurred four years ago—a six-month nursing strike that alienated the workforce, decimated public confidence, and directly cost at least $19.5 million, effectively eradicating the hospital's capital reserves. Most of the senior management was replaced after the strike. When hired, the new CEO and CFO uncovered extensive inaccuracies that resulted in a reduction of reported net assets by almost $30 million and the near-bankruptcy of the hospital. The new management restated financial statements, began resolving extensive litigation, and set out to reestablish immediate operations, future finances, and a long-term strategy. The new CEO states that “years of board and management neglect, plus the ravages of the strike complicated recovery, because standards, systems, and middle managers were universally absent or ineffective.”

Among its many issues, the challenges within the hospital's emergency department (ED) are particularly important to the overall recovery effort. The ED is described by the hospital CEO as the organization's “financial, clinical, and public relations backbone.” The ED sees 34,000 patients per year and admits 24 percent of them, constituting 51 percent of all inpatient admissions. In addition, the ED is a clinically distinguished Level II trauma center, with a long legacy of outcomes that compare favorably against regional, state, and national benchmarks. Finally, most community members have experience with the ED and consider it a proxy for the hospital as a whole, whether or not they have experienced an inpatient stay.

Currently, Newcastle ED patient satisfaction compared to patient satisfaction among peer organizations ranks at the 14th percentile in the Press Ganey New York State survey and the 5th percentile in national surveys. Since the start of the new millennium, three organized initiatives to improve these results (especially regarding walkouts and waiting times) have failed, even though two involved prestigious consultants. After the management change, the new CEO diagnosed two core barriers to overcoming the ED problems: first, inflexibility and unwillingness to change among the ED physician management group that had been in place for ten years, and, second, an almost complete absence of the data required to define, measure, and improve

the ED's service performance. The first barrier was addressed via an RFP process that resulted in engaging a new physician management group two years ago.

Information Systems Challenge The present IS challenge follows directly from Newcastle Hospital's overarching strategic objectives: “satisfying patients and staff,” “supporting ourselves,” and “getting better every day” (that is, improving performance). The ED as presently structured has ill-defined manual processes and no information system. The challenge is selecting an ED information system with an emphasis on informing, not just automating, key ED processes in order to support the overall strategic initiatives of the organization.

Several organizational and IT system factors that affect this IT challenge have been identified by the hospital CEO.

Organizational Factors Undefined strategy. Newcastle Hospital operated without a formal strategic action plan and corresponding tactics until two years ago. As a result, systematic prioritization and measurement of institutional imperatives such as improving the ED did not occur.

Data integrity. Data throughout the hospital were undefined and unreliable. For example, two irreconcilable daily census reports made timely bed placement from the ED impossible.

Culture. “Looking good,” that is, escaping accountability, was valued more highly than “doing good,” that is, substantively improving performance. Serious problems in the ED were often masked or dismissed as anecdotes, even in the face of regulatory citations and six- to eight-hour waiting times. The previous ED contract had contained no quality standards, and the ED physicians claimed to be busy “saving lives” whenever their poor service performance was questioned.

IT System Factors IT strategy. Paralleling the hospital, the IS department had no defined strategies, objectives, or processes. Alignment with hospital strategy and IT performance measurements were not considered. Although some progress has been made, this remains an area needing attention.

IT governance. There is no IT steering committee at either the board or management level. IT policies, service-level agreements, decision criteria, and user roles and responsibilities do not exist.

Functionality. The IT applications portfolio is missing critical elements (for example, order entry, case management, nursing documentation, radiology) that would greatly benefit the ED, even without a dedicated ED system. The hospital's core information system is three versions out-of-date and certain functions have been bypassed by users altogether.

IT infrastructure and architecture. The data center and most IT staff members are located twelve miles away from the hospital, isolating IT physically and culturally from users and patients. Software and networks have been arbitrarily and extensively customized over the years, without documentation, and inadequate hardware capacity has often been given as an excuse for not pursuing an ED system.

IT organization and resources. IT spending has been, on average, less than 1 percent of the hospital's budget and IT staff members have lacked essential training in critical applications and tools. Newcastle Hospital has been dependent on multiple IT vendors for a variety of implementation and operations support activities.

Case 21: Board Support for a Capital Project Lakeland Medical Center is a 210-bed public hospital located in the Southeast. It is governed by a politically appointed nine-member board and serves a market of approximately one hundred thousand people. The hospital has been financially successful, but in recent years several capital investments have not brought high returns. As a result, project investment decisions became more conservative and oriented toward financial returns. Competitive forces have continued to grow in the market, and significant internal expense items (such as the organization's pension program, paid leave bank, and health insurance program) have put strains on Lakeland's financial resources.

Revenue continues to grow at an average rate of about 10 percent each year, but controlling expenses remains a challenge. Bad debt has grown from $5 million last year to a budgeted amount of $14 million this year. The hospital continues to accomplish high patient and employee satisfaction scores, high quality scores, and an A+ credit rating. Debt is approximately $55 million, and cash reserves are approximately $95 million. Total operating revenues are approximately $130 million. The hospital employs 940 staff members. The average length of stay is 4.3 days. Annual capital expenditure is $4 million.

Information Systems Challenge Three years ago, the installation of computed radiography (CR) components to build a picture archiving and communication system (PACS) began, at an estimated total cost of $1 million. The following year, $400,000 was spent for additional CR components. Most recently the board of directors (with three new members) did not approve the request of $1.9 million for completion of the PACS, saying that it represented far too large a percentage of the organization's annual capital budget. Lakeland is still in need of completing the PACS program, with a board that is unlikely to approve the expenditure.

A number of factors are contributing to the board's decision not to authorize the additional $1.9 million for completion of the PACS:

Leadership's inability to guarantee to the board's satisfaction a financial return on the proposed investment

The board's perception that the radiologists are not committed to the hospital and to the community because none of the radiologists live in the community The board's perception that the cardiologists are not committed to the hospital or to the community; the five cardiologists on staff are considered to be uncooperative among themselves and not supportive of the hospital's goals Poor leadership within the IT department for providing the proper guidance on acquisition and implementation The board's philosophy that Lakeland Medical Center should be more high-touch and less high-tech, and thus there is a philosophical difference over the need for a PACS Jealousy among the medical staff members that the diagnostic imaging department continues to obtain capital approvals for large items representing a major percentage of the annual capital budget; thus, many influential members of the medical staff, such as surgeons, are not supportive of the expenditure A few vocal employees speaking directly to board members expressing their concern that the PACS implementation will result in job loss for them Leadership's inability to make a connection between this capital project and the strategic goals of the organization The chief of staff, Iesha Brown, firmly believes that a PACS will increase patient and physician satisfaction because waiting times for results will decrease, enhance patient education, improve staff member and physician productivity, improve clinical outcomes, improve patient safety, eliminate lost films, reduce medical liability, assist in reducing patient length of stay, and increase revenue potential. She believes it is management's challenge to understand the key issues of the board and to present the necessary supportive information for ultimate approval of the PACS program.