study
Kayla0206
HLAD3103-CaseStudies.pdf
il racuity members an<l others who teach health administration students are often in search
-i. ' of case stuclies that can be used to help students apply theory and concepts to real-life IT
management situations, encolrrage problem solving and critical thinking, and foster discussion
ancl collaboration among students. This chapter provides a compendium of case studies tiorn
a variety of health care organizations and settings. it is intended to sere as a supplement to
the precedilg chapters and as a resource to faculty members and students. Many of these case
studies were originally written by working health care executives enrolled as students iir the doc-
toral program in health administration offered at the Medical University of South Carolina. \L'e
rvish to acknowledge and thank these students for allowing us to share their stories and experi-
ences with you:
Penney Burlingame
Barbara Chelton
Stuart Fine
David Freed
David Gehant
Patricia Givens
Shirley Harkey
Victoria Harkins
Randail Jones
Calrin Jones-Nazar
Honald Kintz
George Mikatarian
Michael Moran
Lorie Shoemaker
Gary Wilde
Most of the cases begin with background information that includes a description of the setting,
the current intbrmation system (IS) challenge facing the organization, and the factors that are felt
to have contributed to the current situation. (Ali real names and identi$ring information have been
changed fi.om the original cases to protect the identity of the individuals and organizations involved.)
Fr:llowing each case is a set of recommended riiscussion questions. To the extent possible, the cases
are organized by the corresponding chapter(s) to which they relate (see Table 14.1).
We hope yol find the cases thought-provoking and useful in applying the concepts covered
in this book to what is happening in health care organizations throughout our nation. We have also
included at the end of the chapter a listing of other published cases and webinars that may be useful
to you and your students.
I{ealth Care Infomation Systems: A Prlr,ctical Approachfor llealth Care Management,Fifth Edition.
Karen A. \tr'ager', Frances W Lee, and Jolin P. Glaser.
@) 2022 John Wiley & Sons, Inc. Published 2a22by lob^n Wiley & Sons. Inc'
Companion websiie : wm'v.wile5'.com/ golwager/healthcaresystems5e
309
310 CHAPTER 14 Health lT Leadership Case Stur,ies
Table 121.1 List of cases and corresponding chapters
Title ot Case Corresponding Chapte(s)
Case 1: Population Health Management in Action
case 2: Registries and Disease Management in the patient-centered Medical Home
Case 3: lmplementing a Capacity Management lnformation System
Case 4: lmplementing a Telemedicine Solution
Case 5: Selecting an EHH for Dermatology practice
Case 6: Watson's Ambulatory EHR Transition
Case 7; Concerns and Workarounds with a Clinical Documentation Systern
Case B: Conversion to an EHR Messaging System
Case 9: lmplementing a Syndromic Surveillance System
Case 10: Replacing a Practice Management System
case 11: lrnplementing Telepsychiatry in a community Hospital Emergency Department
Case 12: Assessing the Value of Health lT lnvestment
Case 13: The Admitting System Crashes
Case 14: Breaching ihe Security of an lnternet patient portal
Case 15: The Decision to Develop an iT Skategic plan
Case '16: Selection of a Patient Safety Strategy
Case 17: Strategic lS Planning for the Hospital ED
Case 18: Board Support for a Capitai Project
Case 19: Liberty Medical Center Network lmpacted by Malware Attack
Case 20: Breach of PHI af Sunrise Healthcare
Case 2.1 : Warren Center for Telehealth Expands
Chapter 3
Chapter 3
Chapter 7
Chapter 7
Chapter 7
Chapter 7
Chapter B
Chapter I Chapters 5 and B
Chapters 6 and I Chapters 6, B, 9
Chapter 9
Chapter 12
Chapter 12
Chapter 5
Chapter 5
Chapter 5
Chapters 5 and 6
Chapter 12
Chapter 12
Chapter 13
Although the integration of patient-centered medical homes and accountabie care organizations into the health system continue to emerge-as are best practices and key learnings fromlhese early efforts-there have been myriad examples demonstrating encouraging returns and improvement in quality of care' The Patient-Centered Primary Care Collaborative profiled several organizations that have adopted popuiation health management (PHM) tools and strategies to address the preventive and chronic care needs of their patient popuiations.
Bon Secours Virginia Medical Group
Richmond, VA
Provider Tlrpe: 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 moclel that is in alignment with heahh 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 technologiej into care tc'am workflows, and engagsFatients in their care.
Bou Secours took a leap of faith in implerne*ting 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 aisn signed value- based contracts with two commercial payers-CIGNA and Anthem-and is in negotiations with
OASE 1:
POPULATION
HEALTH
MANAGEMENT
IN ACTION
Case 1: Population Health Management in Action 311
severai 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 tr: position itself to achieve quality outcomes and flnancial success in the changing health care environment.
BON SECOUR$'s CAHE TEAM MODEL
The foundation of Bon Secours's strategy for value-based care is its medical home initiative*the Advanced Medical Horne Froject. The project began as a pilclt five years ago. Since that time, eleven practices have earned NCQA recognition as patient-centered medical homes. One of the most signiflcant objectives of the Advanced Medical Home Project is to improve capacity-making it pos- sible for care tearns to doubie the size of their patient panel without overburdening themselves or sacrificing quality of care.
At the heart of this medical horne strategy is the effort to reengineer practices by creating high- performance physician-led care teams, which requires changes in u,orkflow, new care coordination activities, and designed deiegation of clinical responsibilities across the care team. To facilitate this proeess, 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 man- agers or actively rnorking toward certification.
Each nurse navigator is assigned a panel of approximately 150 high-risk patients. He or she
cuitivates a personal relationship r,vith these patients, usualiy through repeated phone contacts" Although most outreach is telephonic, navigators have the skill to assess which patients require face-to-t'ace intervention. And because they are embedded in the practice, they can spend time with these patients doing assessments, care planning, and education,
B0N SECOURS's eHEALTH STRATEGIES
An important aspect of Bon Secours's strategy is impiementing health information technology that empowers the care team to ef{iciently manage the health of their populations. They consider this technologl,-standardized across the medical group-as the key to enable them to scale their systern for value-based care. As a first step, Bon Secours implemented an EHR and all its rnodules 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 identifu 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 ftrr a more robust, scalable registry that would drive efficient population health workflows in their practices and enable analytics and pre- dictive modeling across multiple ciinical conditions.
Integrating their EHR with a PHM platformo Bon Secours is able to aggregate all source data into a population-wide registry that enables the organization to impiement multiple quality- improvement programs simultaneously. The registry stratifles the population by risk-providing a tr:tai population view while enabling each care team to driil dorvn to the data they need about cohorts and individuai patients.'fhe 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 signiflcant 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 (Pe_P), and pinpoint those who are a! high risk for readmission. Flagged patients are then called within twenty-four to seventy-fwo hours to reinforce discharge instructions, make sure their medications are reconciled, and set up affi-ppointment with the primary care team within five to ten days of discharge. Bon Secours will soon implernent a read- missions 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.
312 cHAPTER I4 Health lT Leadership Case Studies
Personal heatth records. Another strategy for patient engagement is activating patients on
an electronic personal health record (PHR), which allows patients to view clinical results and com-
municate conveniently with their caregivers via e-mail. Bon Secours works to gain physician con-
sensus on poiicies that drive the use of PHR: physicians agreed to allow automatic release of norrnal
results to the PHR, but abnorrnal 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 irelp 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 themseives as the ciinician and the rest of the
teem as support staff rnembers. 'lb help ph,trsicians emtrrace the care tearn and delegate patient-
care tasks, Bon Secours placed tremendous emphasis on physician education. The organization
also allows physicians to adjust some of the standardizerl care team protocols to meet the needs
of their practice, which fosters ownership of the process and assures physicians that they remain
in control. Payrng for the transition to value-based care. As mentioned previousll', Bon Secours
implemented its medical home model with the hope that payers would come to them if they buiit a viable program. CIGNA currently gives the organization a per-member per-month (PMPM) adjust-
ment for care coordination. Anthem, the group's biggest payer, pays a care coordination fee and will change to PMFM in the coming year. Several more commercial payers are lined up to sign contracts
with the group" Hou,ever, 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 investmcnt. Bon Secours is also demonstrating significant progress managing its CIGNA population. in
the first six months of their value-based contract, they have achieved a27 percenL reduction in read-
missions and are 91.8 million below their projected spend. They have hit many of their care quality
metrics and need to improve their gap-in-care metrics only siightly to achieve the index necessary
to quali$i for gain sharing with CIGNA-a development that r,vill bring a projected annual savings
of $4 million. Bon Secours's mantra fbr the future is "health care without walls." The organization is
aggressively pursuing remote, noninvasive monitoring for highly acute case management. Their vision is to bring care outside the four walls of the hospital into the patient's home using tech-
nology. They are operationalizing a geriatric medical home that will enable patients to age in place with home visits for preventive and acute management. They are alsct expanding their implementation of the PHM platform to include performance measurement at the group, site,
and provider levels; feedback to providers on variance in care; and quaiity reporting. I'his added
functionality for analytics and insight on the clinical and adrninistrative levels will help the
organization ensure that it is meeting the Triple Aim (to improve the patient experience of care,
inciuding quality and satisfaction; to improve the health of populations; and to reduce the per
capita cost of health care).
INNOVATION IMPACT
1. Thirty-day readmission rate for medical home patients was < 2 percent for two years.
2. Patient engagement scores were in the 97th percentile.
3. Patient ouJreach effnrts generated approximately forry thousand unique patient visits for preventive, folloiv-up, or acute care, leading ts$f miliion increased revenue"
Source: Shaljiarr, M., & Nielsen, M. (2013). Managing populothns, mtximizin| technolog)): Population health management in the wled
ical neighbarkood- Patient,Centered Primary Care Collaborative. Retrieved from https://pcpcc.org/resource/managing-populations-
maximizing-tech nology. Used r,'r'irh permission.
case 2'. Registries and Disease Managernent in the patient-centered Medical Home 313
What do you think are the important take- home messages in this case?
What is your assessment of the approach Bon Secours has taken in embracing its commit- ment to population health management by investigating in different IT capabilities? How useful are capabiiities such as nsk stratifica- tion, automated outreach, and PHR.s in
impn:r,'ing quality while managing costs? Are there other tools that could have been useful? If so, what are they? How might they be used?
3. Bon Secours's mantra for the future is ,,health
care without walls." What might success in achieving this vision look trike? What chal- lenges rnay they face? How might they overcome these challenges?
Unir:n Health Center (UHC)
New York, trIY
Provider Tlpe: Communify Health Center
Medical Home NCQA Level 3
Patients: 11,000
Office Visits: 5"5.00i)
UHC,s CAHE TEAM MODEL
Union Flealth Center (UHC) embraced the patient-centered carc 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 tearns, composed of physicians, rrurse practilioners, physician assistants, nurses! rnedical assis- tants, and administrative staff members. The practice uses a full capitation motlel with standard fee-for-service and a fee-for-serrice plus care management paynrent model.
Ten years ago, UHC instituted the California Health Care Foundation's Ambulatory Intensive Caring Unit (AICU) rnodel, which emphasizes intensive education and self-management strategies for clrronic disease patients. The model relies heaviiy on the role of medical assistants (called patient care assistants or PCAs) and health coaches. Working closeiy with other ritembers of the care team, PCAs and health coaches review and update patient information in the record, conilucting personal outreach and self-management support, and prorriding certain clinical tasks. For instance, iU pCat have been trained to review rneasures (e.g., HgbAlC, blood pressure: and LDL cholesterol), pro- vide disease education, and set and review patient health goals. A subset of higher-trained heaith coaches works more intensely with recently diagnosed diabetic patients or those patients whose condition is not well managed.
UHC's eFIEALTH STRATEGTES
Patient registries. UHC uses patient registries to identify patients with speci{ic conditions to ensure that those patients receive the right eare. in the right place, ar 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 chatrges. In the future, UHC would like to construct queries that combine diagnosis groups with control groups and stratiSr patients by risk group. For example, care teams .orta p.,iiu report of all patients over the age of sixry-five with multiple chronic conditions or rece-n1ffi"rg"rr.y ,ou* admissions.
Maximizing time and expertise. UHC uses technology such as custom El{R. templates to support PCAs and free up clinicians for rnore specialized tasks and cclmplex patients. Iror example, a PCA or health coach taking the bir:od pressure of a high-risk diaberic patient has been trained io
CASE 2: BEG.
ISTRIES AND
DISEASE
MANAGEMENT
IN THE PATIENT.
CENTERED
MEDICAL HOME
314 cHAPTER 14 Health lT Leadership Case Studies
determine whether or not blood pressure is controlled. If it is not controiled, the health coach checks
the eiectronic health record for standard instructions on how to proceed and may carry out instruc-
tions noted in the record" or, if no information is availabie, he or she witrl consult with another pro-
vider to adjust antl compiete the note. Following all visits with PCAs or health coaches' the patient's
record is electronically hagg"a for review and signed by the primary care physician'
working wittr meaical neighbors. rhe teams also collaborate u'ith on-site specialists'
pharmacists, social workers, physical therapists, psychologists' and nutritionists t0 enhance care
c.or.dination and whoie-pati",t "*,., UHC has aiso adopted curbside cr:nsultations and e.consults to
reduce specialty office visits. For example, if a hypertensive patient has uncontrolled blood pressure'
the record is fiagged by the PCA for further foito*-up with a physician or nurse practitioner' u'ho
may opt for an e-consutt r,vith the nephrr:logist to discuss recommendations' ulJC also has a spe-
cialty coordination team-composeJ of 6*o primary care physicians, one registered nurse' one
PCA, and one health coach-that functions as a iiaison between primary and specialty providers'
customized reporting. uHC will have the capacity to generate stanrlardized reports' UHC
intencls to construct queries that generate reports that group diagnosis groups with control groups
and identif, and munage subgrorips of high-risk patients (or risk stratification). For example, care
teams can ,un u ,"po.iof all-patients with diabeies that have an elevated LDL and have not been
prescribed a statin.
CHALLENGES AND LESSONS LEAHNED
Recruiting staff members with IT and clinical informatics expertise' Over the years' UHC
has faced challenges in iclentiffing and recruiting staffmembers with the right mix of IT and clinical
informatics skills. ,A.lthougt, "it*J*" in troubleshooting routine issues and hardware maintenance'
UHC felt there was a clinical data analysis gap. To resolve this, UHC works closelywith an IT consui-
tant anrl also recruited a clinical informatics professional to work w-ith providers and performance
improvement staff members.
consistent data entry. uHC',s lack of consistent tlata entry ruies and structured data fields
led to several challenges in producing reports and tracking patient subgroups' The problem stems
from UHC's lack of internai data entry foiicies as wetrl as the record's 4esign' For instance' UHC
cannot run reports on patients taking ;spirin because this information may have been entered
inconsistently u..o$ puti"rrt recorcts. laoving forward, uHC will be implementing data entry ruies
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 wirkaround they considered disserninating raw reports to clinical teams in
real time, followed by tabulared, reforrnatted data. They are exploring the possibiiity of purchasing
report writing software to streamline the process'
Managing multiple data sources. similar to many practices, UHC pulls dala from its biliing
system and clinical recirds, causing issues with data extraction. Rrr example, pulling by billing
coiles does not provicle the most accurate <lata rvhen it comes to clinicai conditions, health status'
or population demographics" UFIC recognizecl that to reduce errors in identiffing patients and sub-
groups this will require custom reports'
INNOVATION IMPACT
1. Forty-six percent reduction in overall annual health costs
2. Eighteen percent reduction in total cost of care -
3.significantdeclineinemergencyroomvisits,,bspitalieations,anddiagnosticservices
4. significant improvements in clinical indicators tbr diabetic patients
source:shaljian,M.,&Nielscn,M.(2013).ManugtngpopuiatLons'ma'imtzingtechnologt:Papulaiionheoithmanagementittthemed' ical neighborhood. patient-centered primary care collaborative. Retrievecl from https://pcpcc.org/resource/managing-populations-
maximizingtechnology Used with permission'
Case 3: lmplementing a Capacity Management lnformation System 315
Doctors, Hospital is a 162-tred, acute-care facility iocated in a small city in the southeastern United
States. The organization haci a rnajor financial upheaval six years ago that resulted in the establish-
ment of a nery governing structure. The new governing body consists of an eleven-member authorify
board. The senior rnanagement of Doctors' I{ospital includes the CEO, three senior vice presidents,
and one vice presiclent. -During
the restructuring, the CIO was changed from a full-tirne staff posi-
tion to a part-time cgutract position, The CIO spends two days e\iery two weeks at Doctors' Hospital'
Doctgrs' Ilr:spital is currently in Phase 1 of a thrce-pirase construction project' In Phase 2 the
hospital will build a new emergency clepartment (ED) ancl surgicatr pavilion, which are scheduled to
he completecl in eleven months.
INFOHMATION SYSTEMS CHATLENGE
'lhe 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 identifled that inefficient patient flow processes, pafticularly
patient transfers and clischarges, have resulted in backlogs in the ED and outpatient areas. The new
construction will only exacerbate the current protltrem.
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 tirneline was tn have the new systern pilot-tested prior to the opening of the new ED and
surgical pavilion. However, with the competing priorities its memlrers face as they deal with major
con"structicn, 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 proposecl but not finalized. No other steps have been taken'
Identiff and discuss the various IT tools and
staff resources UHC used to depioy its
education and self:management strategies
among patients with chrorlic disease. What are
their strengths? Limitaiions?
UHC identified several challenges and lessons
learned in this case. Discuss each of these,
including UHC's approach to overcorning the
challenges. What other strategles or approaches
might you have considered? Why? Explain yout:
rationale.
UHC used curbside consultations and e-visits
to reduce specialty office visits. To what extent
are these used by pr:ovider organizations in
\.,our communiff/ Or others as evidenced by
the literature? How effective have e-visits been?
FJow do you establish the right tnix between
e-visits and face to face visits?
How might other health care provider
organlzations learn from UHC's experiences?
What a.re the critical take-horne messages?
Discuss who you think should serve on the
project steering committee. Who shouid serve
as chair? Why?
At this point, what do you think is a realistic
time ftame for implemerrtation of the capacity
management system? What steps can be taken
to ensure the new timeline is met despite
competing priorities?
Do you think the absence of a full-tine CIO
lTas had an impact on this acquisition project?
Why or why not?
What steps should the CIIO take to elsure that
the capaciiy management system will be
purchased and implemented? What do you see
as the critical flrst step in this process? Why?
CASE 3: lMPtE"
MENTING
A CAPACITY
MANAGEMENT
INFOHMATION
$YSTEM
316 CHAPTEH 14 Health lTLeadershipCaseStudies
Grand Hospital is in a somewhat rural area of a Midwestern state. It is a 209-bed, comrnunity, not- for-profit entity offering a broad range of inpatient and outpatient services. Employing approxi- mately 1,600 individuals (1,2-q0 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 rnore than $150 million, and is one of only a smali number of organizations in this market with an A credit rating frorn Moody's, Standard & Poor's, and Fitch Ratings. Operating in a remarkably competitive market (there are roughly one hundred hospitals within seventy-five min- utes' driving time nf Grand), the organization is r:ue of the few in the region-proprietary or not- for-profit-that has consistently realized positive operating margins. Crand attends on an annual basis tn the health care needs ot more than tr1,000 inpatients and 160,000 r:utpatients, addressing
more than 36 percent of its primary service area's consumption of hospital services. In expansirrn
mode and currently ir.r 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 populaticin of the
service area and to succeed retiring physicians.
Grand has been an early adopter of health care inftrrmation systems and currently employs a
health care information system that provides (among other components) these services:
. Patient registration and revenue management
. EHR.s with computerized physician order entry
. Imaging via a Picture Archiving and Communication System (PACS)
. Laboratory management
. Pharrnacy management
INFORMATION SYSTEMS CHALLENGE
For the past two decades, Grand Hospital has transitioned from being an institution that consis-
tently 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. Con-
sequentiy, a need exists fetr Grand to investigate and evaluate creative approaches to enhancing its ph),sician coverage for certain specialty selvices. These potential approaches include the effective
implementation of IT sr:lutions. The findings and conclusions r:f a medical staff development plan, which has been endorsed
and accepted by Grand's medicai 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 apprr:aching this challenge are radiology, behavioral health crisis intervention serices, and intensivist physician services. In the area of radiology, Grand needs qual- ified and appropriately cretlentialed radiologists available to interpret studies twenty-four hours per day, seven days per week, Similarly, it needs qualified and appropriately credentialed psychiatrists available an a 2417 basis to assess whether behayioral 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 inpa- tient basis. Finaily, inasmucf. as Crand is a community hosp_itel that relies on its voiuntary medical staff members to attend to the needs of patients admitted by staff members such as some ED per-
sonnel, it aiso needs to have intensivist physicians availdfilfaround the ciock 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.
CASE 4: IMPLE-
MENTING
A TELEMEDI.
CINE SOLTJTION
Case 5: Selecting an EHB System for a Dermatology practice g1Z
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.
What are the ways in which Grand's early adoption of other health care infotmation system technologies might affect its adoption of telemedicine sol utions?
What do )rou see as the most likely Lrarriers to the success of telemedicine in the areas of radiology, behavioral health, and intensive care? Which of these areas do vou think wouid
be the easiest to transition into telemedicine? Which would be the hardest? Why?
3. If you were charged bv Grand to bring telemedicine to the faciliry within eighteen months, what are the first steps you wouid take'? Whom would you involve in the planning process? Det'end your response.
Greenfieid Dermatology .Associates is an eight-physician dermatology practice located in central North Carolina. Alter several )€ars of contemplation and serious deliberations, the physicians have most recently made the strategic decision to replace their current practice management system (patient scheduling and billing) and to invest in the selection and implementation of an EHR system. Their current practice rnanagement system that is antiquated, rather clunky, and not well supported by the current vendor. Ideally, they d like to select and implement a new integrated prac- tice rnanagement system that has a user-friendly EHR cornponent, customizable for dermatology care. The practice does not have full-time in-house IT support, so they are open to exploring cloud- based options.
BACKGNOUND AND OVERVIEW
Greenfield Dermatr:logy Associates originally plannecl to participate in the CMS EHR incentive program years ago, but clpted against it, primarily because they had no system champion eager to lead the effort at the time, Dr. Dan Brown, the senior managing partner at Greenfield Dermatology, has little knowledge of infr:rmation systems technology. He was reluctant to move toward an El{l1 system for many years, primarily trecause he had heard stories from colleagues in nther specialty areas who had implemented EHRs in their practices and founel the systems to be highly cumber- some and disruptive to the patient care process. Dr. Brown also has a ciose friend who is a cardiol- ogist who complains she "spends an extra two hours a night in the office because of the additional time demands of the EHR" She said the system never iived up to expectations." Dr. Brown and his colleagues now feel that the time is right to make an investment in heaith IT. With increased competition and value-based payment grr:wing, a more mature dermatoiogy-specific EI{R market, and greater patient demand for access to records and teiehealth visits, the physician partners came together as a team in making this strategic decision. The business manager had been nudging them for a few years.
The composition of the physician associates has changed slightly in recent years. One of the practice's newest partners, Dt'. Pam lr4artin, just finished her residency program where EHRs and AI were an integral part of her training. She is a vocal champion of the effort antl willing to help lead in any way she can. Another parfner, Dr. John Harris, recently visited another colleague who uses Nextech EHRs and is convjnced it's the way the practice ought to go. His coileague's practice has been successful in following up on suspicious lesions, tracking referrais, improving outcomes, and achieving high satisfaction scores'among patients,
As for the other physieians in the practice; fivo are nearing retirernent and-nervous about the possible disruption to the office, but ttiey understand the desire to "move;[lg.practice into the hventy-frrst centuty." The other three plrysicians have some experience with Ellns and are onboard but are concerned about the new system's financial impact on the practice. In fact. one of the partners
CASE 5: SELECTING
AN EHH SYSTEM
FOR A DERMA"
TOLOGY PHACTICE
318 CHAPTER 14 Health lT Leadership Case Studies
shared a recent article about a local community hospital that experienced severe financial problems after replacing its EHR system. Anoiher has expressed concern that it will decrease productivl6r.
In addition to the eight physicians, the practice employs twelve nurses, four front office staff, three support staffincluding an IT technician, nryo billing staff, and a business manager. The IT tech- uician works on a contract basis (as needed) as he provides onsite technical support to several other physician practices in the area.
The practice currently provides service to approximately two hundred patients per day. Fifty percent of patients are covered under Medicare, and hatf of the Medicare population is pari of an ACO. The ACO tracks referrals and Greenfield is incentivized to see high-risk patients who are referred to them within seventy-two hours after the referral, The remaining patients are covered by private insurance, self-pay, and Medicaid.
CURRENT SYSTEMS
Even though the patient records at Greenfield are still predominateiy paper-based, the practice has been using computerized practice management systems for patient scheduling and billing for years. Referrals are also tracked electronically.
In anticipation of the migration to an EHR system, six months ago they starteci to have nurses enter physician-dictated notes intr: 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. ftris 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 EHRs. The expectation is that nurses will do the buik 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.
You are tasked rvith assisting in providing leadership to the team charged r.vith the selection oi the nelrr prac- tlce management and EHR system for the practice.
You begin by convening a practice management-EHR selection team. Who would serve on the team? Who should lead the team? Explain your rationale.
How might you conduct an EHR readiness assessment for thls practice? What factors rvi11
be important to consider? Why?
Conduct an initial review of the practice maniigement-EHR systems available on the market that axe tailored to the uni.que needs of dermablogy What resources wnuld you use to identi$r vendorsiproducts? Identifu at least
three to live vendors/EHR systems that Creenfieid may wish to send an request for information in order to gain additional information.
Develop a system selection plan for this practice. What do you envislon will be the practice's great challenge in selecting and implementing a new system? Explain your rati0nale.
Greenfield participates in an ACO that tracks referrals and the practice is incentivized to see
high-risk patients u,ho are referred to them within seventy-two hours after the referral. How will the new system enable the practice to track and monitor their performance?
Primary care physicians play a key role in the US health care delivery system. These providers inte- grate internal and externai information with their clinical knowledge to cletermine the patient's treatment options. An effective ambulatory electronic health record (EHR) is critical to supply phy- sicians with the information they need to provide high-quality, evidence-based, cost-effecii* rur". This case describes the decision-making process and plan that a team of health care leaders used to repiace an inadequate E'HR system;n a prlmary care neffirk owned by a community hospital.
DISCUSSION
QUESTIONS
CASE 6: WATSON,S
AMBULATOHY EHR
TRANSITION
Case 6: Watson's Ambulatory EHB Transition 319
BACKGHOU ND INFORMATION
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 u ,trut"gy 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 uti-
lize the hospital. WCH employs thirty-six physicians and seven mid{evel providers in eight clinics,
specializing in internai 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, irnprove patient safety, integrate information from ancillary systems,
and provide access to patient information for ail WCH caregivers. ln 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
functionaiity were secondary consiclerations. As a result, physician system adoption and support has
6een poor. Under prior leadership, the hospital information technology (IT) department provided
iimited support for the XyZ EHR. The clinic organization rvas left to develop its own internal I'I
capabiiities to manage theXYZsystem and, as a result, the system has nnt been routinely updated'
The hospital has decided to stay with the Meditech platform to address the IT strategic plan for
an integrated bHn. fir* clinic organization must now evaluate whether it is in their best interest to
stay rvith the XyZ sysrem, with strong Meditech compatibility, or rrlove 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 coultl be implemented much sooner' A neu'HHR system
would require an evatruation and selection process and a significant conversion. With either sce-
nario, physician support will be critical to a successful transition'
The next sections describe the planning process proposed by the leadership team to select a
replacement EHR. Focus your analysis on the selection process'
PHOJECT ORGANIZATION
The organizational phase of the project will involve establishing a project steering committee and
identi$ring the leadership members who wili ensure the project's success. WCH operates eight sepa-
rate 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
hventy to twenty-five members. In addition to physician representatives, the steering committee will
also inciude nurses, medical assistants, and office managers from each clinic. IT representation is
critical to the success of the project, and since the department provided poor lT support in the past,
the chief information officer (CIO) will play an active role on the steering cornmittee. A represen-
tative from finance shouid 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 would be chaired by a provider
who is respected within the group, is objective, ancl is a supporter of EHR technology. Although the
clinic organization does not harre a provider who meets all of these criteria, a physician with strong
peer support and credibility will be selected to co-chair the steering committee' 1b complement the
"titricuiGua"rship, the CIO will serve as a co-chair for the committee, providing technical exper-
tise. This indiviclual has implemented other EHR systems ancl will bring a structured process to the
committee to ensure a thorough evaluation process.
I
320 cHAPTEFI 14 Health lTLeadership Case Studies
COMMITTEE DEVELOPMENT
Organizations often overlook the importance of understanding the culture and 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 criticai to establish trust and overcome resistance during the EFIR conversion (from the old to the new system).
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 iarge group into teams of four to five memhers, and each team will discuss the lessons learned from the XYZ implemen- tation that took place four years earlier. Team leaders w'ill be handpicked for their facilitation skills and ability to listen" The group discussions will address the "change readiness" and will surface rhe major issues associated with tire implementation. It will aiso allow the group rnembers to get to kuow each other in a less formai setting than the large group. The larger cnmmittee will reconvene to discuss their findings and prepare a master list of implementation lessons learned.
While this exercise may raise several issues related to implementation, it is also important to clpenly discuss the current issues with the existing EHR. Once again, small groups will be asked to discuss these issues to ensure participation by all rnembers of the steering committee. Small groups wiil report out to the large group, and a summary of issues will be developed. This list, as rvell as
the list of implementation issues, wiil set the stage for a later discussion regarding the scope of the project.
PHOJECT SCOPE AND OBJECTIVES
Once the group has had the opportunity to express personal concerns and key issues have been identified, the group can turn their attention to defining the project objectives. Arlxious committee members are often tempted to begin discussing whether the steering committee should upgrade this system or consider alternatives. When this occurs, discussions and conciusions are usually based on the emotional attachment to or disappointrnent with the current system. A more systematic review process will heip irame this discussion lo ensure that 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 cornmittee on the most pressing issues that must be addressed. With this background work, the committee rvill be positioned to articulate the project goals. Theyrvill also define the scope of the project by determining what the project is and isn't intended to address. Invariably, users wili raise issues that may not be solved by an EHR application. It is important that the end nsers review all issues, even though some of those issues may not prove to be i,vithin 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.
COMMUNlCATION
The steering cornmittee will need to establish plans to communicate rn ith 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 soiicit feedback from stakeholders dur- ing the evaluation and selgction process. Regular minutes_eltablish the record of the committee's work and provide ameans for communicating with stakeholders. Special meetings with individual clinic groups rvill also he necessary to addres, ,urnu., nrffiide more detailed iuforrnation reganling the process. 'Ihe steering comrnittee must communicate regulariy to ensure information is flowing to individuals.
Case 6: Watson's Ambulatory EHR Transition 321
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 ptan of work focuses on the decision to upgrade the existing XYZ application and
remiin with a Meditech platfonn or move to a different software solution. The plan of work provides
the steering committee with the road map to achieve their goals'
The iey steps in the plan of work are identi$'ing possiirle vendors, establishing systern require-
ments, and compieting a request for proposal (RFP) process, Vendor identification can occur simul-
tareously wittr estaUtlstring the project goals. This is a reasonabie assertion as it will save time and
will engage the ciinic representatives in the process. The steering committee will select individuals
to attend trade shows to maximize exposure to EHR products. IT staff will also participate in this
review process to address technical requirements and issues.
Elstattishing system requirements is a critical step in the EHR selection process. The system
requirements identify the needs of the organization and are the basis for the vendor evaluation
pro""rr. The implementation and current issues lists developed by the committee will be used to
develop the system requirements. Each clinic ernployee will r'eceive a summary of these lists, and
staff;ll 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 iurpact the EHR choice. The first draft of the system requirements will be
pr"lirrinury. As the steering committee begins to interact with vendors and complete site visits,
addltional functionality may be adcled to the reqriirements. It weiuld not be prudent to submit RFPS
to all vendors who claim to have a functional EHR. The steering committee rnrill need to determine
the top five to seven vendors, judging by the initiai survey of qualified vendors, trade shows, and
market information. Weil-definecl systern requirements will need to be estabiished and included in the RFP. Pack-
aging the systen requirements in a fcrrmat that provides structure for vendcr responses and steering
committee evaluations of vendor re$ponses will be irnportant, as wiil establishing a record of docu-
rnentation throughout the acquisition process. The RFP document will provide the foiiowing:
. instructions for vendors
. Organizational objectives
. Baekground information on the organization
" System goals and requirements
The vendors will be required to submit the follow'ing:
1. Vendorqualifications
2. Proposed soiutions
3. Criteria tbr evaluating proposals
4. Contractualrequirements
5. Pricing and suPPort
The vendor review process will also encclmpass technical calls, vendcr 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 tly the vendors' It will
not be feasible for all steering.cornmittee members to participate in these activities; therefore, indi-
viiluals rniill be appointed to participate on their behalf. prior to revier,ving the vendor proposals, the steering committee wili develop vendor criteria
that can be used to evaluate the proposais. Each:nember of the steering ee4!fifiittee will Lre asked to
score the proposals based on the criteria, and a summary score report will be developed. The WCH
CEO wi1 give the final approval to proceed with contract negotiations rvith the EHR vendor based
322 C H A PT E Ft 1 4 Health lT Leadership Case Studies
on the repcrt and recommendation from the steering committee. Ho\ /ever, the final recommenda-
tion of the commitiee will nclt be based solely on the score report. Ideally, the finai deliberations will involve a robust dialogue based on the mutual trust that has developed over time^ Ultimately, the
committee will balance their objective assessment of options with their intuition and their consider-
able knowledge of the clinic organization'
CONCLUSION
The WCH ciinic organization will undergo a signiflcant EHR transition if they upgrade the XYZ
systern or purchase another EHR system. The process that is outlined in this plan provides the orga-
nization the best opportunity to make the right decision for the organization and establish support
rvith key stakeholders for an EHR cr:nversion. A good IT decision-making process requires disci-
pline and objectivity. The structural elements of the process involve leadership, committee struc-
ture, system requirements, and a thorough RFP and evaluation process'
What are the streilgths of this EHR seiection
ptran? What aspects do you think are particu-
larly important? Explain your rationale"
FIow could the plan be improved? What, if anyhing, might you do differently if you were
leading the effort? llxplain your rationale.
What factors should the leadership team
consider when deciding whether to stay with a
single vendor for supporting both the hospitai
and primary care settings? Explain r.vhy they
are impclrtant.
4. Assume the leadership team is successful in
identifying a replacement EHR that meets their
organization's needs. Contract negoliations
have treen finalized. Discuss the major
elernents of your plan to implement the new
system, including your approach to managing
change. How rnight Kotter's principles of
managing change be useful? Explain your
rationale.
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 i1l neonates. The
twenty-eight-bed pediarric intensive care unit (PICU) cares for critically ill children from birth to
eighteen years of age. Patients in this unit inciude those with iife-threatening conditions that are
acquired (trauma, child abuse, burns, surgical complications, and so forth) or congenital (congen-
itai heart defects, craniofacial malformatinns, genetic disorders, inborn errors of metabolism, and
so forth). Garrison is part of Premier Heaith Care, an academic medicai center compiex located in the
Southeast. Premier Health Care atrso includes an adult hospital, a psychiatric hospital, and a fuIl
spectrurn of adult and pediatric outpatient clinics. Within the past si-r 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 rnedical and
surgery units and intensive care units. Electronic scheduling is to be implemented next'
The adult hospital clrives the decisions for the pediatric hospital, a circumstance that led to the
adult hospital's computerized provider order entry (CPOE) vendor being chosen as the documen-
tation vendor for both hospitals. A CPOE system was implemented at Garrison Children's Hospital
several years prior to implementatior of the electronic clinical documentation system.
INFOHMATION SYSTEMS CI,IALLENGH
A pressing challenge facing Garrison Children's Uospffis that nurses are very concerned and dis-
satisfied with the new clinical documentation system. They have voiced concerns formally to several
DISCUSSIO N
AU ESTIO NS
CASE 7: CON.
CERNS AND
WORKAROUNDS
WITH A CLINICAL
DOCUMENTA.
T]ON SYSTEM
case 7: concerns and workarounds with a clinical Documentation system 323
nurse managers, and one nurse went directly to the chief nursing officer (CNO), stating that the
flowsheets 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 under-
s1anaing of why the organization is automating clinical documentation or what it hopes to achieve.
Nurses in the NICU and PiCU seern to be the most vocal about their concerns. They claim there is
inconsistency in what is being documented and a iack of standardization of content. The computer
workstations are located outside the patients' rooms, so nurses generally docu[rent their notes on
paper and then enter the data at the end of the shift or when they have time.
T'he system support team, consisting of nurses as rvell as technology specialists, began the
workflow analysis, system installation, staff training, and go-live first with a small number of units
in the aciuit 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 timeiine for each unit implementa-
tion was based on the number of beds in the unit and the number of staff members to be trained. No
consideratiop was given to staff mernbers' prior experience with computers and keyboarding skills
or to complexity of documentation and existing work processes'
Although there are simiiarities between the aduit 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 evaiuating or planning for these diff'erences and completing a thorough workflow atlalysis.
After the initial units went live, less and less time was spent on training and addressing unit-specific
neecls because of the {emands placed on training staff rnembers to stay on the timeline in prepara-
tion for the next system implementation involving electronic scheduling.
The clinical documentation system was implemented to the great consternation and dissat-
isfaction of the end users (physicians, nurses, social u,orkers, and so forth) at Garrison. yet the Pre-
mier clinicians are happy with it. Many Garrison physicians and nurses initially refused to use the
system, stating it was "unsafe," "added to workload," ancl was not intuitive" A decision to stop using
the system ancl return to the paper documentation process uras not then and is not now an option.
fhysician "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 essentialiy f'orced underground, Garrison
clinical staffmembers der,eloped workarounds, morale rvas negatively affected, and the expectation
that everyone would eventually "get it" and adapt has not become a reaiity. Instead, staff members
are writing on a self-created paper system and then translating those notes tci the computer system;
physicians are unable to retrieve important, tirnely patient information; and the time team mem-
Lers spend trying to retrieve pertinent patient information has increased. There have been clear
instances r.vhen patient safety has treen affectecl because of the problems with the appropriate use
of this system.
What is the major problem in this case? What
factors seem to have contributed to the current
situation?
Ihe nurses at Garrison argue that pediatric
hospitals and intensive care units, in particul&r,
are different from adult hospitals and that these
dlfferences should be clearly.addressed in the
implementation of a new clinical documenta-
tion system. Do you agree with this argument? '
Why or rvhy not? Give exarnples from the
literature to support ytlur views.
Horv might the workflow issues and concerns
mentioned in this case have been
detected earlier?
Assume you are part of the ieadership team at
Garrison. How would you assess the current
situation? What wouid you do first? Next?
Explain the steps you would take and whyyou feel your approach is necessary.
What lessons can be learned from this case and
appliecl to other settir4$f
l
324 CHAPTER 14 Health lT LeaCership Case Studies
Goodwill Health Care Clinic is the ciinical arm of Jefferson Flealth Sciences Center in a large Southern city. The clinic was founded in the early 1950s as a place for faculry physiciaus to engage in clinicai practice. Over the years the clinic has grown to nine hundred faculty physicians and fwo thousand employees, with over one million patient visits per year. Clinic services are spread across eleven primary care and specialty care units. Each unii operates somewhat independently but shares a comrnon medical record numbering system that enabies consolidation of ail documentation across units. Paper charts were used until two years ago, when the clinic adopted an EHR systen.
Goodwill f{ealth Care Clinic uses a centralized cali center to receive all patient calls. Patients call a central switchboard to schedule appointments, request medication refiils, or speak to anyone in any of the eleven units" Call center staff members are responsible for tracking all cails to ensure that each is dealt with appropriately. The clinic has treen using an obsolete 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 iaken. Notes created frorn closed messages are printed and fiied in the appropriate patients' paper records. These notes cannot be accessed via the EHR.
Ciinic staffmernbers are very comtbrtable with the current 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 system means that the same information must be documented in hvo locations-first in the call center note and then in the EHR. This leads to duplica- tion of eftbrt and documentation errors. I'he potential for serious error is present. Physicians and other health care providers look in the EtiR for the most up-to-date medication infonnation.
Although the adoption of the EHR has been rather successful, not ail units use all of the available components of the EHR. A cornpanion paper record is needed for miscellaneous notes, messages, and so forth. A11 units are recording office visits into the EHR, but not a1l have activated the lab results or the prescription writing features. Severai units have been experiencing physician resistance to adding more EHR functions.
The EI{R system has a messaging component that works similar to a ciosed e-mail system. Messages can be sent, received, and stored by EHR-authenticated users. Pertinent patient care mes- sages are automaticaily stored in the correct patient record. In addition, the EHR messaging system works seamlessly with the prescription writing module, which includes patient safefy checks such as allergy checks and drug interactions,
The challenge for Goodwill l{ealth Care Clinic is to implement the messaging feature and prescripti<ln-writing component (where it is not currentiy being used) of their current EF{R. in the call center and the clinical units, replacing the existing system and irnproving the quality of the doc- umentation, 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 ro their providers, and refi ll prescriptions electronicaily.
Outline the steps that you would take to ensure a successful conversion frorn the existing call center system to the new EIIR-compatible system. Defend your response.
Who should be involved ln the conversion planning and irnplemeulatlon? Discuss the roles of the people on your list and your reasons for selecting them.
What arc some strategies lhal you wou!d employ to minimize physicians'and other users' resistance to the conversion?
4. Do you think that making sure all units are running the same EHR functions is a necessary precursor to the conversion to the messaging and prescription-writing components? What information would be helpful in making this determination?
5. Hor.r' might the implemenration of rhe parient-** - ^"portal l-eature address some of the current issues? What workflow considerations will need to be made?
DISCUSSION
QUESTIONS
CA$E 8r
CONVERSION
TO AN HHH MES.
SAGING SYSTEM
Case 10: Replacing a Practice Management System 325
Syndromic surveillance systems collect and analyze pre-diagnostic and nonclinical disease indica-
tors, drawing on preexisting electronic data that can be found in systems such as EHRs, schoell
absenteeism records, and pharmacy systems. These surueillance systems are intended to identifl specific symptoms within a population that may indicate a pubtric health event or emergency. For
example, the data being coliected by a surveillance system might reveal a sharp increase in diarrhea
in a community and that could signal an outbreak of an infectious disease,
The infectious disease epidemiology section of a state's public health agency has been gil'en
the task cf implementing the Early Aberration Reporting System of the Centers for Disease Control
and Prevention. The agency views this system as significantly irnproving its abiiity to monitor and
respond to potentialiy problematic bioterrorism, food poisoning, and infectious disease outbreaks.
The need for such a system has been heightened b), the Covid pandemic"
The implementation of the system is also seen as a vehicle for improving collaboration among
the agency, health care providers, II vendors, researchers, and the business community.
INFCIHMATION SYSTEMS CHALLENGE
The agency and its infectious disease epidemiology section face several major challenges.
First, the nece$sary data must be collected largely frorn 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 stan-
rlards, and uneven willingness to divert IT staffmembers and budget to the implementation of these
inter{aces. To help address this chatlenge, the section will acquire a commerciai package or buiid the
needed soltware to ease the integration challenge. In addition, the section will provide each hospital
urith information it can use fo assesri its own mk of patients and their presenting problems. The
agency is also contemplating the development of reguiations that would require the hospitais to
repr:rt the necessary data.
Second, the system rnust be designed so that patient privacy is protected and the systern
is secure.
Third, the implementation and support of the system will be funded initiaily through federal
grants. The agency will need to develop strategies fcrr 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 orrerreacts or underreacts to the data it coiiects.
If 1,ou were the head of the agency's epidemiol-
ogy section, how would you address the four challenges descrihed here?
Which of the chalienges is the most important to address? Wh]4
Il you were a hospital CEO treing asked to
redirect IT resources for this project, what
would 1.ou lvant in return frorn the agency to
ensure that this system provided value to your organization and clinicians?
4. A sirong privacy advocacy group has erpressed
alarm about the potential probierns that the
system could create. How would you respond
to those concerns?
University Physician Group (UPG) is a multispecialty group practice pian assqciated with the
Coilege of Osteopathic Medicine (COM). UPG employs ninety physicians and 340 clinicai and
business support personnei, '::*€ UPG has recently been profitable (with revenue from operations this fiscal year of $32 million
and a retained profit of $500,000 from operations). However, prior year losses make UPG a break-
even organization.
CA$E 9: IMPLE-
MENTING
A SYNDROMIC
SUHVEIL.
LANCE SYSTEM
CASE 10: REPLAC"
ING A PRACTICE
MANAGEMENT
SYSTEM
I
326 cHAPTER 14 Health lT Leadership Case Studies
Management and the physicians are focusing on strengthening the fiscal position of the orga- nization. This focus has led to plans to restructure physician compensation, establish a self-insurance trust for prolbssionai 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 iocated in the same city as UFG. NAMG holds a contract with the local county hospital to provide indigent care and serve as the fac-
ulry for the graduate medicai education programs in family rnedicine. Both organizations believe that the merged organization would be able to reduce expenses
through the eiimination of redundant functions and, because of greater geographical coverage and size, would improve their ability to obtair more favorable payer contracts"
INFORMATION SYSTEMS CHALLENGE
For many;rssrs UPG has obtained practice management systerns from Gleason Solutions (GS). The applications are hosted in a GS data center, reducing UPG's need fbr IT staff members.
Prior to the merger, UFG was in the process of exarnining replacements for GS. UPG had become displeased because of the GS application's failure to incorporate new technologies and application features, limited abilily to generate reports, and inflexible integration approaches to other applications.
Despite its displeasure, UPG now appears to be on the path to renewing the CS contract. GS executives have effectively lobbied several important physicians and administrators, and UPG's
limited cash position makes the GS lowcost financial proposal attractive. NAMG uses the GS applications and has also been examining replacing the system. NAMG
has a strong trT department and will be providing IT support to the newly merged organization. After examining the market, NAMG has identified four potential vendors, including GS.
a
Would you suspend both organizations' pursuit of a new systerr until an IT strategic plan for the merged organization has been
developed? Why?
What steps would you take to integrate the system selectioll processes of the two organizations?
Implementing a practice management system
1s always challenging. What additional
implementation risks are introduced by the merger?
4. Both organizations expect the result of the merger to be lower costs, improved patient
service, and increased market porver. What steps would you take to make sure that the new practice management system furthers these
objectives?
Westend Hospital is a midsize, not-frrr-profit, community hospital in the Sr:utheast. Each year, the hospital provides care to more than trvelve 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 rnental health reform act, which shifted care for patients with mental illness from state psychiatric hospitals to community hospitais and outpatient facilities. The Westend ED has in essence become a safety net for many individuals living in the community who need mental health services.
Largel.v considered a farming community, Westend County has a population of 120,000. Wes-
tend llospital is the third largest employer in the county. However, Westend is not the only hospital in the cotinfy. The state stili operates one of three psychiatric facilities in the counly. Within a five- mile radius of Westend }fospital is a 270-bed inpatient psychiatric hospital, Morton Hospital. Mor- ton Hospital selds the citizens of thirty-eight coun_l5gjp the eastern part of the state.
Westend Hospital is fiscally strong with a stabie management team. Anika Lewis has served
as president-CE0 for the past fifteen years. The rernainder of the senior management team has
Dtscussl0N QU ESTIONS
CASE 11r IMPLE-
MENTING TELE.
PSYCHIATRY
IN A COMMUNITY
HOSPITAI.
EMEHGENCY
DEPARTMENT
Case 11: lmplementing Telepsychiatry in a Community Hospital Emergency Department
been employed with Westend for eight to thirteen years. There are more than 150 active or affiliate members of the organized hospitai medical staff and approximately 1,600 employees. The hospital has partnered with six outside management companies for serv-ices rvhen the expertise is not easily found locally, including HighTech for assistance with IT sefl/ices"
In terms of its information systems, Westend llospital has used Meditech for nearly twenty- five years, including tbr nursing documentation, order entry and diagnostic results. The nursing staffmembers use bar-coding technology for medication administration and have done so for years. The organization implemented an updated EI{R enterprise-wide four years ago.
TI.IE CHALLENGE
Westend Hospital has seen increasing numbers of mental health patients in the ED oyer the past decade. Iror the past three years, the ED has averaged one hundrecl mental health patients per month. Depending on the level of patient acuity and availability of state- or cornmunity-operated behavioral health beds, the patient may be held in the ED from fwo 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 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 dis- position frr:m the ED. The Westend Flospital'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 IiD are complex. The physicians have not been able to reach an agreement on this topic. Senior leaders have suggested that telepsychiatry may be a partial solution to address this challenge.
TELEPSYCI{'ATRY AS A STRATEGY
Westend Hospital has chosen to consider contracting with a telepsychiatry hospital netrvol'k to provide telepsychiatry selices in the ED. The nefwork has demonstrated good patient outcomes and is considered frnancially feasible at a rate of $4,500 per month. This fee inciudes the equip- ment, management fees, and physician fees. The director of telepsychiatry in the hospital network has verbally committed to work very closely with the Westend Hospitai team to ensure a smooth implernentation.
Teiepsychiatry as a solution to the mental health crisis in the ED was not immediately embraced by the medical staffmembers. They did agree to the implementation of teleradiology four years prerriously. However, the most recent revision of the medical staffbylav,,s to support telemedi- cine explicitly states that the medical executive cbmmittee must approve, by a two-thirds vote, any additional telemedicine programs that rnay be introduced at the hospital. The medical staff leaders wanted to preserve their ability to maintain a financially viabtre medical practice in the community as well as protect the quality of care,
The idea of telepsychiatry was introduced to portions of the medicai staff. The psychiatrists realized that telepsychiatry could relieve them of the burden of daily rounds in the ED for boarding patients. They were also concerned about their workload when teiepsychiatry \ /alpot available.
The emergency medicine physicians immediately verbalized their d]gg&proval on several levels. []irst, they were concerned about the reliabilily of the technology based on their experiences over the past several years with video remote interpreting. Then, the emergency medicine physicians
927
328 CHAPTEH 14 Health lT LeadershipCase Studies
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 psychia- trists could not meet the needs of the ED" The barriers to adoption of telepsychiatry crossed three arenas: financial, behavioral, and technical. Subsequently, many conversations were conducted. Eventually, the medical executive cornmittee approved telepsychiatry as a new patient care service on June 25 of this ,v.-ear.
IMPLEMENTATICIN PLAN
The CEO appointed the vice president of patient sewices as the executive sponsor. The implementa- tion team includes the IT hardware and nelworking specialist, IT interface specialists, nursing infor- matics anaiyst, ED nurse director, behavioral health nurse director, assistant vice president patient services, physician ciinical systerns anaiyst, and the medical staffservices coordinator. These individ- uals represent the major activities for impiementation: provicler credentialing, physician documen- tation, 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 heaith crisis affecting the ED is the focal driver for change. Patient safety is at risk" Barriers to implementing telepsychiatry have been well documented. The strategies to overcome the barriers include defining the new role for the Westend psychiatrists, developing a process fbr ease
of access and reliability of equipment for the ED physicians, and development of a plan when the teiepsychiatry program is not available.
An unexpected barrier has been recently identified. On initiation of the telepsychiatry pro- vider credentialing process, the medical staff services coordinator discovered that the bylaws do not have a provisiein 1'or credentialing of physician extenders in the telemedicine category. The teiepsychiatry providers include six board-certified psychiatrists and twelve mental health-trained nurse practitioners, The medical executive committee has agreed to ask the medical staft bylaws committee to convene and revise the bylaws accordingly. The original go-live rlate of September has
been changed to December. The executive sponsor along with the implementation team will be responsibie for managing
the organizational change$ necessary to sr.lpport the introduction of technology and neu,patient care flow processes" Managing organizational change will be essentiai to the success of this project. Some items in the project will be viewed as incremental change and other items wili be viewed as
step-shift change. Commuuication strategies will be deveioped to support the change.
What are the benefits associated with using telepsychiatry services in the ED? To the patient? To the hospital? To the rnedical staff rnernbers? What are the potential barriers or challenges?
Ba^sed on the information provided in this case,
hou,equippeci is Westend Hospital to imple-
ment telepsychiatry services? What resources
do they have in place? What other resources
might they consider?
3. How might Westend Hospital evaluate or rneasure the success of its telepsychiatry services? What metrics might they use?
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 Chil- dren's Hospital, Ir4cSinsey flospital, and the Institute of Pslchiatry. 1'hey contracted with a major health IT vendor to implernent the following applicatiog5;-
. El) tracking systern
. Replacement pharma.cy intbrmation system
DISCUSSION OUESTIONS
CASE 12: AS$ESS-
ING THE VALUE
OF HEAUTH IT
INVESTMENT
Case 12: Assessing the Value of Health lT lnvestment 329
. Clinical documentation system (for all nurses and ancillary persclnnel; dr:es not include physi-
cian notes)
, Medication administration using bar-coding technoiogy
. Computerized provider order entry (CPOE)
ln addition, several administrative applications were implemented, including a new operative
scheduling system and materials managemerit system. T'hey also upgraded their clinicai data repos-
itoryviewer. A11 applications are now operational.
Most recently, the board of trustees has approved replacement of Southeast's ambuiatory care
EHR system. However, the system was viewed by clinicians and lT stafl members as antiquated and
cumbersclme to navigate. It is also very dif&cult to retrieve aggregate data from the system' Much of
this is apparently trecause of its underlying database architecture and structtlre" The system also did
not interface with the hospitai clinical applicatinns.
Clinicians have also been f'rustrated that Southeast has been using two diflbrent EHR systems,
one for inpatient and another for outpatient, and the two don't interface or give a complete picture
of the patient's healttrr record. With payment relbrm and the need to be able to more effectively
manage patient care quatrity and outcomes, senior ieaders recommended, and the board approved,
replacement of the EasyDoc EliR with Epic ambulatory care EHR. The patient registration and
Uiiling system used in ambulatory care wili also be replaced with Epic's practice management appii-
cation. Long-term plans are to eventually replace the existing clinical applications with Epic in the
inpatient sector as well. The total cost of ownership for the replacernent ambulatory EHR and practice management
system is approximately $30 million. Inclucled in this estimate are not only the software and hardware
upgrades but also the staffmembers needed to implement and support the new applications. Replac-
lnftne current clinical products with Epic inpatient EHR will cost an additional $90 rnillion. 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 EliR 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. CuI'
iently a local health information exchange (HIE) exists that provides ED visit information to all local
hospitals. This is to be expanded to include US Core Data for Interoperability (USCDI) aud other
relevant health information. Patients wilt be given access to their health inforrnation such as lab
tests, X-ray results, and medications. T'hey will also be able to schedule appointments and pay their
bills online through a patient portai known as MyChart. Southeast physician leaders view'patients
as partners in their own care and are pieased to provide them access to information eiectronically'
Southeast providers treat a large population of patients with multiple chronic conditions.
Managing chrnnic diseases using evidence-based, real-time support is considered essential. In
addition, Southeast Medical Center has available a secure data rvarehouse of patient data that
researchers and clinicians wili be using more fully in the future to ensure that ciinical research
drives best care.
Assume you've been tasked with develeiping a plan 1.
to assess the value of Southeast's investment in the
Epic outpatient and inpatient systems and expansion Z.
of its use of the data warehouse. The board is inter-
ested in knowing how these new and replacement sys-
tems have affected or will affecl Southeast's ability to
offer coordinated, coliaborative care in a cost-effective'- 3.
manner. They realize that the traditionai fee-for-
service system in whlch providers are pald on volume
will be a thing of the past.
How would yon determine which metrics to
use? Who would be involved in the process'i
!{ow rvould you know that a change is
attributable to the HI:IR or datalvarehouse
system and not something else?
Do you think traditioral rettrn-on-investment methods are usefu 1 in- tl]is*ase? Why
or why not?
330 CHAPTER r4 Health lT Leadership Case Studies
Jones Regional Medical Center is a large academic health center With nine hundred beds, Jones had forty-seven thousand adrnissions last y,ssL Jones frequently has occupancy in excess of 100 percent, requiring diversion of ambulances. In addition, Jones had 1,300,000 ambulatory and emergency roomvisits in the past three years.
.Iones is internationallv renorvned for its research and teaching prograrns. The IT staff mem- bers at Jones are highly regarded. They support more than three hundred applications and lwelve thousand workstations.
'llhe admitting systern at Jones is provided by the vendor Technology Med (TechMed). The TechMed system supports the master patient index; registratiou 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 w'as inrplemented twelve years ago and uses now-obsolete iechnology, 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 nor,v.
INFORMATION SYSTEMS CHALLENGE
On December 20, the link between the main data center (where the TechMed seryers 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 sy$tem hecame sluggish and then unresponsive. Database corruption was discovered. The backup performed earlier in the day was also corrupt. The iink to the disaster recovery data center had not been restored folk:wing the performance testing.
Because there was no viable irackup copy of the database, the Jones 1T and hospital staffmem- bers began the arduous process of a full database recovery from journaled tra:nsactinns. This process
was completed the evening of Decernber 22.
l'he loss of the TechMed syslem for more than thirty-six hours and the failure during that time of registration transactions to update patient care and anciliary department systems resuited in a wide variety of operational problems. The patient census had to be maintained manually. Reports of results were delayed, Paper orders were needei{ 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 svstems, 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.
If you were the CIO of Jones Regional Medical Center during this system failure, what steps
would you take during the oulage? What steps
would you take after the outage to reduce the likelihood of a reoccurrence of this problem?
T'he root cause analysls of the outage showeci
that process, technoiogy, and staffing factors all contribl-rted to the problem. What are some of the like1y factors? Which-of these factors dr:
you believe are iikely to har,e been the most important?
If you were a mernber of the audit committee of the Jones board of trustees, what questions
*,ould you ask the CIO?
What issues and problems should a disaster
recovery plan prepare for? How does an
organization determine how mueh to spend to reduce the occurrence and serrerity of such_episodes?
DISC U SSIO N
OU ESTlON S
l
CASE 13:
THE ADMITTING
SYSTEM CRASHES
Case 14: Breaching the Security of an lnternet Patient Portal 331
Kaiser permanente is an integrated health delivery system that serves more than eight million mem-
bers in nine states and the District of Coiumbia. In the late 1990s, Kaiser Permanente introduced an
Internet patient portal, Kaiser Permanente Online (also known as KP Oniine). Members can use KP
Oniine 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 securiry of the KP Online pharmacy refill applica-
tion. prograrnmers wrote a flawed script that concatenated over eight hundred individual e-mail
*"ruug., "o,rtaining
individualty identifiable patient information, instead of separating them as
lntended. 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 orga-
nization that they had receir,ed the concatenated e-mail messages. Kaiser leadership considered
this inciclent a significant breach of confldentiality and security. I'he organization immediately took
steps to investigate anri to offer apologies to those a{Tected"
On the same day the first member ncltified Kaiser about receiving the probiem e-rnail, a crisis
team was formed. The crisis team began a root cause anaiysis and a mitigation assessment process.
Three days later Kaiser began notifiing its rnembers and issued a press release'
The investigation oi the cause of the breach uncovered issues at the technical, individuai,
group, and organizational ievels. At the technical level, Kaiserwas using newr.veb-based tools, appli-
cations, and processes. The pharmacy mo<lule had been evaluated in a test environment that was
not equivalent to the production environment. At the individual levei, trvo 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 ade-
quately test code they produced as a patch for the pharmacy application. Three groups within Kaiser
had reiponsibilities for KP Online: operations, e-mail, and development. Traditionally these groups
workeclindependentiy ancl hacl distinct missions and organizational cultures. The breach reveaied
the differences in the way groups approached priorities' For example, the development group often
Iet meeting deadlines dictate priorities. At ihe organizational level, Kaiser IT had a very complex
organizational structui'e, leacling to what Collmann and Cooper (2OOZ, p. 239) call "compartmen-
talizecl sensemaking." Each IT group "cleveloped highly locaiized definitions of a situation, which
created the possibility for failure when integrated in a common infrastructure."
1. }{ow serious was this e-rnai1 security breach?
Why rlid the Kaiser Permanente leadership
react so quickly to mitigate the possible darnage
done by the breach?
2" Assume that you were appointed as the
administrative member of the crisis team
created the day the breach was utrcovereet.
After the initial apologies, what recornmenda-
tions would you make for investigating the root
cause(s) of the breach? Outline your suggested
investigative steps.
F{ow likely do you think fulure security
breaches would be if Kaiser Permanente did
not take steps to resolve underlying group and
organizational issues? Whfl
What role should the administrative ieadership
of Kaiser Permanente take in ensuring that KP
Online is secure? Apart from security and
HIPAA tralning for all petsonnel, rvhat steps
can be taken at the organizational level to
improve the security of KP Online?
Note: Information for this case was taken ftom Coilmann, J. C., & Cooper, T. (2007). Breaching the security of the Kaiser Perma-
nente Intemet patient portal: The prganizational foundations of.in{ormation secu/ity, Iournal of the Amefican Medical Infownatics
Asso ciotion, I 4(2), z3g -243.
CASE 14: BREACH-
ING TI.IE SECUHITY
OF AN INTERNET
PATIENT POBTAL
I
332 CHAPTER 14 Health lT Leadership Case $tudies
Meadow Hills Hospital is a 21l-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. "4s 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 miltrion in resenres"
Meadow Hills has never had ar: IT strategic plan.
INFOHMATiON SYSTEMS CI{ALLENGE
The IT function reports to the Meadow Hills chief financiai ofEcer (CfO). The CEO ancl other mem-
bers of the senior leadership feam have largely left IT decisions up to the CFO. As a result, the orga-
nization's frnancial systems are very well developed, but the EHR system is very basic and becoming
outdated. Integration between the financial and EFIR systems is achieved through in-house-
developed interfaces, which have not been updated in a couple ofyears. IT support for departments
such as nursing, phannacy, ialroratory imaging, and risk management is limited. The lvteadow 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 currentll, have a CIO.
The CEO has never felt the need to pay attention to IT. Ilowever, he is worried that reimburse-
ment based on care quality witl arrive at Meadow Hills soon. He also believes that the Meadow }{ills Clinical Latroratory 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 resutrts. And he suspects that
the lack of IT support may eventually lead to nurses and physicians choosing to practice elsewhere.
What steps should the CEO iake to develop an
IT strategy for the organization?
Are there unique risks to the abilify of Meado*' Hills Hospital to develop and implement an
IT stHtegy?
3" Meadow Hills appears to have been successful
despite years without an IT strategy.
Why is this?
Langley &Iason Health (LMIf) is located in North Reno County, the largest public health care ciis-
trict in the state of Nevada, sen,ing an 850-square-mile area encompassing seven distinctly differ- ent 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 heaith system comprises Langley
Medicai Center, a 317-bed tertiary medical center and level II trauma center; Mason Hospital, a 107-
tred community hospital; and Mason Continuing Care Center and Villa Langley, rwo 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 seisrnic requirements, LMI{ 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 carnpus, double the size of its Mason Hospital, and build satellite clinics in four of its out- Iying cornmunities. The cost associated with actualizing this FMP is estimated to be $1 biilion. Sev-
eraX years ago, LMI{ undertook and successfully passed the largest health care bond measure in the state's.history and in so doing $ecured $496 million in general obligation bonds to help fund its massiye facilities expansion project. The remaining funds must come from revenue bonds, growth strategies, philanthrrrpic efforts, and strclng operational per{-ormance over the next ten years. Addi- tionally, $5 million of routine capital funds wiil be dirc+tef,every fiscal year for the next five years to
help offset the huge capitai outlay that rvill be necessary to equip the new facilities. That leaves Ltr4H
DISCUSSION OU ESTION$
CASE.IS:
THE DECISION
TO DEVELOP AN IT
STRATEGIC PLAN
CASE 16; SELEC-
TION OF A PATIENT
SAFETY STRATEGY
I
Case 16: Selection of a Patient Safety Strategy 33S
with only $10 million per year to spend on routine rnaintenance, equipment, and technology for ail 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 tacilities. The challenge is to provide for patient safety and safe medication practices given the rninimal capital doliars avaiiable to spend today.
LMH developed an IT strategic plan and identified the foilowing ten goals:
1,. Empower health consumers and physicians.
2. Transform data into information.
3. Support the expansion of clinical services.
4. Expand e-business opportunities.
5. Realize the benefits of innovation.
6. Maximize the value of iT"
7. Irnpror,e project outcomes.
8. Prepare for the unexpected.
9. Deploy a robust and agile technical architecture.
10. Digitaliy enable new facilities, including the new hospital.
INFORMATION SYSTEMS CI.IALI.ENGE
LMH has implemented Phase l-an enterprise-wide EHR system developed by Cerner Corporation at a cost of $20 miliion. Phase 2 of the project is to implement a new CPOE rvith decision-support capabilities. This phase was to have been cornpleted previousiy but has been delayed because of the many challenges associated with Phase 1, which still must be stabilized and optimized. LMII does have a fully autornated pharmacy information system, albeit older technology, and p5nds
medication-dispensing systems on all units in the acute-care hospitals. Computerized discharge prescriptions and instructions are available onl,v for patients seen and discharged from the LMFI emergency departments.
Currently', the pharmacy and nursing staffmembers 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 treen shown to significantly reduce medication administration errors, thus reducing patient harm. This expenditure would con- sume roughly half of all of the available capitai dollars for that fiscal year.
The CIO, Marilyn Chen, understands the pharmacists' and nurses'desire to purchase smart IV pumps but believes the impiementation of this technology should not be considered in isoia- tion. She sees the smart pumps as one facet of an overall rnedication management capitai purchase and patient safety strategic plan, Marilyn Chen suggests that the pharrnacS, and nursing leadership team lead a medication management sirategic planning process and evaluate a suite ofl availatrle technr:logies that taken together could optimize medication safefy (for example, CPOE, electronic medication administration records [e-rnar], 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 reacliness to embrace these technol- ogies. Paul Robinson, the director of pharmacy, appreciates Marilyn Chen's suggestion but feels that smart IV purnps are criticai to patient safety and that LMH doesn't have time to go through a long, drawn-out planning process that could take years to implernent and the process of gaining board support. Others argue that all new proposals shouid be placed on hold until CPOE is up and running. They argue that there are too many other pressing issues at hand to invcst in yet another newtechnologv. --*#
DISCUSSION QUESTIONS
334 CHAPTER 14 Health lT Leadership Case Studies
Descritre the current situation as you see it. What are the major issues in this case?
Marilyn Chen, CIO, and Paul Robinson,
director of pharmacy, have different vierns of how LMI{ should proceed. What are the pros
and cons of their respectir,e approaches? Which
approach, if either, seems like an appropriate
course of action to you? Explain your rationale.
3. Assume you are to mediate a discussion on this issue and that participants are to come to
consensus on how best to proceed. What would you do?
Founded in 1900, Newcastle Hospital today is a 375-bed, not-for-profit community hospital that selves rnore than two hundred thousand residents of Newcastle County, Neu.. York. The hospital is approxirnately 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 Ciry hospital systems for tertiary referrals and select residency programs" Newcastle Hospital has an independent governing bodyu,ith twenty-five trustees, 604 active physicians. and 1,121 fuli-time equivalent (FTE)
staff members. Revenues of approximately $130 rnillion per year come frorn 15,600 inpatient admis-
sions, 7i,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 r,vorkforce, decimated public confldence, and directly cost at least
$19.5 million, effectively eradicating the hospital's capital reserryes. 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 rnillion and the near-bankruptcy of the hospital. The new management restated financial statements, began resolving extensive iit- igation, 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 universaily absent or ineffective."
Among its many issues, the challenges within the hospital's emergency department (ED) are
particularly important to the overail recovery effort. The ED is described by the hospital CEO as the organization's "financial, ciinical, and public relafions 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 Ler,el II trauma center, with a long legacy of outcomes that com- pare favorably against regional, state, and nationai benchrnarks. 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, Nervcastle ED patient satisfaction compared to patient satisfaction among peer
organizations ranks at the 14th percentiie in the Press Ganey New York State suwey and the 5th percentile in national surveys. Since the start of the new miliennium, three organized initiatives to improve these results (especially regarding ualkouts and waiting times) have failed, even though two involved prestigious consultants. After the management change, the new CEO diagnosed two core barriers to overcnming the ED problems: first, inflexibiliry and unwillingness to change among the ED physician management group that had been in piace for ten years, and, second, an alrnost complete absence of the data required to define, measure, and improve the H,D's service performance. The first barrier was addressed via an RFP process that resulted in engaging a new physician managemeni group two years ago.
lN F0 RMATION SYSTEMS Cl'lALLEl,l G E
The present IS challenge follows directly from NewcaslE Hospital's overarching strategic objec-
tives: "satisfying patients and staff" "supporting our#Ives," and "getting better every day" (that is, improving performance). The ED as presently structured has ill-defined manual processes and
CASE 17: STRA-
TEGIC IS PLANNING
FOR THE
HOSPITAL ED
Case 17: Strategic is Planning for the Hospital ED 335
no information system. The challenge is selecting an ED information system with an emphasis on informing, notjust automating, key ED processes in order to support the overali strategic initiatives of the organization.
Several organizational and IT system factors that affect this lT challenge have been identified by the hospital CEO.
OHGANIZATIONAL FACTORS
Undefined strategy. Newcastle Hospitai operated without a fcrrnal strategic action plan and corresponding tactics undl rwo 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 frorn the ED impossible.
Culture. "Looking good," that is, escaping accountability, was valued more highly than "doing good," that is, substantivel-v 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 En 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 lS department had no defined strategies, objectives, or processes. Alignrnent with hospital strategy and IT perfbrmance measurements were not consid- ered. 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-ievel agreements, decision criteria, and user roles and responsibilities do not exist.
Functionality, The IT applications porttblio is missing critical elements (for example, order entry case management, nursing documentation, radiology) that would greatiy beneflt 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 blpassed by users altogether.
IT infrastructure and architecture. The data center and most 1T staffmembers are located twelve miles away from the hospital, isolating IT physically and culturally from users and patients. Software and nefworks have been arbitrarily and extensively customized over the years, without documentation, and inadequate hardware capacity has often been given as an excuse for not pur- suing 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 toois. New'castle Hospital has been dependent on multiple IT vendors for a variefy of implementa- tion and operations $uBport activities.
Outline the steps you would take to initiate a
strategic planning process for improrzing the
ED information system. How will you ensure
that ihis plan is in alignment with the hospital's 4.
and department's overall strategic plans?
Multiple factors have contributed to the currenl state of the EI) at Newcastle Hospital and are
listed in the case. Which of these do you think will be the most difficult to overcome? Why?
__
The new CEO has gocld insight into the?D issues. Assuming that his assessment of the
situation is accurate, discuss how his continued supporl could affect the outcome of any ED IS strategic plan.
Assume the CEO has appointed you to spearhead the ED IS strategic planning effort. What are the first steps you will take? Outline a
general plan of action for the next three months. Indicate, by title, whom you would involve in the process. Explain your choices.
336 CHAPTER 14 Health lT Leadership Case Studies
Lakeiand Medical Center is a 210-bed public hospital located in the Southeast. It is governed by a potritically appointed nine-member board and serves a market of approximately one hundred thou- sand people. The hospitai has been financially successful, but in recent years several capital invest- rnents have not brought high returns" As a result, project investment decisions have become more conselative 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 healtir 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 controiling experses remains a challenge. Bad debt has grown fiom $5 million last year to a budgeted amount of $14 million this year. The hospital continues to accomplish high patient and employee satisfac- tion scores, high quality scores, and an A+ credit rating. Debt is approximately $55 million, and cash reserves are approxirnately $95 million. Totai operating revenues are approximately $130 rnil- lion, The hospital employs 940 staffmembers" The average length of stay is 4.3 days. Annual capital expenditure is $4 million.
INFOHMATION SYSTEMS CHALLENGE
Three years ago. the instailation of computed radiography (CR) components to iLlild a picture archiving and communication systern (PACS) began, at an estimated total cost of $1 million. The fol- lowing year, $400,000 was spent for additional CR components" Most recently the board of direetors (with three new mernbers) did not approve the request of $1.9 miliion for completion of the PACS,
saying that it representeci 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 r:f the PACS:
1. l,eadership's inability to guarantee to the board's satisfaction a tlnancial return on the pro- posed investment
2. The board's perception that the radiologists are not cornmitted to the hospital and to the com- rnunily because none of the radiologists live in rhe communily
3. The board's percepticln that the cardioiogists are not committed to the hospital or to the com- munity; the five cardiologists on staff are considered to be uncooperative among themselves and not supportive of the hospital's goals
4" Poor ieadership within the IT departrnent for providing the proper guidance on acquisition and implementation
5. Ihe board's phiiosophy that Lakeiand Medical Center should be more high-touch and less
high-tech, and thus there is a philosophicai difference over the need for a PACS
6. Jealousy among the medical staff members that the diagnostic imaging department eontin- ues to obtain capital approvals for large items representing a major percentage of the annual capital budget; thus, many influential members of the rnedical'staff. such as surgeons, are not supportirre of the expenditure
7. A f'er.v vocal employees speaking direr:tly to board members expressing their concern that the PACS implementation will result in job loss for them
8. t,eadership's inability to rnake a connection betr.veen this capital project and the strategic goals of the organization
The chief of staff, IesM Brown, lirmly believes that a PACS will increase patient and physician satisfaction because wa.iting times for results will decreaqg.sahance patient education, improve staff
CASE 18: BOARD
SUPPORT FOR A
CAPITAL PROJECT
Case 19: Liberty Medical Center Network lmpacted by Malware Attack 337
member and physician productivify, 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.
1. Conduct a role-play. Divide into lor.rr teams*. the Lakeland Medical Center administrative team, the board, the medical staff members,
and the hospital and community at large.
Assume the role of your constituent group and
anslver these questions: What are your views on this proposal i What are your major concerns? What questions do you have? And for whom? Do you think this is a case of someone tailing to do his or her homework in putting iogether a sound business plan for the PACS project, or do you think there are bigger issues at play here? Explain your ansl /efs as
necessary.
Assurne that the CEO believes that the PACS
project is well aligned with Lakeland's strategic goais but that this case hasn't been made clear
to the board. Hou,might Lakeland build this case? Who should iead that effort? What work needs to be done that has not occurred yet?
Are the board's ooncerns about medical staff commitment relevant in this case? lVhy r:r why not?
Develop a strates/ for addressing the board's
concerns and winning their buy-in and approval
fbr the PACS project. Include in your descrip-
tion the who, what, where, when, and how.
Liberty Medical Center is in the Southeast in a coastal communify serving approxirnately 200,000 individuals and relatively large tourist population. Liberty was recently impacted by a mal- ware attack. The attack happened early Friday morning and officials reported that portions of the network were offline during recovery.
INFORMATION SYSTEMS CHALLENGE
According to the CIO, George Burns, rvho manages the IT department, the medical center resorted to downtime procedures while they continued to see, treat, and adrnit patients. Systems were down for over two weeks, inciuding the organization's electronic health record system. liberty conducts daily backups of all of their systems. In this incident, only one day's worth of data was iost. Although not ideal, it could have been much worse. Staffwent immediately into dorvntime procedures. Given that they a.re in a hurricane-prone area and electricity outages are common due to severe weather, staff are well equipped and trained on downtime procedures.
Six months after the atteck, Mr. Burns admits that he is finally able to breathe and reflect on the incident. He acknowledges that Liberty was very lucky. The IT team detected the virus infec- tion before it was able to deliver its final blow and demand ransom" Had it come to a demand for ransom, lhe senior leadership team indicatecl that they would seriously consider paying given the risks of a iong-term Gutage. Mr. Burns was pleased that the organizatiorl had strong backup, strcng downtime procedures, and the servers were divided in such a way that when the attack occurred, it was contained. Minimal data rvas lost, except for clinical notes that had not been closed by cli- nicians at the end of day'. No patients died nor did an adverse patient events occur because of the maiware incident.
Even though Libertylvas lucky, they did not escape the incident unscathed. The incident cost the organization nearly eight miilion do11ars, half clf which was due to lost revenue" A class action lawsuit wes aiso flled by two patients against the organization.
According to Mr. Burns and the leadership team, the}, learned a lot foliowing the rnalware incident. First, having a stl'ong backup in piace and up-to-date dr-rwntime procedures helped. At least twice a year, on both the day and night shifts, they simulated downtime procedures to ensure staffwere ready. They also added Carbon 6lack, a high-tech malware protectllp#onsulted wittr two
CA$E 19: LIBERTY
MEDICAL CENTER
NETWORK
IMPACTED BY MAL.
WARE ATTACK
338 CHAPTER 14 Health lT Leadership Case Studies
cybersecurity flrms to aid in monitoring and response, and added additional flrewalls. Leadership
had also had conversations in advance about what to do in the event of a ransomware attack, so they
had plans in place.
Liberty has found, like many health care organizations, that the attempts to attack their sys-
tems do not stop. In the past rnonth alone, the firewall protection blocked nearly ten thousand
malicigus attacks. Attacks from other countries are on the rise. Spam Filter blocked over 275,000
emails in the last month. Red Canary/Carbon Black investigated over 25 miilion pieces of data into
and out of the systerns ancl found 70,000 malicious events, 120 confirmed attacks, and one high
security event that was stoppecl in less than r:ne minute. Mr. Burns argues you cau't let your guard
down. Malicious attacks on health IT are relentless'
INFOHMATION SYSTEMS CHALLENGE
Sunrise Healthcare is a physician specialty practice located in Tennessee" Dr. DeMarco, the lead
physician manager of the practice, recently learned that two former ernployees of Sunrise Health-
care accessed protected health information (PHl) outside of their normal job duties and used this
information to process fraudulent tax returns. The breach report indicated that the PHl of approxi-
mately 3,645 individuals was involved in the breach; however, Sunrise Healthcare verified that the
flnal count of affected individuals was 3,891.
According to Dr. DeMarco, Sunrise sent an e-mail to all affected patients notifying them of the
breach within 30 days of the incident. Following the incident, the practice increased its safeguards
by installing a new software system to help monitor and detect inapproprlate access to its electronic
health records system, updated its securiff policies and procedures, retrained employees, and initi-
ated steps to address and mitigate the issues identified in its risk analysis.
What did Liberty do well in detecting'
preventing, and managing lhe malicious
malware attack? What might they have done
differently?
Mr. Burns indicated that should this attack led
to a ransom, the senior leadership at Liberty
was inclined to pay the ransom. Do you think this is a good idea? Why or why not? Explain
your rationale.
What role does the CIO or chief information security officer have in educating senior
Critically evaluate hot' well Sunrise Healthcare
handled the breach. What did they do well?
What else shouid they have done to ensure
compliance rvith HIPAA security regulations
and trreach notification requirements? And
help restore community confidence?
Could Sunrise Healthcare and/or the two
former empioyees be at risk for clvil penalties?
Criminal penalties? Explain your rationale.
leadership and the board cybersecurity threats?
Who should decide how much is spent on IT
security? The CIO, CISO, the senior leadership
team, the board?
4. Conduct an interview with a local CiO or CISO
to find out what strategies they employ to
detect, prevent, and manage IT security
breaches. How are ernployees educated on besi
practices?
3. Ifyou were part of the leadership team helplng
to prevent instances like this (or other breaches
of protected health information) from occurring, what recommendations
would,vou rnake?
DISCUSSION OUESTIONS
DI SC U SSI ON
QUESTIONS
CASE 20: BHEACH
OF PHIAT SUNHISE
HEALTHCAHE
Case 21 : warren center for Telehealth: prior to, During, and Following the covid Pandemic 339
The warren center for ,relehealth was established nine years ago and was funded largely by the
state legislature' Its initial primary goalwas to lead it-*tt't::T:::l:lti:1-":l*;:f:t?;illi;dffi?H::il ffi ffi;;i ffi ;Ji";ity u n 4",,".,* 01. c,: mm u n iti e' th'::.Y1:,1t" :T.:.'T
* partnership with local hospitals, clinics and schools. T0<1ay, the warren Center fbr Telehealth offers
seventy unique setvices in forty.ounties, including 250 sites (tbrty hospitals' 125 community clinics'
eighty schools). The Center offers a wide .*rg" nf-horpital semices including telestroke and remote
lcu monitoring, outpatient clinic services, school-based telehealth' and health services through
prisons and correctional facilities. Most recently, selices were expanded to skilled nursing facil-
ities throughout the state to enable seniors and most vuinerable to receive care within their local
communitlr
INFORMATION SYSTEMS CHALLENGE
Dr. David Garrison selves as the chief medical information offlcer for the warren center for Tele-
health. He has been in the role fclr three years and has been a true leader in expansion of the center'
I{e encourages clinicians, administrators, anil staff to think beyond "replicating care over a dis-
tance,, and instead focus on serrices that foster efficiency among care teams, add value to care across
the continuum, ancl mitigate time and distance barrieis to care' Given that the warren center for
Teleheaith is located in ultat. with a large rural population, it plays a vital role in increasing access
to care and reducing heaith clisparities'
whenever a new telehealth service is proposed (which happens quite often), Dr. Garrison and
the telehealth leadership team require thai the requestor consider the impact of the new services
on key stakeholders, lnctuamg paiients, referring providers, consulting providers' payers' and the
health system as a rnhole. They also use a standardized scoring tool for considering proposals that
includes the following elements:
SUPPORT OF IMPLEMENTATION
. Physician chamPion
. Provider capacity
. Strategic alignment
POTBNTIAL IMPACT
. QualitY
. Cost
. Access to care
GROWTH OPPORTUNITY
. Market size
. Saturation
' l)emand
In early 2020, the covlD pandemic hit, and Dr. Garrison and the leadership team at the war-
ren Center for Telehealth rapidly shifted gears to ensure state-wide needs for virtual urgent care and
remote parient moni,"ii"s'f", iovrn-politive patients were put into place' Virtual electronic sitters
were also set up to reduce COVID rlsklexposuie to health cart workers' Warren quickly converted
its ambulatory care selices to telehealth. By May 2A21,,ha11of the sta$istizens have bt"-l-:*ti-
nated and covlD cases are way down. During this period, warren expeiienced a rapid expansion of
telehealth rn ith 100 million asynchronous encounters representing a 400 percent increase'
CASE 21: WARREN
CENTER FOR TELE.
HEALTHIPRIOR
TO, DUHING, AND
FOLLOWING THE
COVID PANDEMIC
340 CHAPTER 14 Health lTLeadershipCaseStudies
The CEO has said that he'd like to see 25 to 30 percent of all care provided in ambulatory care
clinics be offered virtually moving forward. I{eturning to the status quo is not an option. At the time of this rvriting, reimbursement post-CoVif) and the telehealth restrictions that were lifted during the pandemic are yet to be determined.
What role did Warren's existiog telehealth infrastructure have in enabling the leadership
team to cluickly expand telehealth services
during the pandemic? F{ow did their experi-
ence compare to other health care organiza-
tions'/providers' experience during this
same 1:eriod?
What factors do you think contributed to the
CEO's vision of Warren providing 25 to 3t)
percent of its ambulatory care visits via telehealth? FIow would one determine that goal
and whether it's feasible/attainable? How might the standardized scoring tool be useful, if at all? Explain your rationale.
3. FIow have telehealth regulations and standards
changed since the pandemic of 2020"1
Reimbursement practices? What t'actors have
led or contributed to this change?
AMAZON ALEXA AND PATIENT ENGAGEMENT
By Kevin Schulman and Stacy Wood Source: Stanford Graduate School of Business, Case No. SM-328.
eduifaculty-researchlcase -studies/amazon-aiexa-patient-engagemen t Publication llate: fiovember 4, 2019
https : / 1www. gsb. stan tbrd.
The Palo Alto Health Sl,stem had three hospitals, 1,600 physicians, and over one million patients each year*and a new risk-based model that incentivized the prevention of iilness as well as early ittervention in patients with chronic il1ness. Engaging rvith patient populations involved clinical interventions, but aiso involved a marketing approach to encourage patients to adopt health behaviors and keep following those practices.
This case study investigates this marketing aspect of hrealth care, and looks at ways in which Amazon's Alexa, an interactive speaker that connects people to the Internet and the cloud-based
Alexa voice service, could euhance health care efforts. With patient permission, Alexa could col- lect specific heaith-related inlormation, and cr:uld help schedule patients for medical screenings
and then report back important laboratory results. One early adopter was the U.K. National Heaith Service, which contracted to use Alexa to provide health-related content to patients-the same
inforrnation that was available on the public website. The case study considers health care privacy issues, and asks students to consider whether a marketing approach to heaith care, in this case
using Alexa clr another Internet personai assistant, wouid be a successful strategy for the Palo Alto Health Systern.
PATIENTSLIKEME: USING SOe IAL NETW0RK HEALTH DATA T0 IMPHOVE PATIENT CAHE
By Stephen E. Chick, Francoise Simon, and Ridhima, ggatwal Source: Insead Publishing. https:l/publishing.insead.edulcase/patientslikeme-using-sociai-
netu,ork-heaith-data-improve-patient-care Publication Date: January 3A,2AL7
PatientsLikeMe, an online health community formed to provide value for patients in exchange for sharing their health data, had grown substantially since its founding in 2004. By 2015 it had over 130 empioyees. [{owever, convincing investors of the viabiligu of the business model proves more challenging. Its three fclunders beiieve it has the potential to'reshape the health care ecosystem, but its "not just for profit" approach is complex to cornmuni(ale. In their ambition to improve the health care experience by capturing health outcomes and learning what works in the real worid (beyond
clinical triais),they must attend to critical issues such as patient privacy in addition to setting their growth strategy.
DISCUSSION
QUESTIONS
SUPPLE.
MENTAL LISTING
OF RELATED
CASE STUDIES,
AHTIGLES,
AND WEBINAHS
