clinical transformation - college of computing &...

DREXEL UNIVERSITY2007-2008 WINTER

INFO780-907-200725 : ORG SOC ISSUES IN HEALTHCARE INFORMATICS

"Is remediation of vendor methodologies in enabling clinical

transformation necessary?"

Sandra Straw Hopper3/19/2008

This white paper address the current state of clinical transformation to Electronic Health Records and the impact of vendors, software, implementers and process re-design on technical clinical transformations.

Clinical Transformation

Executive Summary

Four Decades after Ross Perot and the Blue Cross Association forged the Florida Shared Systems as a

means to electronically bill for medical services, providers still struggle with full automation of the health

record. Enterprise Resource Planning (ERP) solutions were implemented successfully in the end of the

last century, in part, as a solution for the Y2K problem and to manage the general ledger, supply chain

and materials and facility management. For the clinician, all of this happens behind the closed office door

and had no impact on the day to day operations in a clinical unit. About the same time vendors emerged

with solutions to manage clinical data but the sell to clinicians has been difficult. Many factors contribute

to the struggle including financial, regulatory, resource issues and a lack of understanding of the

technology language used in the sales process. All of this has led to a slow adoption of electronic records.

According to the HIMSS, there are no hospitals which are 100% electronic defined as able to contribute to

and electronic health record as a byproduct of electronic medical record.

In order to understand the dilemma facing providers an examination of the approach taken in clinical

transformations and system implementations needs to happen including the role of the system vendor,

the system implementer, the customer and its’ leadership in project management. The user of the system

is the key to success; vendors and the associated consultants need to address this key stakeholder,

which goes beyond IT and Administration, and develop a plan for transformation of the clinical processes

and system touch-points which includes all stakeholders present and future. The end user must

understand how the data entered in an individual record is contributing to the patient’s overall health

management but also in the management of health globally. The vendors and their methodologies are

key to the success if the methodologies include the critical elements of a complete transformation.

.

Sandra Straw Hopper


Table of Contents

Executive Summary..................................................................................................................................... 2

Current State of Clinical Transformation......................................................................................................4

Hospital Provider Capabilities.................................................................................................................. 4

Ambulatory Care...................................................................................................................................... 6

RHIO’s..................................................................................................................................................... 6

Regulatory Issues.................................................................................................................................... 7

Financial Challenges................................................................................................................................ 8

Physicians’ role in Informatics Transformation.........................................................................................9

Nursing Informatics................................................................................................................................ 10

Healthcare Vendors............................................................................................................................... 12

Impacts on Change.................................................................................................................................... 14

The New Healthcare World........................................................................................................................15

Information Technology Impact..............................................................................................................15

Vendor Methodologies........................................................................................................................... 15

Vendors Impact...................................................................................................................................... 15

People.................................................................................................................................................... 18

Process.................................................................................................................................................. 19

Technology............................................................................................................................................ 19

Appendix.................................................................................................................................................... 21

Appendix A............................................................................................................................................. 21

Appendix B............................................................................................................................................. 24

End Notes.................................................................................................................................................. 27

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Current State of Clinical Transformation

Healthcare providers are at varying states of technology

assimilation in their clinical practices and institutions for many

reasons including resources, organizational structure, fear of

change, technical experience and its’ capability awareness. From a

resource perspective there are financial and physical resource

issues such as funding and lack of staff, from an organizational

perspective, fear of the change or complacency with the current

situation overrides the need of the capabilities a technology affords. Capability awareness, the third

reason, has most likely the greatest impact as providers do not understand what capabilities exist as far

as information sharing, knowledge generation. Technology is the key to information assimilation and the

resulting knowledge. Vendors are the front line support for providers and need to assist not only in the

technical implementation but managing the organizational changes which are required for a full

transformation

Hospital Provider Capabilities

Healthcare Information Management System Society (HIMSS)i published on May 30, 2007 an EHR

assessment tool to ensure objectivity in the assessment of the current state of the United States

hospitals. The analytics were performed on the 4000 hospitals in the HIMSS database. The United States

currently has approximately 6000 hospitals according to JAMIA, 2008.ii The analytics demonstrate

presently there are no US hospitals which are 100% automated. This seven stage EMR Adoption Model

is cumulative and total adoption is dependent on an end to end completion, not the completion of

disparate applications in silo systems. All the capabilities are expected to be completed by 2014. We are

six years into the ten year plan which expects closed loop medication administration which is dependent

on regional health information data exchange between providers. There are many social and technical

reasons for this state of affairs which is dependent on closing the continuum from ambulatory care to

Regional Health Information Operability (RHIO’s).

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Vendors are the front line support for

providers and need to assist not only in

the technical implementation but

managing the organizational changes

which are required for a full

transformation.


Stage Cumulative Capabilities % of US Hospitals Adoption

Stage 7 Medical Record fully electronic; CDO able to contribute to the EHR as a byproduct of the EMR

0%

Stage 6 Physician documentation (Structured templates), Full Clinical Decision Support System, Full PACS

0.8%

Stage 5 Closed Loop Medication Administration 1.4%Stage 4 CPOE, CDSS 22%Stage 3 Clinical Documentation Flowsheets 25%Stage 2 Clinical Data Repository 37%Stage 1 Ancillaries Installed- Lab, Radiology, Pharmacy 14%Stage 0 All three Ancillaries not installed 19.3%

KLAS performed a survey of the nation’s hospitals in the third quarter of 2006 which was presented at

HIMSS in February, 2008. The report examined the present state of electronic health implementations by

software vendors and implementation partners. KLAS requested the name of the software and the

implementation partners aiming to assess the product, service, satisfaction and progress. From the 4600

respondents KLAS determined the leading software vendors are Cerner, Eclipsis, Epic and Solarian for

inpatient units. Cerner and Eclipsis led the market in the last decade but Epic demonstrated a rapid rise

over the last three years and in 2006 had nearly as many implementations as the decade leaders.

Solarian, a new Siemens product replacing Invision had three successful implementations out of three

purchases since the debut in 2007. Part of Epic’s rise, KLAS felt, was due to the enterprise capabilities.

Most enterprise resource planning software (ERP) platforms are over a decade old and need an upgrade

and Epic can manage some of the enterprise needs.

KLAS also presented the lead implementation partners were CSC/First Consulting Group which

represented a 33% market share, IBMHealthlink and Bearing Point at 14% and the consulting companies

at 10% or below. Hayes Consulting which was not a market leader in the number of implementations

scored the number one spot in customer satisfaction in the KLAS satisfaction survey. Vendor

methodologies were not addressed in the presentation. KLAS did not include the numbers related to EHR

vendors who manage their own product delivery, nor did they discuss other transformation partners or the

methodology to achieve the implementation, total costs or time involved in the implementations.

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Ambulatory Care

Ambulatory Care has a different set of issues related to electronic health record adoption. According to

Wikepediaiii in 2001 18.2% of primary care physicians were using full or partial EMR’s; in 2005 the

number increase a third to 25% for the office-based physicians. It also states that less than 10% are fully

automated with CPOE for prescriptions and tests, receive and store lab results and document

electronically. Of those adopted 10% are Pediatric Providers and 40% are Internal Medicine iv this is

compared to a 90% adoption rate in Sweden, 62% in Denmark and 55% in Australia, countries which

have government supported EHR. The authors indicate the reason for this is a perception that providers

only reap 10% of the value of the technology and the real benefit is to the care partners such as

pharmacies and labs, the consumer and the third party payers.

In Massachusetts, a statewide survey was sent to the 1,884 ambulatory care providers; 71% responded

or 1345 physicians which represents 45% of practicing physicians or 23% of the state’s practices. The

study found that the larger the practice, the greater the rate of adoption at 52%; solo practices are at 14%

with reasons for non-adoption being upstart costs, maintenance and loss of productivity.v

According to Health News Direct, ambulatory care has increased in CCHIT certification from 10% at the

end of 2006 to 40% at the end of 2007. Some of the products certified are AllScripts, NextGen, Misys,

Epic and less known products like CareData Solutions Corporation and numerous others but not nearly

the 400 plus available on the market. The products achieved certification based ability to manage general

care not specialties, emergency or behavioral health.

RHIO’s

Regional Health Information Organizations are intended to take structured data from contributing

providers both professional and institutional to connect healthcare communities. The databases are the

end of the continuum of provider’s data and can be used to access patient data within a community of

providers, aggregate data to improve quality of care and lower technology costs. The nation is moving

towards a national health information infrastructure and supports this initiative by forming Office of the

National Coordinator for Health Information Technology (ONCHIT), designed to solve some of the issues

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which surfaced after Katrina when all non VA medical records were lost. The Department of Health and

Human Services awarded nearly 20 million to build prototypes of national health information networks

showing a federal commitment to the technology and the benefits derived from the technology. For

RHIO’s to work, systems must behave heterogeneously accepting data from multiple sources and

preserve secure access to data.

Regulatory Issues

All healthcare providers and payers must be Medicare Certified in order to deliver care and accept

payments other than cash. This means there are parameters which guide all interactions with members or

patients including verbal, documentation, billing and access to files. The Centers for Medicare and

Medicaid (CMS) have set the tone since inception in the Johnson Administration in terms of coverage

criteria and payment parameters. CMS is promoting Pay for Performance (P4P) as a way of encouraging

physicians to receive payments, not on the basis of the service provided, but according to the outcome. In

order to accomplish this, data is required to determine best practices according to outcomes and the

providers’ ability to provide the outcome. This goal is dependent on good records and technology. The

congress and the senate are responsible for legislation and funding related to HIT; recently the Senate

proposed a bill for HIT fundingvi but congressional leaders are less than optimistic. On March 17

legislation was introduced to block Medicare payment cuts due to start on July 1, 2008vii which would

decrease payments by 10% to providers. The impact of legislation amidst a war and a plunging economy

is a double edged sword for providers. The addition of congressional action adds some needed

governance to protect our privacy and security but has a potential to bottleneck progress. Providers need

both an incentive and protection from the federal government to feel secure in absorbing the costs both

real and inferred to implement an clinical information system. A case in point, the New Hampshire

legislature voted to not extend HIPAA to vendors and business interests and not allow patients to get

copies of their electronic audit trails even if they pay for the documents.viii This is another example of how

the federal government must step in and protect our privacy from those who are not involved with our

clinical care by extending HIPAA to protect data not only related to verbal and electronic transmissions

but also who can access clinical data behind a firewall.

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Financial Challenges

From a financial perspective, technology is expensive to own, implement and maintain. In addition there is

a fear associated with technology purchases ranging from product lifespan in an ever changing technical

market to cost overruns due to inadequate estimates. Ambulatory and Institutional providers are

considered small to medium business which typically have very little leeway to absorb the costs of an

implementation or even worse yet a failed implementation. Lewis Reddix of Accenture surveyed hospital

executives, payers, providers and HIT vendors and received 84 respondents 71% of which felt electronic

health records will have a positive impact financially over the long term but there were many other factors

including capital cost outlays which are the greatest barrier to transformation. Nearly 60% of those

surveyed have taken positive steps towards EHR but 10% had taken no steps at all.

Likewise, at HIMSS,

2007x Sensmeier and

Weaver found the

greatest deterrent from

initiating or completing a

project was financial and

that it was responsible

65% of the unfinished efforts while HIPAA accounted only 2% of the time, the remaining 33% were

technical, stakeholder or resource readiness in a hospital or health care system1. In a separate study Ash

and Batesxi state that EHR’s are the largest capital investment hospitals will make and over a five year

period and 66% of hospitals lost money last year. In fact, most providers state that all studies regarding

return on investment (ROI) weigh the future earnings rather than present day. It is difficult for providers to

embrace a long term ROI as a result. Primary care physicians acknowledge a return on investment

related to medical records space, transcription services, paper chart costs, staffing costs medical coding,

bargaining with payer contracts, research generation (data collection based on population groups). Issues

1 Appendix A Figure 1

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with ROI are related to implementation non-measurable costs such as downtime, requirements sessions,

training and scanning old records or data entry.xii

GE Financial Services HIT Funding Initiatives Task Force in December, 2007xiii presented their

perspective on the current capital cost issues facing providers in the adoption of HIT, which included lack

of equity, hard assets, and a inherent volatile source of income since it may be driven by one or two in

small practices. In addition an inability to lease, fear of software obsolescence, lack of system

interoperability with other community providers, in both institutions and ambulatory care practices

contribute to difficulty with financing IT projects. Traditional banks look for multiple streams of payment

options which are not the case in ambulatory care and often are reluctant to loan money. Software leases

are not possible under HIT standards since it has no tangible value at the end of term also software

licenses are issued only to providers. GE Financing is therefore unable to structure financing for EHR in

the same way it does large imaging devices and other equipment. This means immediate value is not

present for the provider.

The Markle Foundation, in conjunction with the Robert Wood Johnson Foundation, in October, 2004

determined the business case for IT adoption was not sufficient to absorb costs and that the appropriate

utilization does not favor the provider’s bottom line. The financial incentives must be $12,000 to $24,000

per year in payments from the payer (3 to 6 dollars per patient visit or 50 cents to a dollar per capita a

month) to meet the capital costs and the going cost of implementation to the provider. At the present time

this is a cost is absorbed by the ambulatory care provider.

The costs of connectivity with other community providers such as hospitals and RHIO’s was an additional

roadblock due to the Stark Legislation. After Stark was relaxed in 2007 hospitals can now pay up to 85%

of software costs for ambulatory care practices associated with a hospital, however the cost of hardware

is not covered.

Physicians’ role in Informatics Transformation

Physicians are very involved in medical informatics with a mission statement “Improve healthcare through

innovative effectiveness and portable application of Information Technology”. The goal is to deliver error

free care. The AMA in its’ commitment to medical informatics elected Navy Capt. Robert Wah, M.D., in

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2005. xiv to its’ board of directors to lead the informatics initiatives. Formerly he served as associate chief

information officer for clinical informatics in the Military Health System. His goal as one of the AMA’s 21

trustees is for the organization to take more of a leadership role in IT.

The American Medical Informatics Association (AMIA) was formed to bring physicians into the forefront of

healthcare IT policy and initiatives. The AMIA contributes to the improvement of the nation’s

implementation of health information technology. Through thought leadership, development of health

information policy and technology guidelines this group focuses on medical informatics as a part of the

medical doctors professional training and stresses the importance of physicians as clinical informatics

specialist as the formation of health databases to manage data in biomedical research, clinical care and

epidemiology. The Physician Informaticist is key to the leadership in the governance, strategy and

maintenance of health information.

Nursing Informatics

Nursing is less involved in the strategic direction of health information management than physicians and

in fact has less clear cut credentialing than physicians. Nursing is less organized and involved in the

direction of health IT. Since nursing is typically the front line in care delivery and the largest end user

group in health care, this is particularly troubling. In 2007 HIMSS released a Nursing Informatics Survey,

sponsored by McKessonxv, the authors Sensmeier and Weaver performed a survey which explored where

nurses in informatics by education, geography, professional title, certifications and how they fit into the

world of medical informatics.

The authors received 457 responses and found most informatics nurses (87%) have practiced nursing

over six years 2 prior to assuming a dedicated informatics position. More informatics nurses work in

hospitals3, 71% up from 64% in the 2004 report, while product vendors and consulting firms experienced

a decrease from 22% to 15% in the same time period. The east coast has more informatics educated

nurses than the central and west regions however 35% live work in the southern states identified as

Maryland and below4. Titles are not consistent among these professionals, 14% are called “Clinical

2 See Appendix A Figure 23 See Appendix A Figure 34 See Appendix A Figure 4

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Analyst” which in the IT world is a non managerial position, 14% are called Nursing Informatics Specialist,

the word specialist infers again a subject matter specialist, not a manager, 9% are called consultants

(advisors) and the remaining 40% are called Directors, Coordinators, Analyst or clinical informatics rather

than nursing informatics which infers different levels of responsibilities based on factors which may or

may not include direct reports5. Clinical informatics is traditionally a broader spectrum of information than

nursing and may report to IT as seen in the study of Sensmeier and Weaver at 50%. Other structures

include 38% report to nursing and 17% report to an another administrative department. Nurses are also

found in quality assurance (5%) and case management6.

Other issues are related to training in informatics, 25% of current “informatics specialist in nursing

received on the job training, the amount of education varies7 and 35% have a masters degree in

informatics, 19% have a PhD and 12% a post masters certificate in informatics8. Of those who practice in

the informatics field 55% have sought no formal certification and 23% have sought ANCC certification9.

While certification is available, similar to a nurse practitioner, there is no requirement for employment as

there is a nurse practitioner. This is an intrinsic problem in defining the role, level of responsibility and

proper reporting structure for autonomy and strength required in the role. It is difficult to define level of

understanding based on role.

At the HIMSS Nursing Symposium in 2007, Brenda Hall, RN, BSN, Susan Heider and Lisa Bewley, MSN-

CPNP stated that in transformation to electronic health records the informatics leader should possess

both technology knowledge and clinical skills but do not include project management as a pre-requisite.

For implementations, the project team selection is owned by nursing informatics leadership and a project

manager should be chosen who has a clinical background and create temporary positions as clinical

analysts from bedside nurses who “need a break”. This presentation is troubling in many ways as it

overlooks the science of project management including milestones, dependencies, earned value

management and communication. Project Management is a well vetted process which includes tools to

manage end to end change process, functional process re-design, requirements and deployment which

5 See Appendix A Figure 56 See Appendix A Figure 67 See Appendix A Figure 78 See Appendix A Figure 89 See Appendix A Figure 9

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includes education. This study demonstrates that the field is still a mystery to clinicians and solutions to

existing problems are not based on proven methodologies but based on lessons learned, which is less

reliable than theories of change management and project management.

Healthcare Vendors

There are two types of vendors in this marketplace, clinical transformation consultants and product

consultants, the latter includes vendor employed and consultant employed. Clinical Transformation

consultants specialize in process re-engineering using lean sigma and predictive modeling. Examples of

this type of consultants are Perot Systems, Accenture, and Beacon Consulting who may or may not

become involved with the implementation. The second are commercial off the shelf (COTS) software

vendors; Cerner, Epic, Eclipsis who offer the software and delivery services, typically using two different

contracts.

Implementation consultant companies includes Deloitte and Accenture which represent 10% market

share, IBMHealthLink (14% MS), CSC and First Consulting Group which lead with 33% market share.

There are two prevailing theories among vendors how to best approach clinical implementations the first

is clinical process transformation intended to be agnostic of software; the purpose is to drive process to

find bottle necks to therapeutic intervention, opportunities for error in treatments and medication. The

rationale is “if the process if good can be mapped to any one of the COTS solutions available on the

market”. Opponents feel it is too costly in both time and resources expended. The second approach,

process and requirements simultaneously is a bit risky since processes may not be fully vetted and

design choices may be made too rapidly. The second approach is subjected to the methodology of the

implementer which may be the solution provider or a third party consulting company. There are often

partner relationships but each partner can possess different philosophies on implementation approaches

and project management. The same product, therefore may be implemented differently according to

vendor.

In the last year, product vendors have been challenged to obtain CCHIT certification as a means of

assessing if software for clinical documentation and capabilities as electronic repositories of clinical data.

The vendors are assessed on security, CPOE, eMar (medication administration reconciliation) and clinical

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decision support. In November, 2007 Epic, CPSI, Eclipsis, Siemens Solarian, Prognosis Health

Information System, Computer Programs and Systems Inc were certified and in January 2008, Cerner,

MediTech, and Siemens Invision received certification. The certifications are based on ability to manage

the functional areas of a clinical record. The certification does not address interoperability both to RHIO’s

and professional providers which are independent of the healthcare system. Interoperability includes HL7

and Snomed coding standards, and RHIO access. Methodologies, time to implement and costs were not

included in the certification.

Other issues under the vendor umbrella are related to software licenses; ability to finance the project and

the lifespan of the software and the ability to implement affect the transformations success. Licenses are

the traditional way to charge customers by usage. This is very expensive for the customer and cost

prohibitive for the mid size customer. In the last decade commercial off the shelf products determined the

only way to penetrate the market was to offer “on demand solutions” or web based solutions which offer

concurrent users rather than dedicated users assuming everyone is not on the system all day long. This

has helped to make SAP and Oracle solutions more affordable. There are legal loopholes for clinical

institutions since it is a web based solution and appears to be a prohibitive lease.

Financing options are offered by large commercial vendors such as IBM and Oracle in which the costs of

hardware, software and services from different vendors are bundled into one payment. This is a new

paradigm for hospitals and most healthcare product vendors are not large enough or old enough to have

the financial resources of an IBM, HP or Oracle.

The last area is the disconnect is between the vendor types; the consultant, the system implementation

and the product. Consultancy companies may have a robust clinical transformation practice but do not act

as a system implementer which leaves customers looking at other options after software is chosen and

the experts which assisted the process re-engineering is not present. Software vendors do not train third

parties unless the customer has employed the vendor which presents a “Catch 22” for implementers. The

end result is system implementers must hire clinicians who may know the system due to their hospital

experience but have very few skills in project management or consulting, those with robust consulting

skills may not have specific vendor skills and may be rejected by the customer.10

10 See Appendix B

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To further add to the quagmire, vendors who advertise for employees do not place value on change

management or project management skills. In a review of the top software vendors, top system

implementers and consultancy company’s website for career opportunities there was a consistent pattern

with software vendors looking for clinicians with three years of either ambulatory care, or hospital

experience and good organizational skills. Epic and Cerner required relocation to Wisconsin and Kansas

City Missouri respectively after which travel nationwide is 80 to 100%. Consultancy vendors such as

Perot, IBM and Beacon allow consultants to maintain a home office and travel to customers. Relocation

demands greatly impacts the caliber of experienced clinical consultants one can employ.

Consultancy companies who are implementation partners such as Hayes Consulting value specific

software vendor skills as the only hiring pre-requisite. One job posting requested project managers and

described what project management entailed. No web sites looked for clinical informaticist; asset based

consultant skills or certified project managers11.

Impacts on Change

In order for change to occur the support must be in place, society must accept electronic health records,

congress must support the governance and the technology must understand the impacts on the

organization and proceed as a sea change not as a system implementation. Society will not accept any

changes which will impact their personal security or impact the care received by providers.

Healthcare has always been a political hot wire since the days of Roosevelt. There exist a divide between

the Democrats and the Republicans on how to manage healthcare dollars. Blue Cross emerged as a way

to block a national health insurance mostly out of fear of increased taxes by manufacturing.xvi Depending

on the administration, steps are taken forward and then backwards. Part of the issue is understanding

and defining the role of the federal government in healthcare. There is a fear among healthcare providers

if a solution is developed, some part of it will be deemed not appropriate by the government and a

tremendous cost will be associated with remediation. Another part of this dilemma is the administration

changes every four to eight years, and the subsequent regulations changes. The politicians in

Washington need to define clear rules about security, access, and audit trails and data integrity to win the

11 Appendix B Figures 1-6

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trust of providers and the states need to administer the RHIO’s and manage the costs and work together

to get a national system. States through their licensure and depart of Health have the ability to manage

providers.

The New Healthcare World

Information Technology Impact

Information Technology has many different faces dependent on the culture of the organization for

example is it insourced or out sourced, the skills of the team and the ability of the organization to support

the mission of the organization. As technology moves to COTS applications there is less a need in IT for

technical resources and more need of skilled professionals who understand the challenges of the industry

i Electronic Health Record Adoption Model May 30, 2007 HIMSS Regional Meeting http://www.himss.org/content/files/EMR053007.pdfii Halamka et al “Early Experiences with Personal Health Records”J Am Med Inform Assoc.2008; 15: 1-7 www.jamia.org/cgi/content/full/12/1/8iii http://en.wikipedia.org/wiki/Electronic_health_recordiv Joan S Ash PhD and David W. Bates MD, MSc “Factors and Forces Affecting EHR Adoption” www.jamia.org.cgi/content/full/12/1/8v Steven R. Simon, MD, MPH, a Rainu Kaushal, MD, MPH, b Paul D. Cleary, PhD, d Chelsea A. Jenter, MPH, b Lynn A. Volk, MHS, c Eric G. Poon, MD, MPH, c E. John Orav, PhD, b Helen G. Lo, c Deborah H. Williams, MHA, b and David W. Bates, MD, MSc

“Correlates of Electronic Health Record Adoption in Office Practices: A Statewide Survey”, http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=17068351J Am Med Inform Assoc. 2007 Jan–Feb; 14(1): 110–117vi Healthcare IT News March, 2008 http://www.healthcareitnews.com/story.cms?id=8893vii Healthcare IT News, March, 2008 http://www.healthcarefinancenews.com/story.cms?id=7776viii Health Imaging News, March, 2008 http://www.healthimaging.com/content/view/10107/118/ix Lewis Redd and Sally Boyle, Electronic Health Records Survey , http://www.accenture.com/NR/rdonlyres/F8453041-A760-48EE-9E68-26D99420F8EB/0/ehr_survey.pdf x Joyce Sensmeier MS, RN-BC, CPHIMS, FHIMSS, Charlotte Weaver RN, PhD, “HIMSS 2005 Survey of The Impact of Health Information on the Role of Nurses and Interdisciplinary Communication” xi Joan S Ash PhD and David W. Bates MD, MSc “Factors and Forces Affecting EHR Adoption” www.jamia.org.cgi/content/full/12/1/8xii HIMSS Ambulatory Paperless Clinics Work Group, “EHR Implementation in Ambulatory Care”, 2007 http://www.himss.org/content/files/Amb_EHR_Implemention081507.pdfxiii Elaine V. Ingebritson, “Financing Healthcare IT: An Industry Overview” December 2007http://www.himss.org/content/files/FinancingHealthcareIT.pdfxiv Angebote zum Thema, “AMA elects medical informatics specialist”, Health-IT World News 2005, http://www.pcwelt.de/index.cfm?pid=829&pk=115721 xv Joyce Sensmeier MS, RN-BC, CPHIMS, FHIMSS, Charlotte Weaver RN, PhD, “HIMSS 2005 Survey of The Impact of Health Information on the Role of Nurses and Interdisciplinary Communication” (http://www.himss.org/content/files/CBO/Meeting9/Nursing_Informatics_Survey.pdfxvi Daschle, Tom “Critical” , St Martin’s Press, New York, NY, 2008

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http://www.himss.org/content/files/CBO/Meeting9/Nursing_Informatics_Survey.pdf

http://www.pcwelt.de/index.cfm?pid=829&pk=115721

http://www.himss.org/content/files/FinancingHealthcareIT.pdf

http://www.himss.org/content/files/Amb_EHR_Implemention081507.pdf

http://www.accenture.com/NR/rdonlyres/F8453041-A760-48EE-9E68-26D99420F8EB/0/ehr_survey.pdf

http://en.wikipedia.org/wiki/Electronic_health_record


in the present and the future. This does not mean that a nurse is better prepared or an implementation

specialist but a hybrid of the two, a person who can look at a clinical process not as a task but as a time

sensitive set of tasks which impact the changes which must occur within the organization.

Vendor Methodologies

There are multiple methodologies for used for transformation projects such as Six Sigma and Lean Sigma

and well known IT methodologies such as waterfall and Agile. The methodologies are rooted in a theory

and from lessons learned from multiple process transformation and technical implementations. Some

methodologies are associated with a vendor (consultancy or product) and others are generic and allow

more flexibility. The methodologies tend to be linear in nature and look at people as those roles which

perform the processes and will have a touchpoint in the new technology. All methodologies are part of the

overall project plan and the steps of the methodology become part of the project plan. This is very

important in the implementation process but it is linear and does not include the organization and the

consumer needs.

Vendors Impact

Vendors need a methodology that is more holistic and looks at organizations as a groups of individuals

who comprise a unique stakeholder group. In this light, the stakeholders include individual consumers of

healthcare, society at large and individual communities (both geography and age groups), healthcare

institutions and administrators, clinical practitioners, educators and researchers. In addition, the current

state of health care and as a nation, the United States has global ranking of 37, beneath Costa Rica,

Columbia and Oman. xvii Vendors need to ask, “Can our methodology roll up and support the greater

umbrella that exist in the delivery of healthcare?”. Institutions are part of a continuum and should not be

viewed as a silo, each organization is part of a bigger organization and all should be vested in the society.

Vendors should consider the business and include the strategic direction of each hospital and how will

this transformation support the CEO’s vision. It is essential that processes meet the vision from bed

through-put to state of the art cardiac or cancer center. This involves not only data collection and storage

but also use of the data to drive best practices for the outcomes desired. This data may allow the hospital xvii WHO Rankings http://www.photius.com/rankings/healthranks.html

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to be quantified as a recognized leader in a certain field, and is ready for reimbursement based on

successful outcomes when pay for performance is in place. Neglecting this perspective will ignore a key

stakeholder in the process.

The practitioner requires access to data in a manner that makes sense to the clinical unit. For example, if

I want a snapshot of my patient following a bone marrow transplant his metrics will vary from the patient

on the same floor who has breast cancer and receiving chemotherapy. Both have cancer, both are

receiving treatments, but the defining metrics are different and the dashboard for this patient should be

different. While templates are offered by vendors they must be flexible to manage key metrics by

diagnosis, if not the end user will be frustrated. Vendors must understand that the addition of information

technology rarely makes data entry easier, nothing is faster than a pen and paper, the value lies in the

access to data in a way that makes sense to all stakeholders.

The academic community requires access to clinical data to perform research and establish trends within

global and local communities. This is as important as if we do not use data to improve the health of

stakeholders there is no reason to collect clinical data. Data is used to enhance knowledge.

Vital patient information

provides crucial decision

making data which will impact

patient care from all areas as

metrics provide the knowledge

to allow assessment and

change. Metrics is the tool

researchers use to make informed decisions, promote educated debate in regulatory issues, provide

society with trends and norms, and providers with patient knowledge to make core decisions. This

paradigm should be at the base of any methodology as it represents the stakeholders who must be

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QA Metrics

Society Research

Regulatory

Providers

Patient


represented in the transformation. The second area of concern is the expected outcomes for the

stakeholders combined these elements and the route to the transformation is defined. This route is called

the methodology.

This holistic approach must be patient centric and include an

awareness of the flow of data within the patient lifecycle of

ambulatory care, institutional care and RHIO’s which may

include personal health record storage databases. This

approach must consider data collection, data sets including

coding, processes to collect data from admission to discharge

and maintenance of data and security issues with electronic

record keeping. This holistic approach also must include the stakeholders from the CEO to the point of

care delivery. In order to accomplish this an end to end approach must be taken what is the information

we need to access and what do we need to access and what are the processes which support the data

entry and access, who are the people involved and what technology, vendor or otherwise, will support the

information. This interdependence of all three entities should drive the methodology by vendors to

achieve a system which supports the healthcare community. The consideration of people, process and

technology should drive change management in the organization and should be considered by the vendor

as important as the application implementation.

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Institutional

Care

Ambulatory

Care

Regional Health

Information Orgs

Accurate collection of clinical

data across the healthcare

continuum supports the future

needs of society in developing

a better healthcare delivery

system.


People

As illustrated earlier, less than 3% of Nursing Informatics specialist work for vendors and in fact, vendors

do not consider the skill valuable in talent hired. Most vendors look for clinical experience in a medical-

surgical unit or ambulatory care as a prerequisite to hire. Vendors look for “organizational skills”, prior

product experience and assume success with hires. Vendors are often in conflict with the nursing

informatics department who may have a more robust vision of the organizational change that most vendor

methodologies can provide using a linear approach to people, processes and tools involved in the

transformation. The right people should be a part of the methodology, this means careful attention to the

knowledge and experience of the leadership and the mentoring of the vendor staff as true consultants,

ones who can assess, analyze, prototype, implement and educate in change. This requires skills in

process re-engineering, gap analysis, functional requirement identification, project management, vision

and consensus building, change management strategy planning, education planning and deployment

strategy. These skills are more important that a certification in the capabilities of the software and have a

much longer shelf life as they are transferrable skills. While clinical experience is valuable it must be

supplemented with education in change theories such as Diffusion of Innovation,xviii project planning and

project management principles, metric driven processes, and principles of lean management.

Process

Methodologies should support process agnostic to the vendor product, should be flexible and support the

data collection to drive quality metrics and the strategic mission. A children’s heart hospital has specific

metrics which drive its’ success. Process design should be aimed at the leanest time to therapeutic

intervention. Processes should be flexible enough to stand up in an emergency and allow the medical

staff rapid access to supplies, equipment and diagnostics and intervention. A process should never

prevent a cardiac patient from rapid entry to an emergency room for example. Process also includes

planning and the planning should include the designation of which units are included based on ability to

go live, and strategic vision of the institution.

xviii Nancy M. Lorenzi and Robert T Riley, “Managing Technological Change” Springer Science and Business Media, 2004 P.150

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Technology

Vendors can impact technology change through deliberate attention to how their product or service fits

into the continuum of healthcare realizing it must support of the following; the customer’s strategic goals,

the patient’s diagnostic and treatment goals, and society’s knowledge needs The product must be

configurable to meet the data and process needs. The vendor must view the entire infrastructure of the

organization and determine how the electronic health record product fits in the model. The methodology

therefore must support the bedside activities to the transmission of data. The processes must support the

touchpoints to the technology. Vendors need to develop methodologies which look at the entire health

care management needs and ask the questions such as where are the opportunities for human error, time

delays in treatments, and documentation errors in our process.

The above graph points to the end to end cycle which vendor methodologies should support. This high

level end to end represents principles of transformation combined with high level project management

principles, organizational culture, strategic vision, the goals of the transformation, and metric goals for

clinical and business goals. This is important in the planning as it drives the use of data to be collected in

the clinical implementation. The “As Is” presents the current issues, philosophical base of the

organization, regulatory constraints and the IT capabilities to accept the changes the transformation will

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Project Management

End to End

To Be

Validate:

VisionPrototype

Technical Infrastructure

Organizational Structure

Implement

Develop:

ApplicationTechnical Infrastructure

Change Plan

Education Plan

Maintain

Re-assess:

Application

Culture Technical Capabilities

Metrics

As IsAnalyze:

Barriers to Chang

Technical Capabilities

Clinical Processes

Metrics

Plan

Assess:Strategic Vision

Organizational Goals

Transformational Goals

Metric Goals

Deploy

Release:ApplicationTechnical Infrastructure

Organization

Change Management

Education


bring including skills of the IT department. The “To Be” includes a prototype of the vision and how the

implementation supports the vision. The data and the processes must map to the strategic vision of the

organization for it to be successful. Implementation involves all the steps to configure the solution,

validate through testing and develop the education which will transform the organization into the new

paradigm of thought and behavior. Deploy includes all the phased steps to deploy the solution both hard

and software, the team, the organizational changes and the new reporting mechanisms and metric

assessment. This is a critical step which is an organization wide approach, even if units and IT solutions

are deployed incrementally. The last phase is the maintain when the functionality is revisited for function

and form and the ability for the technology to support the strategic vision as configured. This methodology

does not get into technical specifications, coding or interfaces for a reason, this methodology is used to

transform the organizations thinking, organizing and responding to information.

Appendix

Appendix A

Figure 1: Reasons Clinical IT projects are aborted

Figure 2: Depicts the years in nursing respondents had prior to entering informatics.

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Figure 3: Where informatics nurses work

Figure 4: Concentration of informatics nurses by geographical region

Figure 5: Direct Reports of Clinical Informatics Specialist

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Figure 6: Who informatics nurses report to independent of employer

Figure 7: General education of respondents

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Figure 8: Formal education in clinical informatics

Figure 9: Percentage of Respondents with professional certification in clinical informatics

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Appendix B

Figure 1 Cerner ConsultantsNote: Informatics Certification not required for multiple project management

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CERNERDelivery Consultant Qualifications

Bachelor's degree preferred

Basic computer skills, including Microsoft Office suite

Background in Healthcare or Information Systems

Prior implementation experience beneficial

Ability to manage multiple projects simultaneously

Excellent verbal and written communication and presentation skills

Qualifications Bachelor's degree

Nursing experience (minimum RN certification) required

Experience participating in full cycle domain, multi-clinical domain or

integrated system installations projects preferred

End user experience with hospital charting systems ideal

Ability to travel 80-100% required

Opportunities are available nationwide

Strong process analysis skills and ability to work in a team and

collaborative environment

Expertise in any of the following areas: Ambulatory Care, Surgery,

Radiology, Pharmacy, Laboratory, Emergency Medicine, Acute

Care/Critical Care, Revenue Cycle


Appendix B, Figure 2 Epic: Project Manager

Note: No informatics or project management skills required

Appendix B, Figure 3: Epic Project Manager Role Note: There are no clinical or technical experience requirements, explains a PM role, no certification .

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Appendix B, Figure 4: Epic Project Manager Role

Note: A bit more requirements but no formal education.

Appendix B, Figure 5: Epic Project Manager Role Note: A bit more requirements but no formal education.

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End Notes

Sandra Straw Hopper

clinical transformation - college of computing &...

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