Health Information Systems

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Copyright © 2019. Jones & Bartlett Learning, LLC. All rights reserved. © Kheng Guan Toh/ShutterStock, Inc. Balgrosky, Jean A.. Understanding Health Information Systems for the Health Professions, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/fiu/detail.action?docID=5723520. Created from fiu on 2021-01-25 16:12:08. CHAPTER 4 HIS Strategic Planning LEARNING OBJECTIVES By the end of this chapter, the student will be able to: Describe terminology and concepts associated with strategic planning for healthcare organizations, and ways these concepts apply to health information systems (HIS). Relate HIS strategy and strategic planning processes to organizational strategy, strategic planning processes, and support of patient care and the health professions. Align HIS strategy with the mission, vision, values, and strategic plan of any type of healthcare organization. Copyright © 2019. Jones & Bartlett Learning, LLC. All rights reserved. Describe elements of the HIS Strategic Planning Hierarchy Model. Identify multiple key components to HIS strategic planning, including organizational strategy, portfolio of application software, internal and external networks and connectivity, data, interoperability, and technology such as hardware and devices. Balgrosky, Jean A.. Understanding Health Information Systems for the Health Professions, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/fiu/detail.action?docID=5723520. Created from fiu on 2021-01-25 16:12:08. ▶ Introduction T his chapter focuses on the HIS Planning Framework, and to understand how best to use that framework we will explore Copyright © 2019. Jones & Bartlett Learning, LLC. All rights reserved. strategy and planning for organizations as well as for HIS. HIS should be nothing more and nothing less than a reflection of the organization itself, including its character and embedded values, in its structure and service components, as well as its strategies. In order to achieve this, we will take it from the top—first understanding what strategy means and what planning principles and techniques are, and then relating those concepts and processes to HIS and to creating HIS strategy and planning processes that inextricably intertwine the organization and its HIS capabilities. We will cover in detail the HIS Planning Framework, which provides an organizing construct for defining the HIS software portfolio to support the strategies, goals, and objectives of the organization and the health professionals who comprise its services, practices, and management. Thus, these tools and principles guide the successful development of a HIS Strategic Plan that reflects the organization’s strategic business plan, capable of successfully propelling the organization, whether large or small, into the future, including population health management, value-based reimbursement, and the dynamics of health care, which are not crystal clear to any of us at this time, given the current challenges. Balgrosky, Jean A.. Understanding Health Information Systems for the Health Professions, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/fiu/detail.action?docID=5723520. Created from fiu on 2021-01-25 16:12:08. ▶ HIS Planning Framework The four quadrants of the HIS Planning Framework provides us with the conceptual structure needed to conduct HIS planning discussions that include all key stakeholders, not just information technology (IT), vendors, or consultants driving the HIS agenda. Clinical, administrative, transactional, and analytical systems are Copyright © 2019. Jones & Bartlett Learning, LLC. All rights reserved. described relative to the types of activities and services of the organization. No significant technical expertise is needed to understand the HIS Planning Framework, hence its usability. The process it describes highlights the interdisciplinary nature of HIS and is based on nontechnical dialogue grounded in technology architecture. The framework begins with the “what we want to do” not “how” or “who” (meaning which function or vendor). The HIS Planning Framework exemplifies the whole concept of this text. It supports the imperative that all disciplines of health professionals become well versed in HIS so they can aptly participate, contribute, and lead in HIS initiatives. After all, HIS exists not for the sake of technology, but for the sake of enabling healthcare organizations and professionals to reach their goals. Principles of Planning The universal principles of planning should guide the HIS planning process and HIS strategy. The importance of planning is crossdisciplinary: Benjamin Franklin’s quote, “If you fail to plan, you are planning to fail,” applies as readily to HIS as it does to any other industry. Perhaps more. Despite this common-sense advice, a common issue is the urge to buy new software in a rush to solve problems that often compels good managers, normally sensible stewards of organizational resources, to take radical departures from those habits and sign contracts that are barely negotiated, Balgrosky, Jean A.. Understanding Health Information Systems for the Health Professions, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/fiu/detail.action?docID=5723520. Created from fiu on 2021-01-25 16:12:08. committing millions of dollars of the community’s resources for illdefined requirements and nonexistent documented strategies and plans. Submitting to these urges can spell disaster for an organization, so do not do it, under any circumstance. A factor in failed implementations is the fact that most publicity and conference content focus on HIS successes; little time is given to failures, in part because of the stranglehold vendors have on organizations’ ability to be transparent about what went wrong. Vendor contracts typically strictly prohibit organizations from saying anything negative about commercial software packages, even if they have errors in them or the vendor provides poor support (Leviss, 2013). We will cover vendor negotiations and contracting guidelines in Chapter 5 and vendor management in Chapter 6. Interestingly, the very few books published on this topic include only anonymous case examples, due to organizations’ desire to avoid retribution for exposing failed implementations in hospitals, ambulatory, and community settings. The most important lesson to remember and follow is that there are no shortcuts in HIS planning. Copyright © 2019. Jones & Bartlett Learning, LLC. All rights reserved. CASE EXAMPLE: NO DECISION IS A DECISION Let’s look at a six-hospital health system in the Midwest, with about 3,000 physicians on its medical staffs, in a variety of community, independent, and group practices plus a large integrated clinic. The implementation of an enterprise-wide, integrated electronic health record (EHR) system for the hospitals took place from 2005 to 2007 to amalgamate a nascent health system that had been recently formed through merger and acquisition. The large integrated clinic had a different, purely ambulatory EHR system that had served them well for many years: this was planned to be replaced as a next step. Following leadership changes (during a time of political unrest between the Balgrosky, Jean A.. Understanding Health Information Systems for the Health Professions, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/fiu/detail.action?docID=5723520. Created from fiu on 2021-01-25 16:12:08. large integrated group and the new health system), the newly combined organization struggled to cooperate to do the planning and coordinated selection of an EHR solution for the clinic, because the questions about how integrated the large clinic with its long independent history would be with the health system loomed large in the process. As they say, “no decision is a decision,” and the planning process was stuck. Copyright © 2019. Jones & Bartlett Learning, LLC. All rights reserved. Then the health system acquired a provider group with about 30 physicians from a local competing health system. Because that new clinic had already recently implemented an EHR system, the decision was made to use that software license and implement that EHR system for the entirety of the existing integrated clinic. Thoughtful consideration of requirements, coordination and integration of workflows and data, and myriad other considerations were dashed aside, and non-decisions resulted in a peculiar, almost nonsensical implementation of an unevaluated system that floated in during an acquisition. This is how the system for a prestigious integrated clinic was chosen, with no planning or comparison and consideration of alternatives. What was the outcome? The doctors and nurses of the large clinic were unhappy: it was a clunky, difficult-to-use system, implemented with little input from the end users, so IT just showed up and installed workstations on the walls of the examination rooms with no place for the doctors and nurses to set anything such as their stethoscopes, notebooks, or other equipment. Clinicians had to hold things in one hand and type with the other. In addition, the workstations were affixed to the wall in such a way that the clinicians using the system had to almost completely turn their backs on the patient while they entered data. The new system also required a full hour of extra work for both the physicians and nurses of a practice to finish Balgrosky, Jean A.. Understanding Health Information Systems for the Health Professions, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/fiu/detail.action?docID=5723520. Created from fiu on 2021-01-25 16:12:08. the additional clerical work that other people used to do, now required of the providers by the new system. A vendor-based consulting group came in and took control of the implementation. The vendor is now in control of the entire EHR function, and thus the organization, as well. The health system has spent an ungodly amount of money on this implementation. Copyright © 2019. Jones & Bartlett Learning, LLC. All rights reserved. The budget was supposed to be $500 million. It has ballooned to $750 million. One has to take a deep breath hearing numbers like that. After all, this is a community, not-for-profit health system. Nurses with 25 years of experience were fired for missing a question on one of three vendor-administered proficiency tests. And then, after all this effort, all this money and time, the implementation stalled after one hospital go-live. There were too many issues to be tolerated or ignored. The next hospital’s implementation is yet to take place. Of course, it doesn’t take a rocket scientist to understand why the budget slipped from $500 to $750 million, nor is it hard to figure out who is benefitting: it’s certainly not the health system and the providers who practice there, serving the patients and community. Unfortunately, only the vendor and their consulting group are reaping the rewards. CASE EXAMPLE: THINKING ABOUT SHORTCUTTING HIS PLANNING? THINK AGAIN In 2005, after $34 million and several years were invested in planning and developing a new, electronic medical record, physicians at Cedars-Sinai Medical Center in Los Angeles revolted after three months of using the new EHR system, demanding that it be abandoned (Connolly, 2005). Of course, in a disastrous situation like this, it becomes painfully clear that the Balgrosky, Jean A.. Understanding Health Information Systems for the Health Professions, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/fiu/detail.action?docID=5723520. Created from fiu on 2021-01-25 16:12:08. physicians who admit patients to a hospital have the power to get their voices heard, especially in regard to new ways of taking care of patients. If most members of the medical staff had decided to admit their patients to a different hospital, CedarsSinai would have been in dire straits clinically, financially, and from the standpoint of reputation and service to the community. Cedars-Sinai found itself in this very predicament and made the decision to abandon this major HIS project at great financial, operational, cultural, and reputational cost. Copyright © 2019. Jones & Bartlett Learning, LLC. All rights reserved. At the time, many other healthcare organizations across the U.S. were also in the midst of EHR implementations or considering investing in these expensive, transformative systems. Fear loomed in the hearts of these people who watched the CedarsSinai situation unfold, who were undoubtedly saying something like, “There but for the grace of God go I.” The Cedars-Sinai EHR failure attracted national and international attention, and those who were in the process of EHR implementations learned from this story. Many hospitals most assuredly took on additional efforts and special care in engaging and involving their medical staff members and other clinicians in the process of introducing a new computer system into a patient care environment. From the standpoint of lessons learned for HIS planning, involving members of key functions within healthcare organizations is vital to the successful definition and accomplishment of HIS plans. In this example, the medical staff departments were merely glanced at as part of the planning process. Individuals from all disciplines must be key participants on steering committees, task forces, process redesign initiatives, and implementations of new HIS. Engagement can make a major difference in how those staff members feel about the changes they are being asked to help define and implement. Change is not easy for any organization but supporting and Balgrosky, Jean A.. Understanding Health Information Systems for the Health Professions, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/fiu/detail.action?docID=5723520. Created from fiu on 2021-01-25 16:12:08. involving staff members “into the fray” of an HIS implementation is truly a role that cannot be overlooked in carrying out HIS plans. To avoid disastrous outcomes, EHR project teams must avoid working only through the medical staff leadership: the project plans must always infiltrate the ranks of the total medical staff Copyright © 2019. Jones & Bartlett Learning, LLC. All rights reserved. through involvement in process redesign, communications, orientation, and engagement in the EHR project. In the CedarsSinai example, only about 15 percent of the total medical staff knew much about the project or felt as if they had a voice in the system’s design and plans. Even though medical staff leaders were involved, receiving word about the project on a secondhand basis was insufficient for the remaining 85 percent of the medical staff, and this mistake ultimately led to the project failure. Since the Cedars-Sinai revolt, many healthcare organizations throughout the U.S. have taken clear note, wisely deciding to invest the time, money, and energy needed to reach as many of their own medical staff members as possible, as well as other department members, regarding their EHR implementations. Successful organizations do their best to involve line physicians in the design of their new EHR systems, and then seek to proactively orient and train all clinicians on the new system before it goes “live.” Successful HIS implementations now recognize that these key users—the physicians, clinicians, and other healthcare professionals essential to the minute-to-minute functioning of the hospital—have a choice whether to use the new system, and accept that each and every one of these professionals must be given the opportunity to learn about and participate in the planning, design, and development of the new system. As a happy footnote, since this trying experience at the renowned institution, the Cedars-Sinai Medical Center and Balgrosky, Jean A.. Understanding Health Information Systems for the Health Professions, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/fiu/detail.action?docID=5723520. Created from fiu on 2021-01-25 16:12:08. Cedars-Sinai Medical Group have successfully implemented a new comprehensive, integrated EHR. Copyright © 2019. Jones & Bartlett Learning, LLC. All rights reserved. The importance of a well-disciplined HIS planning process cannot be overemphasized, given, among other things, the expensive nature of HIS—they are costly to acquire, implement, and maintain. Once in place, these systems have just begun to exact the financial toll on an organization, which, over the long-term (including annual support fees paid to each software vendor), for the software maintenance alone, generally totals 20–25 percent of the total license cost of the software. Typically, in three to four years, the software maintenance fees alone exceed the original purchase fees for the license itself. Plus, this does not include other operational costs for training, backfill of operational staff during the project, internal IT support, help desk expansion, training, upgrades, and other ongoing costs. So, a careful detailed plan is essential, to avoid unhappy financial surprises, missed project deadlines, suffering for the organization’s culture, missed financial targets, and redirected budget funds such as using resources intended for personnel wage increases or other important expenses to make up for the shortfall. This is not a desired scenario, and yet it can easily happen without a careful, forward-looking plan that includes detailed implementation plans including a five-year cost estimate for each HIS project in the context of all HIS within an organization. HIS plans should be intertwined with other principles, such as patient-centric, missionsupporting care; the health of patients, practices, and organizations; the facilitation of trusted relationships and interactions with external parties; and the creation of a promising future for the organization and the community it serves. Balgrosky, Jean A.. Understanding Health Information Systems for the Health Professions, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/fiu/detail.action?docID=5723520. Created from fiu on 2021-01-25 16:12:08. ▶ HIS Strategy: Using Organizational Strategy as a Roadmap The term “strategy” is a word we often hear, readily applied to many different arenas, especially when discussing organizations and their work or important activities. It is easy to dilute the meaning of this term into something amorphous or general, so that Copyright © 2019. Jones & Bartlett Learning, LLC. All rights reserved. the term “strategies” is often used interchangeably (and erroneously) with terms such as “goals,” “tactics,” “policies,” “schemes,” “agendas,” “plans,” or “objectives.” At the uppermost levels of an organization’s agenda are directional statements or overarching aims directly tied to mission and vision, the largescale ways that the organization will be able to successfully move itself forward toward its purpose over a period of years. These are strategies. Strategies are defined and developed by first reflecting on the organization’s reason for existing (its mission) and examining the organization in the context of its market; outlining a long-term and evolving view of its place in that environment or market in the future (its vision); and then understanding the ways it wants to behave, the philosophies it wants to support, its guiding principles, and the ways it wants to …
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