A Tale of Two Hospitals A Tale of Two Hospitals How an Electronic Health Records (EHR) Implementation Can Be A Strategic Advantage 1 A Tale of Two Hospitals Academic Abstract The Tale of Two Hospitals case illustrates a dynamic and complex set of issues associated with Electronic Health Records (EHR) implementation in two hospitals. It primarily deals with the entrepreneurial process undertaken to implement a revolutionary type of technology. The case facilitates robust discussion on the state of Healthcare in the US, the role strategic entrepreneurship, intrapreneurship, and implementing change within an organization. Students must evaluate carefully what decisions St. Alexander must undertake in lieu of the actions they have made. Executive Summary Electronic Health Records (HER) has numerous advantages that are outlined by proponents. The most widely touted benefits included increased quality of care and decreased cost of medical care. Proponents claim that an interconnected, interactive EHR would decrease medical errors including medication related errors. It would also allow all physicians treating a patient to know all of the medications the patient is taking and alert them to possible interactions. It would also contain treatment algorithms to help the treating physician optimize care. An interconnected medical record would also give researchers a wealth of data. Researchers could theoretically know the out come of all treatment protocols in the country and would be able to devise better treatment algorithms for nearly every disease process. There are significant disadvantages with the current and future use of EHR in the United States. With no one uniform payer, there are a large number of private vendors that are competing for this growing market. This leads to inter-operability problems (systems 2 A Tale of Two Hospitals unable to communicate or transfer information), variance in system quality (there has been more than one \"revolt\" where a new system was dumped after implementation), and variance in cost. In transitioning to an EHR system, scanning old paper records is time consuming and up to 20% of the time of such poor quality, that they are rendered nearly useless. Proper, secure destruction of the old paper records has to be reliable. People and organizations can have an inertial resistance to change that can also impede a successful transition to a new EHR system. The Tale of Two Hospitals presents a live case of two hospitals undergoing implementation of an EHR system. The decisions made by senior management on the technology used, implementation strategy, and how to handle organizational change are presented. In presenting the approaches the two hospitals used illustrates a dynamic and robust scenario of the entrepreneurial processes hospitals are undergoing throughout the United States. Hospitals are not supposed to be entrepreneurial in nature as they try to minimize risks in order to safe and improve patient's lives. Yet, with the introduction of revolutionary technologies to a static business processes, disruptive change occurs that creates both opportunities and dire threats. The case allows students to read first hand such actions and reactions based on strategic decisions taken by management and implemented by staff. Collectively, the case showcases the impact of entrepreneurial interventions bringing a new business model to a well established archaic mode of business. The health care industry is transforming and students can start to evaluate and discuss the impact of such looming change. 3 A Tale of Two Hospitals A Tale of Two Hospitals Chevy Chase, Maryland is a very unique medical market. Essentially, the market is an oligopoly on both the hospital facility side and the physician practice side. There are two large teaching hospitals which are affiliated with Southern Maryland School of Medicine (SMS). There are two large multispecialty physician groups SM Physicians and Surgeons and the Maryland Clinic. Sintley has a large primary care (60 providers) physician network. These two hospitals have a shared medical staff and compete vigorously for market share in what is a very stable medical market in terms of total inpatient admissions per year. That total has not changed in over a decade. St. Alexander's Hospital (SAH) is the 700 bed flagship hospital of the 13 hospital system Health Hospital System (HHS). Sintley Medical Center (SMC) is the 500 bed flagship hospital of the 3 hospital Sintley Health System. Ten years ago St. Alexander's had a 60% market share; today that market share differential has reversed. With a shared medical staff that can choose where they want to admit patients, the two hospitals have developed individual strategies to draw market share. In a fixed admission (by total discharges) market the difference between profitability and loss can turn on a 5% market share difference. In fiscal year 2008 on an operating basis St. Alexander's lost $21.6 million dollars while Sintley had a profit of 43.4 million dollars (see Fig. 1 1). _________________ Insert Fig 1 _________________ 4 A Tale of Two Hospitals In the hospital industry with very high fixed costs, operating leverage is a powerful tool for profitability and Sintley operated at near capacity in 2008 while St. Alexander's closed many beds. On top of the underlying market share differential, in the first quarter of fiscal year 2009 the differential in market share widened coincident with St. Alexander's implementation of an Electronic Health Record (EHR) (Fig 2.). The two organizations have employed widely different approaches to EHR implementation and this difference has resulted in a significant strategic advantage for Sintley. There were some dramatic differences in process and decision making that resulted in significant physician dissatisfaction with the St. Alexander's EHR while the Sintley EHR implementation was accepted readily. _________________ Insert Fig 2 _________________ Fig. 1 Market Share Sintley (blue) vs. St. Alexander (red) Sintley launched Cerner's (www.cerner.com) PowerChart Millennium edition in 2003. This system combines access to documents, labs, e-signatures and various reports under a single program. St. Alexander implemented 3 separate programs, one for document access, one for e-signature and one for access to lab results. Physicians saw the difference in approach but the differences weren't substantial enough to affect physician behavior. In January of 2008 Sintley made a key strategic decision in the hiring of David Owen, MD as Chief Medical Information Officer (CMIO). Dr. Owen had extensive experience 5 A Tale of Two Hospitals in launching EHR's in four previous locations, including the University of California. He was a national thought leader in the field of medical informatics. He also had a 15% teaching appointment at SMS School of Medicine in the department of Family Medicine. As a practicing physician Dr. Owen brought a unique perspective to EHR implementation. Dr. Owen said his experience gave him an edge in \"process evaluation and workflow optimization which is key to success. I also had experience with governance and process/change control. I had learned that engaged users are the key and keeping them involved in development/training and implementation is essential to success. I had learned to maximize functionality and customize only where needed. I also knew we needed to plan the time - we went live at a prescribed time - SAH kept pushing theirs back: June 1, July 1, September 1, December 1.\" St. Alexander's did not choose to have a CMIO either for the hospital or for the HHS system. St. Alexander's managed their IT department from system headquarters which was at a remote location. Dr Owen notes, \"I would say that it is hard to tell what, if any, governance St. Alexander's has. In fact, I am not sure St. Alexander's has any control or authority over decisions. All of the Meditech project is run by Corporate at HHS and there were only a handful of SAH people involved in the design, training and implementation. That being said, ours was not as good as it should be for this project. There was too much control in the hands of the nursing staff. We were able to be successful because I was able to put in place a lot more control and governance over the 15 months I worked on the project. However, it was still immature with poorly defined scope and parameters to hold the scope in check. Our outcomes were more successful because we took a year to hone the process and put some controls in place. 6 A Tale of Two Hospitals We also had better outcomes because of the deep involvement of nursing. The biggest difference was our culture. The quickest answer is that our governance was immature and risky but better because it was purely local. SAH was both external and systemlevel controlled. Yes, it hurt their outcomes for staff and physicians.\" The IT division at Hospital Health System headquarters did not include any clinicians. In 2003 at the launch of PowerChart Millennium, Sintley established a physician IT committee. This committee was chaired by the then CMO Dr. Alant Venkat and it included physicians from all of the various clinical disciplines who were active users of PowerChart. The sole purpose of the committee was to address enhancements, new projects and to help guide the further development of the EHR, PACS systems, Medical Records systems and any other aspect of technology which directly impacted physicians. Dr. Owen took the reigns of the committee on his arrival at Sintley in January 2008. St. Alexander's did not have a focused physician IT committee until the spring of 2009 after its dismal launch of its clinical documentation EHR application and even then, the committee was ad hoc and did not focus on prospective aspects of medical informatics but instead its focus was on fixing a bad EHR implementation. Dr. Owen's philosophy surrounding EHR is that the final pieces of the EHR implementation, nursing documentation, physician order entry and physician documentation have the greatest impact and are potentially the most disruptive to clinical care. The implementation of an EHR can be thought of as a pyramid in structure (fig. 3) but in terms of impact on the clinician the last pieces have the largest impact on work flow for the clinician. (fig. 4) 7 A Tale of Two Hospitals Shortly after Dr. Owen's arrival a critical series of strategic decisions were made by both of the hospitals. Sintley had been planning to \"go live\" with nursing documentation in May of 2008. _________________ Insert Fig 3 and 4 _________________ At the same time St. Alexander's announced a push to go \"fully\" electronic with a target of implementation of nursing documentation by December of 2009 using Meditech (www.meditech.com) for the documentation and Medicity ProAccess (www.medicity.com ) as a portal platform from which physicians could access the now four separate programs that were the EHR for the HSHS system. Computerized Physician Order Entry (CPOE) and physician clinical documentation was to follow in short order. Medicity is an early stage development company with limited implementations. Dr Owen commented that there are \"too many different systems at St. Alexander's. Physicians were taught to use the Medicity Portal as an overlay on the Meditech charting system. Many doctors find that half of the information they need is in each system. Thus they are constantly trying to toggle between the two. Many have found that it is easier to just go to the Meditech system even though it is slower and it takes many more clicks to get to data, but it is still more thorough than Medicity. Also, the chart review software is another different system that has a nearly impossible search capability therefore, old data is not discoverable. The signing function for physician documents is in yet another system. The second big issue is the system's 8 A Tale of Two Hospitals VERY slow performance. The speed of response was and remains slow. It has improved slightly; however, one often feels that the system is locked. Sometimes it is and sometimes it is not. The system had major instability they had hours long crashes daily for the first month. They continue to have unexplained downtimes for up to two hours up to five times a month. They have a mandatory four hour system downtime monthly. This unreliability is devastating. For contrast, our system has been running at peak performance since \"go-live\". We tested heavy loads and found an error before \"golive\" that would have killed us. We fixed it and if couldn't have fixed we were prepared to push the date forward up until three days prior to \"go-live\". We have no necessary downtimes on a recurring basis. We have one or two necessary two to four hour downtimes that will be needed for reasons unrelated to ClinDoc, but we are planning those in the future and have adapted our needs to keep them far from the \"go-live\". Also, we have only one system for all clinical applications. The doctors just had added functionality in the same system they were used to. The only change was taking away the bedside chart. We gave them an easy way to see all of the new data. As Dr. Owen assessed the state of the Cerner nursing documentation module ClinDoc in the spring of 2008 and quickly came to the conclusion that it would not be ready for implementation until the spring of 2009. He halted implementation in 2008 in spite of the competitive disadvantage of being behind St. Alexander's. \"We decided to push the project to 2009 in about March 2008. The key decisions not to implement were probably twofold: 9 A Tale of Two Hospitals 1. We needed to upgrade to 2007 Code - Cerner's old 2005 platform was not going to be supported long term. There was additional functionality in 2007 that we needed. 2. We had unclear process control. Both Michael Owen (the CIO) and I were new in our roles and the June deadline seemed not only aggressive but risky. We wanted the best product on day one.\" He felt there was more time needed to customize the ClinDoc system with input from nursing staff and physicians and Sintley needed to get a more appropriate infrastructure in place to enhance computer access in the hospital for both the nurses and physicians. At about the same time Dr. Owen cancelled the roll out of Cerner's ambulatory EMR, PowerChart Office, for Sintley's employed physicians, Sintley Physicians Services, as he felt it was also not ready for implementation. Dr. Owen was very focused on having implementation be seamless, regardless of timing issues. St. Alexander's moved ahead on their rapid timeline of EHR implementation. According to KLAS (www.klasresearch.com) the two EHR systems, Cerner and Meditech were virtually identical in terms of satisfaction of users. If anything, Cerner ranked lower. The difference in the systems could not explain the difference in implementation. Quoting Dr. Owen \"the case really is about implementation and not about vendor. IT is not the differentiator - process, workflow and implementation are the differentiator.\" In the spring of 2008 Dr. Owen attended the annual meeting of the Scottsdale Institute. The Scottsdale Institute is a not-for-profit consortium of high performing hospitals and 10 A Tale of Two Hospitals hospital systems dedicated to moving the field of medical informatics forward. (http://www.scottsdaleinstitute.org/documents/uploads/members.pdf) At that meeting a Cerner user's group of CMIO's from around the country was formed in order to share experience, difficulties and upgrades as well as to get more leverage with the vendor. This network proved to be invaluable in the Sintley ClinDoc implementation process. The users at the Institute confirmed that the Cerner ambulatory product was not \"user friendly\" and needed a high degree of customization. Dr. Owen also discovered that some Cerner users had turned to the Allscripts ambulatory EHR (www.allscripts.com) for their outpatient application. This would turn out to be a fortuitous collaborative discovery. In the fall of 2008 St. Alexanders continued the installation of their Meditech EHR in spite of the extreme reservations of the medical staff. Rather than customize the Meditech software to meet the needs of the clinical situation at the hospital, St. Alexander's took an \"out of the box\" approach, applying the software \"as is\". HSH had chosen their EHR based on the needs of their entire thirteen hospital system. Most of these hospitals were much smaller than St. Alexander's and the software was developed to meet the needs of the entire system, not their flagship hospital. Training on the new system began in mid November 2008. There were only two physician educators for a medical staff of over 700 physicians. Fewer than 80 physicians were trained on the day of the \"go live\" of the new Meditech clinical documentation system. On the first Monday of December 2008 the nursing documentation was launched. While this was a high utilization time, there were only 20 support staff to help all of the nurses and physicians with the implementation and they 11 A Tale of Two Hospitals only covered the day and evening shifts. The nurses had been incompletely trained and were quite frustrated with the new implementation. In the first week the system crashed in 6 hour blocks on 4 occasions often during the heaviest use times of the day, there was no ability to enter data. There were insufficient computer stations and not enough tablet PC's to meet demand. It was a fiasco. Scott Fillmore, CEO of Sintley Health System comments \"The big mistake St. Alexander's made was to make the implementation an IT project. IT is there to build a platform; the clinicians have to do the implementation. If an organization doesn't have the resources to do it right then, don't do it.\" Dr. Owen commented \"At Sintley we sought frequent and methodical physician involvement through Physician IT committee for over fifteen months and with every medical staff department for three months prior to \"go live\". St. Alexander's had rare, if any, physician involvement until the Physician Informatics Lab (their version of our physician learning lab) went to train them. No one showed up for training, so they brow beat them to come to them to get training.\" Steve Connely, MD, the Chief Medical Officer at St. Alexander's, said this in response to the question \"If you had to do your implementation over again, what would you have done differently? \": \"Briefly, it would have been beneficial to have had a \"go live\" that was based on the realistic ability of the organization, with its resource challenges, to go live after: (his emphasis) Adequate preparatory process evaluation and revision to accommodate the system 12 A Tale of Two Hospitals More staff training with resources to support real time training immediately following \"go live\" More medical staff involvement with the decision makers at the HHS system level in the choice and development of the system If possible (not) be able to implement in an environment that doesn't require standardization of our environment with dissimilar hospitals in our system Our go live was imposed by other priorities, not those listed above. As my father would tell me when there was an auto accident, \"the only mechanical failure was the \"nut\" behind the wheel.\" Dr. Owen commented \"Describing where St. Alexander's went wrong could be an entire paper itself. 1. There was no analysis of workflow and process change analysis (we did not do great at this either). 2. There was no local control. 3. There was no local customization. 4. There was minimal nursing staff and physician involvement. 5. There was very poor support for the \"go live\" in terms of IT, trainers, and \"rounders\". 6. Their culture was not prepared or engaged from the start of the project. 7. They were already promising future state enhancements before \"go-live\". Basic tools were not ready or developed at time of \"go-live\". On top of the implementation issues, the software was dangerously flawed. Medication lists were absent or inaccurate. Doses of medications were missed or not recorded. Information on the patient's vital signs was often impossible to retrieve and data entry 13 A Tale of Two Hospitals was very challenging for nursing. The cardiac surgeons were so frustrated with the lack of information that they demanded, and got, a return to paper charting in the cardiovascular ICU. The two cardiac surgeons that are primarily based at St. Alexander's did a record number of cases at Sintley in the first 3 months after the \"go live\". Physicians were highly dissatisfied with the St. Alexander's EHR and clinical department meetings became heated discussions with Dr. Connely about the deficiencies and dangers of the system. Four months after \"go-live\" St. Alexander's formed a physician advisory committee related to the EHR. Alec Dennis, MD, a hospitalist with St. Alexander, describes these meetings as a \"gripe fest\" and stated no meaningful progress had been made on changes in the system. In the meantime Dr. Owen continued steadily on the implementation timeline. The system was tested both for functionality and the system was load tested to make sure the infrastructure was up to the task the additional massive amounts of use would entail. The downtime that St. Alexander's experienced was to be avoided. In the six months prior to the Sintley \"go live\" information about the upcoming transformation was presented at department meetings of the medical staff. The physicians IT committee was shown the test environment and their input was used to modify the presentation of data to meet their clinical needs. Dr. Owen was insistent that the users be included in the development of the ultimate product. He said \"We asked for feedback and made changes based on that feedback. We could make the necessary changes. St. Alexander's was tied to a vendor and HHS corporate approving changes. We were nimble and experienced. They were centralized and slow. We kept on the docs to be 14 A Tale of Two Hospitals sure we were getting it right. We probably over communicated which is much better than not enough.\" The design of the Cerner ClinDoc system was to give no click access to all pertinent clinical documentation including vital signs, laboratory tests, X-ray results and nursing notes. When the physician entered the system, all of the pertinent data was on the initial screen. In contrast, it took 8 clicks to get the same data on the St. Alexander's system. Given the events at St. Alexander's, the medical staff was understandably anxious about the upcoming change at Sintley. They were untrusting of the EHR. Dr. Owen engaged Predia Consulting to assist with training and education after go-live. In his words \"that decision was the key to our success.\" \"Go live\" for Sintley was planned for June 6th 2009. This date was chosen based on historical inpatient census patterns (low volume month), day of the week (Saturday) and time of day (midnight). Sintley has used a data driven \"Safecon\" system to understand when the high demand periods are. No \"go-live's\" with any IT project are ever scheduled during the high demand periods of November, January, February or March. It was strategically planned to have the \"go live\" occur at the time with the least potential impact on hospital operations allowing the EHR system to have a more gradual implementation. In early May all clinical staff began training on the new system. Training consisted of 8 hours of hands on usage of the system in labs set up throughout the hospital. Staff was paid overtime for the time spent in training. Presentations to the medical staff continued on a regular basis and physician training was done in the physician's lounge and on the clinical units. By the time of \"go-live\" all of the top 15 A Tale of Two Hospitals admitting physicians and 75% of the active medical staff had received extensive training. A special point was made to identify physicians that were going to be on call for the weekend of \"go-live\" and to insure they were comfortable with the new system. On June 6th the implementation was staffed by a team of 160 rounders who were provided by Predia Consulting. Dr. Owen insisted that this support was critical in spite of the cost of $700,000. He proved to be correct. There were three rounders at each nursing unit with one being there to support physicians and the other two to support clinical staff. These rounders were all experienced with Cerner ClinDoc nursing documentation and included nurses, physicians and residents from around the country. Physician rounders were used to help the physicians and nurse rounders helped all of the clinical staff. Dr. Owen stated \"The rounders were an absolute key to our success. People could not complain or moan without someone hearing them and being ready to help. I heard one staff person say that she was in the bathroom commenting to a friend about a problem and a rounder came out of the stall and offered to go help. We had rounders who were nurses - specific to individual units. We had rounders who were doctors - specific to individual units (Nephrology, burn, ICU, etc). This level of \"go-live\" support was beyond what I had ever seen. We probably would have been successful with 2/3rds as many. However, we were very successful with them. SAH had a total of about 20 rounders around the entire facility at their implementation. Most of them were technical and not clinical. We had plenty of technical staff on duty also - but the rounders were clinical.\" These rounders were present on a 24/7 basis for more than a full week after implementation t his time was allotted to allow all of the \"per diem\" staff to rotate through 16 A Tale of Two Hospitals while clinical support was there. Additionally a \"war room\" with more than a dozen programmers was set up to handle any glitches in the implementation which might occur. Also, all department managers were on duty for the \"go live\" The implementation of Cerner ClinDoc was both seamless and uneventful. The Predia rounders commented that they had never seen a more successful implementation of the ClinDoc system. Nursing satisfaction in all units, including the ICU's was very high, the nurses quickly adapted to the electronic environment. Physicians routinely commented \"this is great\" and \"this is easy\". The physician learning lab staff heard this comment \"Wow, this is so easy. I am on suspension at St. Alexander's because of delinquent charts. This is so good I think I might just stay on suspension and bring all of my patients here.\" As CMO I rounded each day of the first week of implementation and tried to find an unhappy physician. There were none. While several small glitches were found, these were easily addressed by the programmers in the \"war room\" within a few hours. At the physician IT meeting during the week following go live, there were many suggestions on how to tweak the data being delivered (different presentation, different timing of data) but there were no substantive changes needed. For the month of June Sintley had a record number of discharges in comparison to the June period for the prior ten years. As an aside, three of the Predia nurse rounders applied for positions at Sintley because the culture of the nursing staff at Sintley was so positive during the \"go-live\". They will be moving to Checy Chase from out of state. This is a testimony to the seamless implementation of ClinDoc. 17 A Tale of Two Hospitals In May of every other year Sintley surveys its medical staff on a wide variety of topics. Among the survey questions is one about access to patient information via the computer system. This survey was conducted in May of 2009 (fig. 5). As the chart below shows in this recent survey Sintley scored the highest in the history of the survey while St. Alexander's was the lowest. This is objective evidence that the medical staff is at the same time happy with the Sintley EHR while the dissatisfaction with the St. Alexander's system increased with the implementation of their clinical documentation module. _________________ Insert Fig 5 _________________ Meanwhile, the other implementation for Sintley, the ambulatory EHR was not going as well. The Cerner outpatient system PowerChart Office was proving difficult to customize to be useful for patient care. Cerner has focused more of its effort on its inpatient product. The Maryland Clinic, a 250 physician multi-specialty group, had already had an important alliance with Sintley. The clinic physicians have a 75% loyalty to Sintley and have had joint ventures with Sintley with an exclusive risk contract with Health Alliance, an HMO with a large presence in the Checy Chase market, and with a medical office building, Maryland Clinic First, located on the Sintley campus. In 2007 the Clinic adopted the Allscripts EHR for use in their outpatient clinics. In February 2009 Dr. Owen approached the Clinic with the concept of them serving as a host for Allscripts for Sintley Physician Services, a 57 physician primary care network. This 18 A Tale of Two Hospitals decision accomplished several strategic goals. Allscripts is the \"best in class\" outpatient EHR according to KLAS, the medical informatics version of JP Powers surveys. Dr. Owen has also served as a consultant to Allscripts, he was quite comfortable and impressed with the Allscripts EHR. Integrating the Maryland Clinic and Sintley Physician Services would give seamless access to the medical information from the consultants at the Checy Chase Clinic and would tighten the ties from this dominant physician group to the primary care network of Sintley. This Sintley network has 85% loyalty to Sintley for inpatient services. The advantage of using Allscripts was that it was a stable, well developed system that had a 2 year history of physician friendly use and would not require the degree of customization that PowerChart Office was requiring. It would be a much more simple \"lock and key\" implementation and would move up the timeline for an outpatient EHR for the Sintley physicians. In addition, Dr. Owen negotiated a shared governance structure for the EHR that insured a level of interaction between the organizations. This was a complete win-win for Sintley and the Clinic. It tightened the linkage with the Clinic making it more probable the Sintley primary care physicians would use Checy Chase clinic specialists, which was good for the Clinic, and increased the probability of patients being referred to Sintley for services. This deal was consummated in May 2009. This is an example of clearly was using the EHR for strategic advantage. In an environment with a stable number of inpatient admissions, alignment with the dominant medical group in the area insures that market share will shift in the direction of Sintley. The Allscripts EHR will be rolled out to Sintley Physician Services starting in August 2009. 19 A Tale of Two Hospitals With careful attention to implementation of both the inpatient and outpatient EHR, Sintley gained even more enthusiasm from physicians and continued its market share advantage. The failure of implementation at St. Alexander's brought significant physician dissatisfaction. Sintley has had record admission months for each of the first 6 months of the year. How should St. Alexander proceed from here? The decision weighs heavily on the senior management of St. Alexander. What issues, of those presented above should carry the most weight in deciding on the next steps St. Alexander should undertake? Should the compatibility with the systems in the hospital be a primary concern? Should costs be considered alone or in conjunction with maintenance and up-date costs? How will they determine the actual savings once the EHR is in place and should that factor play a major role in their decision making? Should they continue to institute this system or investigate a brand new system? If they decide on a new system, should they choose a well-known EHR company or go with a standard low cost vendor that they can a \"modify-as-you-go\"-type? One additional consideration in present day America is the executive office, which is President Obama, has made a point of indicating his searing desire to institute a national EMR. Should this occur, will any decision makes with regards to EHR be a moot point? If the administration is able to pass legislation that mandates and puts into place a national EHR, estimated at $75-$100 Billion, would St. Alexander's investment be wasted and have to be converted to the nationalized EMR system? 20 A Tale of Two Hospitals FIGURES Figure 1 \"St. Alexander's\" Hospital (SAH) The 700 bed flagship hospital of a 13 hospital system Affiliated with a major medical school Market share in 1998 - 60% Current market share - 40% FY 2008 operating loss of $21.6 million \"St. Alexander's\" Hospital (SAH) The 700 bed flagship hospital of a 13 hospital system Affiliated with a major medical school Market share in 1998 - 60% Current market share - 40% FY 2008 operating loss of $21.6 million 21 A Tale of Two Hospitals Figure 2 22 A Tale of Two Hospitals Figure 3 and 4 Provider Order Entry CPOE Future In Progress Health Maintenance (PCO) Discern Rules & Alerts Implemented Integrated Care Planning (PowerPlan) Bedside Device Integration Cardiology CVNet OutPatient Schedules E Signature Caregiver / Home Health Nursing Documentation Dictation/ Transcription Document Imaging (CPDI) Results Viewing (PowerChart) PACS HIM Coding Abstracting (3M) MammoGraphy HIM Chart Tracking & ROI Enterprise Backup& Storage Dictaphone ED Nursing Doc (FirstNet) Order Management e-MAR Medication Profile ED Triage/ Tracking (FirstNet) Height Weight Allergies Laboratory/ Pathology Results Patient Registration Guiding POC Meds Admin Surgery Doc & Scheduling (SurgiNet) ICU/CCU Doc & Workflow Respiratory Doc & Results HIM Chart Completion Management Evidence Driven Process Dose Range Checking Clinical Decision Support ED Physician Doc (PowerNoteED ) Pharmacy Physician Interaction Enterprise Decision Support (PowerInsight) IP Structured Physician Documentation I&O Vital Signs Ancillary Workflow & Doc Metro Lab Interfaces Clinical Workflow PAL/Kardex EKG/ Echo Results Radiology Reports Case Management Fetal Monitoring Interacting Ambulatory Doc & Workflow (PCO) Phys Office Document Imaging ADTs Demographics EMPI Viewing Patient Lists Patient Keeper PDA Results Access Supporting Technology Inverse Affect on all Clinical Users Computer Provider Order Entry (CPOE) Inpatient Physician Documentation Health Maintenance (PCO) Discern Rules & Alerts Bedside Device Integration Integrated Care Plans - PowerPlan ICU/CCU document Pharmacy SurgiNet ADTs Demographics Order E Signature Management Future In Progress Implemented Lab Interfaces Meds Allergies eMAR Medication Profile Home Health Radiology Reports PDA Access Dose Range Checking Clinical Decision Support Patient Patient I/Os Nursing ED Physician Vital Lists Signs Documentation Doc- FirstNet CVNet Physician Interaction Enterprise Decision Support - PowerInsight POC Meds Admin ED Nursing Doc- FirstNet Evidence Driven Process Guiding Interacting ECG/Echo Results PACS Laboratory/ Pathology Results Viewing Fetal Monitoring Dictaphone Supporting Technology 23 A Tale of Two Hospitals Figure 5 24 Hands-on Guide: How to Analyze a Case Study A case study helps students learn by immersing them in a real-world business scenario where they can act as problem-solvers and decision-makers. The case presents facts about a particular organization. Students are asked to analyze the case by focusing on the most important facts and using this information to determine the opportunities and problems facing that organization. Students are then asked to identify alternative courses of action to deal with the problems they identify. A case study analysis must not merely summarize the case. It should identify key issues and problems, outline and assess alternative courses of action, and draw appropriate conclusions. The case study analysis can be broken down into the following steps: 1. 2. 3. 4. 5. Identify the most important facts surrounding the case. Identify the key issue or issues. Specify alternative courses of action. Evaluate each course of action. Recommend the best course of action. Let's look at what each step involves. Identify the most important facts surrounding the case. Read the case several times to become familiar with the information it contains. Pay attention to the information in any accompanying exhibits, tables, or figures. Many case scenarios, as in real life, present a great deal of detailed information. Some of these facts are more relevant than others for problem identification. One can assume the facts and figures in the case are true, but statements, judgments, or decisions made by individuals should be questioned. Underline and then list the most important facts and figures that would help you define the central problem or issue. If key facts and numbers are not available, you can make assumptions, but these assumptions should be reasonable given the situation. The "correctness" of your conclusions may depend on the assumptions you make. 2. Identify the key issue or issues. Use the facts provided by the case to identify the key issue or issues facing the company you are studying. Many cases present multiple issues or problems. Identify the most important and separate them from more trivial issues. State the major problem or challenge facing the company. You should be able to describe the problem or challenge in one or two sentences. You should be able to explain how this problem affects the strategy or performance of the organization. 1. You will need to explain why the problem occurred. Does the problem or challenge facing the company comes from a changing environment, new opportunities, a declining market share, or inefficient internal or external business processes? In the case of information systems-related problems, you need to pay special attention to the role of technology as well as the behavior of the organization and its management. Information system problems in the business world typically present a combination of management, technology, and organizational issues. When identifying the key issue or problem, ask what kind of problem it is: Is it a management problem, a technology problem, an organizational problem, or a combination of these? What management, organizational, and technology factors contributed to the problem? To determine if a problem stems from management factors, consider whether managers are exerting appropriate leadership over the organization and monitoring organizational performance. Consider also the nature of management decision-making: Do managers have sufficient information for performing this role, or do they fail to take advantage of the information that is available? To determine if a problem stems from technology factors, examine any issues arising from the organization's information technology infrastructure: its hardware, software, networks and telecommunications infrastructure, and the management of data in databases or traditional files. Consider also whether the appropriate management and organizational assets are in place to use this technology effectively. To determine the role of organizational factors, examine any issues arising from the organization's structure, culture, business processes, work groups, divisions among interest groups, relationships with other organizations, as well as the impact of changes in the organization's external environment-changes in government regulations, economic conditions, or the actions of competitors, customers, and suppliers. You will have to decide which of these factorsor combination of factorsis most important in explaining why the problem occurred. 3. Specify alternative courses of action. List the courses of action the company can take to solve its problem or meet the challenge it faces. For information system-related problems, do these alternatives require a new information system or the modification of an existing system? Are new technologies, business processes, organizational structures, or management behavior required? What changes to organizational processes would be required by each alternative? What management policy would be required to implement each alternative? Remember, there is a difference between what an organization "should do" and what that organization actually "can do". Some solutions are too expensive or operationally difficult to implement, and you should avoid solutions that are beyond the organization's resources. Identify the constraints that will limit the solutions available. Is each alternative executable given these constraints? Evaluate each course of action. Evaluate each alternative using the facts and issues you identified earlier, given the conditions and information available. Identify the costs and benefits of each alternative. Ask yourself "what would be the likely outcome of this course of action? State the risks as well as the rewards associated with each course of action. Is your recommendation feasible from a technical, operational, and financial standpoint? Be sure to state any assumptions on which you have based your decision. 5. Recommend the best course of action. State your choice for the best course of action and provide a detailed explanation of why you made this selection. You may also want to provide an explanation of why other alternatives were not selected. Your final recommendation should flow logically from the rest of your case analysis and should clearly specify what assumptions were used to shape your conclusion. 4. There is often no single "right" answer, and each option is likely to have risks as well as rewards