# ( Health Care Information Systems: A Practical Approach for Health Care Management, 3rd Edition PREV NEXT Chapter 17: Asses... ' " Appendixes CHAPTER 18 Health IT Leadership A Compendium of Case Studies Faculty and others who teach health administration students are often in search of case studies that can be used to help students apply theory and concepts to real-life IT management situations, encourage problem solving and critical thinking, and foster discussion and collaboration among students. This chapter provides a compendium of case studies from a variety of health care organizations and settings. It is intended to serve as a supplement to the preceding chapters and as a resource to faculty and students. Many of these case studies were originally written by working health care executives enrolled as students in the doctoral program in health administration offered at the Medical University of South Carolina. We wish to acknowledge and thank these students for allowing us to share their stories and experiences with you: Penney Burlingame Randall Jones Barbara Chelton Catrin Jones-Nazar Stuart Fine Ronald Kintz David Freed George Mikatarian David Gehant Michael Moran Patricia Givens Lorie Shoemaker Victoria Harkins Gary Wilde Each case begins with background information that includes a description of the setting, the current information system (IS) challenge facing the organization, and the factors that are felt to have contributed to the current situation. (All real names and identifying information have been changed from the original cases to protect the identity of the individuals and organizations involved.) Following each case is a set of recommended discussion questions. To the extent possible, the cases are organized by major theme, such as strategic IS planning, system acquisition, and system implementation. (See Table 18.1.) We hope you find the cases thought-provoking and useful in applying the concepts covered in this book to what is happening in health care organizations throughout our nation. We have also included at the end of the chapter a listing of other published cases that may be useful to you and your students. Table 18.1. List of cases and major themes Title of Case Major Theme(s) Case 1: Board Support for a Strategic planning Capital Project and IT alignment; IT governance Case 2: The Decision to Develop an IT Strategic Strategic planning and IT alignment Plan Case 3: Selection of a Patient Safety Strategy Case 4: Strategic IS Planning for the Hospital ED Case 5: Planning an EHR Implementation Case 6: Implementing a Strategic planning and IT alignment Strategic planning and IT alignment IT strategy; system implementation System acquisition Capacity Management Information System Case 7: Implementing a Telemedicine Solution System acquisition; use of emerging technologies Case 8: Replacing a Practice Management System IT governance; system implementation Case 9: Conversion to an EHR System Messaging System implementation; project management Case 10: Concerns and System Workarounds with a implementation; Clinical Documentation project System management Case 11: Strategies for Implementing CPOE System implementation; project management Case 12: Implementing a Syndromic Surveillance IT strategy; system implementation System Case 13: The Admitting Disaster recovery System Crashes Case 14: Breaching the IT security Security of an Internet Patient Portal Case 15: Assessing the Value and Impact of CPOE Assessing the value of an HIT investment Case 16: Selecting an EHR for System acquisition Dermatology Practice Case 17: Watson's Ambulatory System acquisition EHR Transition Case 18: Assessing the Value Value assessment of Health IT Investment CASE 1: BOARD SUPPORT FOR A CAPITAL PROJECT Major themes: strategic planning and IT alignment; IT governance Background Information Lakeland Medical Center is a 210-bed public hospital located in the Southeast. It is governed by a politically appointed nine-member board and serves a market of approximately 100,000 people. The hospital has been financially successful, but in recent years several capital investments have not brought high returns. As a result, project investment decisions became more conservative and oriented toward financial returns. Competitive forces have continued to grow in the market, and significant internal expense items (such as the organization's pension program, paid leave bank, and health insurance program) have put strains on Lakeland's financial resources. Revenue continues to grow at an average rate of about 10 percent each year, but controlling expenses remains a challenge. Bad debt has grown from $5 million last year to a budgeted amount of $14 million this year. The hospital continues to accomplish high patient and employee satisfaction scores, high quality scores, and an A+ credit rating. Debt is approximately $55 million, and cash reserves are approximately $95 million. Total operating revenues are approximately $130 million. The hospital employs 940 staff members. The average length of stay is 4.3 days. Annual capital expenditure is $4 million. Information Systems Challenge In 2008, the installation of computed radiography (CR) components to build a picture archiving and communication system (PACS) began, at an estimated total cost of $1 million. In 2009, $400,000 was spent for additional CR components. But in 2010, the board of directors (with three new members) did not approve the request of $1.9 million for completion of the PACS, saying that it represented far too large a percentage of the organization's annual capital budget. A year later Lakeland is still in need of completing the PACS program, with a board that is unlikely to approve the expenditure. A number of factors are contributing to the board's decision not to authorize the additional $1.9 million for completion of the PACS, including Leadership's inability to guarantee to the board's satisfaction a financial return on the proposed investment. The board's perception that the radiologists are not committed to the hospital and to the community because none of the radiologists live in the community. The board's perception that the cardiologists are not committed to the hospital or to the community. The five cardiologists on staff are considered to be uncooperative among themselves and not supportive of the hospital's goals. Poor leadership within the IT department for providing the proper guidance on acquisition and implementation. The board's philosophy that Lakeland Medical Center should be more high-touch and less hightech, and thus there is a philosophical difference over the need for a PACS. Jealousy among the medical staff that the diagnostic imaging department continues to obtain capital approvals for large items representing a major percentage of the annual capital budget. Thus, many influential members of the medical staff, such as surgeons, are not supportive of the expenditure. A few vocal employees speaking directly to board members expressing their concern that the PACS implementation will result in job loss for them. Leadership's inability to make a connection between this capital project and the strategic goals of the organization. The chief of staff, Dr. Mary White, firmly believes that a PACS will increase patient and physician satisfaction because waiting times for results will decrease, enhance patient education, improve staff and physician productivity, improve clinical outcomes, improve patient safety, eliminate lost films, reduce medical liability, assist in reducing patient length of stay, and increase revenue potential. She believes it is management's challenge to understand the key issues of the board and to present the necessary supportive information for ultimate approval of the PACS program. Discussion Questions 1. Conduct a role-play. Divide into four teamsthe Lakeland Medical Center administrative team, the board, the medical staff, and the hospital and community at large. Assume the role of your constituent group and answer these questions: What are your views on this proposal? What are your major concerns? What questions do you have? And for whom? Do you think this is a case of someone failing to do his or her homework in putting together a sound business plan for the PACS project, or do you think there are bigger issues at play here? Explain your answers as necessary. 2. Assume that the CEO believes that the PACS project is well aligned with Lakeland's strategic goals but that this case hasn't been made clear to the board. How might Lakeland build this case? Who should lead that effort? What work needs to be done that has not occurred yet? 3. Are the board's concerns about medical staff commitment relevant in this case? Why or why not? 4. Develop a strategy for addressing the board's concerns and winning their buy-in and approval for the PACS project. Include in your description the who, what, where, when, and how. CASE 2: THE DECISION TO DEVELOP AN IT STRATEGIC PLAN Major themes: strategic planning and IT alignment Background Information Meadow Hills Hospital is a 211-bed acute care hospital with 400 members on its medical staff. Meadow serves a population of 300,000. There are three other similarly sized hospitals in the region. As an organization, Meadow Hills is very well run. It has a good reputation in the community and is considered to be technically advanced based on its investments in imaging technology. The organization is also in a strong financial position, with $238 million in reserves. Meadow Hills has never had an information technology strategic plan. Information Systems Challenge The IT function reports to the Meadow Hills chief financial officer (CFO). The CEO and other members of the senior leadership team have largely left IT decisions up to the CFO. As a result, the organization's financial systems are very well developed. Computerized provider order entry (CPOE), an electronic health record (EHR) system, and a PACS have not been implemented. IT support for departments such as nursing, pharmacy, laboratory, imaging, and risk management is limited. The Meadow Hills IT team is well regarded and the limited IT support for clinical processes has not drawn complaints from the nursing or medical staff. The organization does not currently have a chief information officer (CIO). The CEO has never felt the need to pay attention to IT. However, he is worried that reimbursement based on care quality will arrive at Meadow Hills soon. He also believes that the Meadow Hills Clinical Laboratory and Imaging Center would be more competitive if it had stronger IT support; rival labs and imaging centers are able to offer electronic access to test results. And he suspects that the lack of IT support may eventually lead to nurses and physicians choosing to practice elsewhere. Discussion Questions 1. What steps should the CEO take to develop an IT strategy for the organization? 2. Are there unique risks to the ability of Meadow Hills Hospital to develop and implement an IT strategy? 3. Meadow Hills appears to have been successful despite years without an IT strategy. Why is this? CASE 3: SELECTION OF A PATIENT SAFETY STRATEGY Major themes: strategic planning and IT alignment Background Information Langley Mason Health (LMH) is located in North Reno County, the largest public health care district in the state of Nevada, serving an 850-square-mile area encompassing seven distinctly different communities. The health district was founded in 1937 by a registered nurse and dietician who opened a small medical facility on a former poultry farm. Today the health system comprises Langley Medical Center, a 317-bed tertiary medical center and level II trauma center; Mason Hospital, a 107-bed community hospital; and Mason Continuing Care Center and Villa Langley, two part-skilled nursing facilities (SNFs); a home care division; an ambulatory surgery center; and an outpatient behavioral medicine center. In anticipation of expected population growth in North Reno County and to meet the state-mandated seismic requirements, LMH developed an aggressive facilities master plan (FMP) that includes plans to build a state-of-the-art 453-bed replacement hospital for its Langley Medical Center campus, double the size of its Mason Hospital, and build satellite clinics in four of its outlying communities. The cost associated with actualizing this FMP is estimated to be $1 billion. Several years ago, LMH undertook and successfully passed the largest health care bond measure in the state's history and in so doing secured $496 million in general obligation bonds to help fund its massive facilities expansion project. The remaining funds must come from revenue bonds, growth strategies, philanthropic efforts, and strong operational performance over the next ten years. Additionally, $5 million of routine capital funds will be diverted every fiscal year for the next five years to help offset the huge capital outlay that will be necessary to equip the new facilities. That leaves LMH with only $10 million per year to spend on routine maintenance, equipment, and technology for all its facilities. LMH is committed to patient safety and is building what the leadership team hopes will be one of the safest hospital-of-the-future facilities. The challenge is to provide for patient safety and safe medication practices given the minimal capital dollars available to spend today. LMH developed an IT strategic plan in late 2010, with the following ten goals identified: Empower health consumers and physicians. Transform data into information. Support the expansion of clinical services. Expand e-business opportunities. Realize the benefits of innovation. Maximize the value of IT. Improve project outcomes. Prepare for the unexpected. Deploy a robust and agile technical architecture. Digitally enable new facilities, including the new hospital. Information Systems Challenge LMH has implemented Phase 1an enterprise-wide EHR system developed by Cerner Corporation in 2008 at a cost of $20 million. Phase 2 of the project is to implement computerized provider order entry (CPOE) with decision-support capabilities. This phase was to have been completed in 2010, but has been delayed due to the many challenges associated with Phase 1, which still must be stabilized and optimized. LMH does have a fully automated pharmacy information system, albeit older technology, and Pyxis medication-dispensing systems on all units in the acute care hospitals. Computerized discharge prescriptions and instructions are available only for patients seen and discharged from the LMH emergency departments. Currently, the pharmacy and nursing staff at LMH have been working closely on the selection of a smart IV pump to replace all of the health system's aging pumps and have put forth a proposal to spend $4.9 million in the fiscal year beginning July 2012. Smart pumps have been shown to significantly reduce medication administration errors, thus reducing patient harm. This expenditure would consume roughly half of all of the available capital dollars for that fiscal year. The chief information officer, Marilyn Moore, PhD, understands the pharmacists' and nurses' desire to purchase smart IV pumps but believes the implementation of this technology should not be considered in isolation. She sees the smart pumps as one facet of an overall medication management capital purchase and patient safety strategic plan. Dr. Moore suggests that the pharmacy and nursing leadership team lead a medication management strategic planning process and evaluate a suite of available technologies that taken together could optimize medication safety (for example, CPOE, electronic medication administration records [e-mar], robots, automated pharmacy systems, bar coding, computerized discharge prescriptions and instructions, and smart IV pumps), the costs associated with implementing these technologies, and the organization's readiness to embrace these technologies. Paul Robinson, PharmD, the director of pharmacy, appreciates Dr. Moore's suggestion but feels that smart IV pumps are critical to patient safety and that LMH doesn't have time to go through a long, drawn-out planning process that could take years to implement and the process of gaining board support. Others argue that all new proposals should be placed on hold until CPOE is up and running. They argue there are too many other pressing issues at hand to invest in yet another new technology. Discussion Questions 1. Describe the current situation as you see it. What are the major issues in this case? 2. Marilyn Moore, CIO, and Paul Robinson, director of pharmacy, have different views of how LMH should proceed. What are the pros and cons of their respective approaches? Which approach, if either, seems like an appropriate course of action to you? Explain your rationale. 3. Assume you are to mediate a discussion on this issue and that participants are to come to consensus on how best to proceed. What would you do? CASE 4: STRATEGIC IS PLANNING FOR THE HOSPITAL ED Major themes: strategic planning and IT alignment Background Information Founded in 1900, Newcastle Hospital today is a 375bed, not-for-profit community hospital that serves over 200,000 residents of Newcastle County, New York. The hospital is approximately thirty miles from midtown Manhattan. It provides a full range of both primary and secondary medical and surgical services and is an affiliate of one of the large New York City hospital systems for both tertiary referrals and select residency programs. Newcastle Hospital has an independent governing body with 25 trustees; 604 active physicians; and 1,121 full-time equivalent (FTE) staff. Revenues of approximately $130 million per year come from 15,600 inpatient admissions; 71,000 outpatient visits; and 65,000 home care visits. Newcastle Hospital operates in a difficult environment characterized by relatively poor reimbursement and severe competition. There is one other acute care hospital in the county and a total of thirty-five others within a twenty-mile radius. The sentinel event in the hospital's recent history occurred four years agoa six-month nursing strike that alienated the workforce, decimated public confidence, and directly cost at least $19.5 million, effectively eradicating the hospital's capital reserves. Most of the senior management was replaced after the strike. When hired, the new CEO and CFO uncovered extensive inaccuracies that resulted in a reduction of reported net assets by almost $30 million and the near-bankruptcy of the hospital. The new management restated financial statements; began resolving extensive litigation; and set out to reestablish immediate operations, future finances, and longterm strategy. The new CEO states that \"years of board and management neglect, plus the ravages of the strike complicated recovery, because standards, systems, and middle managers were universally absent or ineffective.\" Among its many challenges, the challenges within the hospital's emergency department (ED) are particularly important to the overall recovery effort. The ED is described by the hospital CEO as the organization's \"financial, clinical and public relations backbone.\" The ED sees 34,000 patients per year and admits 24 percent of them, constituting 51 percent of all inpatient admissions. In addition, the ED is a clinically distinguished Level II trauma center, with a long legacy of outcomes that compare favorably against regional, state, and national benchmarks. Finally, most community members have experience with the ED and consider it a proxy for the hospital as a whole, whether or not they have experienced an inpatient stay. Currently, Newcastle ED patient satisfaction compared to patient satisfaction among peer organizations ranks at the 14th percentile in the Press Ganey New York State survey and the 5th percentile in national surveys. Since 1997, three organized initiatives to improve these results (especially regarding walkouts and waiting times) have failed, even though two involved prestigious consultants. After the management change, the new CEO diagnosed two core barriers to overcoming the ED problems: first, inflexibility and unwillingness to change among the ED physician management group that had been in place since 1987 and, second, an almost complete absence of the data required to define, measure, and improve the ED's service performance. The first barrier was addressed via an RFP process that resulted in engaging a new physician management group two years ago. Information Systems Challenge The present IS challenge follows directly from Newcastle Hospital's overarching strategic objectives: \"satisfying patients and staff,\" \"supporting ourselves,\" and \"getting better every day\" (that is, improving performance). The ED as presently structured has ill-defined manual processes and no information system. The challenge is selecting an ED information system with an emphasis on informing, not just automating, key ED processes, in order to support the overall strategic initiatives of the organization. Several organizational and IT system factors that affect this IT challenge have been identified by the hospital CEO. Organizational Factors Undefined strategy. Newcastle Hospital operated without a formal strategic action plan and corresponding tactics until two years ago. As a result, systematic prioritization and measurement of institutional imperatives such as improving the ED did not occur. Data integrity. Data throughout the hospital were undefined and unreliable. For example, two irreconcilable daily census reports made timely bed placement from the ED impossible. Culture. \"Looking good,\" that is, escaping accountability, was valued more highly than \"doing good,\" that is, substantively improving performance. Serious problems in the ED were often masked or dismissed as anecdotes, even in the face of regulatory citations and six- to eight-hour waiting times. The previous ED contract had contained no quality standards, and the ED physicians claimed to be busy \"saving lives\" whenever their poor service performance was questioned. IT System Factors IT strategy. Paralleling the hospital, the IS department had no defined strategies, objectives, or processes. Alignment with hospital strategy and IT performance measurement were not considered. Although some progress has been made, this remains an area needing attention. IT governance. There is no IT steering committee at either the board or management levels. IT policies, service-level agreements, decision criteria, and user roles and responsibilities do not exist. Functionality. The IT applications portfolio is missing critical elements (for example, order entry, case management, nursing documentation, radiology) that would greatly benefit the ED, even without a dedicated ED system. The hospital's core information system is three versions out of date and certain functions have been bypassed by users altogether. IT infrastructure and architecture. The data center and most IT staff are located twelve miles away from the hospital, isolating IT both physically and culturally from users and patients. Software and networks have been arbitrarily and extensively customized over the years, without documentation, and inadequate hardware capacity has often been given as an excuse for not pursuing an ED system. IT organization and resources. IT spending has been, on average, less than 1 percent of the hospital's budget and IT staff have lacked essential training in critical applications and tools. Newcastle Hospital has been dependent on multiple IT vendors for a variety of implementation and operations support activities. Discussion Questions 1. Outline the steps you would take to initiate a strategic planning process for improving the ED information system. How will you ensure that this plan is in alignment with the hospital's and department's overall strategic plans? 2. Multiple factors have contributed to the current state of the ED at Newcastle Hospital and are listed in the case. Which of these do you think will be the most difficult to overcome? Why? 3. The new CEO has good insight into the ED issues. Assuming that his assessment of the situation is accurate, discuss how his continued support could affect the outcome of any ED IS strategic plan. 4. Assume the CEO has appointed you to spearhead the ED IS strategic planning effort. What are the first steps you will take? Outline a general plan of action for the next three months. Indicate, by title, whom you would involve in the process. Explain your choices. CASE 5: PLANNING AN EHR IMPLEMENTATION Major themes: IT strategy; system implementation Background Information The Leonard Williams Medical Center (LWMC) is a 240-bed, community acute care hospital operating in a small urban area in upstate New York. The medical center offers tertiary services and has a captive professional corporation, Williams Medical Services (WMS). WMS is a multispecialty group employing approximately fifty primary care and specialty physicians. WMS has its own board, made up of representatives of the employed physicians. The WMS board nominations for members and officers are subject to the approval of the medical center board. The capital and operating budgets of WMS are reviewed and approved during the LWMC budget process. The WMS board is responsible for governing the day-to-day operations of the group. LWMC serves a population of approximately 215,000. There are five other hospitals in the region. One of these, aligned with a large clinic, is viewed as the primary competitor. In its most recent fiscal year, LWMC had an operating margin of 0.4 percent. LWMC has $40 million in investments and has a long-term debt to equity ratio of 25 percent. Information Systems Challenge LWMC has been very effective in its IT efforts. It was the first hospital in its region to have a clinical information system. Bedside computing has been available on the inpatient units since the 1990s. The CIO and IT department are highly regarded. LWMC has received several industry recognitions for its efforts. The LWMC information systems steering committee recently approved the acquisition and implementation of a CPOE system. This decision followed a thorough analysis of organizational strategies, the efforts of other hospitals, and the vendor offerings. LWMC is poised to begin this major initiative. During a recent steering committee meeting, it was learned that the WMS physicians were anxious to acquire an electronic health record (EHR) system. Two years ago a rival physician group had purchased an EHR system. WMS, concerned about a competitive threat, obtained approval of $300,000 to acquire its own EHR. The rival group has since encountered serious difficulties with implementation and has deinstalled the system. This troubled path caused WMS to slow down its efforts. Now WMS has decided to return to its plans to implement a certified EHR. The physicians have begun to look at vendor offerings but have not involved the LWMC CIO and IT staff. The physicians have ignored the CIO's technical and integration advice and requirements during their EHR search. The CEO is concerned about the EHR process and its disconnect from the medical center's IT plans. Discussion Questions 1. What is your assessment of this situation? What are the physician group's possible reasons for deciding to proceed on an independent path? 2. If you were the CEO, what steps would you take to bring the hospital and physician group IT plans back into alignment? Should the EHR effort proceed or wait until the CPOE initiative is complete? Should you require that both systems come from the same vendor? Explain your rationale. 3. The LWMC board is concerned that the physicians are being naive about the challenges of EHR implementation, have established no measurable goals for the system, and have only weak incentives to make the implementation successful. How would you address these concerns? CASE 6: IMPLEMENTING A CAPACITY MANAGEMENT INFORMATION SYSTEM Major theme: system acquisition Background Information Doctors' Hospital is a 162-bed, acute care facility located in a small city in the southeastern United States. The organization had a major financial upheaval six years ago that resulted in the establishment of a new governing structure. The new governing body consists of an eleven-member authority board. The senior management of Doctors' Hospital includes the chief executive officer (CEO), three senior vice presidents, and one vice president. During the restructuring, the chief information officer (CIO) was changed from a full-time staff position to a parttime contract position. The CIO spends two days every two weeks at Doctors' Hospital. Doctors' Hospital is currently in Phase 1 of a threephase construction project. In Phase 2 the hospital will build a new emergency department (ED) and surgical pavilion, which are scheduled to be completed in eleven months. Information Systems Challenge The current ED and outpatient surgery department have experienced tremendous growth in the past several years. ED visits have increased by 50 percent, and similar increases have been seen in outpatient surgery. Management has identified that inefficient patient flow processes, particularly patient transfers and discharges, have resulted in backlogs in both the ED and outpatient areas. The new construction will only exacerbate the current problem. Nearly one year ago Doctors' Hospital made a commitment to purchase a capacity management software suite to reduce the inefficiencies that have been identified in patient flow processes. The original timeline was to have the new system pilot-tested prior to the opening of the new ED and surgical pavilion. However, with the competing priorities its members face as they deal with major construction, the original project steering committee has stalled. At its last meeting nearly six months ago, the steering committee identified the vendor and product suite. Budgets and timelines for implementation were proposed but not finalized. No other steps have been taken. Discussion Questions 1. Do you think the absence of a full-time CIO has had an impact on this acquisition project? Why or why not? 2. What steps should the CIO take to ensure that the capacity management system will be purchased and implemented? What do you see as the critical first step in this process? Why? 3. Discuss who you think should serve on the project steering committee. Who should serve as chair? Why? 4. At this point, what do you think is a realistic time frame for implementation of the capacity management system? What steps can be taken to ensure the new timeline is met despite competing priorities? CASE 7: IMPLEMENTING A TELEMEDICINE SOLUTION Major themes: system acquisition; use of emerging technologies Background Information Grand Hospital is located in a somewhat rural area of a midwestern state. It is a 209-bed, community, not-for-profit entity offering a broad range of inpatient and outpatient services. Employing approximately 1,600 individuals (1,250 fulltime equivalent personnel), and having a medical staff of more than 225 practitioners, Grand has an annual operating budget that exceeds $130 million, possesses net assets of more than $150 million, and is one of only a small number of organizations in this market with an A credit rating from Moody's, Standard & Poor's, and Fitch Ratings. Operating in a remarkably competitive market (there are roughly 100 hospitals within seventy-five minutes' driving time of Grand), the organization is one of the few in the regionproprietary or not-for-profitthat have consistently realized positive operating margins. Grand attends on an annual basis to the health care needs of more than 11,000 inpatients and 160,000 outpatients, addressing more than 36 percent of its primary service area's consumption of hospital services. In expansion mode and currently in the midst of $57 million in construction and renovation projects, the hospital is struggling to recruit physicians, both to meet the health care needs of the expanding population of the service area and to succeed retiring physicians. Grand has been an early adopter of health care information systems and currently employs a proprietary health care information system that provides (among other components) Patient registration and revenue management Electronic health records with computerized physician order entry Imaging via a PACS Laboratory management Pharmacy management Information Systems Challenge Since 1995, Grand Hospital has transitioned from being an institution that consistently received many more inquiries than could be accommodated concerning physician practice opportunities, to a hospital at which the average age of the medical staff has increased by eight years. There is a widespread perception among physicians that because of such factors as high malpractice insurance costs, an absence of substantive tort reform, and the comparatively unfavorable rates of reimbursement being paid physician specialists by the region's major health insurer, this region constitutes a \"physician unfriendly\" venue in which to establish a practice. Consequently, a need exists for Grand to investigate and evaluate creative approaches to enhancing its physician coverage for certain specialty services. These potential approaches include the effective implementation of information technology solutions. The findings and conclusions of a medical staff development plan, which has been endorsed and accepted by Grand's medical executive committee and board of trustees, have indicated that because of needs and circumstances specific to the institution, the first areas of medical practice on which Grand should focus in approaching this challenge are radiology, behavioral health crisis intervention services, and intensivist physician services. In the area of radiology, Grand needs qualified and appropriately credentialed radiologists available to interpret studies 24 hours per day, 7 days per week. Similarly, it needs qualified and appropriately credentialed psychiatrists available on a 24/7 basis to assess whether behavioral health patients who present in the hospital's emergency room are a danger to themselves or to others, as defined by state statute, and whether these patients should be released or committed against their will for further assessment on an inpatient basis. Finally, inasmuch as Grand is a community hospital that relies on its voluntary medical staff to attend to the needs of patients admitted by staff members such as some ED personnel, it also needs to have intensivist physicians available around the clock to assist in assessing and treating patients during times when members of the voluntary attending staff are not present within or immediately available to the intensive care unit. The leadership at Grand Hospital is investigating the potential application of telemedicine technologies to address the organization's need for enhanced physician coverage in radiology, behavioral health, and critical care medicine. Discussion Questions 1. What are the ways in which Grand's early adoption of other health care information system technologies might affect its adoption of telemedicine solutions? 2. What do you see as the most likely barriers to the success of telemedicine in the areas of radiology, behavioral health, and intensive care? Which of these areas do you think would be the easiest to transition into telemedicine? Which would be the hardest? Why? 3. If you were charged by Grand to bring telemedicine to the facility within eighteen months, what are the first steps you would take? Whom would you involve in the planning process? Defend your response. CASE 8: REPLACING A PRACTICE MANAGEMENT SYSTEM Major themes: IT governance; system implementation Background Information University Physician Group (UPG) is a multispecialty group practice plan associated with the College of Osteopathic Medicine (COM). UPG employs 90 physicians and 340 clinical and business support personnel. UPG has recently been profitable (with revenue from operations this fiscal year of $32 million and a retained profit of $500,000 from operations). However, prior year losses make UPG a breakeven organization. Management and the physicians are focusing on strengthening the fiscal position of the organization. This focus has led to plans to restructure physician compensation, establish a self-insurance trust for professional liability, and improve the financial budgeting and reporting processes. UPG has entered into a preliminary agreement to merge with Northern Affiliated Medical Group (NAMG). NAMG is a 150-physician multispecialty group located in the same city as UPG. NAMG holds a contract with the local county hospital to provide indigent care and serve as the faculty for the graduate medical education programs in family medicine. Both organizations believe that the merged organization would be able to reduce expenses through the elimination of redundant functions and, because of greater geographical coverage and size, would improve their ability to obtain more favorable payer contracts. Information Systems Challenge For many years UPG has obtained practice management systems from Gleason Solutions (GS). The applications are hosted in a GS data center, reducing the UPG's need for IT staff. Prior to the merger, UPG was in the process of examining replacements for GS. UPG had become displeased because of the GS applications' failure to incorporate new technologies and application features, limited ability to generate reports, and inflexible integration approaches to other applications. Despite its displeasure, UPG now appears to be on the path to renewing the GS contract. GS executives have effectively lobbied several important physicians and administrators, and UPG's limited cash position makes the GS low-cost financial proposal attractive. NAMG uses the GS applications and has also been examining replacing the system. NAMG has a strong IT department and will be providing IT support to the newly merged organization. After examining the market, NAMG has identified four potential vendors, including GS. Discussion Questions 1. Would you suspend both organizations' pursuit of a new system until an IT strategic plan for the merged organization has been developed? Why? 2. What steps would you take to integrate the system selection processes of the two organizations? 3. Implementing a practice management system is always challenging. What additional implementation risks are introduced by the merger? 4. Both organizations expect the result of the merger to be lower costs, improved patient service, and increased market power. What steps would you take to make sure that the new practice management system furthers these objectives? CASE 9: CONVERSION TO AN EHR MESSAGING SYSTEM Major themes: system implementation; project management Background Information Goodwill Health Care Clinic is the clinical arm of Jefferson Health Sciences Center in a large southern city. The clinic was founded in the early 1950s as a place for faculty physicians to engage in clinical practice. Over the years the clinic has grown to 900 faculty physicians and 2,000 employees, with over one million patient visits per year. Clinic services are spread across eleven primary care and specialty care units. Each unit operates somewhat independently but shares a common medical record numbering system that allows consolidation of all documentation across units. Paper charts were used until two years ago, when the clinic adopted an electronic health record (EHR) system. Goodwill Health Care Clinic uses a centralized call center to receive all patient calls. Patients call a central switchboard to schedule appointments, request medication refills, or speak to anyone in any of the eleven units. Call center staff are responsible for tracking all calls to ensure that each is dealt with appropriately. Currently the call center uses a customized Lotus Notes system that can be accessed by anyone in the system who needs to process messages. Messages can be tracked and then closed when the appropriate action has been taken. Notes created from closed messages are printed and filed in the appropriate patients' paper records. These notes cannot be accessed via the EHR. Clinic staff are very comfortable with the current Lotus Notes system and it is used routinely by all units. Information Systems Challenge Goodwill Health Care Clinic requires all medication lists and refill information to be kept up to date in the EHR. Therefore, the existence of the current Lotus Notes system means that the same information must be documented in two locationsfirst in the call center note and then in the EHR. This leads to duplication of effort and documentation errors. The potential for serious error is present. Physicians and other health care providers look in the EHR for the most up-to-date medication information. Although the adoption of the EHR has been fairly successful, not all units use all of the available components of the EHR. A companion paper record is needed for miscellaneous notes, messages, and so forth. All units are recording office visits into the EHR, but not all have activated the lab results or the prescription writing features. Several units have been experiencing physician resistance to adding more EHR functions. The EHR system has a messaging component that works like a closed e-mail system. Messages can be sent, received, and stored by EHR authenticated users. Pertinent patient care messages are automatically stored in the correct patient record. In addition, the EHR messaging system works seamlessly with the prescription writing module, which includes patient safety checks such as allergy checks and drug interactions. The challenge for Goodwill Health Care Clinic is to implement the messaging feature and prescription writing component (where it is not currently being used) of their current EHR in the call center and the clinical units, replacing the existing Lotus Notes system and improving the quality of the documentation, not only of medication refills but of all patient-related calls. The long-term goal is to add a patient portal feature where patients can schedule appointments, send messages to their providers, and refill prescriptions electronically. Discussion Questions 1. Outline the steps that you would take to ensure a successful conversion from the existing call center system to the new EHR compatible system. Defend your response. 2. Who should be involved in the conversion planning and implementation? Discuss the roles of the people on your list and your reasons for selecting them. 3. What are some strategies that you would employ to minimize physicians' and other users' resistance to the conversion? 4. Do you think that making sure all units are running the same EHR functions is a necessary precursor to the conversion to the messaging and prescription writing components? What information would be helpful in making this determination? 5. How might the implementation of the patient portal feature address some of the current issues? What workflow considerations will need to be made? CASE 10: CONCERNS AND WORKAROUNDS WITH A CLINICAL DOCUMENTATION SYSTEM Major themes: system implementation; project management Background Information Garrison Children's Hospital is a 225-bed hospital. Its 77-bed neonatal intensive care unit (NICU) provides care to the most fragile patients, premature and critically ill neonates. The 28-bed pediatric intensive care unit (PICU) cares for critically ill children from birth to eighteen years of age. Patients in this unit include those with life-threatening conditions that are acquired (trauma, child abuse, burns, surgical complications, and so forth) or congenital (congenital heart defects, craniofacial malformations, genetic disorders, inborn errors of metabolism, and so forth). Garrison is part of Premier Health Care, an academic medical center complex located in the Southeast. Premier Health Care also includes an adult hospital, a psychiatric hospital, and a full spectrum of adult and pediatric outpatient clinics. Within the past six months or so, Premier has implemented an electronic clinical documentation system in its adult hospital. More recently the same clinical documentation system has been implemented at Garrison in both pediatric medical and surgery units and intensive care units. Electronic scheduling is to be implemented next. The adult hospital drives the decisions for the pediatric hospital, a circumstance that led to the adult hospital's CPOE vendor being chosen as the documentation vendor for both hospitals. A CPOE system was implemented at Garrison Children's Hospital several years prior to implementation of the electronic clinical documentation system, which began in 2010. Information Systems Challenge A pressing challenge facing Garrison Children's Hospital is that nurses are very concerned and dissatisfied with the new clinical documentation system. They have voiced concerns formally to several nurse managers, and one nurse went directly to the chief nursing officer (CNO) stating that the \"flow sheets\" on the new system are grossly inadequate and she fears using them could lead to patient safety issues. Lunchroom conversations among nurses tend to center on their having no clear understanding of why the organization is automating clinical documentation or what it hopes to achieve. Nurses in the NICU and PICU seem to be most vocal about their concerns. They claim there is inconsistency in what is being documented and lack of standardization of content. The computer workstations are located outside the patients' rooms, so nurses generally document their notes on paper and then enter the data at the end of the shift or when they have time. The system support team, consisting of nurses as well as technology specialists, began the workflow analysis, system installation, staff training, and golive first with a small number of units in both the adult hospital and the children's hospital, beginning in January 2010. The NICU and PICU did not implement the system until May and June 2010. System support personnel moved rapidly through each unit, working to train and to manage questions. The timeline for each unit implementation was based on the number of beds in the unit and the number of staff to be trained. No consideration was given to staff members' prior experience with computers and keyboarding skills or to complexity of documentation and existing work processes. Although there are similarities between the adult and pediatric settings, there are also many differences in terms of unit design, computer resources (hardware), level of computer literacy, information documented, and work processes, not to mention patient populations. Little time was spent evaluating or planning for these differences and completing a thorough workflow analysis. After the initial units went live, less and less time was spent on training and address- ing unit-specific needs, due to the demands placed upon training staff to stay on the timeline in preparation for the next system implementation involving electronic scheduling. The clinical documentation system was implemented to the great consternation and dissatisfaction of the end users (physicians, nurses, social workers, and so forth) at Garrison, yet the Premier clinicians are happy with it. Many Garrison physicians and nurses initially refused to use the system, stating it was \"unsafe,\" \"added to workload,\" and was not intuitive. A decision to stop using the system and return to the paper documentation process was not then and is not now an option. Physician \"champions\" were encouraged to work with those who were recalcitrant and nursing staff were encouraged to \"stick it out,\" in hopes that system use would \"get easier.\" As a result, with their concerns and complaints essentially forced underground, Garrison clinical staff developed workarounds, morale was negatively affected, and the expectation that everyone would eventually \"get it\" and adapt has not become a reality. Instead, staff are writing on a self-created paper system and then translating those notes to the computer system; physicians are unable to retrieve important, timely patient information; and the time team members spend trying to retrieve pertinent patient information has increased. There have been clear instances where patient safety has been affected due to the problems with the appropriate use of this system. Discussion Questions 1. What is the major problem in this case? What factors seem to have contributed to the current situation? 2. The nurses at Garrison argue that pediatric hospitals and intensive care units, in particular, are different from adult hospitals and that these differences should be clearly addressed in the implementation of a new clinical documentation system. Do you agree with this argument? Why or why not? Give examples from the literature to support your views. 3. How might the workflow issues and concerns mentioned in this case have been detected earlier? 4. Assume you are part of the leadership team at Garrison. How would you assess the current situation? What would you do first? Next? Explain the steps you would take and why you feel your approach is necessary. 5. What lessons can be learned from this case and applied to other settings? CASE 11: STRATEGIES FOR IMPLEMENTING CPOE Major themes: system implementation; project management Background Health Matters is a newly formed nonprofit health system comprising two community hospitals (Cooper Memorial Hospital and Ashley Valley Hospital), nine ambulatory care clinics, and three imaging centers. Since its inception two years ago, the information services department has merged and consolidated all computer systems under one umbrella. Each of the facilities within the health system is connected electronically with the others through a fiberoptic network. The organizational structure of the two hospitals is such that each has its own executive leadership team and board. Seven years ago, the leadership team at Cooper Memorial Hospital made the strategic decision to choose Meditech as the vendor of choice for its clinical and financial applications. The philosophy of the leadership team was to solicit a single vendor solution so that the hospital could minimize the number of disparate systems and interfaces. Since then, Meditech has been deployed throughout the health system and applications have been kept current with the latest releases. Most nursing and clinical ancillary documentation is electronic, as is the medication administration record. Health Matters does have several ancillary systems that interface with Meditech; these include a picture archiving and communication system (PACS), a fully automated laboratory system, an emergency department tracking board, and an electronic bed board system. The leadership team at Ashley Valley Hospital chose to select non-Meditech products, because at the time Meditech did not offer these applications or its products were considered inadequate by clinicians. However, the current sentiment among the leadership team is to continue to go with one predominant vendor, in this case, Meditech, for any upgrades, new functionality, or new products. The information system (IS) group at Health Matters consists of a director of information systems (who reports to the chief financial officer) and fifteen staff members. The IS staff are highly skilled in networking and computer operations but have only moderate skill as program analysts and project managers. The CEO, Steve Forthright, plans to hire a chief information officer (CIO) to provide senior-level leadership in developing and implementing a strategic IS plan that is congruent with the strategic goals of Health Matters. Currently, the senior leadership team at Health Matters has identified the following as the organization's top three IS challenges. The current director of information systems has been somewhat involved in discussions related to the establishment of these priorities. To implement successfully computerized provider order entry (CPOE) To increase the variety and availability of computing devices (workstations or handheld devices) at each nursing station To implement successfully medication administration using bar-coding technology Information Systems Challenge The most pressing IS challenge is to move forward with the implementation of CPOE. The decision has already been made to implement the Meditech CPOE application. Several internal and external driving forces are at play. Internally, the physician leaders believe that CPOE will further reduce medication errors and promote patient safety. The board has established patient safety as a strategic goal for the organization. Externally, groups such as Leapfrog and the Pacific Business Group on Health have strongly encouraged CPOE implementation. The CEO Steve Forthright has concerns, however, because Health Matters does not yet have a CIO on board and he feels the CIO should play a pivotal role. Much of Steve's concern stems from his experience with CPOE implementation at another institution, with a different vendor and product. Steve had organized a project implementation committee, established an appropriate governance structure, and the senior leadership team thought it had \"covered the bases.\" However, according to Steve, \"The surgeons embraced the new CPOE system, largely because they felt the postoperative order sets were easy to use, but the internists and hospitalists rebelled. The CPOE project stalled and the system was never fully implemented.\" Steve is not the only person reeling from a failed implementation. The clinical information committee at Health Matters is chaired by Mary White, who was involved in a failed CPOE rollout at another hospital several years ago. She was a strong supporter of the system at the time, but now speaks of the risks and challenges associated with getting physician buy-in and support throughout the health system. Members of the medical staff at Cooper Memorial Hospital have access to laboratory and radiology results electronically. They have access through workstations in the hospital; most physicians also access clinical results remotely through smart phones. An estimated 35 percent of the physicians take full advantage of the system's capabilities. Almost all active physicians use the PACS to view images, and most use a computer to look up lab values. Fewer than half of the physicians use electronic signatures to sign transcribed reports. Discussion Questions 1. Assume you are part of a team charged with leading the implementation of CPOE within Health Matters. How would you approach the task? What would you do first? Next? Who should be involved in the team? Lead the team? 2. The CIO hasn't been hired yet. Do you see that as a problem? Why or why not? What role, if any, might the CIO have in the CPOE implementation project? 3. To what extent does the fact that Health Matters is a relatively new health system simplify or complicate the CPOE implementation project? How do other health systems typically implement CPOE or other clinical information system projects of this magnitude? 4. How might you solicit the wisdom and expertise of others who may have undergone CPOE projects like this one? Or who have used Meditech's CPOE application? How might Steve Forthright's and Mary White's prior experiences with partially and fully failed implementations affect their views in this case? 5. Develop a high-level implementation plan of key tasks and activities that will need to be done. How will you estimate the time frame? The resources needed? What role does the vendor have in establishing this plan? CASE 12: IMPLEMENTING A SYNDROMIC SURVEILLANCE SYSTEM Major themes: IT strategy; system implementation Background Information Syndromic surveillance systems collect and analyze prediagnostic and non-clinical disease indicators, drawing on preexisting electronic data that can be found in systems such as electronic health records, school absenteeism records, and pharmacy systems. These surveillance systems are intended to identify specific symptoms within a population that may indicate a public health event or emergency. For example, the data being collected by a surveillance system might reveal a sharp increase in diarrhea in a community and that could signal an outbreak of an infectious disease. The infectious disease epidemiology section of a state's public health agency has been given the task of implementing the Early Aberration Reporting System of the Centers for Disease Control and Prevention. The agency views this system as significantly improving its ability to monitor and respond to potentially problematic bioterrorism, food poisoning, and infectious disease outbreaks. The implementation of the system is also seen as a vehicle for improving collaboration between the agency, health care providers, information technology vendors, researchers, and the business community. Information Systems Challenge The agency and its infectious disease epidemiology section face several major challenges. First, the necessary data must be collected largely from hospitals and in particular emergency rooms. Developing and supporting necessary interfaces to the applications in a large number of hospitals is very challenging. These hospitals have different application vendors, diverse data standards, and uneven willingness to divert IT staff and budget to the implementation of these interfaces. To help address this challenge, the section will acquire a commercial package or build the needed software to ease the integration challenge. In addition, the section will provide each hospital with information it can use to assess its own mix of patients and their presenting problems. The agency is also contemplating the development of regulations that would require the hospitals to report the necessary data. Second, the system must be designed so that patient privacy is protected and the system is secure. Third, the implementation and support of the system will be funded initially through federal grants. The agency will need to develop strategies for ensuring the financial sustainability of the application and related analysis capabilities should federal funding end. Fourth, the agency needs to ensure that the section has the staff and tools necessary to appropriately analyze the data. Distinguishing true problems from the \"noise\" of a normal increase in colds during the winter, for example, can be very difficult. The agency could damage the public's confidence in the system if it overreacts or underreacts to the data it collects. Discussion Questions 1. If you were the head of the agency's epidemiology section, how would you address the four challenges described here? 2. Which of the challenges is the most important to address? Why? 3. If you were a hospital CEO being asked to redirect IT resources for this project, what would you want in return from the agency to ensure that this system provided value to your organization and clinicians? 4. A strong privacy advocacy group has expressed alarm about the potential problems that the system could create. How would you respond to those concerns? CASE 13: THE ADMITTING SYSTEM CRASHES Major theme: disaster recovery Background Information Jones Regional Medical Center is a large academic health center. With 900 beds, Jones had 47,000 admissions in 2010. Jones frequently has occupancy in excess of 100 percent, requiring diversion of ambulances. In addition, Jones had 1,300,000 ambulatory and emergency room visits in 2007. Jones is internationally renowned for its research and teaching programs. The IT staff at Jones are highly regarded. They support over 300 applications and 12,000 workstations. The admitting system at Jones is provided by the vendor Technology Med (TechMed). The TechMed system supports the master patient index; registration; inpatient charge and payment entry; medical records abstracting and coding; hospital billing and patient accounting; reporting; and admission, discharge, and transfer capabilities. The TechMed system was implemented in 1998 and uses now obsolete technology, including a rudimentary database management system. The organization is concerned about the fragility of the application and has begun plans to replace the TechMed system two years from now. Information Systems Challenge On December 20, the link between the main data center (where the TechMed servers were housed) and the disaster recovery center was taken down to conduct performance testing. On December 21, power was lost to the disaster recovery center, but emergency power was instantly put in place. However, as a precaution, a backup of the TechMed database was performed. During the afternoon of December 21, the TechMed system became sluggish and then unresponsive. Database corruption was discovered. The backup performed earlier in the day was also corrupt. The link to the disaster recovery data center had not been restored following the performance testing. Because there was no viable backup copy of the database, the Jones IT and hospital staff began the arduous process of a full database recovery from journaled transactions. This process was completed the evening of December 22. The loss of the TechMed system for over thirty-six hours and the failure during that time of registration transactions to update patient care and ancillary department systems resulted in a wide variety of operational problems. The patient census had to be maintained manually. Reports of results were delayed. Paper orders were needed for patients who were admitted on December 21 and 22. Charge collection lagged. Once the TechMed system was restored, additional hospital staff were brought in to enter, into multiple systems, the data that had been manually captured during the outage. By December 25, normal hospital operations were restored. No patient care incidents are believed to have resulted. Discussion Questions 1. If you were the CIO of Jones Regional Medical Center during this system failure, what steps would you take during the outage? What steps would you take after the outage to reduce the likelihood of a reoccurrence of this problem? 2. The root cause analysis of the outage showed that process, technology, and staffing factors all contributed to the problem. What are some of the likely factors? Which of these factors do you believe are likely to have been the most important? 3. If you were a member of the audit committee of the Jones board of trustees, what questions would you ask the CIO? 4. What issues and problems should a disaster recovery plan prepare for? How does an organization determine how much to spend to reduce the occurrence and severity of such episodes? CASE 14: BREACHING THE SECURITY OF AN INTERNET PATIENT PORTAL Major theme: IT security Background Information Kaiser Permanente is an integrated health delivery system that serves over eight million members in nine states and the District of Columbia. 1 In the late 1990s, Kaiser Permanente introduced an Internet patient portal, Kaiser Permanente Online (also known as KP Online). Members can use KP Online to request appointments, request prescription refills, obtain health care service information, seek clinical advice, and participate in patient forums. Information Systems Challenge In August 2000, there was a serious breach in the security of the KP Online pharmacy refill application. Programmers wrote a flawed script that actually concatenated over eight hundred individual e-mail messages containing individually identifiable patient information, instead of separating them as intended. As a result, nineteen members received e-mail messages with private information about multiple other members. Kaiser became aware of the problem when two members notified the organization that they had received the concatenated e-mail messages. Kaiser leadership considered this incident a significant breach of confidentiality and security. The organization immediately took steps to investigate and to offer apologies to those affected. On the same day the first member notified Kaiser about receiving the problem e-mail, a crisis team was formed. The crisis team began a root cause analysis and a mitigation assessment process. Three days later Kaiser began notifying its members and issued a press release. The investigation of the cause of the breach uncovered issues at the technical, individual, group, and organizational levels. At the technical level, Kaiser was using new web-based tools, applications, and processes. The pharmacy module had been evaluated in a test environment that was not equivalent to the production environment. At the individual level, two programmers, one from the e-mail group and one from the development group, working together for the first time in a new environment and working under intense pressure to quickly fix a serious problem, failed to adequately test code they produced as a patch for the pharmacy application. Three groups within Kaiser had responsibilities for KP Online