Posted: August 3rd, 2022

Adopting Health Information Systems

Understanding health care information systems planning and implementation is an important skill for health care leaders. Technology is advancing and the adoption of information systems in health care has progressed from being just a cool tool to a must have in terms of quality, access, profitability, and competitiveness. It is inevitable that managers and/or leaders will be faced with technology changes and/or upgrades, making the need to understand the basics of health care information system development and the standards required fundamental. Many organizations are opting out of acquiring a new health information system due to the high cost. Meanwhile, other health care organizations face resistance from their employees and other stakeholders when there is new system implementation.

Evaluate at least three of the barriers faced by health care leaders in adopting health information systems and identify how they can be prevented.

AHRQ Health IT. (2014, May 15).

Health IT success: Building a foundation for health information exchange to improve poison control (Links to an external site.)

[Video file]. Retrieved from https://youtu.be/lH_i5qRflPM

  • This video provides information about success stories in health information technology and will assist you in your Adopting

AHRQ Health IT. (2013, March 22).

Health IT success: Electronic standing orders empower staff and improve care (Links to an external site.)

[Video file]. Retrieved from https://youtu.be/MEBPLcIwRoc

The enactment of the Affordable Care Act (ACA) brought about sweeping legislation intended to
reduce the numbers of uninsured and make health care accessible to all Americans. It also
ushered in an era in which changing reimbursement and care delivery models are driving
providers from the current fragmented system focused on volume-based services to an
outcomes orientation. As a result, the health care system now taking shape is one in which
value-based payment models financially reward patient-centered, coordinated, accountable
care.
Against this backdrop, providers’ increasing use of evidence-based medicine and growing
capabilities in managing volumes of clinical evidence through sophisticated health IT systems
will mean that treatments can be tailored for the individual and interventions can be made earlier
to keep patients well. Furthermore, patient engagement is fast becoming a critical component in
the care process, particularly in the area of population health management (PHM).
Health care providers’ interest in improving population health appears to be increasing because
of the sudden ubiquity of the phrase, because many are participating in accountable care
organizations (ACOs), and because even hospitals not participating in an ACO increasingly
have incentives to reduce their number of potentially unavoidable admissions, readmissions,
and emergency department visits (Casalino, Erb, Joshi, & Shortell, 2015).
In this chapter we’ll not only seek a common understanding of PHM but also explore how the
advent of shared accountability financial arrangements between providers and purchasers of
care has created significant focus on PHM. We’ll also review the core processes associated
with accountable care and examine the strategic IT investments and data management
capabilities required to support population health management and enable a successful
transition from volume-based to value-based care.
PHM: Key to Success
Although the ACO model is still new and evolving, approximately 750 ACOs are in operation
today, covering some 23.5 million lives under Medicare, Medicaid, and private insurers.
Although not all ACOs have demonstrated success in delivering better health outcomes at a
lower cost, many have achieved promising results (Houston & McGinnis, 2016). As such,
significant ACO growth is expected. In fact, it is predicted that upward of 105 million people will
be covered by an ACO by 2020 (Leavitt Partners, 2015).
Similarly, although the industry’s move to value-based payment is also in its early stages,
value-based contracts are expected to substantially increase throughout the next decade. CMS
has a stated goal that 50 percent of Medicare payments will be tied to alternative payment
models by the end of 2018 (US DHHS, 2015). In fact, the projected impact of MACRA, which
we discussed in Chapter One, on the adoption of value-based payment models is expected to
rival the impact of Meaningful Use on adoption of EHRs. In addition, the substantial payment
reform activity at the federal level is paralleled by private insurers’ efforts to support value-based
payment and new models of care. For example, Aetna expects that 75 percent of its contracts
will be value-based by 2020 (Jaspen, 2015).

These trends will accelerate the demand for services and technology that enable health
systems and other organizations (health plans, Medicaid, community-based organizations,
employers, and so forth) to jointly manage the health and care of populations—either as an ACO
or in an ACO-like fashion. Although diverse, these organizations will all have a common need to
improve operational efficiency, drive better patient outcomes while reducing the overall cost of
care, and effectively engage consumers in managing their health and care.
Although the new reimbursement system is still taking shape, it’s clear that population health
management will become a required core competency for provider organizations in a post
fee-for-service payment environment (Institute for Health Technology Transformation, 2012).
Understanding Population Health Management
Population health as a concept first appeared in 2003 when David Kindig and Greg Stoddart
(2003) defined it as “the health outcomes of a group of individuals, including the distribution of
such outcomes within the group” (p. 380).
It is important to note that medical care is only one of many factors that affect those outcomes.
Other factors include public health interventions; aspects of the social environment (income,
education, employment, social support, and culture); the physical environment (urban design,
clean air and water); genetics; and individual behavior (Institute for Health Technology
Transformation, 2012). “Improving the health of populations” was later identified as one element
in the Institute for Healthcare Improvement’s triple aim for improving the US health care system,
along with improving the individual experience of care and reducing the per capita cost of care
(Berwick, Nolan & Whittington, 2008, p. 759).
Today, population health management comprises the proactive application of strategies and
interventions to defined groups of individuals (e.g., diabetics, cancer patients with tumor
regrowth, the elderly with multiple comorbidities) to improve the health of individuals within the
group at the lowest cost. PHM interventions are designed to maintain and improve people’s
health across the full continuum of care—from low-risk, healthy individuals to high-risk
individuals with one or more chronic conditions (Felt-Lisk & Higgins, 2011). PHM also seeks to
minimize the need for expensive encounters with the health care system, such as emergency
department visits, hospitalizations, imaging tests, and procedures. This not only lowers costs
but also redefines health care as an activity that encompasses far more than sick care,
because it systematically addresses the preventative and chronic care needs of every
patient—not just high-risk patients who generate the majority of health care costs (Institute for
Health Technology Transformation, 2012).
Although population health can also mean the health of the entire population in a geographic
area, the population health efforts most health systems and ACOs are undertaking are aimed at
providing better preventive and medical care for the “population” of patients “attributed” to their
organizations by Medicare, Medicaid, or private health insurers (Casalino et al., 2015).
New Care Delivery and Payment Models: The Link to PHM

As we know, historically, there has been a lack of accountability for the total care of patients, the
outcomes of their treatment, and the efficiency with which health resources are used. The fact
that health care services are paid primarily on a fee-for-service basis has contributed to the
fragmentation and lack of accountability. Fee-for-service emphasizes the provision of health
services by individual hospitals or providers rather than care that is coordinated across
providers to address the patient’s needs. Providers are rewarded for volume and for conducting
procedures that are often more complex, when simpler, lower-cost, better methods may be
more appropriate (Guterman & Drake, 2010).
Value-based care is emerging as a solution to address rising health care costs, clinical
inefficiency and duplication of services, and to make it easier for people to get the appropriate
care they need. As the federal government continues to test and implement several new
payment models designed to achieve optimal health outcomes at a sustainable cost,
commercial insurers are also partnering with health care providers in various arrangements that
similarly seek to reward value rather than volume of services.
As discussed in Chapter One, two popular models of delivery system reform are the
patient-centered medical home (PCMH) and the ACO. The PCMH emphasizes the central role
of primary care and care coordination, with the vision that every person should have the
opportunity to easily access high-quality primary care in a place that is familiar and
knowledgeable about his or her health care needs and choices. The ACO emphasizes the
urgent need to think beyond patients to populations, providing a vision for increased
accountability for performance and spending across the health care system (Patient-Centered
Primary Care Collaborative, 2011). Both models rely on health care organizations and
physicians providing coordinated and integrated care in an evidence-based, cost-effective way.
This, of course, has significant implications for an organization’s ability to manage information
effectively.
In conjunction with new models of care are new or modified forms of payment for health care
services, which are being piloted in various communities around the nation. These include
bundled payments, pay for performance, shared savings programs, capitation or global
payment, and episode-of-care payments.
Bundled payments may take different forms such as making a single payment for hospital and
physician services instead of separate payments, bundling payments for inpatient and
post-acute care, or paying based on diagnosis instead of treatment. Bundled payments are often
applied to surgical procedures such as hip replacements. Pay-for-performance (P4P) programs
reward hospitals, physician practices, and other providers with financial and nonfinancial
incentives based on performance on select measures. These performance measures can
cover various aspects of health care delivery: clinical quality and safety, efficiency, patient
experience, and health information technology adoption. Most P4P programs, however, are still
a bonus to a fee-for-service model (Miller, 2011). An integral part of the ACA, shared savings
programs are intended to reward providers by paying them a bonus that is explicitly connected
to the amount by which they reduce the total cost of care compared to expected levels.

Capitation or global payment places full risk with the provider organization; the provider is
responsible for the costs of all care that a patient receives. An episode-of-care payment system
would pay the provider organization a single payment for all of the services associated with a
hospitalization or other episode of acute care, such as a heart attack, including inpatient and
post-acute care (Miller, 2011).
The revised payments associated with these programs signal the federal government’s most
all-encompassing effort thus far to distribute risk and hold providers financially accountable for
the quality of care they deliver. Although an in-depth discussion of these and other proposed
payment reform systems is beyond the scope of this book, the following resources can provide
a wealth of detailed information on health care payment reform initiatives:
Centers for Medicaid & Medicare Services (www.CMS.gov)
Healthcare Financial Management Association (www.hfma.org)
American College of Healthcare Executives (www.ache.org)
Progress to Date: PCMHs
Growing support for the PCMH has arisen across the vast majority of the US health care
delivery system to include commercial insurance plans, multiple employers, state Medicaid
programs, numerous federal agencies, the Department of Defense, hundreds of safety net
clinics, and thousands of small and large clinical practices nationwide (Grundy, Hacker,
Langner, Nielsen, & Zema, 2012). Private and public payer initiatives together have grown from
eighteen states in 2009 to forty-four states in 2013, and they now cover almost twenty-one
million patients. These heterogeneous initiatives overall are becoming larger, paying higher fees,
and engaging in more risk sharing with practices (NCQA, 2015).
Because the patient-centered medical home is foundational to ACOs—with ACOs often
described as the “medical neighborhood”—the PCMH is likely to gain even greater prominence
as ACOs continue to develop in the marketplace (Grundy et al., 2012). Moreover, a growing
body of scientific evidence shows that PCMHs are saving money by reducing hospital and
emergency department visits, mitigating health disparities, and improving patient outcomes.
Examples of specific outcomes achieved by various PCMHs include the following:
Lower Medicare spending
More effective care management and optimized use of health care services
Improved care management and preventative screenings for cardiovascular and diabetes
patients
Reduced socioeconomic disparities in cancer screening (NCQA, 2015)
Additionally, more than nine thousand primary care practices and forty-three thousand clinicians
(doctors and nurse practitioners) across the country have earned the PCMH designation from
the National Committee for Quality Assurance (NCQA), the nation’s largest credentialing
organization. The designation is earned by demonstrating achievement of goals related to
accessible, coordinated, and patient-centered care (Olivero, 2015).
Progress to Date: ACOs

In the value-based care world, ACOs are expected to play a leadership role in improving
population health—whether participating in contracts with Medicare, Medicaid, or managed care
organizations (MCOs) or health plans. These arrangements are often complex and may differ
widely, including elements such as governance requirements, payment structures, quality
metrics, reporting requirements, and data sharing (Houston & McGinnis, 2016).
Several different ACO models, including the Pioneer ACO program and the Medicare Shared
Savings Program (MSSP), are testing and evaluating various risk-sharing agreements. In
December 2011, CMS signed agreements with thirty-two organizations to participate in the
Pioneer ACO model, designed to show how particular ACO payment arrangements can best
improve care and generate savings for Medicare. As of May 1, 2016, there are nine Pioneer
ACOs participating in the model for a fifth and final performance year (CY2016). The MSSP is a
key component of the Medicare delivery system reform initiatives included in the Affordable
Care Act and is designed to facilitate coordination and cooperation among providers to improve
the quality of care for Medicare fee-for-service (FFS) beneficiaries and reduce unnecessary
costs. Eligible providers, hospitals, and suppliers may participate in the MSSP by creating or
participating in an ACO.
Although there has been considerable debate among policymakers as to the success of the
ACO model, some of these ACOs are already reporting positive results for improving patient
outcomes and controlling costs, as shown in Table 4.1 (Houston & McGinnis, 2016).
Table 4.1 Key attributes and broad results of current ACO models
Source: R. Houston and T. McGinnis. January 2016. “Accountable Care Organizations: Looking
Back and Moving Forward.” Center for Health Care Strategies. Used with permission.
Medicare
Attribute MSSP Pioneer ACO Commercial ACOs Medicaid ACOs
ACO prevalence 333 ACOs in 47 states 18 ACOs in 8 states 528 commercial
contracts 66 ACOs in 9 active state-based programs
Key model features Shared savings payment methodology
33 quality metrics Designed for large hospital systems
Shared savings system with higher risk and reward potential than MSSP
Same 33 quality metrics as MSSP Often independent contracts between ACOs and MCOs
Many feature narrow provider networks. Various approaches to payment including shared
savings and capitation
Various approaches to quality measurement
Results to date CMS has reported results for different cohorts of MSSP ACOs based on
start date, which have shown significant savings, but it is difficult to aggregate these results,
though only 26% of ACOs received shared savings payments
ACOs consistently improved on 27 of 33 quality metrics.
Increases in patient satisfaction relative to patients not enrolled in ACOs $304 million in
savings over three years
ACOS consistently improved on 28 of 33 quality metrics.

Increases in patient satisfaction relative to patients not enrolled in ACOs
Began with 32 participants; 14 have left program Not many publicly reported results available
across programs due to proprietary information and difficulty comparing results CO, MN, and
VT have collectively reported $129.9 million in savings.
ED visits in OR decreased by 22%.
ACO Challenges
Now with years of observation and learnings to draw from, several key challenges facing ACOs
have been identified, including difficulties working across organizational boundaries, building the
requisite infrastructure for effective data sharing, and truly engaging patients in the care process.
One of the more notable challenges currently being worked on is the alignment and
consolidation of myriad quality measures being used in public and private programs.
Effective quality measures are imperative to accountability in organized systems of care,
especially when performance affects the ability of the provider to share in savings or determines
whether a provider avoids penalties or receives bonus payments (Bipartisan Policy Center,
2015). However, the notion of “measurement fatigue” and the increasing administrative burden it
places on providers is a legitimate concern (Buelt, Nichols, Nielsen, & Patel, 2016). Another
challenge with quality metrics is that although they tend to capture performance on specific
outcomes, such as lower avoidable readmissions, or processes, such as screening for
depression, they may not accurately measure the overall health of the patient, making it difficult
to assess the true impact and efficacy of ACO arrangements (Houston & McGinnis, 2016).
Implications for Health Care Leaders
Through the combination of changing health care business models and payment mechanisms,
we are witnessing transformational change in the nature of health care delivery. It is evolving
from one of reactive care with fragmented accountability and a dependence on full beds to a
model of health management, care that extends over time and place and rewards for efficiency
and quality. This transformation poses potent challenges for providers and has enormous
implications for today’s health care leaders, particularly by placing greater emphasis on these
issues:
Keeping patients well and managing and preventing disease
Establishing more efficient organization and utilization of care teams and venues of care
Creating a care culture that is comfortable with change and ongoing automation
Engaging patients in managing their care and overall health
Ensuring the most cost-effective care is provided and that clinical processes are streamlined
and follow the best evidence
More specifically, accountable care and the move to population health management will require
industry perspectives and health care delivery practices to shift from
Care providers working independently to collaborative teams of providers
Treating individuals when they get sick to keeping groups of people healthy
Emphasizing volumes to emphasizing outcomes
Maximizing the use of resources and assets to applying appropriate levels of care at the right
place

Offering care at centralized facilities to providing care at sites convenient to patients
Treating all patients the same to customizing health care for each patient
Avoiding the sickest chronically ill patients to providing special chronic care services
Being responsible for those who seek services to being responsible for the needs of the
community
Putting forth best efforts to becoming high-reliability organizations (Glaser, 2012b)
Additionally, accountability will bring new performance and utilization risks to providers as the
focus shifts from optimizing business unit performance to optimizing network performance. At
the same time, instead of maximizing the profitability of care, organizations will increase the
volume of desired bundled episodes while controlling costs. At an operational level,
organizations must change their structure as well as workflows to implement PHM and adopt
new types of automation tools and reporting. This will require setting clear goals, the active
participation of leadership—including physician leaders, an assessment of technology
requirements, and an effective rollout strategy (Institute for Health Technology Transformation,
2012).
Health IT clearly plays a vital role in the success of new models of care and payment reform
and should be an integral part of the organization’s planning process. Whether participating in an
ACO or not, all health care organizations should be thinking about building a population health
management strategy and addressing related gaps in their information technology (IT)
capabilities. Minimally, this would include acquiring the capabilities and tools to do the following:
Know, characterize, and predict the health trajectory that will happen within a population.
Engage members, families, and care providers to take action.
Manage outcomes to improve health and care.
Accountable Care Core Processes
Accountable care frameworks are based on risk and reward, with providers and organizations
agreeing to share the financial risk for a population in return for the opportunity to access
rewards on meeting health care quality and cost goals. ACOs are responsible for tracking and
measuring specific quality metrics to indicate that patient outcomes are improving or
evidence-based processes are being used. Some, but not necessarily all, metrics may be tied
directly to the payment methodology, meaning that performance on these metrics will trigger
either a quality incentive (such as an increased percentage of shared savings) or a disincentive
(such as not receiving any shared savings) (Houston & McGinnis, 2016).
To accomplish the goals of PHM, a provider must deliver proactive preventive and chronic care
to its attributed patient population. As such, the care team must maintain regular contact with
patients and support their efforts to manage their own health. At the same time, care managers
must closely monitor high-risk patients to prevent them from deteriorating or developing
complications. The use of evidence-based protocols to diagnose and treat patients in a
consistent, cost-effective manner is also central to PHM efforts. In many respects, success in
population health management depends largely on a provider’s ability to manage several core
processes in an accountable care environment. We’ll review these core processes in the next
sections.
Identifying, Assessing, Stratifying, and Selecting Target Populations

To manage population health effectively, an organization must be able to track and monitor the
health of individual patients, while also stratifying its population into subgroups that require
particular services at specified intervals. ACOs typically stratify their patient population by
common care needs, conditions, and expenditure levels and then deploy tailored interventions
based on these characteristics (Houston & McGinnis, 2016). For example, a high-risk
pregnancy may require more frequent interventions (office visits, fetal heart monitoring, etc.)
than standard prenatal care warrants.
Stratification also involves the ability to identify a patient or cohort at risk for a negative health
event (e.g., myocardial infarction, stroke, mental health crisis) or preventable health care
utilization (e.g., surgical procedure or hospitalization) (Gibson, Hunt, Knudson, Powell,
Whittington, & Wozney, 2015). The Agency for Healthcare Research and Quality (AHRQ)
describes another method of stratification as being able to identify subpopulations of patients
who might benefit from additional services. Examples of these groups include patients needing
reminders for preventive care or tests, patients overdue for care or not meeting management
goals, patients who have failed to receive follow-up after being sent reminders, and patients who
might benefit from discussion of risk reduction (Institute for Health Technology Transformation,
2012).
Although there are numerous ways to identify and segment patients, having the ability to identify
risk, alert appropriate stakeholders, and intervene in the care process at the right time is a key
component of population health management.
Providing High-Quality Care and Care Management Interventions across the Continuum
A key tenet of accountable care is to ensure that the health and wellness of a population is
managed, the most cost-effective care is provided, clinical processes are streamlined and
follow the best evidence, the necessary reporting is in place, and payments and reimbursement
are appropriate. Although this is an obvious goal for all providers, ACOs must facilitate
cross-continuum medical management of patients for active episodes and acute disease
processes or for any patient outside of the defined goals of a target population. An ACO must
demonstrate, in a variety of ways, its commitment to being patient centered and to engaging
patients in their care and overall health.
To effectively care for populations, care management involves the patient-centered
management and coordination of care events and activities in multiple care settings by one or
more providers (e.g., fine-tuning coordination among care team members, identifying care gaps
and situations requiring additional interventions, as well as managing care transitions). For
example, research indicates that poorly executed transitions of care between different locations
(e.g., from hospital to primary care) are associated with increased risks of adverse medication
events, hospital readmissions, and higher health care costs. Determining which transitions
present the greatest risks and targeting care management services to patients undergoing those
transitions should conserve resources and lead to better cost and quality outcomes (AHRQ,
2015).

Additionally, lack of follow-up care after hospital discharge can result in complications,
worsening of patients’ conditions, and a higher chance of readmission (Nielsen & Shaljian,
2013). Therefore, another example of a care management intervention is ensuring that hospitals
notify primary care practices when patients are discharged and that primary care teams follow
up with patients shortly thereafter.
The overall aim of care management is to manage the most complex patients through the health
care system, as well as managing the overall health of a select population (e.g., diabetics and
elderly), taking their preferences and overall situation into consideration. Care management
ensures that all patients from the lowest risk level to high-risk “super users” receive care at the
right time, in the right place, and in a manner best suited for the patient. This requires proactive
care, communication, education, and outreach.
Managing Contracts and Financial Performance
Under new payment models, proactively understanding patient coverage and financial
responsibility will be more critical than ever. Financial teams must have a solid handle on
estimating reimbursement and associated payment distributions, carrying out predictive
modeling for reimbursement contracts, measuring performance against contracts and predicting
profitability, as well as integrating with other key processes to share information.
For example, profit maximization under a shared savings-risk model requires a shift away from
revenue-focused strategies to cost-containment strategies (Houston & McGinnis, 2016). To
effectively manage costs, health care executives will need tools and data to support different
types of financial modeling, such as modeling the implications of moving patient care to settings
other than the hospital or physician’s office. ACOs will also need actuarial cost and utilization
predictors to effectively manage the care of a defined population.
These changes represent a significant cultural shift for provider organizations that must be
prepared to handle a complex mix of public and private sector payment mechanisms.
Measuring, Predicting, and Improving Performance
Data analytics is an integral part of PHM. ACOs typically measure quality and outcomes data
against national guidelines or peer groups, and they seek to demonstrate longitudinal
improvements. They might also measure costs, utilization, and patient experience on a
population-wide basis, and they may use these reports as the basis for quality reporting to
payers and other outside entities.
With payment so tightly linked to quality and outcomes, predicting, monitoring, and measuring
system performance in key areas becomes paramount in an accountable care environment.
Under value-based payment programs, there will be real ramifications for poor care and rewards
for improved care. In fact, even low-performing areas can qualify for high payments if they
demonstrate year-over-year improvement.

Therefore, providers must have the ability to forecast which patients are likely to become
high-risk so they can intervene before a patient’s condition worsens. They must also understand
in real time if they are complying with a certain set of measures and monitor their continual
performance. For example, ACOs will want to measure the effectiveness of care protocols,
such as exercise compliance, for a population of diabetic patients. Surgical services providers
will need to understand the costs and quality of proposed procedure bundles. Understanding
what works and what does not is key to ensuring reimbursements, controlling costs, and, most
important, providing the best care for patients (Glaser, 2012a).
Equally important is retrospective monitoring—finding out what didn’t happen and why. For
example, if a care provider failed to respond to an alert in a timely fashion or deviated from a
given standard of care process, they can use these data to determine if new care interventions
are necessary or if they need to alter an individual’s plan of care. Likewise, knowing that a
patient failed to keep an appointment or was unexpectedly seen in the emergency room will
enable the care team to engage patients in new ways to better manage chronic disease. With
providers facing penalties for readmission, it will be more important than ever to understand if it’s
the treatment that failed, the discharge plan that failed, or the patient who did not follow through
on the post-discharge plan (Chopra & Glaser, 2013).
Preparation and Automation Is Key
Overall, the accountable care movement demands that providers be more focused and
aggressive in managing their organization and their patients. Among other challenges, changes
in reimbursement will require providers to predict which patients will need extra care, more
intensively engage and manage high-risk patients, model the financial implications of delivering
sub-par care, assess the performance of core organizational processes such as transitions of
care, determine conformance to medical evidence, and report quality measures to purchasers
of care.
The long-term success of the transition to value-based payment models and PHM relies largely
on health care providers investing in the IT tools and infrastructure—as well as acquiring the
data management and analysis expertise—needed to automate and support these core
processes. In addition, as with any IT endeavor, expertise in change management and workflow
redesign is also a core requirement.
Even for providers that may not be participating in an ACO, building the organizational and IT
competencies to support accountable care is critical to staying competitive. Organizations that
fail to develop and demonstrate accountable care capabilities may not fulfill their obligations to
the community they serve—in fact, they may not survive.
Yet, organizations embracing the transformation from traditional fee-for-service to value-based
PHM are finding significant gaps in their IT capabilities (Gibson et al., 2015). In the following
section we examine the core IT building blocks and capabilities necessary to support
accountable care and the move to PHM.
Data, Analytics, and Health IT Capabilities and Tools

As more providers and health systems evolve into ACOs, they are becoming increasingly
aware of what it takes to manage care from a population health perspective. As we know, this
includes establishing new partner networks, targeting populations, aligning providers and
contracts, developing cross-continuum protocols for care management, and enabling efficient
data sharing.
It’s All about the Data
For a PHM program to be effective there is a critical need to focus on the data and information
that will increasingly power clinical decisions. This includes aggregating and normalizing clinical
data, claims data, administrative data, and self-reported patient data to create a holistic view of
the patients within a health care network. These data enable the network to identify populations
of patients whose conditions can be managed through evidence-based care plans that are
coordinated across care settings.
For example, the risk of progression from glucose intolerance to diabetes mellitus can be
influenced by diet and exercise. Individuals within this “rising risk” population are at different
stages of readiness to change and consequently at different stages of modifiable risk. Having
this insight enables providers to offer services at the appropriate level and time (AHRQ, 2015).
However, for many organizations, obtaining population health data can be difficult because it
must be collected and organized from many disparate sources (e.g., laboratory information
systems, EHRs, practice management systems, and home-monitoring devices). Data types
that require aggregation and normalization include labs, radiology reports, medications, vital
signs, diagnoses, demographic information, and more. Returning to our diabetes example,
although a diabetic’s blood glucose result is discrete data that can be found in an EHR, the
results of the same patient’s foot or eye exam may be found only in text format within a practice
management system.
Data management for PHM purposes is also challenging because there’s no guarantee the
various IT systems talk to each other, and each provider and health plan may have a different
system for patient identification and provider attribution. An important first step in connecting
patient data across different care settings is to establish master patient indices (Glaser &
Salzberg, 2011). Patient indices can serve as a crosswalk among the different medical record
numbers and identifiers that may be used by various provider organizations to correctly identify
patients. In addition, a record locator service may be used to determine which patient records
exist for a member and where the source data is located. The key concept behind having a
record locator service is that a patient’s health information is housed on computers at the
various sites of his or her care and this information is queried and aggregated from these sites
at the time of a request.
Beyond the EHR: Core PHM Solution Components
Although a certified EHR certainly provides the necessary foundation for effectively responding
to new payment models, population health requires a range of IT applications, PHM solution
components, and analytical capabilities. In fact, early adopters of PHM solutions are already
seeing the need for next-generation capabilities to support the following transitions:

From management of the sickest patients to management of all patients
Static risk categorization to risk categorization that follows a patient’s evolving risk
Focus on a single disease or condition based on simple data values and events to a focus on
multi-disease or condition using evidence-based care plans
“List” generation with significant manual work for care managers to significant process
automation
Loosely connected care “actors” to a care team that includes the patient and family
Retrospective analysis to concurrent analysis (Glaser, 2016a)
As organizations look to enhance their population health management strategies, they should
make investments that enable the IT platform to do the following:
Collect data from multiple, disparate sources in near–real time, including any EHR, devices
used in the home and at work, and other data sources, such as pharmacy benefit managers or
insurance claims.
Support organizations in not only aggregating but also transforming and reconciling data to
establish a longitudinal record for each individual within a population.
Identify and stratify populations to pinpoint gaps in care, enabling providers to act on information
and match the right care programs to the right individuals (Glaser, 2016a).
In addition to having an EHR that spans the continuum of care, providers pursuing PHM might
invest in a PHM platform that sits above the EHR and other sources of data and must be EHR
agnostic. In general, the following key technologies will enable the core accountable care
processes.
Revenue Cycle Systems and Contract Management Applications
One could argue that the revenue cycle system forms the foundation of a provider’s response to
accountable care and payment reform. As the reimbursement environment becomes more
complex, revenue cycle systems must evolve to support payments based on quality and
performance, requiring new capabilities such as these:
Aggregating charges to form bundles and episodes, with the aggregation logic enabling different
groupings for different payers
Managing the distribution of payment for a bundle to the physicians, hospitals, and non-acute
facilities that delivered the care
Streamlining transitions between disparate reimbursement methodologies and contracts when
billing and collecting
Providing tools for retrospective analysis of clinical and administrative data to identify areas for
improving the quality of care and reducing the cost of care delivered
These new capabilities must complement routine activities such as registering patients,
scheduling appointments, and administering patient billing.
Care Management Systems
Used by care managers and discussed previously, care management systems enable
proactive surveillance, automation, coordination, and facilitation of services for many different
subpopulations across the care continuum. Specific capabilities might include helping to
facilitate transitions of care more efficiently, use of automated campaigns (e-mail, text, phone) to

better manage high-risk patients, and supporting care teams in delivering evidence-based
interventions to reduce high-cost utilization.
According to time-motion studies published in the journal Population Health Management by
Prevea Health, automation of routine care management tasks enables care managers to
manage two to three times as many patients as they can with manual methods (Handmaker &
Hart, 2015).
Rules Engines and Workflow Engines
Processes that are efficient, predictable, and robust enable an organization to thrive in an
accountable care environment. Workflow and rules engines can monitor process performance,
alerting staff members to missed steps, sequence issues, or delays.
Workflow engines specialize in executing a business process, not just decisions made at a
discrete point in time. The technology can greatly assist in clinical decision making by not only
presenting clinicians with alerts and reminders, such as a rules engine, but also by encouraging
teamwork in clinical decisions, assisting with the time management and task allocation in
process delivery, stating changes in patient or operational conditions, and creating
behind-the-scenes automation of process steps.
In a value-based purchasing world where each core measure needs to be associated with
what’s happening today, performance improvement interventions must occur in real time—that
is, while the patient is still in the acute care cycle. Therefore, sophisticated IT tools such as
workflow and rules engines that push information to the front lines, guiding decisions at the point
of highest possible impact, will be required.
Data Warehouse, Analytics, and Business Intelligence
Analytics will facilitate proactive management of key performance metrics, because
accountable care creates a greater need to assess care quality and costs, examine variations in
practice, and compare outcomes.
An enterprise data warehouse will fuel a wide range of analytic needs and provide intelligence to
enable continual care process improvement initiatives. For example, it will be imperative that an
organization can compare a hypertensive patient’s total cost of care relative to its peers and
national benchmarks, and perhaps even more important, predict if those costs will significantly
increase because of comorbidities, complications, or gaps in care.
Applied to the data in registries or warehouses, predictive analytics tools can also help
caregivers identify patients who are likely to present in the ER or be readmitted so they can
tailor appropriate interventions and avoid penalties for excessive readmissions.
Although most providers lack experience with the tools and techniques associated with
advanced data analysis, the application of business intelligence (BI) in health care will become
the platform on which the organization not only monitors performance but also makes critical
decisions to uncover new revenue opportunities, reduce costs, reallocate resources, and

improve care quality and operational efficiency. Thus, enhancing an organization’s competency
in data analytics and BI will become essential for success in population health management.
Health Information Exchange (HIE)
Essential to successful implementation of new models of care and payment reform is the
exchange of clinical and administration information among different health care entities and
between providers and patients. Although there has been some success in the regional health
information exchange (HIE) movement, much of the focus now is on HIE capabilities at the
integrated delivery system or ACO level. This enables providers to obtain a composite clinical
picture of the patient regardless of where that patient was seen. By participating in an HIE or
sharing health information, a number of potential important benefits may be realized:
Serves as a building block for improved patient care, quality, and safety
Makes relevant health care information readily available when and where it is needed
Provides the means to reduce duplication of services that can lead to reduced health care costs
Enables automation of administrative tasks
Provides governance and management over the data exchange process
Facilitates achievement of meaningful use requirements (HIMSS, 2010)
The concept of HIE is not new. For nearly two decades organizations and collaborators have
tried to facilitate HIE, but unfortunately a number of HIE initiatives have failed to be sustainable
over the long term (Vest & Gamm, 2010). The HITECH Act placed renewed interest in the
success of HIE by providing incentive payments to eligible providers for Meaningful Use of
electronic health records, which includes having the ability to exchange information
electronically with others in order to have a comprehensive view of the patient’s health and care
(Rudin, Salzberg, Szolovitis, Volk, Simon, & Bates, 2011). However, despite investment at the
national, state, and local levels, the increase in HIE utilization remains modest.
In fact, a recent survey of organizations facilitating health information exchange found that 30
percent of hospitals and 10 percent of ambulatory practices now participate in one of the 119
operational health information exchange efforts across the United States (Adler-Milstein, Bates,
& Jha, 2013). Although this is substantial growth from prior surveys, the researchers also found
that 74 percent of HIE efforts report struggling to develop a sustainable business model. These
findings suggest that despite progress, there is a substantial risk that many current efforts to
promote health information exchange will fail when public funds supporting these initiatives are
depleted. Adding to the challenge, HIE efforts have struggled to engage payers, and only 40
percent of HIE efforts in the country have one or more payers providing financial support
(Adler-Milstein, Cross, & Lin, 2016).
Still, there is reason to remain optimistic, with more recent data showing that hospitals’ rates of
electronically exchanging laboratory results, radiology reports, clinical care summaries, or
medication lists with ambulatory care providers or hospitals outside their organization has
doubled since 2008 (see Figure 4.1). Moreover, this exchange has significantly increased
annually since 2011 (Henry, Patel, Pylypchuk, & Searcy, 2016).

Figure 4.1 Percent of nonfederal acute care hospitals that electronically exchanged laboratory
results, radiology reports, clinical care summaries, or medication lists with ambulatory care
providers or hospitals outside their organization: 2008–2015
Source: Henry, Patel, Pylypchuk, and Searcy (2016).
Although there is still significant progress to be made to improve the use of exchanged
information and to address barriers to interoperability, HIE is critically important to the success
of care transformation efforts nationwide. Thus, the industry must continue its efforts toward
achieving sustainable HIE approaches to ensure that the massive national investment in health
IT throughout the past decade delivers its intended return—higher-quality care, improved
outcomes, and lower cost.
Registries and Scorecards
Serving as a kind of central database for PHM, registries can be used for patient monitoring,
care gap assessment, point-of-care reminders, care management, and public health and quality
reporting, among other uses. By integrating clinical, financial, and operational data across
disparate sources into a single chronic condition and wellness registry solution, data can be
normalized and turned into meaningful, actionable information.
For example, registries and scorecards enable providers to identify, score, and predict risks of
individuals or populations to allow targeted interventions to be implemented. When applied to a
population, the registry can show, for example, how all of a particular provider’s patients with
type 2 diabetes are doing, which diabetic patients are out of control, or how well an entire
organization is treating patients with that condition (Nielsen & Shaljian, 2013).
Longitudinal Record and Care Plan
As we know, even if a provider is diligently capturing patient information in an EHR, the data are
valuable only in the world of collaborative, accountable care if the information can be integrated
with patient data from other sources and harmonized to produce a single, consolidated record at
the member level. The longitudinal record presents a complete picture of the patient’s medical
history in an organized, coherent view.
Serving as the sister solution to the longitudinal record, a longitudinal care plan provides a
consolidated, normalized view of indicators to be monitored, events due to happen, and actions
to be taken to ensure that a patient maintains and improves his or her level of health.
Patient Engagement Tools
Medical interventions that occur solely through office-based patient-provider interactions will no
longer provide the level of monitoring and scrutiny needed to manage the health of individuals
and populations. As such, providers must continue to harness the power of technology to
engage patients in their care via tools such as home-monitoring devices, patient portals, and
personal health records (PHRs), as well as through the use of social media, texting, and e-mail.
Portals and PHRs

Although patient portal use is still considered modest at best, given later-stage meaningful-use
requirements and the anticipated benefits of patient engagement in the value-based care world,
many providers are ramping up their portal efforts and seeing adoption rates well above 20
percent (Buckley, 2015). Another recent study predicts that PHR adoption will exceed 75
percent by 2020, an optimistic projection that outpaces the PHR goals set under the Meaningful
Use incentive program (Ford, Hesse, & Huerta, 2016). These consumer-centric technologies
are designed to help patients and consumers better manage their own health and care, securely
communicate with providers, pay bills, obtain test results, view doctors’ notes, refill
prescriptions, schedule appointments, and so on.
Perspective
The HIE Lessons
Despite the fact that the environment for building, creating, and developing an HIE organization
has never been better, the concerns about long-term sustainability and the impact and value of
exchanging health information persist. The National eHealth Collaborative (NeHC) conducted a
comprehensive study of twelve fully operationally HIEs across the nation to find out from their
leaders what factors have led to their success (NeHC, 2011). In-depth structured interviews
were conducted with senior executives representing the business, clinical, and technical areas
of each HIE. The key critical success factors these leaders identified in sustaining an HIE are
as follows:
Aligning stakeholders with HIE priorities in an intensive and ongoing effort. Create a shared
vision that all stakeholders can embrace and that serves as the cornerstone to success. Foster
an environment that is built on trust and that promotes learning and resolves differences when
they arise. Make ongoing and effective stakeholder engagement a priority.
Establishing and maintaining consistent brand identity and role as a trusted, neutral entity
dedicated to protecting the interests of participants. Data use and data integrity are two critical
elements. The culture, policies, and procedures regarding the use of data must ensure that no
entity will gain competitive advantage at the expense of others. Consent and security policies
must meet the requirements of various stakeholders and regions or states. The HIE
infrastructure must ensure that patient data are accurate, reliable, and trustworthy.
Ensuring alignment with vision in making strategic choices. Assess the stakeholders’ alignment
with the initiative and congruence with the vision before deciding to pursue them. Regardless of
how promising a source of funding may have initially appeared, some HIEs chose not to pursue
it because the funding source did not have the full support of all stakeholders.
Considering structural characteristics and dynamics of the HIE market. The geographic
location, composition of stakeholders, and resource capabilities are all factors to consider.
Understanding clinical workflow and managing change. The implementation of an HIE requires
that clinicians and administrative staff members understand the impact of HIE applications on
workflow and identify opportunities to improve efficiencies.
Different business models, governance structures, and strategies may be used to create value
for the HIE participants.
Source: NeHC (2011).

Some patient portals and PHRs are integrated into a provider’s existing website, and others are
extensions of the organization’s EHR system. For example, New York-Presbyterian (NYP)
Hospital’s award-winning patient portal, myNYP.org, was built to expand on its existing EHR.
Use of the portal led to a 42 percent increase of appointments scheduled using myNYP.org, and
it lowered the no-show rated from 20 percent to 12 percent over a period of six months after it
was made available in January 2012 (Glaser, 2013). Additional applications of the same
appointment-alert technology can provide customized patient education material and
personalized reminders to patients who fit a specific clinical profile, such as patients who
missed an immunization.
Social Media
Additionally, with one-third of consumers using online forums and social media sites such as
Facebook, Twitter, and YouTube for health-related matters (PwC, 2012), many providers are
actively engaged in using social media to communicate with patients and disseminate
information on everything from emergency department wait times to new clinical offerings and
research endeavors. They might also use social media channels to provide useful links to
self-management tools and invitations to chronic care management programs. In fact, nearly 95
percent of hospitals have a Facebook page and just over 50 percent have a Twitter account
(Griffis et al., 2014).
Automated Messaging
Similar to social media, the use of automated messaging tools (via text, e-mail, or phone) can
be equally beneficial in urging patients to schedule necessary appointments, fill their
prescriptions, and comply with discharge orders. For example, one study showed that diabetic
and hypertensive patients were two to three times more likely to attend a chronic care visit if
successfully contacted using automated provider communications (Nielsen & Shaljian, 2013).
Perspective
Top Tips for Portal Adoption
Given the modest adoption rates of PHRs and patient portals to date, research firm KLAS asked
providers what best practices for patient portal adoption they would pass along to other
providers trying to improve their rates. The following are their suggestions:
Educate patients.
“What contributes to adoption is educating our patients about the portal, helping them sign up,
and encouraging them to use it. But education is key. Patients have embraced the portal and
use it for much of our communication, bill pay, results review, and more.”
Educate patients—again and again.
“We ask patients on the phone whether they have signed up for the portal, and at their
appointments we check to see whether they have filled things out on the portal. Then the
medical assistants who greet the patients ask whether they have put their information on the
portal. We promote the portal five or six times. On their way out, the doctors tell the patients that
they are going to send their results to the portal.”
Educate staff members as if they were patients.

“The patients get inundated and get tired of hearing it, but it was the kickoff that got everybody in
the practice used to pushing the portal. We also made everyone here register on the portal to
see what the patients would go through and so we could make changes and adjustments to fit
our needs. It is an ongoing process, and we try to do contests every quarter. That is what
contributes to our success, and it is pretty impressive.”
Give patients a reason to use the portal.
“We are apparently doing something right in encouraging patients to come to our portal. They
come to the portal to fill out the patient history and the medication list. I think that is because of
the way our front desk staff members make new-patient appointments and the way they present
the portal to the patients. They tell them that we can give them less waiting time when they
come in if they get on the portal. We have an aggressive sign-up process. We give patients a
Chromebook in the waiting room and help them sign up for the portal right away. We have a
similar process in the ED and inpatient areas. We try to push as much content to the portal as
possible.”
Talk to your vendor and physicians.
“We drove adoption from the top down. In our initial phase, the adoption didn’t go well because
we thought we knew what we were doing and could do it ourselves. We went back and listened
to Medfusion. We took the portal to the doctors who understand technology. They came back
from a CMS meeting and said we had to do the portal. They said we might not like it, but we
have to do it.”
Hold your vendor accountable.
“When we started to deploy Empower in our ambulatory area, we hit challenges and barriers
with the physician group. The physicians really wanted to yank the product out; they didn’t want
anything to do with it. They were beyond frustrated. We worked with MEDSEEK and the
physicians, and in the last year and a half, we went from having a handful of patients on the
portal to having sixty-five thousand. We were finally able to leverage the solution in the
ambulatory space after we made changes to the product and the interface. There were deal
breakers in how the product looked and felt from a patient perspective, and we worked through
those.”
PHM is most effective when a symbiotic relationship exists between human interventions and
automation tools. Patient engagement tools and outreach programs enable providers to
correspond with each person in their patient populations, with the goal of raising the percentages
of patients receiving the recommended care as reflected in the quality measures payers use to
evaluate provider and health system performance. More important, such programs assist
providers in keeping patients as healthy as possible for as long as possible, a core tenant of
PHM.
Telemedicine and Telehealth
The growing use of telemedicine can make patient interactions more convenient, expand
geographic horizons particularly where needed medical specialists are few in number, and make
care more accessible to those with mobility issues.

Perspective
Five Reasons to “Like” Consumers’ Use of Social Media
With an abundance of patient-generated health information now available through online patient
communities, social media can play a vital role in improving our understanding of disease and
accelerating new approaches to treatment. Consider the following ways patient and consumer
use of social media is benefiting health care.
Creates a Sense of Community
For those seeking emotional support and tips for coping with a disease, social media delivers on
many fronts. It can enable the formation of communities regardless of member locations and
enable members to communicate asynchronously.
Sites such as PatientsLikeMe and Inspire provide virtual medical communities focused on
chronic diseases where patients can discuss their conditions, track key health information,
share side effects of medications and therapies, and bond with others as they chronicle the
highs and lows of their health care journeys.
In fact, a 2014 survey of PatientsLikeMe members found that the vast majority of adult social
media users with health conditions embrace the idea of sharing their health information online if it
helps clinicians improve care, assists other patients, or advances medical research.
Users of online health communities also frequently cite as reasons for their membership the
accountability the sites provide them in managing their own health and reaching their
health-related goals, as well as the motivation, support, and advice they receive from others.
Online communities can also lessen the feeling of isolation that often accompanies those with
rare conditions or parents with a critically ill child.
Delivers New Clinical Research Insights
As more and more patients use social media to track their health conditions and actively
participate in their care, there is a greater opportunity to use this real-world data to better inform
new treatments and treatment decisions, enhance symptom management, and ultimately
improve outcomes.
For example, in analyzing the results of observational data housed on PatientsLikeMe,
researchers found that lithium therapy had no impact on ALS disease progression, which was
later confirmed by subsequent randomized trials (Chretien & Kind, 2013).
Although PatientsLikeMe began as a social network enabling people to crowdsource the
collective wisdom of others, it has developed into a powerful analytical platform for clinicians and
researchers. In fact, the network is quite transparent with its members about how it makes
money—by sharing the information members provide about their experience with diseases and
selling it to their partners (companies that are developing or selling products to patients). This
may include drugs, devices, equipment insurance, or medical services.

In addition to helping patients find and take advantage of clinical trials, health care social
networks also provide an opportunity for participant-led research, in which members initiate new
fields of study. For instance, Inspire members with spontaneous coronary artery dissection
(SCAD) persuaded researchers at the Mayo Clinic to launch new research about their condition,
which led to the creation of a SCAD registry, a key step in the further study of this rare disease
(Tweet, Gulati, Aase, & Hayes, 2011). Indeed, there is tremendous potential for online patient
communities to contribute to the notion of a continuously learning health system.
Builds Awareness of Cause-Related Issues or Personal Health Care Crises
Social media can also serve as the birthplace for beneficial social movements, as well as hubs
for galvanizing emotional and financial support for a personal health care crisis.
The ALS Ice Bucket Challenge is a terrific example of social media’s power to deliver on the
fund-raising aspect of the campaign and on the equally important goal of helping the public
become more aware of ALS and efforts to find a cure.
The simple act of pouring ice on one’s head, capturing it on video, and calling out another person
to do the same spread across social media channels like wildfire. With everyone from
schoolchildren to celebrities getting in on the act, the ALS Association raised $115 million in
2014, a staggering increase from its $23.5 million intake in 2013 (ALS Association, 2015).
On a smaller scale, sites such as GoFundMe and My Cancer Circle can help keep family and
friends abreast of a loved one’s illness and treatment status, provide tools to coordinate meal
deliveries and rides to medical appointments, as well as enable financial contributions to help
offset personal health care expenses.
Provides Assistance with Treatment, Physician, or Hospital Selection
Although physician rating sites have been around for many years, social media has given health
care consumers a more active voice and an ever-present tool set for broadcasting opinions on
all things health care–related—from physicians and hospitals to medications, devices, and
insurance plans.
Like it or not, social media is proving to be a vehicle that can help scale positive and negative
attitudes about one’s health care experience at Internet speed. In fact, a 2012 survey by Demi &
Cooper Advertising and DC Interactive found that 41 percent of people said social media would
affect their choice of a specific doctor, hospital, or medical facility.
Of course, the downside here is that the negative opinions of a vocal minority could cause
unjust reputation management issues for providers.
With the viewpoints of those in online social networks playing such a key role in influencing
health care decisions, providers ought to ensure they are optimizing their social media channels
and actively participating in helping consumers share positive opinions online.
Complements Traditional Approaches to Measuring Patient Satisfaction

Beyond just randomly monitoring opinions shared on social media, savvy providers may want to
turn to social media to supplement their traditional means of capturing patient satisfaction and
feedback on inpatient experience.
In fact, researchers at Boston Children’s Hospital conducted a study to determine if Twitter
could provide a reasonable form of complementary quality measurement, given the real-time
nature of tweets. The team amassed unsolicited knowledge (versus data gleaned from very
targeted survey questions) about what pleased or angered consumers by collecting more than
400,000 tweets directed at the Twitter handles of nearly 2,400 US hospitals between 2012 and
2013 (Ulrich, 2015).
Although certainly no replacement for patient satisfaction surveys, according to the researchers
the data are suggestive and provide proof of principle that Twitter and the right analytical tools
may provide a valuable means for complementing standard approaches to measuring quality.
Moreover, the ability to correlate social media data points such as tweets with actual outcomes
measures (e.g., patient length of stay in the emergency department or readmission rates)
provides an interesting avenue for further exploration.
The American Telemedicine Association defines telemedicine or telehealth as exchanging
medical information via electronic communications to improve a patient’s clinical health status.
Health care providers are embracing telemedicine because they see it as an efficient and
cost-effective way to deliver quality care and improve patient satisfaction (Glaser, 2015a).
Today’s telehealth framework spans the continuum of care and can include services such as
the following:
Telepsychiatry
Remote image interpretation (teleradiology, teledermatology)
e-Visits or televisits between providers and their patients
Video visits for semi-urgent care
Clinician-to-clinician consultations
Critical care (virtual ICU, telestroke)
Remote monitoring of a patient with a chronic disease
Cybersurgery or telesurgery
Let’s take a closer look at some of the more popular applications of telemedicine and telehealth.
Two-way interactive video-conferencing or other web-based technologies can be used when a
face-to-face consultation is necessary. In addition, a number of peripheral devices can be linked
to computers to aid in interactive examination. For example, a stethoscope can be linked to a
computer, enabling the consulting physician to hear the patient’s heartbeat from a distance.
Electronic monitoring of physiological vital signs can be done through electronic intensive care
unit (eICU) patient-monitoring systems, and telesurgery can enable a surgeon in one location to
remotely control a robotic arm to perform surgery in another location.
Telehealth is also being used to capture and monitor data from patients at home. Examples
include monitoring patient blood sugar levels through glucometers attached to cell phones and
conducting teledermatology visits with the aid of cell phone cameras.

According to the American Hospital Association (AHA), 52 percent of hospitals used some form
of telehealth in 2013, and another 10 percent were beginning to implement such services (AHA,
2015). Its growth potential is also notable. Business information provider IHS predicts the US
telehealth market will grow from $240 million in revenue in 2013 to $1.9 billion in 2018—an
annual growth rate of more than 50 percent (EY, 2014).
In addition to the growing demand for access and convenience, the need for telemedicine is
driven by other factors such as the following:
Significant increase in the US population
Shortage of licensed health care professionals
Increasing incidence of chronic diseases
Need for efficient care of the elderly, homebound, and physically challenged patients
Lack of specialists and health facilities in rural areas and in many urban areas
Avoidance of adverse events, injuries, and illnesses that can occur within the health care
system
These factors become increasingly important as new health care delivery and payment models
evolve and providers are challenged to better manage chronic diseases, avoid readmissions,
improve quality, and remove low acuity care from high-cost venues. As we know, the long-term
benefits of population health programs are predicated in large part on managing high-cost,
chronically ill patient populations more effectively. Furthermore, the rapid deployment of high
deductible health plans, which make consumers more conscious and accountable for their
health care consumption and spending, has added to the pressure on providers to provide
low-cost, convenient options.
Despite all its promise, several major barriers must be addressed if telemedicine is to be used
more widely and become available. Concerns about provider acceptance, interstate licensure,
overall confidentiality and liability, data standards, and lack of universal reimbursement for
telemedicine services from public and private payers are among the complex and evolving
issues affecting the widespread use of telemedicine. Furthermore, its cost-effectiveness has yet
to be fully demonstrated.
Nonetheless, the barriers are beginning to erode under mounting pressure from all health care
constituents. Licensure portability will further ease the barriers to accessing services, whereas
regulatory and payment policy changes in support of telehealth are widely expected in the
coming years. For instance, on the private payer side, telemedicine use has been bolstered by a
growing number of states enacting parity laws, which require health insurers to treat telehealth
services the same way they would in-person services.
Transitioning from the Record to the Plan
As we reviewed in this chapter, the profound changes in reimbursement and care models are
altering the structure of care provision, requiring providers to make investments in a
comprehensive IT portfolio—beyond the EHR—to support PHM and enable the core processes

associated with accountable care. These changing business and payment models are leading
not only to significant changes in organization and practice but also to changes in the
fundamental nature and design of the EHR itself. These changes can be characterized as a
transition from the electronic health record to the electronic health plan (Glaser, 2015b).
The EHR does not disappear as a result of this shift. We will still need traditional EHR
capabilities: providers need to review a radiology report and document a patient’s history and the
care delivered. Problems must be recorded and medications reconciled. However, the strategic
emphasis will move to technologies and applications that assist the care team (including the
patient) in developing and managing the longitudinal, cross-venue health plan and assessing the
outcomes of that plan.
For example, evidence-based pathways and decision-support logic have been embedded into
EHRs to guide provider decisions according to a plan based on patient condition. EHRs can
now include or be enhanced by the specific PHM technologies we discussed that enable the
organization to understand its aggregate performance in undertaking disease-specific plans for
multiple patients.
Provider organizations will not thrive in an era of health reform because they have a superb and
interoperable EHR. They will thrive because the care they deliver consistently follows a plan
designed to ensure desired outcomes. The EHR must evolve so it focuses on individual
patients’ care plans—the steps required to maintain or create health.
Every patient’s EHR should clearly display the master care plan—a long-term care plan to
maintain health integrated with short-term plans for transient conditions. The EHR should be
organized according to this master plan: it should highlight the steps needed to recover or
maintain health, list the expectations of every caregiver the patient interacts with, and include
tools such as decision support and a library of standard care plans. Interoperability is a
necessity, because various providers must be able to use the plan-based EHR.
Care Plan Attributes
The care health plan has attributes that need to be present to ensure health and should be based
on some fundamental ideas.
First, all people have a foundational plan. If the person is a healthy young man, the plan may be
simple: establishing health behaviors such as exercise. If the person is a middle-aged man with
high cholesterol and sleep apnea, the plan may be annual physicals, statins, a CPAP machine,
and a periodic colonoscopy. If a person is frail and elderly with multiple chronic diseases, the
plan may be merging the care for each chronic condition, ensuring proper diet, and providing
transportation for clinic visits.
Second, plans are a combination of medical care strategies with goals to maintain health (such
as losing weight) along with public health campaigns (such as immunizations).

Third, on top of foundational plans there may be transient plans. For the patient undergoing a hip
replacement there is a time-bounded plan beginning with presurgery testing and ending when
rehabilitation has been completed. A patient undergoing a bad case of the flu has a
time-bounded plan.
Fourth, people who have a common plan are members of the same population. These
populations may be all patients undergoing a coronary artery bypass graft in a hospital, all
patients with a certain chronic disease, or all patients at high risk of coronary artery disease.
Moreover, a particular person may be a member of multiple populations at the same time.
Fifth, risk is the likelihood that the plan will not be followed or will not result in desired outcomes.
A patient motivated to manage his or her blood pressure has a lower risk than a patient who is
not motivated. A frail person with multiple chronic diseases is at greater risk that the plans will
not keep him or her out of the hospital than a person whose health is generally good despite
having multiple chronic diseases.
Sixth, not all care will be amenable to a predefined patient plan. Life-threatening trauma,
diseases of mysterious origin, sudden complications—all require skilled caregivers to make the
best decisions possible at the moment.
Seventh, plans should be based on the evidence of best care and health practices. And the
effectiveness of a plan should be measurable, either in terms of plan steps being completed or
desired outcomes being achieved (Glaser, 2015a).
The Plan-Centric EHR
The EHR needs to evolve into plan-centric applications. Among others, these applications will
have several key characteristics.
A Library of Plans That Cover a Wide Range of Situations
This library will include, for instance, plans for managing hypertension, removing an appendix,
losing weight, and treating cervical cancer. There will be variations in plans that reflect variations
in patient circumstances and preferences, for example, plans that depend on whether the patient
is a well-managed diabetic or plans that reflect the slower surgical recovery time of an elderly
person.
A master plan will combine, for example, the patient’s asthma, hysterectomy, depression, and
weight-reduction plans into a single plan. These algorithms will identify conflicts and
redundancies among the plans and highlight the care steps that optimize a patient’s health for all
plans. For example, if each of the five plans has six care steps, the algorithms can determine
which steps are the most important.
Team-Based
The master plan will cover the steps to be carried out by a patient’s primary care provider,
specialists, nurse practitioners, pharmacists, case managers, and the patient. Each team

member can see the master plan and his or her specific portion of the plan. Team members can
assign tasks to each other (Glaser, 2015a).
Business Models in Other Industries
Major changes in an industry’s business model invariably lead to major changes in the focus
and form of the core applications used by that industry. For example, financial services,
retailers, and music distributors, along with many other industries, have also experienced
massive shifts in their business models.
Several decades ago, financial deregulation enabled banks to offer brokerage services. The
business model of many banks shifted from banking (offering mortgages as well as checking
and savings accounts) to wealth management. As banks shifted from transaction-oriented
services to services that optimized a customer’s financial assets, their core applications
broadened to include an additional set of transactions (buying and selling stocks) and new
services (financial advisory services).
Prior to the web, most retailers’ business models focused on establishing a brand, offering an
appropriate set of well-priced products, and building attractive stores in convenient locations.
The web enabled retailers to gather significantly richer data about a customer’s buying patterns
and interests (and to use real-time logic to guide purchasing decisions). Retailers’ core
applications broadened to include well-designed e-commerce sites and analytics of customer
behavior.
In both examples, even though there was a significant shift in the business model, applications
needed for the previous model continued to be necessary. Banks still had to handle savings
account and mortgage payment transactions. Retailers still needed to manage inventory. And
advances in these legacy applications—expanding inventory breadth and reducing
inventory-carrying costs—continue to be important. In each case, a critical new set of
applications were added to the legacy applications. Often, these new applications were more
important than legacy applications.
The business model changes in health care will lead to a shift from applications focused on the
patient’s record to applications focused on the patient’s plan for health. This evolution in the
nature of the EHR is a key component to achieving success in population health management.
Summary
As the health care industry continues its transition from a fragmented, volume-based system
toward one that embraces the notion of patient-centered, accountable care driven by
value-based payment models, providers must consider what new relationships, processes, and
IT assets and skills will be required to succeed—particularly when it comes to managing the
health and care of attributed populations.
By implementing a PHM strategy, organizations have enormous opportunity to use data and
analytics to improve inefficiency and waste, thereby reducing costs, and monitor adherence to
evidence-based protocols to drive better outcomes. Several PCMHs and ACOs are already

showing promising performance in the emerging world of value-based payment and population
health management.
In addition to having a robust EHR, organizations looking to enhance their PHM strategies
should consider several key solution components. PHM technologies can help providers stratify
and select target populations, identify gaps in care, predict outcomes and apply early
interventions, and actively engage patients in their care. Moreover, they can enable an
organization to understand its aggregate performance in undertaking disease-specific plans for
multiple patients and better manage contracts and financial performance.
Additionally, because value-based payment is based on conformance to chronic disease
protocols, providers must have the ability to aggregate and normalize real-time, accurate,
cross-continuum data from disparate sources illustrating how well the data conform to those
protocols. As we know, many hospitals and health systems do not operate from a position of
excess revenue, and as outcomes become increasingly tied to the reimbursement stream, it will
become critical that providers can rely on their data and IT tools to detect and remedy variations
in care.
Population health management solutions are intended to complement—not replace—the
traditional EHR. They represent a shift from applications focused on documenting the patient’s
record of care to applications focused on developing the patient’s plan for health.

System Acquisition
Learning Objectives
To be able to explain the process a healthcare organization generally goes through in selecting a
healthcare information system.
To be able to describe the systems development life cycle and its four major stages.
To be able to discuss the various options for acquiring a health care information system (for
example, purchasing, leasing, contracting with vendors for cloud computing services, or building
a system in-house) and the pros and cons of each option.
To be able to discuss the purpose and content of a request for information and request for
proposal in the system acquisition process.
To gain insight into the problems that may occur during the system acquisition process.
To gain an understanding of the healthcare IT industry and the resources available for identifying
healthcare IT vendors and learning about their history, products, services, and reputation.
To gain insight into the importance of understanding IT architecture.
By now you should have an understanding of the various types of healthcare information
systems and the value they can bring to health care organizations and the patients they serve.
This chapter describes the typical process a healthcare organization goes through in acquiring
or selecting a new clinical or administrative application. Acquiring an information system (IS)
application can be an enormous investment for health care organizations. In addition to the initial
cost, there are a host of long-term costs associated with maintaining, supporting, and enhancing
the system. Health care professionals need access to reliable, complete, and accurate
information in order to provide effective and efficient health care services and to achieve the
strategic goals of the organization. Selecting the right application, one that meets the
organization’s needs, is a critical step. Too often information systems are acquired without
exploring all options, without evaluating costs and benefits, and without gaining sufficient input
from key constituent user groups. The results can be disastrous.
This chapter describes the people who should be involved, the activities that should occur, and
the questions that should be addressed in acquiring any new information system. The
suggested methods are based on the authors’ years of experience and on countless case
studies of system acquisition successes and failures published in the health care literature.
System Acquisition: A Definition
In this book system acquisition refers to the process that occurs from the time the decision is
made to select a new system (or replace an existing system) until the time a contract has been
negotiated and signed. System implementation is a separate process described in the next
chapter, but both are part of the systems development life cycle. The actual system selection, or
acquisition, process can take anywhere from a few days to a couple of years, depending on the
organization’s size, structure, complexity, and needs. Factors such as whether the system is
deemed a priority and whether adequate resources (time, people, and funds) are available can
also directly affect the time and methods used to acquire a new system (Jones, Koppel,
Ridgley, Palen, Wu, & Harrison, 2011).

Prior to arriving at the decision to select a new system, the health care executive team should
engage in a strategic IS planning process in which the strategic goals of the organization are
formulated and the ways in which information technology (IT) will be employed to aid the
organization in achieving its strategic goals and objectives are discussed. We discuss the need
for aligning IT plans with the strategic goals of the organization and for determining IT priorities in
Chapter Twelve. In this chapter, we assume that a strategic IT plan exists, IT priorities have
been established, the new system has been adequately budgeted, and the organization is ready
to move forward with the selection process. We also assume that the organization has
conducted a readiness assessment and is well equipped to move forward with the health IT
project or initiative. The AHRQ National Resource Center for Health IT has available a number
of tools publicly available that can be helpful to health care organizations in assessing their
readiness for health IT projects such as EHR implementations and for ensuring that they have in
place the personnel, technical, and financial resources to embark on the initiative. These tools
can be found at https://healthit.ahrq.gov/health-it-tools-and-resources. Additionally, the Office of
the National Coordinator for Health Information Technology (ONC) has readiness tools available
and implementation blueprints that serve as excellent resources at
https://www.healthit.gov/providers-professionals/ehr-implementation-steps.
Systems Development Life Cycle
No board of directors would recommend building a new health care facility without an architect’s
blueprint and a comprehensive assessment of the organization’s and the community’s needs
and resources. The architect’s blueprint helps ensure that the new facility has a strong
foundation, is well designed, fosters the provision of high-quality care, and has the potential for
growth and expansion. Similarly, the health care organization needs a blueprint to aid in the
planning, selection, implementation, and support of a new health care information system. The
decision to invest in a health care information system should be well aligned with the
organization’s overall strategic goals and should be made after careful thought and deliberation.
Information systems are an investment in the organization’s infrastructure, not a one-time
purchase. Health care information systems require not only up-front costs and resources but
also ongoing maintenance, support, upgrades, and eventually, replacement.
The process an organization generally goes through in planning, selecting, implementing, and
evaluating a health care information system is known as the systems development life cycle
(SDLC). Although the SDLC is most commonly described in the context of software
development, the process also applies when systems are purchased from a vendor or leased
through cloud-based computing services. Cloud computing is a general term that refers to a
broad range of application, software, and hardware services delivered over the Internet.
Regardless of how the system is acquired, most health care organizations follow a structured
process for selecting and implementing a new computer-based system. The systems
development process itself involves participation from individuals with different backgrounds and
areas of expertise. The specific mix of individuals depends on the nature and scope of the new
system.
Many SDLC frameworks exist, some of which employ an incremental approach, but most have
four general phases, or stages: planning and analysis, design, implementation, and support and
evaluation (Wager & Lee, 2006) (see Figure 5.1). Each phase has a number of tasks that need

to be performed. In this chapter we focus on the first two phases; Chapter Six focuses on the
last two.
The SDLC approach assumes that this four-phase life of an IS starts with a need and ends
when the benefits of the system no longer outweigh its maintenance costs, at which point the life
of a new system begins (Oz, 2012). Hence, the entire project is called a life cycle. After the
decision has been made to explore further the need for a new information system, the feasibility
of the system is assessed and the scope of the project defined (in actuality it is at times difficult
to tell when this decision making ends and analysis begins). The primary focus of this planning
and analysis phase is on the business problem, or the organization’s strategy, independent of
any technology that can or will be used. During this phase, it is important to examine current
systems and problems in order to identify opportunities for improvement. The organization
should assess the feasibility of the new system—is it technologically, financially, and
operationally feasible? Furthermore, sometimes it is easy to think that implementing a new IS
will solve all information management problems. Rarely, if ever, is this the case. But by critically
evaluating existing systems and workflow processes, the health care team might find that
current problems are rooted in ineffective procedures or lack of sufficient training. Not always is
a new system needed or the answer to a problem.
Once it is clear that a new IS is needed, the next step is to assess the information needs of
users and define the functional requirements: What functions must the system have to fulfill the
need? This process can be very time-consuming. However, it is vital to solicit widespread
participation from end users during this early stage—to solicit and achieve buy-in. As part of the
needs assessment, it is also helpful to gather, organize, and evaluate information about the
organization in which the new system is to operate. Through defining system requirements, the
organization specifies what the system should be able to do and the means by which it will fulfill
its stated goals.
Once the team knows what the organization needs, it enters the second stage, the design
phase, when it considers all its options. Will the new system be designed in-house? Will the
organization contract with an outside developer? Or will the organization purchase a system
from a health information systems vendor or contract with a vendor for cloud-based services? A
large majority of healthcare organizations purchase a system from a vendor or at least look first
at the systems available on the market. Contracting with the vendor to host the applications,
software, hardware, and infrastructure via cloud computing is also growing in popularity in health
care (Griebel et al., 2015). System design is the evaluation of alternative solutions to address
the business problem. It is generally in this phase that all alternatives are considered, a
cost-benefit analysis is done, a system is selected, and vendor negotiations are finalized.
After the contract has been finalized or the system has been chosen, the third phase,
implementation, begins. The implementation phase requires significant allocation of resources in
completing tasks, such as conducting work-flow and process analyses, installing the new
system, testing the system, training staff members, converting data, and preparing the
organization and staff members for the go-live of the new system. Finally, once the system is

put into operation, the support and evaluation phase begins. It is common to underestimate the
number of staff and resources needed to effectively keep new and existing information systems
functioning properly. No matter how much time and energy were spent on the design and build
of the application, you can count on the fact that changes will need to be made, glitches fixed,
and upgrades installed. Likewise, most mission-critical systems need to be functioning 99.99
percent of the time—that is, with little downtime. Sufficient resources (people, technology,
infrastructure, and upgrades) need to be allocated to maintain and support the new system.
Moreover, maintaining and supporting the new system is not enough. Health care executives
and boards often want to know the value of the IT investment, thus the degree to which the new
system has achieved its goals and objectives should be assessed. Eventually, the system will
be replaced and the SDLC process begins again.
With this general explanation of the SDLC established, we begin by focusing on the first two
phases—the planning and analysis phase and the design phase. Together they constitute what
we refer to as the system acquisition process.
System Acquisition Process
To gain an understanding of and appreciation for the activities that occur during the system
acquisition process, we will follow a health care facility through the selection process for a new
information system—specifically, an electronic health record (EHR) system. In this case the
organization, which we will call Valley Practice, is a multi physician primary care practice.
What process should the practice use to select the EHR? Should it purchase a system from a
vendor, contract with a vendor for cloud-based services, or seek the assistance of a system
developer? Who should lead the effort? Who should be involved in the process? What EHR
products are available on the market? How reputable are the vendors who develop these
products? These are just a few of the many questions that should be asked in selecting a new
IS.
Although the time and resources needed to select an EHR (or any health care information
system) may vary considerably from one setting to another, some fundamental issues should
be addressed in any system acquisition initiative. The sections that follow the case study
describe in more detail the major activities that should occur (see Exhibit 5.1), relating them to
the multi physician practice scenario. We assume that the practice wishes to purchase (rather
than develop) an EHR system. However, we briefly describe other options and point out how the
process may differ when the EHR acquisition process occurs in a larger health care setting,
such as integrated health systems.
Exhibit 5.1 Overview of System Acquisition Process
Establish a project steering committee and appoint a project manager.
Define project objectives and scope of analysis.
Screen the marketplace and review vendor profiles.
Determine system goals.
Determine and prioritize system requirements.
Develop and distribute a request for proposal (RFP) or a request for information (RFI).

Explore other options for acquiring systems (e.g., leasing, hiring system designer, building
in-house).
Evaluate vendor proposals.
Develop evaluation criteria.
Hold vendor demonstrations.
Make site visits and check references.
Prepare vendor analysis.
Conduct cost-benefit analysis.
Prepare a summary report and recommendations.
Conduct contract negotiations.
Establish a Project Steering Committee
One of the first steps in any major project such as an EHR acquisition effort is to create a
project steering committee. This committee’s primary function is to plan, organize, coordinate,
and manage all aspects of the acquisition process. Appointing a project manager with strong
communication skills, organizational skills, and leadership abilities is critical to the project. In our
Valley Practice case, the project manager was a physician partner. In larger health care
organizations such as hospitals, it would likely be a CIO involved in the effort and that person
might also be asked to lead it.
Increasingly, clinicians such as physicians and nurses with training in informatics are being
called on to lead clinical system acquisition and implementation projects. Known as chief
medical informatics officers (CMIOs) or chief nursing informatics officers (CNIOs), these
individuals bring to the project a clinical perspective as well as an understanding of IT and
information management processes. (The roles of CMIOs and CNIOs are described more fully
in Chapter Eight.) Regardless of the discipline or background of the project manager (for
example, IT, clinical, or administrative), he or she should bring to the project passion, interest,
time, strong interpersonal and communication skills, and project management skills and should
be someone who is well respected by the organization’s leadership team and who has the
political clout to lead the effort effectively.
Case Study
Replacing an EHR System
Valley Practice provides patient care services at three locations, all within a fifteen-mile radius,
and serves nearly one hundred thousand patients. Valley Practice is owned and operated by
seven physicians; each physician has an equal partnership. In addition to the physicians, the
practice employs nine nurses, fifteen support staff members, a business officer manager, an
accountant, and a chief executive officer (CEO).
During a two-day strategic planning session, the physicians and management team created a
mission, vision, and set of strategic goals for Valley Practice. The mission of the facility is to
serve as the primary care “medical home” of individuals within the community, regardless of the
patients’ ability to pay. Valley Practice wishes to be recognized as a “high-tech, high-touch”
practice that provides high-quality, cost- effective patient care using evidence-based standards
of care. Consistent with its mission, one of the practice’s strategic goals is to replace its legacy
EHR with an EHR system that adheres to industry standards for security and interoperability

and that fosters patient engagement, with the long-term goal of supporting health fitness
applications.
Dr. John Marcus, the lead physician at Valley Practice, asked Dr. Julie Brown, the newest
partner in the group, to lead the EHR project initiative. Dr. Brown joined the practice two years
ago after completing an internal medicine residency at an academic medical center that had a
fully integrated EHR system available in the hospital and its ambulatory care clinics. Of all the
physicians at Valley Practice, Dr. Brown has had the most experience using EHR applications
via portable devices. She has been a vocal advocate for migrating to a new EHR and believes it
is essential to enabling the facility to achieve its strategic goals.
Dr. Brown agreed to chair the project steering committee. She invited other key individuals to
serve on the committee, including Dr. Renee Ward, a senior physician in the practice; Mr.
James Rowls, the CEO; Ms. Mary Matthews, RN, a nurse; and Ms. Sandy Raymond, the
business officer manager.
After the project steering committee was formed, Dr. Marcus met with the committee to outline
its charge and deliverables. Dr. Marcus expressed his appreciation to Dr. Brown and all of the
members of the committee for their willingness to participate in this important initiative. He
assured them that they had his full support and the support of the entire physician team.
Dr. Marcus reviewed with the committee the mission, vision, and strategic goals of the practice
as well as the committee’s charge. The committee was asked to fully investigate and
recommend the top three EHR products available in the vendor community. He stressed his
desire that the committee members would focus on EHR vendors that have experience and a
solid track record in implementing systems in physician practices similar to theirs and that have
Office of the National Coordinator for Health Information Technology (ONC)–certified EHR
products. He is intrigued with the idea of cloud-based EHR systems provided they can ensure
safety, security, and confidentiality of data; are reliable and scalable; and have the capacity to
convert data easily from the current system into the new system. The vendor must also be
willing to sign a business associates’ agreement ensuring compliance with HIPAA security and
privacy regulations.
Dr. Marcus is also interested in exploring what opportunities are available for health information
exchange within the region. He envisions that the practice will likely partner with specialists,
hospitals, and other key stakeholders in the community to provide coordinated care across the
continuum under value-based reimbursement models. Under the leadership of Dr. Brown, the
members of the project steering committee established five project goals and the methods they
would use to guide their activities. Ms. Moore, the consultant, assisted them in clearly defining
these goals and discussing the various options for moving forward. They agreed to consider
EHR products only from those vendors that had five or more years of experience in the industry
and had a solid track record of implementations (which they defined as having done twenty-five
or more). Dr. Ward, Mr. Rowls, and Ms. Matthews assumed leadership roles in verifying and
prioritizing the requirements expressed by the various user groups.

The five project goals were based on Valley Practice’s strategic goals. These project goals were
circulated for discussion and approved by the CEO and the physician partners. Once the goals
were agreed on, the project steering committee appointed a small task group of committee
members to carry out the process of defining system functionality and requirements. Because
staff time was limited, the task group conducted three separate focus groups during the lunch
period—one with the nurses, one with the support staff members, and a third with the
physicians. Ms. Moore, the consultant, conducted the focus groups, using a semi-structured
nominal group technique.
Concurrently with the requirements definition phase of the project, Mr. Rowls and Dr. Brown,
with assistance from Ms. Moore, screened the EHR vendor marketplace. They reviewed the
literature, consulted with colleagues in the state medical association, and surveyed practices in
the state that they knew used state-of-the-art EHR systems. Mr. Rowls made a few phone calls
to chief information officers (CIOs) in surrounding hospitals who had experience with ambulatory
care EHR to get their advice. This initial screening resulted in the identification of eight EHR
vendors whose products and services seemed to meet Valley Practice’s needs.
Given the fairly manageable number of vendors, Ms. Moore suggested that the project steering
committee use a short-form RFP. This form had been developed by her consulting firm and had
been used successfully by other physician practices to identify top contenders. The short-form
RFPs were sent to the eight vendors; six responded. Each of these six presented an initial
demonstration of its EHR system on site. Following the demonstrations, the practice staff
members completed evaluation forms and ranked the various vendors. After reviewing the
completed RFPs and getting feedback on the vendor presentations, the committee determined
that three vendors had risen to the top of the list.
Dr. Brown and Dr. Ward visited four physician practices that used EHR systems from these
three finalists. Mr. Rowls checked references and prepared the final vendor analysis. A detailed
cost-benefit analysis was conducted, and the three vendors were ranked. All three vendors, in
rank order, were presented in the final report given to Dr. Marcus and the other physician
partners. Dr. Marcus, Dr. Brown, and Mr. Rowls spent four weeks negotiating a contract with the
top contender. It was finalized and approved after legal review and after all the partners agreed
to it.
Pulling together a strong team of individuals to serve on the project steering committee is also
important. These individuals should include representatives from key constituent groups in the
practice. At Valley Practice, a physician partner, a nurse, the business officer manager, and the
CEO agreed to serve on the committee. Gaining project buy-in from the various user groups
should begin early. This is a key reason for inviting representatives from key constituent groups
to serve on the project steering committee. They should be individuals who will use the EHR
system directly or whose jobs will be affected by it.
Consideration should also be given to the size of the committee; typically, having five to six
members is ideal. In a large facility, however, this may not be possible. The committee for a
hospital or health systems might have fifteen to twenty members, with representatives from key

clinical areas such as laboratory medicine, pharmacy, and radiology in addition to
representatives from the administrative, IT, nursing, and medical staff.
It is important to have someone knowledgeable about IT serving on the project steering
committee. This may be a physician, a nurse, the CEO, or an outside consultant. In a physician
group practice, having an in-house IT professional is not always possible. The committee chair
might look internally to see if someone has the requisite IT knowledge, skills, interests, and also
the time to devote to the project, but the chair also might look externally for a healthcare IT
professional who might serve in a consultative role and help the committee direct its activities
appropriately.
Define Project Objectives and Scope of Analysis
Once the project steering committee has been established, its first order of business is to clarify
the charge to the committee and to define project goals. The charge describes the scope and
nature of the committee’s activities. The charge usually comes from senior leadership or a lead
physician in the practice. Project goals should also be established and communicated in
well-defined, measurable terms. What does the committee expect to achieve? What process
will be used to ensure the committee’s success? How will milestones be acknowledged? How
will the committee communicate progress and resolve problems? What resources (such as
time, personnel, and travel expenses) will the committee need to carry out its charge? What
method will be used to evaluate system options? Will the committee consider contracting with a
system developer to build a system or outsourcing the system to an application service
provider? Or is the committee only considering systems available for purchase from a health
care information systems vendor?
Once project goals are formulated, they can guide the committee’s activities and also clarify the
resources needed and the likely completion date for the project. Here are some examples of
typical project goals:
Assess the practice’s information management needs and establish goals and objectives for the
new system based on these needs.
Conduct a review of the literature on EHR products and the market resources for these
products.
Investigate the top-ten EHR system products for the ambulatory care arena.
Visit two to four health care organizations similar to ours that have implemented an EHR
system.
Schedule vendor demonstrations for times when physicians, nurses, and others can observe
and evaluate without interruptions.
As part of the goal-setting process, the committee should determine the extent to which various
options will be explored. For example, the Valley Practice project steering committee decided at
the onset that it was going to consider only EHR products available in the vendor community
and ONC-certified. Users can be assured that certified EHR products meet certain standards
for content, functionality, and interoperability.
The committee further stipulated that it would consider only vendors with experience (for
example, five or more years in the industry) and those with a solid track record of system

installations (for example, twenty-five or more installations). The committee members felt the
practice should contract with a system developer only if they were unable to find a suitable
product from the vendor community—their rationale being that the practice wanted to be known
as high-tech, high-touch. They also believed it was important to invest in IT personnel who could
customize the application to meet practice needs and who would be able to assist the practice in
achieving project and practice goals.
Screen the Marketplace and Review Vendor Profiles
Concurrently with the establishment of project goals, the project steering committee should
conduct its first, cursory review of the EHR marketplace and begin investigating vendor profiles.
Many resources are available to aid the committee in this effort. For example, the Valley
Practice committee might obtain copies of recent market analysis reports—from research firms
such as Gartner or KLAS—listing and describing the vendors that provide EHR systems for
ambulatory care facilities. The committee might also attend trade shows at conferences of
professional associations such as the Healthcare Information and Management Systems
Society (HIMSS) and the American Medical Informatics Association (AMIA). (Appendix A
provides an overview of the healthcare IT industry and describes a variety of resources
available to healthcare organizations interested in learning about health care IT products, such
as EHR systems, available in the vendor community.)
Determine System Goals
Besides identifying project goals, the project steering committee should define system goals.
System goals can be derived by answering questions such as, What does the organization
hope to accomplish by implementing an EHR system? What is it looking for in a system? If the
organization intends to transform existing care processes, can the system support the new
processes? Such goals often emerge during the initial strategic planning process when the
decision is made to move forward with the selection of the new system. At this point, however,
the committee should state its goals and needs for a new EHR system in clearly defined,
specific, and measurable terms. For example, a system goal such as “select a new EHR
system” is very broad and not specific. Here are some examples of specific and measurable
goals for a physician practice.
Our EHR system should do the following:
Enable the practice to provide service to patients using evidence-based standards of care.
Aid the practice in monitoring the quality and costs of care provided to the patients served.
Provide clinicians with access to accurate, complete, relevant patient information, on-site and
remotely.
Improve staff member efficiency and effectiveness.
More fully engage patients in their own care by providing patients with ready access to their test
results, immunization records, patient education materials, and other aids.
Enable the practice to manage chronic disease patient care more effectively.
These are just a few of the types of system goals the project steering committee might establish
as it investigates a new EHR for the organization. The system goals should be aligned with the
strategic goals of the organization and should serve as measures of success throughout the
system acquisition process.

Determine and Prioritize System Requirements
Once the goals of the new system have been established, the project steering committee
should begin to determine system requirements. These requirements may address everything
from what information should be available to the provider at the point of care to how the
information will be secured to what type of response time is expected. The committee may use
any of a variety of ways to identify system requirements. One approach is to have a subgroup
of the committee conduct focus-group sessions or small-group interviews with the various user
groups (physicians, nurses, billing personnel, and support staff members). A second approach
is to develop and administer a written or an electronic survey, customized for each user group,
asking individuals to identify their information needs in light of their job role or function. A third is
to assign a representative from each specific area to obtain input from users in that area. For
example, the nurse on the Valley Practice project steering committee might interview the other
nurses; the business office manager might interview the support staff members. System
requirements may also emerge as the committee examines templates provided by consultants
or peer institutions, looks at vendor demonstrations and sales material, or considers new
regulatory requirements the organization must meet.
The committee may also use a combination of these or other approaches. At times, however,
users do not know what they want or will need. Hence, it can be extremely helpful to hold
product demonstrations, meet with consultants, or visit sites already using EHR systems so
that those who will use or be affected by the EHR can see and hear what is possible. Whatever
methods are chosen to seek users’ information system needs, the end result should be a list of
requirements and specifications that can be prioritized or ranked. This ranking should directly
reflect the specific strategic goals and circumstances of the organization.
The system requirements and priorities will eventually be shared with vendors or the system
developer; therefore, it is important that they be clearly defined and presented in an organized,
easy-to-understand format. For example, it may be helpful to organize the requirements into
categories such as software (system functionality, software upgrades); technical infrastructure
(hardware requirements, network specifications, backup, disaster recovery, security); and
training and support (initial and ongoing training, technical support). These requirements will
eventually become a major component of the RFP submitted to vendors or other third parties
(discussed next).
Develop and Distribute the RFP or RFI
Once the organization has defined its system requirements, the next step in the acquisition
process is to package these requirements into a structure that a third party can respond to,
whether that third party be a development partner or a health information systems vendor. Many
health care organizations package the requirements into a request for proposal. The RFP
provides the vendor with a comprehensive list of system requirements, features, and functions
and asks the vendor to indicate whether its product or service meets each need. Vendors
responding to an RFP are also generally required to submit a detailed and binding price
quotation for the applications and services being sought.

RFPs tend to be highly detailed and are therefore time-consuming and costly to develop and
complete. However, they provide the health care organization and each vendor with a
comprehensive view of the system needed. Healthcare IT consultants can be extremely
resourceful in assisting the organization with developing and packaging the RFP. An RFP for a
major health care information system acquisition generally contains the following information
(sections marked with an asterisk [*] are completed by the vendor; the other sections are
completed by the organization issuing the RFP):
Instructions for vendors:
Proposal deadline and contact information: where and when the RFP is due; whom to contact
with questions
Confidentiality statement and instructions: a statement that the RFP and the responses
provided by the vendor are confidential and are proprietary information
Specific instructions for completing the RFP and any stipulations with which the vendor must
comply in order to be considered
Organizational objectives: type of system or application being sought; information management
needs and plans
Background of the organization:
Overview of the facility: size, types of patient services, patient volume, staff composition,
strategic goals of organization
Application and technical inventory: current systems in use, hardware, software, network
infrastructure
System goals and requirements: goals for the system and functional requirements (may be
categorized as mandatory or desirable and listed in priority order). Typically this section includes
application, technical, and integration requirements. Increasingly, health care providers are
interested in assessing and testing system usability. Incorporating scripted scenarios in the
requirements section of the RFP that are based on existing workflow and business processes
can provide meaningful information during the selection process (Corrao, Robinson, Swiernik, &
Naeim, 2010; Eisenstein, Jurwishin, Kushniruk, & Nahm, 2011; IOM, 2011).
Vendor qualifications: *general background of vendor, experience, number of installations,
financial stability, list of current clients, standard contract, and implementation plan
Proposed solutions: *how the vendor believes its product meets the goals and needs of the
health care organization. Vendors may include case studies, results from system analysis
projects, and other evidence of the benefits of its proposed solution.
Criteria for evaluating proposals: how the healthcare organization will make its final decisions on
product selection
General contractual requirements: *warranties, payment schedule, penalties for failure to meet
schedules specified in contract, vendor responsibilities, and so forth
Pricing and support: *quote on cost of system, using standardized terms and forms
The RFP may become the basis for a legally binding contract or obligation between the vendor
and the solicitor, so it is important for both parties to carefully consider the wording of questions
and the corresponding responses (AHIMA, 2007).
RFPs are not the only means by which to solicit information from vendors. A second approach
that is often used is the request for information. An RFI is less formal, considerably shorter than
an RFP, and less time-consuming to develop. It is often used as part of the fact-finding process

to obtain basic information on the vendor’s background, product descriptions, and service
capabilities. Some health care organizations send out an RFI before distributing the RFP in order
to screen out vendors whose products or services are not consistent with the organization’s
needs or to narrow the field of vendors to a manageable number. The RFI can serve as a tool in
gathering background information on vendors’ products and services and providing the project
steering committee with a better sense of the health IT marketplace. How does one decide
whether to use an RFP, an RFI, both, or neither during the system acquisition process? Several
factors should be considered. Although time-consuming to develop, the RFP is useful in forcing
a healthcare organization to define its system goals and requirements and prioritize its needs.
The RFP also creates a structure for objectively evaluating vendor responses and provides a
record of documentation throughout the acquisition process. System acquisition can be a highly
political process; by using an RFP the organization can introduce a higher degree of objectivity
into that process. RFPs are also useful data collection tools when the technology being selected
is established and fully developed, when there is little variability between vendor products and
services, when the organization has the time to fully evaluate all options, and when the
organization needs strong contract protection from the selected vendor (DeLuca & Enmark,
2002). However, not all vendors may wish to submit a response to an RFI or RFP because of
costs or suitability.
There are also drawbacks to RFPs. In addition to taking considerable time to develop and
review, they can become cumbersome and so detail oriented that they lose their effectiveness.
For instance, it is not unusual to receive three binders full of product and service information
from one vendor. If ten vendors respond to an RFP (about five is ideal), the project steering
committee may be overwhelmed and find it difficult to wade through and differentiate among
vendor responses. Having too much information to summarize can be as crippling to a
committee in its deliberations as having too little.
Therefore a scaled-back RFP or an RFI might be a desirable alternative. An RFI might be used
when the healthcare organization is considering only a small group of vendors or products or
when it is still in the exploratory stages and has not yet established its requirements. Some
facilities use an even less formal process consisting primarily of site visits and system
demonstrations.
Regardless of the tool(s) used, it is important for the healthcare organization to provide sufficient
detail about its current structure, strategic IT goals, and future plans so that the vendor can
respond appropriately to its needs. Additionally, the RFP or RFI (or variation of either) should
result in enough specific detail that the organization gets a good sense of the vendor—its
services, history, vision, stability in the marketplace, and system or product functionality. The
organization should be able to easily screen out vendors whose products are undeveloped or
not yet fully tested (DeLuca & Enmark, 2002).
Explore Other Acquisition Options
In our Valley Practice case, the physicians and staff members opted to acquire an EHR system
from the vendor community. Organizations such as Valley Practice often turn to the market for
products that they will run on their own IT infrastructure. But there are times when they do not go
to the market—they choose to leverage someone else’s infrastructure (by contracting with an

application service provider or vendor who offers cloud computing services) or they build the
application (by contracting with a system developer or using in-house staff members).
Option to Contract with Vendor for Cloud Computing Services
In recent years, there has been a wider availability of high-speed or broadband Internet
connections, more sophisticated vendor solutions, and a growing number of options for hosting
software, hardware, and infrastructure via the Internet. These services are generally referred to
as cloud computing, a general term that refers to the applications delivered as services over the
Internet and the hardware and software in the data centers that provide those services. Vendors
and companies may use different terms to describe cloud-based services. Common options
include application service provider (ASP), software as a service (SaaS), infrastructure as a
service, and platform as a service. The scope of services and payment methods also can vary
considerably. However, cloud computing options generally require less upfront capital expenses,
fewer IT staff members and resources, and greater scalability and access to analytic
capabilities (Armbrust et al., 2010). Essentially the health care provider contracts with the
vendor to host and maintain the clinical or administrative application and related hardware; the
health care organization or provider simply accesses the system remotely over a network
connection and pays the monthly or negotiated fees.
Why might a healthcare organization consider contracting with a vendor in a cloud-based
service arrangement rather than purchasing an EHR system (or other application) from a
vendor? There are several reasons. First, the facility may not have the IT staff members needed
to run or support the desired system. Hiring qualified personnel at the salaries they demand may
be difficult, and retaining them may be equally challenging. Second, cloud-based options enable
health care organizations to use clinical or administrative applications with fewer up-front costs
and less capital. For a small physician practice, these financial arrangements can be particularly
appealing. Because many vendors offer cloud-based services on fixed monthly fees or fees
based on use, organizations are better able to predict costs. Third, by contracting with a vendor
to host, manage, or support IT, the health care organization can focus on its core business and
not get bogged down in IT support issues, although it may still have to deal with issues of
system enhancements, user needs, and the selection of new systems. Other advantages are
rapid deployment and 24/7 technical support. They also offer scalability and flexibility, so as the
practice or organization grows or shrinks in size or volume, they pay only for the services used.
Other benefits include upgrades that can be made once and applied across a network of users
instantaneously; users can access services from any standardized device no matter their
location; and a cloud-based network can easily accommodate changes in use (increase and
decrease during certain periods).
However, cloud computing services have some disadvantages and limitations that the health
care organization should consider in its deliberations. Although rapid deployment of the
application can be a tremendous advantage to an organization, the downside is the fact that the
application will likely be a standard, off-the-shelf product, with little if any customization. This
means that the organization has to adapt or mold its operations to the application rather than
tailoring the application to meet the operational needs of the organization. A second drawback
deals with technical support. Although technical support is generally available, it is unrealistic to
think that the vendor’s support personnel will have intimate knowledge of the organization and its

operations. Frustrations can mount when one lacks in-house IT technical staff members when
and where they are needed. Third, health care providers have long been concerned about data
ownership, security, and privacy—worries that increase when another organization hosts their
clinical data and applications. How the vendor will secure data and maintain patient privacy
should be clearly specified in the contract. Likewise, to minimize downtime, the vendor should
have clear plans for backing up data, preventing disasters, and recovering data.
As the industry matures, we will likely see different variations and greater choices among
organizations offering cloud-based services. A recent review of the literature found cloud
computing used in six primary domains: (1) telemedicine and teleconsultation, (2) medical
imaging, (3) public health and patients’ self-management, (4) clinical information systems, (5)
therapy, and (6) secondary use of data (Griebel et al., 2015). Additionally, cloud computing is
designed to support cooperation, care coordination, and information sharing.
The health care executive considering a move to cloud computing should carefully consider the
type of application moving to the cloud (clinical, administrative) and the cloud service model that
will be the most attractive economic option (Cloud Standards Customer Council, 2012). Health
care executives should also thoroughly research the company and its products and consider
factors such as company viability, target market, functionality, integration, implementation and
training help desk support, security, pricing, and service levels. It is important to be able to trust
the vendor and products and to choose systems and services wisely.
Option to Contract with a System Developer or Build In-House
An alternative to purchasing or leasing a system from a vendor is to contract with a developer to
design a system for your organization. The developer may be employed in-house or by an
outside firm. Working with a system developer can be a good option when the health care
organization’s needs are highly uncertain or unique and the products available on the market do
not adequately meet these needs. Developing a new or innovative application can also give the
organization a significant competitive advantage. The costs and time needed to develop the
application can be significant, however. It is also important to consider the long-term costs. If the
developer leaves, how difficult would it be to hire and retain someone to support and maintain
the system? How will problems with the system be addressed? How will the application be
upgraded? What long-term value will it bring the organization? These are a few of the many
questions that should be addressed in considering this option. It is rare for a healthcare
organization to develop its own major clinical information system.
Evaluate Vendor Proposals
In the Valley Practice case, the project steering committee decided to focus its efforts at first on
considering only EHR products available for purchase or lease in the vendor community. The
committee came to this conclusion after its initial review of the EHR marketplace. Committee
members felt there were a number of vendors whose products appeared to meet practice
needs. They also felt strongly that in-house control of the EHR system was important to
achieving the practice goal of becoming a high-tech, high-touch organization, because they
wanted to be able to customize the application. Realizing this, the committee had budgeted for
an IT director and an IT support staff member. Members felt that the long-term cost savings
from implementing an EHR would justify these two new positions.

Develop Evaluation Criteria
The project steering committee at Valley Practice decided to go through the RFP process. It
developed criteria by which it would review and evaluate vendor proposals. Criteria were used to
grade each vendor’s response to the RFP. Grading scales were established so the committee
could accurately compare vendors’ responses. These grading scales involved assigning more
weight to required items and less weight to those deemed merely desirable. Categories of “does
not meet requirement,” “partially meets requirement,” and “meets requirement” were also used.
RFP documents were compared item by item and side by side, using the grading scales
established by the committee (see Table 5.1 for sample criteria). To avoid information overload,
a common condition in the RFP review process, the project steering committee focused on
direct responses to requirements and referred to supplemental information only as needed.
Summary reports of each vendor’s response to the RFP were then prepared by a small group of
committee members and distributed to the committee at large.
Table 5.1 Sample criteria for evaluation of RFP responses
Type of Application: Electronic Health Record System
Vendor Name: The EHR Company
Criteria Meets Requirement Partially Meets Requirement Does Not Meet Requirement
1. Alerts user to possible drug interactions x
2. Provides user with list of alternate drugs x
3. Advises user on dosage based on patient’s weight x
4. Allows user to enter over-the-counter medications x (on different screen)
5. Allows easy printout of prescriptions x
Hold Vendor Demonstrations
During the vendor review process, it is important to host vendor system demonstrations. The
purpose of these demonstrations is to give the members of the health care organization an
opportunity to (1) evaluate the look and feel of the system from a user’s point of view, (2)
validate how much the vendor can deliver of what has been proposed, (3) conduct system
usability testing, and (4) narrow the field of potential vendors. It is often a good idea to develop
demonstration scripts and require all vendors to present their systems in accordance with these
scripts. Scripts generally reflect the requirements outlined in the RFP and contain a moderate
level of detail. For example, a script might require demonstrating the process of registering a
patient or renewing a prescription. The use of scripts can ensure that all vendors are evaluated
on the same basis or functionality. At the same time, it is important to allow vendors some
creativity in presenting their product and services. When scripts are used, they need to be
provided to vendors at least one month in advance of the demonstration, and vendors and
health care organizations must adhere to them. It is also important to have end users carry out
certain functions or procedures that they would usually do in the course of the day using the
vendor’s system. You might ask them to complete a system usability survey after they have
had a chance to use the system and practice on several records. Figure 5.2 is an example of a
system usability scale questionnaire in which end users are asked to respond to each item
using a Likert scale of 1 to 5, from strongly disagree to strongly agree. Criteria should be

developed and used in evaluating vendor demonstrations, just as they are for reviewing vendor
responses to the RFP.
Figure 5.2 System usability scale questionnaire
Source: Brooke (1996); Lewis and Sauro (2009).
Make Site Visits and Check References
After reviewing the vendors’ RFPs and evaluating their product demonstrations, it is advisable to
make site visits and check references. By visiting other facilities that use a vendor’s products,
the health care organization should gain additional insight into what the vendor would be like as a
potential partner. It can be extremely beneficial to visit organizations similar to yours. For
instance, in the Valley Practice case, representatives from key practice constituencies decided
to visit other ambulatory care practices to see how a specific system was being used, the
problems that had been encountered, and how these problems had been addressed.
How satisfied are the staff members with the system? How responsive has the vendor been to
problems? How quickly have problems been resolved? To what degree has the vendor
delivered on its promises? Hearing answers to such questions firsthand from a variety of users
can be extremely helpful in the vendor review process.
Other Strategies for Evaluating Vendors
A host of other strategies can be used to evaluate a vendor’s reputation and product and service
quality. Organizational representatives might attend vendor user group conferences, review the
latest market reports, consult with colleagues in the field, seek advice from consultants, and
request an extensive list of system users.
Prepare a Vendor Analysis
Throughout the vendor review process, the project steering committee members should have
evaluation tools in place to document their impressions and the views of others in the
organization who participate in any or all of the review activities (review of RFPs, system
demonstrations, site visits, reference checks, and so forth). The committee should then prepare
vendor analysis reports that summarize the major findings from each of the review activities.
How do the vendors compare in reputation? In the quality of their product? In quality of service?
How do the systems compare in terms of their initial and ongoing costs? To what degree is the
vendor’s vision for product development aligned with the organization’s strategic IT goals?
Conduct a Cost-Benefit Analysis
The final analysis should include an evaluation of the cost and benefits of each proposed
system. Figure 5.3 shows a comparison of six vendor products. Criteria were developed to
score and rank each vendor’s system. As the figure illustrates, the selection committee ranked
vendor 4 the top choice.
Figure 5.3 Cost-benefit analysis
The capital cost analysis may include software, hardware, network or infrastructure, third-party,
and internal capital costs. The total cost of ownership should factor in support costs and the

costs of the resources needed (including personnel) to implement and support the system.
Once the initial and ongoing costs are identified, it is important to weigh them against the
benefits of the systems being considered. Can the benefits be quantified? Should they be
included in the final analysis?
Prepare a Summary Report and Recommendations
Assuming the capital cost analysis supports the organization in moving forward with the project,
the project steering committee should compile a final report that summarizes the process and
results from each major activity or event. The report may include these elements:
System goals and criteria
Process used
Results of each activity and conclusions
Cost-benefit analysis
Final recommendation and ranking of vendors
It is generally advisable to have two or three vendors in the final ranking, in the event that
problems arise with the first choice during contract negotiations, the final step in the system
acquisition process.
Conduct Contract Negotiations
The final step of the system acquisition process is to negotiate a contract with the vendor. This,
too, can be time-consuming, and therefore it is helpful to seek expert advice from business or
legal advisors. The contract outlines expectations and performance requirements, who is
responsible for what (for example, training, interfaces, support), when the product is to be
delivered (and vendor financial liability for failing to deliver on time), how much customization
can be performed by the organization purchasing the system, how confidentiality of patient
information will be handled, and when payment is due. The devil is in the details, and although
most technical terms are common among vendors, other language and nuances are not.
Establish a schedule and a pre-implementation plan that includes a timeline for implementation
of the applications and an understanding of the resource requirements for all aspects of the
implementation, including cultural change management, workflow redesign, application
implementation, integration requirements, and infrastructure development and upgrades, all of
which can consume substantial resources.
Project Management Tools
Throughout the course of the system acquisition project, a lot of materials will be generated,
many of which should be maintained in a project repository. A project repository serves as a
record of the project steering committee’s progress and activities. It includes such information
and documents as minutes of meetings, correspondence with vendors, the RFP or RFI,
evaluation forms, and summary reports. This repository can be extremely useful when there are
changes in staff members or in the composition of the committee and when the organization is
planning for future projects. The project manager should assume a leadership role in ensuring
that the project repository is established and maintained. Following is a sample of the typical
contents of a project repository.

Perspective
Sample Contents of a Project Repository
Committee charge and membership (including contact information)
Project objectives (including method that will be used to select system)
System goals
Timeline of committee activities (for example, Gantt chart)
System requirements (mandatory and desirable)
RFP
RFI
Evaluation forms for
Responses to RFPs
Vendor demonstrations
Site visits
Reference checks
Summary report and recommendations
Project budget and resources
Managing the various aspects of the project and coordinating activities can be a challenging
task, particularly in large organizations or when a lot of people are involved and many activities
are occurring simultaneously. It is important that the project manager helps those involved to
establish clear roles and responsibilities for individual committee members, set target dates, and
agree on methods for communicating progress and problems. Many project management tools
exist that can be useful here. For example, a simple Gantt chart (Figure 5.4) can document
project objectives, tasks and activities, responsible parties, and target dates and milestones. A
Gantt chart can also display a graphical representation of all project tasks and activities,
showing which ones may occur simultaneously and which ones must be completed before
another task can begin. Other tools enable one to allocate time, staff members, and financial
resources to each activity. (Gantt charts and other timelines can be created with software
programs such as Visio or Microsoft Project. A discussion of these tools is beyond the scope of
this book but can be found in most introductory project management textbooks.)
It is important to clearly communicate progress within the project steering committee and to
individuals outside the committee. Senior management should be kept apprised of project
progress, budget needs, and committee activities. Regular updates should be provided to senior
management as well as other user groups involved in the process. Communication can be
formal and informal—everything from periodic update reports at executive meetings to facility
newsletter briefings to informal discussions at lunch.
Things That Can Go Wrong
Managing the system acquisition process successfully requires strong and effective leadership,
planning, organizational, and communication skills. Things can and do go wrong. Upholding a
high level of objectivity and fairness throughout the acquisition process is important to all parties
involved. Failing to do so can hamper the overall success of the project. Following is a list of
some common pitfalls in the system acquisition process, along with strategies for avoiding
them.

Failing to manage vendor access to organizational leadership. The vendor may schedule private
time with the CEO or a board member in the hope of influencing the decision and bypassing the
project steering committee entirely. It is not unusual to hear that processes or decisions have
been altered after the CEO has been on a golf outing or taken a trip to the Super Bowl with a
vendor. The vendor may persuade the CEO or a board member to overturn or question the
decisions of the project steering committee, crippling the decision process. Hence, it should be
clearly communicated to all parties (senior management, board, and vendor) that all vendor
requests and communication should be channeled through the project steering committee.
Failing to keep the process objective (getting caught up in vendor razzle-dazzle). Related to the
need to manage vendor access to decision makers is the need to keep the process objective.
The project steering committee should assume a leadership role in ensuring that there are
clearly defined criteria and methods for selecting the vendor. These criteria and methods should
be known to all the parties involved and should be adhered to. In addition, it is important that the
committee and other organizational representatives remain unbiased and not get so impressed
with the vendor’s razzle-dazzle (in the form, for example, of exquisite dinners or fancy gadgets)
that they fail to assess the vendor or the product objectively. Consider the politics of a situation
but do not allow the vendor to drive the result—take the high road to avoid the appearance of
favoritism.
Overdoing or undergoing the RFP. Striking a balance between too much and too little information
and detail in the RFP and also determining how much weight to give to the vendors’ responses
to the RFP can be challenging. The project steering committee should err on the side of being
reasonable—that is, the committee should include enough information and detail that the vendor
can appropriately respond to the organization’s needs and should give the vendor responses to
the RFP appropriate consideration in the final decision. Organizations should also be careful that
they do not assign either too much or too little weight to the RFP process.
Failing to involve the leadership team and users extensively during the selection process. A
sure way to disenchant the leadership team and end users is to fail to involve them adequately
in the system acquisition process. There should be ample opportunity for people at all levels of
the organization who will use or be affected by the new information system to have input into its
selection. Involvement can include everything from being invited and encouraged to attend
vendor presentations during uninterrupted time to being asked to join a focus group in which
user input is sought. It is important that the project steering committee seek input and
involvement throughout the acquisition process, not simply at the end when the decision is
nearly final. Far too often information system projects fail because the leadership team and end
users were not actively involved in the selection of the new system. Involving people from the
very beginning helps them to be an integral part of the process and the solution.
Turning negotiations into a blood sport. You want to negotiate a fair deal with the vendor and not
leave the vendor’s people feeling as though they have just been “beaten” in a contest. A lopsided
deal results in a disenchanted partner and can create a bad climate. Understand what is
required from all parties and establish performance criteria for payments and remedies for
nonperformance. It is important to form a healthy, respectful long-term relationship with the
vendor.
These are just a few of the many issues that can arise during the system acquisition process
that the health care executive should be aware of. Failing to appropriately address these issues

can interfere with the organization’s ability to successfully select and implement a system that
will be adopted and widely used.
Information Technology Architecture
Congruent with the selection process, it is important for health care executives to have an
understanding of the underlying IT architecture. In other words, how does the organization
choose among different technologies and ultimately bring them together into a cohesive set of
healthcare information systems? This section addresses this important question by examining
health care information system architecture.
An organization’s information systems require that a series of core technologies come together,
or work together as whole, to meet the IT goals of the organization. The way that core
technologies, along with the application software, come together should be the result of
decisions about what information systems are implemented and used within the organization
and how they are implemented and used. For example, the EHR system or the patient
accounting system with which users ultimately interact involves not just the application software
but also the network, servers, security systems, and so forth that all come together to make the
system work effectively. This coming together should never be a haphazard process. It should
be engineered.
In discussing IT architecture, we will cover several topics:
A definition of architecture
Architecture perspectives
Architecture examples
Observations about architecture
A Definition of Architecture
A design and a blueprint guide the coming together of a house. The coming together of
information systems is guided by information technology architecture. For the house, the
development of the blueprint and the design is influenced by the builder’s objectives for the
house (is it to be a single-family house or an apartment building, for example) and the desired
properties of the house (energy efficient or handicap accessible, for example). For an
organization’s information systems, the development of an architecture is influenced by the
organization’s objectives (EHRs that span multiple hospitals, for example) and the systems’
desired properties (efficient to support and having a high degree of application integration, for
example).
Following the design and the blueprints, the general contractor, plumbers, carpenters, and
electricians use building materials to create the house. Following the architecture for the
organization’s information systems, the IT staff members and the organization’s vendors
implement the core technologies and application software and integrate them to create the
information systems.

IT architecture consists of concepts, strategies, and principles that guide an organization’s
technology choices and the manner in which the organization integrates and manages these
choices. For example, an organization’s architecture discussion concludes that the organization
should use industry standard technology. This decision reflects an organizational belief that
standard technology will have a lower risk of obsolescence, be easier to support, and be
available from a large number of IT vendors that use standard technology. Guided by its
architecture decision, the organization chooses to implement networks that conform to a
specific standard network protocol and decides to use the Windows operating system for its
workstations.
Two additional terms are sometimes used either as synonyms for or in describing architecture:
platform and infrastructure. In this text, however, we adhere to accepted distinctions among
these three terms. For example, you might hear IT personnel say that “our systems run on a
Microsoft, HP, and Cisco platform.” Platforms are the specific vendors and technologies that an
organization chooses for its information systems. You might hear of a Windows platform or
web-based platform. Platform choices should be guided by architecture discussions. You might
also hear IT personnel talk about the infrastructure of the healthcare information system.
Infrastructure refers to the entire base of IT that an organization uses—its networks, servers,
workstations, and so on. Organizations choose specific platforms from specific vendors to
implement their infrastructure. An organization’s infrastructure can have several
platforms—CISCO for networks, Microsoft for workstations, and so on. Although infrastructure
is not vendor or technology specific, it is not quite as broad a term as architecture, which
encompasses much more than specific technologies and networks.
In creating an infrastructure, an organization will implement platforms and be guided by its IT
architecture.
Architecture Perspectives
Organizations adopt various frames of reference as they approach the topic of architecture. This
section will illustrate two approaches, one based on the characteristics and capabilities of the
desired architecture and the other based on application integration.
Characteristics and Capabilities
Glaser (2002, p. 62) defines architecture as “the set of organizational, management, and
technical strategies and tactics used to ensure that the organization’s information systems have
critical, organizationally defined characteristics and capabilities.” For example, an organization
can decide that it wants an information system that has characteristics such as being agile,
efficient to support, and highly reliable.
In addition, the organization can decide that its information systems should have capabilities
such as being accessible by patients from their homes or being able to incorporate clinical
decision support. If it wants high reliability, it will need to make decisions about fault-tolerant
computers and network redundancy. If it wants users to be able to customize their clinical
information screens, this will influence its choice of a clinical information system vendor. If it
wants providers to be able to structure clinical documentation, it will need to make choices about
natural language processing, voice recognition, and templates in its electronic medical record.

Architecture choices are guided by organizational decisions about the capabilities and
characteristics that are desired of its information systems.
Application Integration
Another way of looking at information systems architecture is to look at how applications are
integrated across the organization. One often hears vendors talk about architectures such as
best of breed, monolithic, and visual integration. Best of breed describes an architecture that
enables each department to pick the best application it can find and that then attempts to
integrate these applications by means of an interface engine that manages the transfer of data
between these applications—for example, it can send a transaction with registration information
on a new patient from the admitting system to the laboratory system.
Monolithic describes the architecture of a set of applications that all come from one vendor and
that all use a common database management system and common user interface.
Visual integration architecture wraps a common browser user interface around a set of diverse
applications. This interface enables the user, for example, a physician, to use one set of screens
to access clinical data even though those data may come from several different applications.
This view of architecture is focused on the various approaches to the integration of applications:
integration by sharing data between applications, integration by having all applications use one
database, and integration by having an integrated access to data. This view does not address
other aspects of architecture, for example, the means by which the organization might get
information to mobile workers.
Architecture Examples
A few examples will help illustrate how architecture can guide IT choices. Each example begins
with an architecture statement and then shows some choices about core technologies and
applications and the approach to implementing them that might result from this statement.
Statement. We would like to deliver an EHR to our small physician practices that is inexpensive,
reliable, and easy to support. To do this we will
Run the application from our computer room, reducing the need for practice staff members to
manage their own servers and do tasks such as backups and applying application
enhancements
Run several practices on one server to reduce the cost
Obtain a high-speed network connection, and a backup connection, from our local telephone
company to provide good application performance and improve reliability
Statement. We would like to have decision-support capabilities in our clinical information
systems. To do this we will
Purchase our applications from a vendor whose product includes a very robust rules engine

Make sure that the rules engine has the tools necessary to author new decision support and
maintain existing clinical logic
Ensure that the clinical information systems use a single database with codified clinical data
Statement. We want all of our systems to be easy and efficient to support. To do this we will
Adopt industry standard technology, making it easier to hire support staff members
Implement proven technology—technology that has had most of the bugs worked out
Purchase our application systems from one vendor, reducing the support problems and the
finger-pointing that can occur between vendors when problems arise
Observations about Architecture
Organizations will often bypass the architecture discussion in their haste to “get the IT show on
the road and begin implementing stuff.” Haste makes waste, as people say. It is terribly
important to have thoughtful architecture discussions. There are many organizations, for
example, that never took the time to develop thoughtful plans for integrating applications and that
then discovered, after millions of dollars of IT investments, that this oversight meant that they
could not integrate these applications or that the integration would be expensive and limited.
As we will see in Chapter Thirteen, the organizations that have been very effective in their
applications of IT over many years have had a significant focus on architecture. They have
realized that thoughtful approaches to agility, cost efficiency, and reliability have a significant
impact on their ability to continue to apply technology to improve organizational performance.
For example, information systems that are not agile can be difficult (or impossible) to change as
the organization’s needs evolve. This ossification can strangle an organization’s progress. In
addition, information systems that have reliability problems can lead an organization to be
hesitant to implement new, strategically important applications—how can they be sure that this
new application will not go down too often and impair their operations?
Organizational leadership must take time to engage in the architecture discussion. The health
care executive does not need to be involved in deciding which vendor to choose to provide
network switches. But he or she does need a basic understanding of the core technologies in
order to help guide the formation of the principles and strategies that will direct that decision. In
the following example, the application integration perspective on architecture (choosing among
best of breed, monolithic, and visual integration) illustrates a typical architecture challenge that a
hospital might face.
Perspective
Choosing the System Architecture
A hospital has adopted a best-of-breed approach and, over the course of several years, has
implemented separate applications that support the registration, laboratory, pharmacy, and
radiology departments and the transcription of operative notes and discharge summaries. An
interface engine has been implemented that enables registration transactions to flow from the
registration system to the other systems.
However, the physicians and nurses have started to complain. To retrieve a patient’s laboratory,
pharmacy, and radiology records and transcribed materials, they have to sign into each of these

systems, using a separate username and password. To obtain an overall view of a patient’s
condition, they have to print out the results from each of these systems and assemble the
different printouts. All of this takes too much time, and there are too many passwords to
remember.
Moreover, the hospital would like to analyze its care, in an effort to improve care quality, but the
current architecture does not include an integrated database of patient results.
The hospital has two emerging architectural objectives that the current architecture cannot
meet:
Provide an integrated view of a patient’s results for caregivers.
Efficiently support the analysis of care patterns.
To address these objectives, the hospital decides to implement a browser-based application that
will do the following:
Gathers clinical data from each application and presents it in a unified view for the caregivers
Supports the entry of one user ID and password that is synchronized with the user ID and
password for each application
In addition, the hospital decides to implement a database that receives clinical results from each
of the applications and stores this data for access by query tools and analysis software.
To achieve its emerging objectives, the hospital has migrated from best-of-breed architecture to
visual integration architecture. The hospital has also extended to visual integration architecture
by adding an integrated database for analysis purposes.
In analyzing what would be the best architecture to meet its new objectives, the hospital
considered monolithic architecture. It could meet its objectives by replacing all applications with
one integrated suite of applications from one vendor. However, the hospital decided that this
approach would be too expensive and time-consuming. Besides, the current applications
(laboratory, pharmacy, and radiology) worked well; they just weren’t integrated. The monolithic
architecture approach to integration was examined and discarded.
Summary
Acquiring or selecting a new clinical or administrative information system is a major undertaking
for a healthcare organization. It is important that the process be managed effectively. Although
the time and resources needed to select a new system will vary depending on the size,
complexity, and needs of the organization, certain fundamental issues should be addressed in
any system acquisition project.
This chapter discussed the various activities that occur in the system acquisition process.
These activities were presented in the context of a multi physician group practice that wishes to
replace its current paper record with an EHR system by acquiring a system from a reputable
vendor. Key activities in the system selection process are (1) establishing a project steering
committee and appointing a strong project manager to lead the effort, (2) defining project

objectives, (3) screening the vendor marketplace, (4) determining system goals, (5) establishing
system requirements, (6) developing and administering an RFP or RFI, (7) evaluating vendor
proposals, and (8) conducting a cost-benefit analysis on the various options. Other options such
as contracting with a vendor for cloud computing service arrangements or a system developer
were also discussed. This chapter presented some of the issues that can arise during the
system selection process and outlined the importance of documenting and communicating
project activities and progress. Finally, the chapter concluded with a general overview of IT
architecture and its relevance in making IT investment decisions.
References
American Health Information Management Association (AHIMA). (2007). The RFP process for
EHR systems (updated). Retrieved February 2013 from
http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_047961.hcsp?dDocName=
bok1_047961
Armbrust, M., Fox, A., Griffith, R. Joseph, A. D., Katz, R., Konwinski, A., . . . & Zaharia, M.
(2010). A view of cloud computing. Communications of the ACM, 53(4), 50–58.
Brooke, J. (1996). SUS: A “quick and dirty” usability scale. In P. W. Jordan, B. Thomas, I. L.
McClelland, & B. A. Weerdmeester (Eds.), Usability evaluation in industry (pp. 189–194).
London, UK: Taylor & Francis.
Cloud Standards Customer Council. (2012). Impact of cloud computing on healthcare. Retrieved
from
http://www.cloud-council.org/deliverables/CSCC-Impact-of-Cloud-Computing-on-Healthcare
Corrao, N. J., Robinson, A. G., Swiernik, M. A., & Naeim, A. (2010). Importance of testing for
usability when selecting and implementing an electronic health or medical record system.
Journal of Oncology Practice, 6(3), 120–124.
DeLuca, J., & Enmark, R. (2002). The CEO’s guide to health care information systems (2nd
ed.). San Francisco, CA: Jossey-Bass.
Eisenstein, E. L., Jurwishin, D., Kushniruk, A. W., & Nahm, M. (2011). Defining a framework for
health information technology evaluation. Studies in Health Technology and Informatics, 164,
94–99.
Glaser, J. (2002). The strategic application of information technology in health care organizations
(2nd ed.) San Francisco, CA: Jossey-Bass.
Griebel, L., Prokosch, H., Kopcke, F., Toddenroth, D., Christoph, J., Leb, I., Engel, I., &
Sedlmayr, M. (2015). A scoping review of cloud computing in healthcare. BMC Medical
Informatics and Decision Making, 15, 17, 1–16.
Institute of Medicine (IOM). (2011). Health IT and patient privacy: Building safer systems for
better care. Washington, DC: National Academies Press.
Jones, S. S., Koppel, R., Ridgley, M. S., Palen, T., Wu, S., & Harrison, M. I. (2011, Aug.). Guide
to reducing unintended consequences of electronic health records. Rockville, MD: Agency for
Healthcare Research and Quality.
Lewis, J. R., & Sauro, J. (2009). The factor structure of the system usability scale. In
Proceedings of the Human Computer Interaction International Conference (HCII 2009), San
Diego, CA.

Oz, E. (2012). Management information systems: Instructor edition (6th ed.). Boston, MA:
Course Technology.
Wager, K. A., & Lee, F. W. (2006). Introduction to healthcare information systems. In M. Johns
(Ed.), Health information management technology: An applied approach (2nd ed.). Chicago, IL:
American Health Information Management Association.

PHARMACY FORECAST 2017 POPULATION HEALTH MANAGEMENT

30 AM J HEALTH-SYST PHARM | VOLUME 74 | NUMBER 2 | JANUARY 15, 2017

Population Health Management:
Improving the Community to Heal the Patient

Panelists (FPs) predicted that within
the next five years, at least 75% of
health systems will have formal pro-
grams aimed at achieving the highest
quality at the lowest cost for specific
patient populations (Figure 1, item 1).
This suggests that pharmacy practice
leaders will need to give a lot of atten-
tion to developing (and continuously
refining) and enforcing data-driven
treatment protocols for illnesses that
are associated with substantial quality
and cost issues.

COMMUNITY PARTNERSHIPS

Integral to managing popula-
tion health is employing nonmedi-
cal strategies to make communities
healthier. About three fourths of FPs
predicted that at least 50% of health
systems will expand nonmedical sup-
port services (Figure 1, item 2) and
that at least 25% of health systems will
heavily engage community leaders
to manage nonmedical and social is-
sues that affect health (Figure 1, item
3). This can be achieved by partner-
ing with community governments to
improve neighborhood walkability,
make outdoor physical activities more
accessible, promote healthy diets,
eliminate smoking, ensure access to
medical and mental health services,
and reduce alcohol and substance
abuse.2 Use of nontraditional support
services that optimize caregiver labor
costs (e.g., distance health programs
using smartphone applications and
video technology) is another impor-
tant consideration.

MANAGING HIGH-RISK
PATIENTS

As more states improve collabora-
tive practice acts that allow pharma-
cists to add, modify, and discontinue
medications, more opportunities
exist to expand the health system’s
primary care footprint in community

Scott J. Knoer, M.S., Pharm.D.,
FASHP, Chief Pharmacy Officer,
Cleveland Clinic, Cleveland, OH.

Address correspondence to Dr. Knoer
(knoers@ccf.org).

Copyright © 2017, American Society of
Health-System Pharmacists, Inc. All rights
reserved. 1079-2082/17/0102-0030.

INCENTIVIZED PATIENT
WELLNESS

Population health management (PHM) continues to be a top stra-
tegic initiative for health-system
pharmacy leaders because evolving
payment models incentivize patient
wellness. Last year’s Pharmacy Fore-
cast report included a chapter on PHM
that focused on financial incentives.1
This year’s chapter offers an expanded
perspective on PHM and emphasizes
health-related behavioral and societal
issues.

Many health systems are learning
from their experience in self-insuring
their employees and assuming fi-
nancial responsibility for keeping
them healthy. These lessons can be
extrapolated to other populations as
the health system enters into at-risk
contracts with health-benefit plans.
Some health systems are experiencing
decreased healthcare expenditures
and increased employee productiv-
ity through wellness initiatives (e.g.,
premium reductions based on health-
ful weight maintenance, compliance
with disease management programs,
regular exercise encouraged by free
access to fitness centers and free pe-
dometers, avoiding tobacco use).

ACHIEVING HIGHEST
QUALITY AT LOWEST COST

A large majority (84%) of Forecast

pharmacies.3 Notably, 63% of FPs pre-
dicted that over the next five years, it
is at least somewhat likely that 50%
or more of health systems will serve
high-risk patients through formal
programs with community phar-
macies (Figure 1, item 4). Electronic
health records can be used to iden-
tify high-risk patients for pharmacist
interventions, including education,
blood pressure screening, medication
adjustment, appointment facilita-
tion, refill authorization, mail-order
program enrollment, and compli-
ance packaging programs such as for
patients using multiple medications
or those with dementia.

MANAGING MENTAL HEALTH

Last year, 70% of FPs predicted that
at least 25% of health systems would
integrate behavioral and mental
health services with primary care. In
this year’s survey, 67% of FPs predicted
that at least 25% of health systems will
achieve significantly improved out-
comes from such integration within
the next five years (Figure 1, item 5).

While it is generally beyond the
pharmacy department’s ability to
ensure that communities have ade-
quate behavioral health services, the
focus of pharmacy practice leaders is
to ensure that pharmacists improve
outcomes by participating in mental
health teams in specialty and prima-
ry care clinics. As pharmacists inte-
grate into PHM models such as the
medical home, they must have the
expertise to manage mental health
disorders (including depression,
dementia, and schizophrenia) as ef-
fectively as they manage hyperten-
sion and metabolic disorders. Medi-
cation nonadherence and untreated
mental health symptoms guarantee
increased visits to emergency rooms,
productivity loss, and increased so-
cietal costs.

PHARMACY FORECAST 2017POPULATION HEALTH MANAGEMENT

AM J HEALTH-SYST PHARM | VOLUME 74 | NUMBER 2 | JANUARY 15, 2017 31

Figure 1 (Population Health Management). Forecast Panelists’ responses to the question, “How likely is it that the
following will occur by the year 2021 in the geographic region where you work?”

8

0%

60%

40%

20%

0%
Very

Likely
Somewhat

Likely
Somewhat

Unlikely

Very

Unlikely

1 At least 75% of health systems will have formal,
assertive programs aimed at achieving the highest
quality at the lowest cost for specific patient
populations (e.g., oncology, diabetes, inflammatory
and immune disorders) across the continuum of
care.

43% 41%

14%

2%

80%
60%
40%
20%
0%
Very
Likely
Somewhat
Likely
Somewhat

Unlikely
Very

Unlikely

2

3%

53%

20%
3%

2 At least 50% of health systems will significantly
expand their nonmedical support services (e.g.,
transportation, health education, counseling, patient
engagement) to address factors related to poor
health.

80%
60%
40%
20%
0%
Very
Likely
Somewhat
Likely
Somewhat
Unlikely
Very
Unlikely

30%

4

5%

22%

3%

3 At least 25% of health systems will be heavily
engaged with community leaders in programs to
manage the nonmedical/social determinants of
health (e.g., environmental, cultural, and economic
factors).

80%
60%
40%
20%
0%
Very
Likely
Somewhat
Likely
Somewhat
Unlikely
Very
Unlikely

17%

46%

27%

9%

4 At least 50% of health systems will serve high-
risk patients (e.g., those with cancer, congestive
heart failure, HIV) through formal programs with
community pharmacies (e.g., for adherence
coaching, patient monitoring) that they own or are in
partnership with.

80%
60%
40%
20%
0%
Very
Likely
Somewhat
Likely
Somewhat
Unlikely
Very
Unlikely

19%

48%

28%

5%

5 Through the integration of behavioral health services
with primary care, at least 25% of health systems
will achieve significantly better outcomes related
to comorbid conditions in patients who suffer from
mental health disorders. 80%

60%
40%
20%
0%
Very
Likely
Somewhat
Likely
Somewhat
Unlikely
Very
Unlikely

66%

22%
12%

0%

6 At least 75% of health systems will have a major
campaign aimed at improving the prescribing of
opioids.

PHARMACY FORECAST 2017 POPULATION HEALTH MANAGEMENT

32 AM J HEALTH-SYST PHARM | VOLUME 74 | NUMBER 2 | JANUARY 15, 2017

STRATEGIC RECOMMENDATIONS FOR PRACTICE LEADERS

1. Leverage the pharmacy enter-
prise to achieve optimal medi-
cation adherence by high-risk
patients. In pursuit of this goal,
include risk-stratification tech-
niques, telehealth applications,
collaborative practice in clinics
and community pharmacies,
refill authorization, compli-
ance packaging, and bedside
discharge-prescription delivery.

2. If your institution self-insures
its employees for healthcare
coverage, use that program to
pilot innovative pharmacy ser-
vices (such as targeted disease
state management) that can be
offered to other health-benefit
plans.

3. Create a pharmacy refill clinic
that allows physicians to opti-
mize their time with patients
while improving medication-
use safety, adherence, and
outcomes.

4. Identify and implement ways
for the pharmacy enterprise
to actively contribute to your
health system’s support ser-
vices for high-risk patients,
including efforts in telehealth,
patient education, and motiva-
tional interviewing for improv-
ing adherence.

5. Assertively incorporate a
behavioral health component
into pharmacist patient care,
including chronic disease
management and prescription
assistance programs.

6. Ensure that your pharmacy
enterprise is actively addressing
the opioid crisis through means
such as an opioid stewardship
program, effective opioid-
diversion prevention, support of
prescription-medication dis-
posal programs, and promo-
tion of improved public access
to naloxone.

THE OPIOID CRISIS
The United States is experiencing

an unprecedented increase in mor-
bidity and mortality associated with
the misuse and abuse of opioids.4
This epidemic results in substantial
treatment costs, decreased workplace
performance, and devastating effects
on families and communities. Con-
gressional recognition of this crisis led
to bipartisan passage of the Compre-
hensive Addiction and Recovery Act of
2016.5

Two thirds of FPs predicted that
within the next five years, it is very
likely that at least 75% of health sys-
tems will have a major campaign
aimed at improving the prescribing
of opioids (Figure 1, item 6). These

efforts will probably include opioid
stewardship programs based on pre-
scribing guidelines for chronic pain
issued by the Centers for Disease Con-
trol and Prevention.6 It is important to
partner with law enforcement, patient
families, community pharmacies, and
ambulance services to ensure nalox-
one access and expanded drug take-
back programs.

Diversion of controlled substanc-
es can have a major financial impact
on health systems, as reflected by the
$2.3 million settlement paid to the
United States by a major Boston insti-
tution to resolve drug diversion allega-
tions.7 In addition to focusing on retail
pharmacy chains and wholesalers, the
Drug Enforcement Administration

now targets health systems for diver-
sion and compliance issues. A proac-
tive health-system approach toward
preventing diversion of controlled
substances could integrate state-
automated opioid reporting into elec-
tronic health records to monitor and
improve prescriber compliance.

Disclosures
Dr. Knoer is a contributing editor of
AJHP. He has declared no other potential
conflicts of interest.

References
1. Shane R, Deculus CL. Population

health management: aligning incen-
tives to transform care delivery. In:
Zellmer WA, ed. Pharmacy forecast
2016–2020: strategic planning advice
for pharmacy departments in hos-
pitals and health systems. Bethesda,
MD: ASHP Research and Education
Foundation; 2015:9-12.

2. Community Commons. Community
health needs assessment toolkit.
http://assessment.communitycom-
mons.org/CHNA/About.aspx
(accessed 2016 Aug 20).

3. Knoer SJ, Luder DD, Hill JM et al.
Lessons learned in updating and im-
proving a state collaborative practice
act. Am J Health-Syst Pharm. 2016;
73:1462-6.

4. Kolodny A, Courtwright DT, Hwang
CS et al. The prescription opioid and
heroin crisis: a public health ap-
proach to an epidemic of addiction.
Annu Rev Public Health. 2015; 36:559-
74.

5. Comprehensive Addiction and Recov-
ery Act of 2016. www.congress.gov/
bill/114th-congress/senate-bill/524/
text (accessed 2016 Aug 20).

6. Centers for Disease Control and Pre-
vention. CDC guideline for prescrib-
ing opioids for chronic pain—United
States, 2016. www.cdc.gov/mmwr/
volumes/65/rr/rr6501e1.htm
(accessed 2016 Aug 20).

7. U.S. Department of Justice. MGH
to pay $2.3 million to resolve drug
diversion allegations (September 28,
2015). www.justice.gov/usao-ma/pr/
mgh-pay-23-million-resolve-drug-
diversion-allegations (accessed 2016
Aug 20).

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Chapter 6
System Implementation and Support
Learning Objectives
To be able to discuss the process that a health care organization typically goes through in
implementing a health care information system.
To be able to assess the organizational and behavioral factors that can affect system
acceptance and use and strategies for managing change.
To be able to develop a sample system implementation plan for a health care information
system project, including the types of individuals who should be involved.
To gain insight into many of the things that can go wrong during system implementations and
strategies that health care manager can employ to alleviate potential problems.
To be able to discuss the importance of training, technical support, infrastructure, and ongoing
maintenance and evaluation of any health care information system project.
Once a health care organization has finalized its contract with the vendor to acquire an
information system, the system implementation process begins. Selecting the right system
does not ensure user acceptance and success; the system must also be incorporated
effectively into the day-to-day operations of the health care organization and adequately
supported or maintained. Whether the system is built in-house, designed by an outside
consultant, or leased or purchased from a vendor, it will take a substantial amount of planning
and work to get the system up and running smoothly and integrated into operations.
This chapter focuses on the two final stages of the system development life cycle:
implementation and then support and evaluation. It describes the planning and activities that
should occur when implementing a new system. Our discussion focuses on a vendor-acquired
system; however, many of the activities described also apply to systems designed in-house, by
an outside developer, or acquired or leased through cloud-based computing services.
Implementing a new system (or replacing an old system) can be a massive undertaking for a
health care organization. Not only are there workstations to install, databases to build, and
networks to test but also there are processes to redesign, users to train, data to convert, and
procedures to write. There are countless tasks and details that must be appropriately
coordinated and completed if the system is to be implemented on time and within budget—and
widely accepted by users. Essential to the process is ensuring that the introduction of any new
health care information system or workflow change results in improved organizational
performance, such as a reduction in medication errors, an improvement in care coordination,
and more effective utilization of tests and procedures.
Concerns have been raised about the potential for EHRs to result in risk to patient safety. Health
care information systems such as EHRs are enormously complex and involve not only the
technology (hardware and software) but also people, processes, workflow, organizational
culture, politics, and the external environment (licensure, accreditation, regulatory agencies).
The Institute of Medicine published a report that offers health care organizations and vendors
suggestions on how to work collaboratively to make health IT safer (IOM, 2011). Poor
user-interface designs, ineffective workflow, and lack of interoperability are all considered

threats to patient safety. Several of the suggested strategies for ensuring system safety are
discussed in this chapter.
Along with attending to the many activities or tasks associated with system implementation, it is
equally important to manage change effectively and address organizational and behavioral
issues. Studies have shown that over half of all information system projects fail. Numerous
political, cultural, behavioral, and ethical factors can affect the successful implementation and
use of the new system (Ash, Anderson, & Tarczy-Hornoch, 2008; Ash, Sittig, Poon, Guappone,
Campbell, & Dykstra, 2007; McAlearney, Hefner, Sieck, & Huerta, 2015; Sittig & Singh, 2011).
We devote a section of this chapter to strategies for managing change and the organizational
and behavioral issues that can arise during the system implementation process. The chapter
concludes by describing the importance of supporting and maintaining information systems.
System Implementation Process
System implementation begins once the organization has acquired the system and continues
through the early stages following the go-live date (the date when the system is put into general
use for everyone). Similar to the system acquisition process, the system implementation
process must have a high degree of support from the senior executive team and be viewed as
an organizational priority. Sufficient staff, time, and resources must be devoted to the project.
Individuals involved in rolling out the new system should have sufficient resources available to
them to ensure a smooth transition.
The time and resources needed to implement a new health care information system can vary
considerably depending on the scope of the project, the needs and complexity of the
organization, the number of applications being installed, and the number of user groups involved.
There are, however, some fundamental activities that should occur during any system
implementation, regardless of its size or scope:
Organize the implementation team and identify a system champion.
Clearly define the project scope and goals.
Identify accountability for the successful completion of the project.
Establish and institute a project plan.
Failing to appropriately plan for and manage these activities can lead to cost overruns,
dissatisfied users, project delays, and even system sabotage. In fact, during the industry rush to
take advantage of CMS incentive dollars, a flurry of EHR stories hit the news—with everything
from CIOs and CEOs losing their jobs as a result of “failed” EHR implementations, to hospital
operations screeching to a halt, to significant financial problems arising from glitches in the
revenue cycle. These high-profile cases brought national attention to the consequences of a
failed implementation. During system implementation, facilities often see their days in accounts
receivable and denials increase while cash flow slows. By organizations anticipating risks to the
revenue cycle prior to go-live and as part of EHR workflow, they are in a much better position to
stay on track and maintain positive financial performance during the transition (Daly, 2016). In
today’s environment, in which capital is scarce and resources are limited, health care
organizations cannot afford to mismanage implementation projects of this magnitude and
importance. Examining lessons learned from others can be helpful.

Organize the Implementation Team and Identify a Champion
One of the first steps in planning for the implementation of a new system is to organize an
implementation team. The primary role and function of the team is to plan, coordinate, budget,
and manage all aspects of the new system implementation. Although the exact team
composition will depend on the scope and nature of the new system, a team might include a
project leader, system champion(s), key individuals from the clinical and administrative areas
that are the focus of the system being acquired, vendor representatives, and information
technology (IT) professionals. For large or complex projects, it is also a good idea to have
someone skilled in project management principles on the team. Likewise, having a strong
project leader and the right mix of people is critically important.
Implementation teams often include some of the same people involved in selecting the system;
however, they may also include other individuals with knowledge and skills important to the
successful deployment of the new system. For example, the implementation team will likely
need at least one IT professional with technical database and network administration expertise.
This person may have had some role in the selection process but is now being called on to
assume a larger role in installing the software, setting up the data tables, and customizing the
network infrastructure to adequately support the system and the organization’s needs.
The implementation team should also include at least one system champion. A system
champion is someone who is well respected in the organization, sees the new system as
necessary to the organization’s achievement of its strategic goals, and is passionate about
implementing it. In many health care settings the system champion is a physician, particularly
when the organization is implementing a system that will directly or indirectly affect how
physicians spend their time. The physician champion serves as an advocate of the system,
assumes a leadership role in gaining buy-in from other physicians and user groups, and makes
sure that physicians have adequate input into the decision-making process. Other important
qualities of system champions are strong communication, interpersonal, and listening skills. The
system champion should be willing to assist with pilot testing, to train and coach others, and to
build consensus among user groups (Miller & Sim, 2004). Numerous studies have
demonstrated the importance of the system champion throughout the implementation process
(Ash, Stavri, Dykstra, & Fournier, 2003; Daly, 2016; Miller, Sim, & Newman, 2003; Wager, Lee,
White, Ward, & Ornstein, 2000; Yackanicz, Kerr, & Levick, 2010). When implementing clinical
applications that span numerous clinical areas, such as nursing, pharmacy, and physicians,
having a system champion from each division can be enormously helpful in gaining buy-in and
in facilitating communication among staff members. The various system champions can also
assume a pivotal role in ensuring that project milestones are achieved and celebrated.
Clearly Define the Project Scope and Goals
One of the implementation team’s first items of business is to determine the scope of the project
and develop tactical plans. To set the tone for the project, a senior health care executive should
meet with the implementation team to communicate how the project relates to the organization’s
overall strategic goals and to assure the team of the administration’s commitment to the project.
The senior executive should also explain what the organization or health system hopes the
project will achieve.

The goals of the project and what the organization hopes to achieve by implementing the new
system should emerge from early team discussions. The system goals defined during the
system selection process (discussed in Chapter Five) should be reviewed by the
implementation team. Far too often health care organizations skip this important step and never
clearly define the scope of the project or what they hope to gain as a result of the new system.
At other times they define the scope of the project too broadly or scope creep occurs. The goals
should be specific, measurable, attainable, relevant, and timely. They should also define the
organization’s criteria for success (Cusack & Poon, 2011).
Let’s look at two hypothetical examples from two providers that we will call Rutledge Retirement
Community and St. Luke’s Medical Center. The implementation team at Rutledge Retirement
Community defined its goal and the scope of the project and devised measures for evaluating
the extent to which Rutledge achieved this goal. The implementation team at St. Luke’s Medical
Center was responsible for completing Phase 1 of a three-part project; however, the scope of
the team’s work was never clearly defined.
Case Study
Rutledge Retirement Community
Rutledge Retirement Community in a Commission on Accreditation of Rehabilitation Facilities
(CARF)–accredited continuum of care community offers residential, assisted living, and skilled
care to residents in southern Georgia. An implementation team was formed and charged with
managing all aspects of the EHR rollout. Rutledge’s mission is to be “the premier continuum of
care facility in the region providing high-quality, resident-centered care with family engagement.”
Considering how to achieve this mission, the team identified the EHR as the building block
needed to improve care coordination, reduce medication errors, and create communication
channels with families of residents by offering a family portal. In addition to establishing this goal,
the team went a step further to define what a successful EHR implementation initiative would
consist of. Team members then developed a core set of metrics—reduction in medication
errors, reduction in duplicate services, and increased communication with family regarding
residents’ health status. Family and caregiver satisfaction with communication were also
assessed.
St. Luke’s Medical Center
St. Luke’s Medical Center set out to implement a digital medical record, planning to do so in
three phases. Phase 1 would involve establishing a clinical data repository, a central database
from which all ancillary clinical systems would feed. Phase 2 would consist of the
implementation of computerized physician order entry (CPOE) and nursing documentation
systems, and Phase 3 would see the elimination of all outside paper reports through the
implementation of a document-imaging system. St. Luke’s staff members felt that if they could
complete all three phases, they would have, in essence, a true electronic or digital patient
record. The implementation team did not, however, clearly define the scope of its work. Was it to
complete Phase 1 or all three phases? Likewise, the implementation team never defined what it
hoped to accomplish or how implementation of the digital record fit into the medical center’s
overall mission or organizational goals. It never answered the question, How will we know if we
are successful? Some project team members argued that a digital record was not the same as

an EHR and questioned whether the team was headed down the right path. The ambiguity of the
implementation team’s scope of work led to disillusionment and a sense of failing to ever finish
the project.
Identify Accountability for the Successful Completion of the Project
Four roles are important in the management of large health care information system projects:
Business sponsor
Business owner
Project manager
IT manager
Business Sponsor
The business sponsor is the individual who holds overall accountability for the project. The
sponsor should represent the area of the organization that is the major recipient of the
performance improvement that the project intends to deliver. For example, a project that
involves implementing a new claims processing system may have the chief financial officer as
the business sponsor. A project to improve nursing workflow may ask the chief nursing officer to
serve as business sponsor. A project that affects a large portion of the organization may have
the CEO as the business sponsor.
The sponsor’s management or executive level should be appropriate to the magnitude of the
decisions and the support that the project will require. The more significant the undertaking, the
higher the organizational level of the sponsor.
The business sponsor has several duties:
Secures funding and needed business resources—for example, the commitment of people’s
time to work on the project
Has final decision-making and sign-off accountability for project scope, resources, and
approaches to resolving project problems
Identifies and supports the business owner(s) (discussed in the next section)
Promotes the project internally and externally and obtains the buy-in from business constituents
Chairs the project steering committee and is responsible for steering committee participation
during the life of the project
Helps define deliverables, objectives, scope, and success criteria with identified business
owners and the project manager
Helps remove business obstacles to meeting the project timeline and producing deliverables, as
appropriate
Business Owner
A business owner generally has day-to-day responsibility for running a function or a department;
for example, a business owner might be the director of the clinical laboratories. A project may
need the involvement of several business owners. For example, the success of a new patient
accounting system may depend on processes that occur during registration and scheduling
(and hence the director of outpatient clinics and the director of the admitting department will both
be business owners) and may also depend on adequate physician documentation of the care
provided (and hence the administrator of the medical group will be another business owner).

Business owners often work on the project team. Among their several responsibilities are the
following:
Representing their department or function at steering committee and project team meetings
Securing and coordinating necessary business and departmental resources
Removing business obstacles to meeting the project timeline and producing deliverables, as
appropriate
Working jointly with the project manager on several tasks (as described in the next section)
Project Manager
The project manager does just that—manages the project. He or she is the person who
provides the day-to-day direction setting, conflict resolution, and communication needed by the
project team. The project manager may be an IT staffer or a person in the business, or function,
benefiting from the project. Among their several responsibilities, project managers accomplish
the following:
Identify and obtain needed resources.
Deliver the project on time, on budget, and according to specification.
Communicate progress to sponsors, stakeholders, and team members.
Ensure that diligent risk monitoring is in place and appropriate risk mitigation plans have been
developed.
Identify and manage the resolution of issues and problems.
Maintain the project plan.
Manage project scope.
tasks. Together they set meeting agendas, manage the meetings, track project progress,
communicate project status, escalate issues as appropriate, and resolve deviations and issues
related to the project plan.
IT Manager
The IT manager is the senior IT person assigned to the project. In performing his or her
responsibilities, the IT manager does the following:
Represents the IT department
Has final IT decision-making authority and sign-off accountability
Helps remove IT obstacles to meeting project timelines and producing deliverables
Promotes the project internally and externally and obtains buy-in from IT constituents
Establish and Institute a Project Plan
Once the implementation team has agreed on its goals and objectives and has identified key
individuals responsible for managing the project, the next major step is to develop and
implement a project plan. The project plan should have the following components:
Major activities (also called tasks)
Major milestones
Estimated duration of each activity

Any dependencies among activities (so that, for example, one task must be completed before
another can begin)
Resources and budget available (including staff members whose time will be allocated to the
project)
Individuals or team members responsible for completing each activity
Target dates
Measures for evaluating completion and success
These are the same components one would find in most major projects. What are the major
activities or tasks that are unique to system implementation projects? Which tasks must be
completed first, second, and so forth? How should time estimates be determined and
milestones defined?
System implementation projects tend to be quite large, and therefore it can be helpful to break
the project into manageable components. One approach to defining components is to have the
implementation team brainstorm and identify the major activities that need to be done before the
go-live date. Once these tasks have been identified, they can be grouped and sequenced based
on what must be done first, second, and so forth. Those tasks that can occur concurrently
should also be identified (see Figure 6.1.). A team may find it helpful to use a consultant to guide
it through the implementation process. Or the health care IT vendor may have a suggested
implementation plan; the team must make sure, however, that this plan is tailored to suit the
unique needs of the organization in which the new system is to be introduced.
The subsequent sections describe the major activities common to most information system
implementation projects (outlined in the “Typical Components of an Implementation Plan” box)
and may serve as a guide. These activities are not necessarily in sequential order; the order
used should be determined by the institution in accordance with its needs and resources.
Workflow and Process Analysis
One of the first activities necessary in implementing any new system is to review and evaluate
the existing workflow or business processes. Members of the implementation team might also
observe the current information system in use (if there is one). Does it work as described?
Where are the problem areas? What are the goals and expectations of the new system? How
do organizational processes need to change in order to optimize the new system’s value and
achieve its goals? Too often organizations never critically evaluate current business processes
but plunge forward implementing the new system while still using old procedures. The result is
that they simply automate their outdated and inefficient processes.
Before implementing any new system, the organization should evaluate existing procedures and
processes and identify ways to improve workflow, simplify tasks, eliminate redundancy,
improve quality, and improve user (customer) satisfaction. In complex settings, it can be
critically important to have informatics professionals such as CMIOs and CNIOs actively
involved in the implementation team in analyzing workflow and information flow (Elias,
Barginere, Berry, & Selleck, 2015). Although describing them is beyond the scope of this book,
many extremely useful tools and methods are available for analyzing workflow and redesigning

business processes (see, for example, Guide to Reducing Unintended Consequences of
Electronic Health Records, by Jones, Koppel, Ridgley, Palen, Wu, & Harrison, 2011). Observing
the old system in use, listening to users’ concerns, and evaluating information workflow can
identify many of the changes needed. In addition, the vendor generally works with the
organization to map its future workflow using flowcharts or flow diagrams. It is critical that all key
areas affected by the new system participate in the workflow analysis process so that potential
problems can be identified and addressed before the system goes live. For example, if a new
CPOE application is to be implemented using a phased-in approach, in which the system will
go-live unit by unit over a three-month process, how will the organization ensure orders are not
lost or duplicated if a patient is transferred between a unit using CPOE and a unit using
handwritten orders? What will downtime procedures entail? If paper orders are generated during
downtime, how will these orders be stored or become part of the patient’s permanent medical
record?
Typical Components of an Implementation Plan
Workflow and process analysis
Analyze or evaluate current process and procedures.
Identify opportunities for improvement and, as appropriate, effect those changes.
Identify sources of data, including interfaces to other systems.
Determine location and number of workstations needed.
Redesign physical location as needed.
System installation
Determine system configuration.
Order and install hardware.
Prepare data center.
Upgrade or implement IT infrastructure.
Install software and interfaces.
Customize software.
Test, retest, and test again . . .
Staff training
Identify appropriate training method(s) to be used for each major user group.
Prepare training materials.
Train staff members.
Test staff member proficiency.
Update procedure manuals.
Conversion
Convert data.
Test system.
Communications
Establish communication mechanisms for identifying and addressing problems and concerns.
Communicate regularly with various constituent groups.
Preparation for go-live date
Select date when patient volume is relatively low.
Ensure sufficient staff members are on hand.

Set up mechanism for reporting and correcting problems and issues.
Review and effect process reengineering.
System downtime procedures
Develop downtime procedures.
Train staff members on downtime procedures.
Involving users at this early stage of the implementation process can gain initial buy-in to the
idea and the scope of the process redesign. In all likelihood, the organization will need to institute
a series of process changes as a result of the new system. Workflow and processes should be
evaluated critically and redesigned as needed. For example, the organization may find that it
needs to do away with old forms or work steps, change job descriptions or job responsibilities,
or add to or subtract from the work responsibilities of particular departments. Getting users
involved in this reengineering process can lead to greater user acceptance of the new system.
Let’s consider an example. Suppose a multiphysician clinic is implementing a new practice
management system that includes a patient portal for appointment scheduling, prescription
refills, and paying bills. The clinic might wish to begin by appointing a small team of individuals
knowledgeable about analyzing workflow and processes to work with staff members in studying
the existing process for scheduling patient appointments, refilling prescriptions, and patient
billing. This team might conduct a series of individual focus groups with schedulers, physicians
and nurses, and patients, and ask questions such as these:
Who can schedule patient appointments?
How are patient appointments made, updated, or deleted?
Who has access to scheduling information? From what locations?
How well does the current system work? How efficient is the process?
What are the major problems with the current scheduling system and process? In what ways
might it be improved?
The team should tailor the focus questions so they are appropriate for each user group. The
answers can then be a guide for reengineering existing processes and workflow to facilitate the
new system. A similar set of questions could be asked concerning the refill of prescriptions or
patient billing processes.
During the workflow analysis, the team should also examine where the new system’s actual
workstations will be located, how many workstations will be needed, and how information will
flow between manual organizational processes (such as phone calls) and the electronic
information system. Here are a few of the many questions that should be addressed in ensuring
that physical layouts are conducive to the success of the new system:
Will the workstations be portable or fixed? If users are given portable units, how will these be
tracked and maintained (and protected from loss or theft)? If workstations are fixed, will they be
located in safe, secure areas where patient confidentiality can be maintained?
How will the user interact with the new system?
Does the physical layout of each work area need to be redesigned to accommodate the new
system and the new process?

Will additional wiring be needed?
How will the new system affect the workflow within the practice among office staff members,
nurses, and physicians?
Will the e-prescribing function with local pharmacies be affected by the change?
System Installation
The next step, which may be done concurrently with the workflow analysis, is to install the
hardware, software, and network infrastructure to support the new information system and build
the necessary interfaces. IT staff members play a crucial role in this phase of the project. They
will need to work closely with the vendor in determining system specifications and
configurations and in preparing the computer center for installation. It may be, for example, that
the organization’s current computer network will need to be replaced or upgraded. During
implementation, having adequate numbers of computer workstations placed in readily
accessible locations is critical. Those involved in the planning need to determine beforehand the
maximum number of individuals likely to be using the system at the same time and
accommodate this scenario. Vendors may recommend a certain number of workstations or use
of hand-held devices; however, the organization must ensure the recommendations are
appropriate.
Typically when a health care organization acquires a system from a vendor, quite a bit of
customization is needed. IT personnel will likely work with the vendor in setting up and loading
data tables, building interfaces, and running pilot tests of the hardware and software using actual
patient and administrative data. It is not unlikely when purchasing a clinical application such as
order entry from a vendor, for example, that the health care organization is provided a shell or
basic framework from which to build the order sets or electronic forms. A great deal of
customization and building of templates occurs. Thus, it is a good idea to pay physicians for
their time involved in the project. For instance, if you need a physician’s time to assist in building
or reviewing order sets for the cardiology division, factor that into the resources needed for the
project, perhaps by allocating two hours per week to the project for a certain period of time.
Otherwise, you may be pulling physicians away from seeing patients and revenue-generating
activities. It demonstrates the value placed on the physician’s time and commitment to the
project.
We recommend piloting the system in a unit or area before rolling out the system
enterprise-wide. This test enables the implementation team to evaluate the system’s
effectiveness, address issues and concerns, fix bugs, and then apply the lessons learned to
other units in the organization before most people even start using the system. Vendors will
often offer guiding principles and strategies that they have found effective in implementing
systems.
Consideration should be given to choosing an appropriate area (for example, a department or a
location) or set of users to pilot the system. Following are some of the questions the
implementation team should consider in identifying potential pilot sites:

Which units or areas are willing and equipped to serve as a pilot site? Do they have sufficient
interest, administrative support, and commitment?
Are the staff and management teams in each of these units or areas comfortable with being
system guinea pigs?
Do staff members have the time and resources needed to serve in this capacity?
Is there a system champion in each unit or area who will lead the effort?
In migrating from one electronic system to another, such as from a legacy EHR to a new EHR,
it may be more appropriate to go-live at once, instead of a more staggered or phased approach.
For example, when Bon Secours Health System embarked on the implementation of an EHR
system among fourteen hospitals, they decided after the second hospital EHR implementation
to adopt the EHR vendor’s revenue cycle system along with the clinical application, and go-live
with both systems at once (Daly, 2016). This enabled them to monitor clinical and financial
indicators at the same time and ensure that the charge master and revenue cycle teams
worked collaboratively prior to and following implementation.
Staff Training
Training is an essential component of any new system implementation. Although no one would
argue with this statement, the implementation team will want to consider many issues as it
develops and implements a training program:
How much training is needed? Do different user groups have different training needs?
Who should conduct the training?
When should the training occur? What intervals of training are ideal?
What training format is best: for example, formal, classroom-style training; one-on-one or
small-group training; computer-based training; or a combination of methods?
What is the role of the vendor in training?
Who in the organization will manage or oversee the training? How will training be documented?
What criteria and methods will be used to monitor training and ensure that staff members are
adequately trained? Will staff members be tested on proficiency?
What additional training and support are available to physicians and others after go-live?
There are various methods of training. One approach, commonly known as train the trainer,
relies on the vendor to train selected members of the organization who will then serve as
super-users and train others in their respective departments, units, or areas. These super-users
should be individuals who work directly in the areas in which the system is to be used; they
should know the staff members in the area and have a good rapport with them. They will also
serve as resources to other users once the vendor representatives have left. They may do a lot
of one-on-one training, hand-holding, and other work with people in their areas until these
individuals achieve a certain comfort level with the system. The main concern with this
approach is that the organization may devote a great deal of time and resources to training the
trainers only to have these trainers leave the institution (often because they’ve been lured away
by career opportunities with the vendor).
Another method is to have the vendor train a pool of trainers who are knowledgeable about the
entire system and who can rotate through the different areas of the organization working with

staff members. The trainer pool might include IT professionals (including clinical analysts) and
clinical or administrative staff members such as nurses, physicians, lab managers, and
business managers.
Regardless of who conducts the training, it is important to introduce fundamental or basic
concepts first and enable people to master these concepts before moving on to new ones.
Studies among health care organizations that have implemented clinical applications such as
CPOE systems have shown that classroom training is not nearly as effective as one-on-one
coaching, particularly among physicians (Holden, 2011; Metzger & Fortin, 2003). Most systems
can track physician use; physicians identified as low-volume users may be targeted for
additional training.
Timing of the training is also important. Users should have ample opportunity to practice before
the system goes live. For instance, when a nursing documentation system is being installed,
nurses should have the chance to practice with it at the bedside of a typical patient. Likewise,
when a CPOE system is going in, physicians should get to practice ordering a set of tests
during their morning rounds. This just-in-time training might occur several times, for example,
three months, two months, one month, and one week before the go-live date. Its purpose is to
enable users to practice on the system multiple times before go-live. Training might be
supplemented with computer-based training modules that enable users to review concepts and
functions at their own pace. Training has to be a priority and at least some of training should be
in an environment free of distractions. Eventually staff members will want to use the system in a
near-live or simulated environment. Additional staff members should be on hand during the
go-live period to assist users as needed during the transition to the new system. In general, the
implementation team should work with the vendor to produce a thoughtful and creative training
program.
Once the details of how the new system is to work have been determined, it is important to
update procedure manuals and make the updated manuals available to the staff members.
Designated managers or representatives from the various areas may assume a leadership role
in updating procedure manuals for their respective areas. When people must learn specific IT
procedures such as how to log in, change passwords, and read common error messages, the
IT department should ensure that this information appears in the procedure manuals and that the
information is routinely updated and widely disseminated to the users. Procedure manuals serve
as reference guides and resources for users and can be particularly useful when training new
employees.
Effective training is important. Staff members need to be relatively comfortable with the
application and need to know to whom they should turn if they have questions or concerns. We
recommend having the users evaluate the training prior to go-live.
Conversion
Another important task is to convert the data from the old system to the new system and then
adequately test the new system. Staff members involved in the data conversion must determine
the sources of the data required for the new system and construct new files. It is particularly

important that data be complete, accurate, and current before being converted to the new
system. Data should be cleaned before being converted. Once converted, the data should run
through a series of validation checkpoints or procedures to ensure the accuracy of the
conversion.
IT staff members who are knowledgeable in data conversion procedures should lead the effort
and verify the results with key managers from the appropriate clinical and administrative areas.
The specific conversion procedures used will depend on the nature of the old system and its
structure as well as on the configuration of the new system.
Finally, the new system will need to be tested. The main purpose of the testing is to simulate the
live environment as closely as possible and determine how well the system and accompanying
procedures work. Are there programming glitches or other problems that need to be fixed? How
well are the interfaces working? How does response time compare to what was expected? The
system should be populated with live data and tested again. Vendors, IT staff members, and
user staff members should all participate in the testing process. As with training, one can never
test too much. A good portion of this work has to be done for the pilot testing. It may need to be
repeated before going live. And the pilot lessons will guide any additional testing or conversion
that needs to be done. In some cases, it may be advisable to run the old and new systems in
tandem (parallel conversion) for a period of time until it is evident that the new system is
operating effectively. This can reduce organizational risk. Again, running parallel systems is not
always feasible or appropriate. Instead, organizations may opt to implement the system using a
phased approach over a period of time.
Communications
Equally as important as successfully carrying out the activities discussed so far is having an
effective plan for communicating the project’s progress. This plan serves two primary purposes.
First, it identifies how the members of the implementation team will communicate and coordinate
their activities and progress. Second, it defines how progress will be communicated to key
constituent groups, including but not limited to the board, the senior administrative team, the
departments, and the staff members at all levels of the organization affected by the new system.
The communication plan may set up formal and informal mechanisms. Formal communication
may include everything from regular updates at board and administrative meetings to written
briefings and articles in the facility newsletter. The purpose should be to use as many channels
and mechanisms as possible to ensure that the people who need to know are fully informed and
aware of the implementation plans. Informal communication is less structured but can be
equally important. Implementing a new health care information system is a major undertaking,
and it is important that all staff members (day, evening, and night shifts) be made aware of what
is happening. The methods for communication may be varied, but the message should be
consistent and the information presented up-to-date and timely. For example, do not rely on
e-mail communication as your primary method only to discover later that your organization’s
nurses do not regularly check their e-mail or have little time to read your type of message.
Preparation for System Go-Live

A great deal of work goes into preparing for the go-live date, the day the organization transitions
from the old system to the new. Assuming the implementation team has done all it can to ensure
that the system is ready, the staff members are well trained, and appropriate procedures are in
place, the transition should be a smooth one. Additional staff members should be on hand and
equipped to assist users as needed. It is best to plan for the system to go-live on a day when
the patient census is typically low or fewer patients than usual are scheduled to be seen.
Disaster recovery plans should also be in place, and staff members should be well trained on
what to do should the system go down or fail. Designated IT staff members should monitor and
assess system problems and errors.
System Downtime Procedures
One thing that you can count on is that systems will go down. Both scheduled and unscheduled
downtime exist, and downtime procedures need to be developed and communicated well before
go-live. Any negative impact will be minimized if the organization has invested in a stable and
secure technical IT infrastructure and backup procedures and fail-safe systems are in place.
But everyone needs to know what to do if the system is down, from the registration staff
members to the nursing staff members to the medical staff members and the transport team.
How will orders be placed? If a paper record is kept during downtime, what is the procedure for
getting the documentation in electronic form when the system is up again? How will scheduled
downtime be communicated to units? And all staff members? If an organization relies heavily on
computerized systems to care for patients, downtime should be minimal or near 0 percent.
However, business continuity procedures must be in place to ensure patient safety and
continuity of care.
Managing Change and the Organizational Aspects
Implementing an information system in a health care facility can have a profound impact on the
organization, the people who work there, and the patients they serve. Individuals may have
concerns and apprehensions about the new system: How will the new system affect my job
responsibilities or productivity? How will my workload change? Will the new system cause me
more or less stress? Even individuals who welcome the new system, see the need for it, and
see its potential value may worry: What will I do if the system is down? Will the system impede
my relationship with my patients? Who will I turn to if I have problems or questions? Will I be
expected to type my notes into the system? With the new system comes change, and change
can be difficult if not managed effectively.
Effecting Organizational Change
The management strategies required to manage change depend on the type of change. As one
moves from incremental to fundamental change, the magnitude and risk of the change increase
enormously, as does the uncertainty about the form and success of the outcome.
Managing change has several necessary aspects:
Leadership
Language and vision
Connection and trust

Incentives
Planning, implementing, and iterating (Keen, 1997)
Leadership
Change must be led. Leadership, often in the form of a committee of leaders, will be necessary
to accomplish the following:
Define the nature of the change.
Communicate the rationale for and approach to the change.
Identify, procure, and deploy necessary resources.
Resolve issues and alter direction as needed.
Monitor the progress of the change initiative.
This leadership committee needs to be chaired by an appropriate senior leader. If the change
affects the entire organization, the CEO should chair the committee. If the change is focused on
a specific area, the most senior leader who oversees that area should chair the committee.
Language and Vision
The staff members who are experiencing the change must understand the nature of the change.
They must know what the world will look like (to the degree that this is clear) when the change
has been completed, how their roles and work life will be different, and why making this change
is important. The absence of this vision or a failure to communicate the importance of the vision
elevates the risk that staff members will resist the change and through subtle and not-so-subtle
means cause the change to grind to a halt. Change is hard for people. They must understand
the nature of the change and why they should go through with what they will experience as a
difficult transition.
Leaders might describe the vision, the desired outcome of efforts to improve the outpatient
service experience, in this way:
Patients should be able to get an appointment for a time that is most convenient for them.
Patients should not have to wait longer than ten minutes in the reception area before a provider
can see them.
We should communicate clearly with patients about their disease and the treatment that we will
provide.
We should seek to eliminate administrative and insurance busywork from the professional lives
of our providers.
These examples illustrate a thoughtful use of language. They first and foremost focus on
patients. But the organization also wants to improve the lives of its providers. The examples use
the word should rather than the word must because it is thought that staff members won’t
believe the organization can pull off 100 percent achievement of these goals, and leaders do not
want to establish goals seen as unrealistic. The examples also use the word we rather than the
word you. We means that this vision will be achieved through a team effort, rather than implying
that those hearing this message have to bear this challenge without leadership’s help.
Connection and Trust
Achieving connection means that leadership takes every opportunity to present the vision
throughout the organization. Leaders may use department head meetings, medical staff forums,

one-on-one conversations in the hallway, internal publications, and e-mail to communicate the
vision and to keep communicating the vision. Even when they start to feel ill because they have
communicated the vision one thousand times, they have to communicate it another one
thousand times. A lot of this communication has to be done in person, where others can see the
leaders, rather than hiding behind an e-mail. The communication must invite feedback, criticism,
and challenges.
The members of the organization must trust the integrity, intelligence, compassion, and skill of
the leadership. Trust is earned or lost by everything that leaders do or don’t do. The members
must also trust that leaders have thoughtfully come to the conclusion that the difficult change
has excellent reasons behind it and represents the best option for the organization.
Organizational members are willing to rise to a challenge, often to heroic levels, if they trust their
leaders. Trust requires that leaders act in the best interests of the staff and the organization and
that leaders listen and respond to the organization’s concerns.
Incentives
Organizational members must be motivated to support significant change. At times, excitement
with the vision will be sufficient incentive. Alternatively, fear of what will happen if the
organization fails to move toward the vision may serve as an incentive. Although important,
neither fear nor rapture is necessarily sufficient.
If organizational members will lose their jobs or have their roles changed significantly, education
that prepares them for new roles or new jobs must be offered. Bonuses may be offered to key
individuals, awarded according to the success of the change and each person’s contribution to
the change. At times, frankly, support is obtained through old-fashioned horse-trading—if the
other person will support the change, you will deliver something that is of interest to him or her
(space, extra staff members, a promotion). Incentives may also take the form of awards—for
example, plaques and dinners for two—to staff members who go above and beyond the call of
duty during the change effort.
Planning, Implementing, and Iterating
Change must be planned. These plans describe the tasks and task sequences necessary to
effect the change. Tasks can range from redesigning forms to managing the staged
implementation of application systems to retraining staff members. Tasks must be allotted
resources, and staff members accountable for task performance must be designated.
Implementation of the plan is obviously necessary. Because few organizational changes of any
magnitude will be fully understood beforehand, problems will be encountered during
implementation. New forms may fail to capture necessary data. The estimate of the time
needed to register a patient may be wrong and long lines may form at the registration desk. The
planners may have forgotten to identify how certain information would flow from one department
to another.

These problems are in addition to the problems that occur, for example, when task timetables
slip and dependent tasks fall idle or are in trouble. The implementation of the application has
been delayed and will not be ready when the staff members move to the new building—what do
we do? Iteration and adjustment will be necessary as the organization handles problems created
when tasks encounter trouble and learns about glitches with the new processes and workflows.
Organizational and Behavioral Factors
The human factors associated with implementing a new system should not be taken lightly. A
great deal of change can occur as a result of the new system. Some of the changes may be
immediately apparent; others may occur over time as the system is used more fully. Many IT
implementation studies have been done in recent years, and they reveal several strategies that
may lead to greater organizational acceptance and use of a new system:
Create an appropriate environment, one in which expectations are defined, met, and managed.
Know your culture and do not underestimate user resistance.
Allocate sufficient resources, including technical support staff members and IT infrastructure.
Provide adequate initial and ongoing training.
Manage unintended consequences, especially those known to affect implementations such as
CPOE and EHR systems.
Establish strong working relationships with vendors.
Each of these strategies is described in the following sections.
Create an Appropriate Environment
If you ask a roomful of health care executives, physicians, nurses, pharmacists, or laboratory
managers if they have ever experienced an IT system failure, chances are over half of the
hands in the room will go up. In all likelihood the people in the room would have a much easier
time describing a system failure than a system success. If you probed a little further and asked
why the system was a failure, you might hear comments such as these: “the system was too
slow,” “it was down all the time,” “training was inadequate and nothing like the real thing,” “there
was no one to go to if you had questions or concerns,” “it added to my stress and workload,”
and the list goes on. The fact is, the system did not meet their expectations. You might not know
whether those expectations were reasonable or not.
Previously we discussed the importance of clearly defining and communicating the goals and
objectives of the new system. Related to goal definition is the management of user
expectations. Different people may have different perspectives on what they expect from the
new system; in addition, some will admit to having no expectations, and others will have joined
the organization after the system was implemented and consequently are likely to have
expectations derived from the people currently using the system.
Expectations come from what people see and hear about the system and the way they interpret
what the system will do for them or for their organization. Expectations can be formed from a
variety of sources—they may come from a comment made during a vendor presentation, a
question that arises during training, a visit to another site that uses the same system,

attendance at a professional conference, or a remark made by a colleague in the hallway.
Furthermore, the main criterion used to evaluate the system’s value or success depends on the
individual’s expectations and point of view. For example, the chief financial officer might
measure system success in terms of the financial return on investment, the chief medical
director might look at impact on physicians’ time and quality of care, the nursing staff members
might consider any change in their workload, public relations personnel might compare levels of
patient satisfaction, and the IT staff members might evaluate the change in the number of help
desk calls made since the new system was implemented. All these approaches are measures
of an information system’s perceived impact on the organization or individual. However, they are
not all the same, and they may not have equal importance to the organization in achieving its
strategic goals.
It is therefore important for the health care executive team not only to establish and
communicate clearly defined goals for the new system but also to listen to needs and
expectations of the various user groups and to define, meet, and manage expectations
appropriately. Ways to manage expectations include making sure users understand that the first
days or weeks of system use may be rocky, that the organization may need time to adjust to a
new workflow, that the technology may have bugs, and that users should not expect
problem-free system operation from the start. Clear and effective communication is key in this
endeavor.
In managing expectations it can be enormously helpful to conduct formative assessments of the
implementation process, in which the focus is on the process as well as the outcomes. Specific
metrics need to be chosen and success criteria defined to determine whether or not the system
is meeting expectations (Cusack & Poon, 2011). For example, if wide-scale use is a priority,
collection of actual numbers of transactions or use logs may be meaningful information for the
leadership team. Other categories of metrics that might be helpful are clinical outcome
measures, clinical process measures, provider adoption and attitude measures, patient
knowledge and attitude measures, workflow impact measures, and financial impact measures.
The Agency for Healthcare Research and Quality published the Health Information Technology
Evaluation Toolkit, which can serve as a guide for project teams involved in evaluating the
system implementation process or project outcomes (Cusack & Poon, 2011).
Know Your Culture and Do Not Underestimate User Resistance
Before embarking on system implementation, it is critical to know your culture. Understanding
the culture is important before you make the investment. For example, you might ask, How
engaged and ready are the physicians and other clinicians for the new system? Are they
comfortable with technology? Do you have hospitalists on staff? Or are you a community
hospital in which the bulk of your medical staff members are physicians who have admitting
privileges at several hospitals and make rounds only once a day? How engaged have the
physicians been in the design and build of the new system? Is there strong support? If you don’t
have sufficient medical staff buy-in and support or hospitalists on staff who are committed to the
project, you run the risk of encountering user resistance and system failure because of
inadequate use.

During the implementation process it is also important to analyze current workflow and make
appropriate changes as needed. Previously we gave an example of analyzing a patient
scheduling process. Patient scheduling is a relatively straightforward process. A change in this
system may not dramatically change the job responsibilities of the schedulers and may have
little impact on nurses’ or physicians’ time. Therefore, these groups may offer little resistance to
such a change. (This is not to guarantee a lack of resistance—if you mess up a practice’s
schedule, you can have a lot of angry people on your hands!) By contrast, changes in
processes that involve the direct provision of patient care services and that do affect nurses’
and physicians’ time may be tougher for users to accept. The physician ordering process is a
perfect example. Historically most physicians were accustomed to picking up a pen and paper
and handwriting an order or calling one in to the nurses’ station from their phones. With CPOE,
physicians may be expected to keyboard their orders directly into the system and respond to
automated reminders and decision-support alerts. A process that historically took them a few
seconds to do might now take several minutes, depending on the number of prompts and
reminders. Moreover, physicians are now doing things that were not asked of them
before—they are checking for drug interactions, responding to reminders and alerts, evaluating
whether evidence-based clinical guidelines apply to the patient, and the list goes on. All these
activities take time, but in the long run they will improve the quality of patient care. Therefore, it is
important for physicians to be actively involved in designing the process and in seeing its value
to the patient care process.
Getting physicians, nurses, and other clinicians to accept and use clinical information systems
can be challenging even when they are involved in the implementation. At times the incentives
for using the system may not be aligned with their individual needs and goals. On the one hand,
for example, if the physician is expected to see a certain number of patients per day and is
evaluated on patient load and if writing orders used to take thirty minutes a day with the old
system and now takes sixty to ninety minutes with the new CPOE system, the physician can
either see fewer patients or work more hours. One should expect to see physician resistance.
On the other hand, if the physician’s performance and income is related to adherence to clinical
practice guidelines, care coordination, and patient health outcomes, using the system may be
far more enticing. A recent study among six health care organizations found that more senior
physicians often feel a loss of power by having junior physicians more comfortable with
computers than they are and a loss in power in the physicians’ ability to shift work to others
(McAlearney et al., 2015). That is, with the implementation of EHRs, the physicians were now
required to use the computers and input their orders rather than delegate the tasks to junior
physicians or nurses.
It perhaps goes without saying that user acceptance occurs when users see or realize the value
the health care information system brings to their work and the patients they serve. This value
takes different forms. Some people may realize increased efficiency, less stress, greater
organization, and improved quality of information, whereas others may find that the system
enables them to provide better care, avoid medical mistakes, and make better decisions. In
some cases an individual may not experience the value personally yet may come to realize the
value to the organization as a whole.
Allocate Sufficient Resources

Sufficient resources are needed during and after the new system has been implemented. User
acceptance comes from confidence in the new system. Individuals want to know that the
system works properly, is stable and secure, and that someone is available to help them when
they have questions, problems, or concerns. Therefore, it is important for the organization to
ensure that adequate resources are devoted to implementing and supporting the system and its
users. At a minimum, adequate technical staff expertise should be available as well as sufficient
IT infrastructure.
We have discussed the importance of giving the implementation team sufficient support as it
carries out its charge, but what forms can this support take? Some methods of supporting the
team are to make available release time, additional staff members, and development funds.
Senior managers might allocate travel funds so team members can view the system in use in
other facilities. They might decide that all implementation team members or super-users will
receive 50 percent release time for the next six months to devote to the project. This release
time will enable those involved to give up some of their normal job duties so they can focus on
the project.
Providing sufficient time and resources to the implementation phase of the project is, however,
only part of the overall support needed. Studies have shown that an information system’s value
to the organization is typically realized over time. Value is derived as more and more people use
the system, offer suggestions for enhancing it, and begin to push the system to fulfill its
functionality. If users are ever to fully realize the system’s value, they must have access to local
technical support—someone, preferably within the organization, who is readily available, is
knowledgeable about the intricacies of the system, and is able to handle hardware and software
problems. This individual should be able to work effectively with the vendor and others to find
solutions to system problems. Even though it is ideal to have local technical support in-house,
that may be difficult in small physician offices or community-based settings. In such cases the
facility may need to consider such options as (1) devoting a significant portion of an employee’s
time to training so that he or she may assume a support role, (2) partnering with a neighboring
organization that uses the same system to share technical support staff members, or (3)
contracting with a local computer firm to provide the needed assistance. The vendor may be
able to assist the organization in identifying and securing local technical support.
In addition to arranging for local technical support, the organization will also need to invest
resources in building and maintaining a reliable, secure IT infrastructure (servers, operating
systems, and networks) to support the information system, particularly if it is a mission-critical
system. Many patient information systems need to be available 24 hours a day, 7 days a week,
365 days a year. Health care professionals can come to rely on having access to timely,
accurate, and complete information in caring for their patents, just as they count on having
electricity, water, and other basic utilities. Failing to build the IT infrastructure that will adequately
support the new clinical system can be catastrophic for the organization and its IT department.
An IT infrastructure’s lifetime may be relatively short. It is reasonable to expect that within three
to ten years, the hardware, software, and network will likely need to be replaced as advances

are made in technology, the organization’s goals and needs change, and the health care
environment changes. Downtime, scheduled and unscheduled, should be limited.
Provide Adequate Training
Previously we discussed the importance of training staff members on the new system prior to
the go-live date. Having a training program suited to the needs of the various user groups is very
important during the implementation process. People who will use the system should be
relatively comfortable with it, have had ample opportunities to use it in a safe environment, and
know where to turn should they have questions or need additional assistance. It is equally
important to provide ongoing training months and even years after the system has been
implemented. In all likelihood the system will go through a series of upgrades, changes will be
made, and users will get more comfortable with the fundamental features and will be ready to
push the system to the next level. Some users will explore additional functionality on their own;
others will need prodding and additional training in order to learn more advanced features.
It is also critical to provide the type of training that works best for your users’ needs and learning
preferences. Do not be afraid to have different training methods for different user groups
(Holden, 2011). Memorial Sloan-Kettering Cancer Center is a perfect example. It is one of the
world’s oldest private cancer centers in the world. All of its physicians are employees of the
organization. When they were first implementing their CPOE, all clinical and administrative staff
members underwent group training sessions (Sklarin, Granovsky, & Hagerty-Paglia, 2011). The
system was not accepted by the physicians for a variety of reasons, and training was a critical
issue. Once the leadership team realized this, they regrouped, changed tactics, and added three
new approaches to working with the physicians: (1) they rolled out one service at a time with
one hour of personalized training to each physician of that service (additional time did not seem
to help); (2) support staff members were stationed at the clinical areas during the
implementation period for individualized assistance; and (3) a physician champion was involved
in workflow discussions and key in facilitating the placement of orders in the system and in
helping ensure physician compliance (Sklarin et al., 2011). Understanding the culture and the
physician training needs of the organization is vital when implementing a new system, as is a
willingness to reevaluate the project. It is important to view the system as a long-term
investment rather than a one-time purchase. The resources allocated or committed to the
system should include not only the upfront investment in hardware and software but also the
time, people, and resources needed to maintain and support it.
Manage Unintended Consequences
Management expertise and leadership are important elements to the success of any system
implementation. Effective leaders help build a community of collaboration and trust. However,
effective leadership also entails understanding the unintended consequences that can occur
during complex system implementations and managing them. Unintended consequences can
be positive, negative, or both, depending on one’s perspective. A decade ago, Ash and
colleagues (2007) conducted interviews with key individuals from 176 US hospitals that had
implemented CPOE. CPOE is one of the most complex and challenging of clinical applications
to implement and a key function of EHR systems. From their work, they identified eight types of
unintended consequences that implementation teams should plan for and consider when
implementing CPOE.

Conflicts can also occur between paper-based and electronic systems if providers who prefer
paper records annotate printouts and place them in patient charts as formal documentation, in
essence creating two distinct and sometimes conflicting patient records (Jones et al., 2011).
Health care executives and implementation teams should be aware of these unintended
consequences, particularly those that can adversely affect the organization, and carefully plan
for and manage them.
Establish Strong Working Relationships with Vendors
Developing strong working relationships with the vendor is key. The health care executive
should view the vendor as a partner and an entity with which the organization will likely have a
long-term relationship. This relationship often begins when the organization first selects a new
information system and continues well after the system is live and operational. The system will
have upgrades, new version releases, and ongoing maintenance contracts. It behooves both
parties, the health care provider organization and the vendor, to clearly define expectations,
resource needs, and timelines. It is important to have open, honest, and candid conversations
when problems arise or differences in expectation occur. Equally important is for both parties to
demonstrate a willingness to address needs and solve problems collaboratively.
Perspective
Unintended Consequences of CPOE
More work or new work. CPOEs can increase work because systems may be slow,
nonstandard cases may call for more steps in ordering, training may remain an issue, some
tasks may become more difficult, the computer forces the user to complete “all steps,” and
physicians often take on tasks that were formerly done by others.
Workflow. CPOEs can greatly alter workflow, sometimes improving workflow for some and
slowing or complicating it for others.
System demands. Maintenance, training, and support efforts can be significant for an
organization, not only in building the system but also in making improvements and
enhancements to it.
Communication. CPOE systems affect communication within the organization; they can reduce
the need to clarify orders but also lead to people failing to adequately communicate with each
other in appropriate situations.
Emotions. Clinician reactions to CPOE can run the gamut from positive to negative.
New kinds of errors. Although CPOE systems are generally designed to detect and prevent
errors, they can lead to new types of errors such as juxtaposition errors, in which clinicians click
on the adjacent patient name or medication from a list and inadvertently enter the wrong order.
Power shifts. Shifts in power may be viewed as less of a problem than some of the other
unintended consequences, but CPOE can be used to monitor physician behavior.
Dependence on the system. Clinicians become dependent on the CPOE system, so managing
downtime procedures is critical. Even then, while the system is down, CPOE users view the
situation as managed chaos.
Source: Adapted from Ash et al. (2007). Reproduced with permission of American Medical
Informatics Association.
System Support and Evaluation

Information systems evolve as an organization continues to grow and change. No matter how
well the system was designed and tested, errors and problems will be detected and changes will
need to be made. IT staff members generally assume a major role in maintaining and supporting
the information systems in the health care organization. When errors or problems are detected,
IT staff members correct the problem or work with the vendor to see that the problem is fixed.
Moreover, the vendor may detect glitches and develop upgrades or patches that will need to be
installed.
Many opportunities for enhancing and optimizing the system’s performance and functionality will
arise well after the go-live date. The organization will want to ensure that the system is
adequately maintained, supported, and further developed over time. Selecting and implementing
a health care information system is an enormous investment. This investment must be
maintained, just as one would maintain one’s home. In fact, health care organizations that have
implemented EHR systems are now actively in the midst of optimizing use of the system in
practice (Sachs & Long, 2016). Optimization can take the form of additional training, revised
workflows, adding new features or functionality, or using data from the system for quality
improvement initiatives, as examples. Optimizing systems and assessing their value is
discussed in Chapter Seven.
As with other devices, information systems have a life cycle and eventually need to be replaced.
Health care organizations typically go through a process whereby they plan, design, implement,
and evaluate their health care information systems. Too often in the past the organization’s work
was viewed as done once the system went live. It has since been discovered how vital system
maintenance and support resources are and how important it is to evaluate the extent to which
the system goals are being achieved.
Evaluating or accessing the value of the health care information system is increasingly
important. Acquiring and implementing systems requires large investments, and stakeholders,
including boards of directors, are demanding to know the actual and future value of these
projects. Evaluations must be viewed as an integral component of every major health
information system project and not an afterthought. Chapter Seven is devoted to this topic.
Summary
Implementing a new information system in a health care organization requires a significant
amount of planning and preparation. The health care organization should begin by appointing an
implementation team comprising experienced individuals, including representatives from key
areas in the organization, particularly areas that will be affected by or responsible for using the
new system. Key users should be involved in analyzing existing processes and procedures and
making recommendations for changes. A system champion should be part of the
implementation team and serve as an advocate in soliciting input, representing user views, and
spearheading the project. When implementing a clinical application, it is important that the
system champion be a physician or clinician, someone who is able to represent the views of the
care providers.
Under the direction of a highly competent implementation team, a number of important activities
should occur during the system rollout. This team should assume a leadership role in ensuring

that the system is effectively incorporated into the day-to-day operations of the facility. This
generally requires the organization to (1) analyze workflow and processes and perform any
necessary process reengineering, (2) install and configure the system, (3) train staff members,
(4) convert data, (5) adequately test the system, and (6) communicate project progress using
appropriate forums at all levels throughout the organization. Attention should be given to the
countless details associated with ensuring that downtime and backup procedures are in place,
security plans have been developed, and the organization is ready for the go-live date.
During the days immediately following system implementation, the organization should have
sufficient staff members on hand to assist users and provide individual assistance as needed. A
stable and secure IT infrastructure should be in place to ensure minimal, ideally zero, downtime
and adequate response time. The IT department or other appropriate unit or representative
should have a formal mechanism in place for reporting and correcting errors, bugs, and glitches
in the system.
Once the system has gone live, it is critical for the organization to have in place the plans and
resources needed to adequately maintain and support the new system. Technical staff
members and resources should be available to the users. Ongoing training should be an integral
part of the organization’s plans to support and further develop the new system. In addition, the
leadership team should have in place a thoughtful plan for evaluating the implementation
process and assessing the value of the health care information system.
Beyond taking ultimate responsibility for completion of the activities needed to implement and
support and evaluate the new system, the health care executive should assume a leadership
role in managing change and the organizational and human aspects of the new system.
Information systems can have a profound impact on health care organizations, the people who
work there, and the patients they serve. Acquiring a good product and having the right technical
equipment and expertise are not enough to ensure system success. Health care executives
must also be attuned to the human aspects of introducing new IT into the care delivery process.
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