Chapter 17
Implementing and Upgrading an Information System Solution
Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Reasons for Net New Implementation or Upgraded Healthcare System
American Reinvestment & Recovery Act (ARRA) and Meaningful Use
Health Insurance Portability and Accountability Act (HIPAA) Mandatory Transition to International Classification of Diseases–10th revision (ICD-10) Codes
HIPAA mandatory migration to 5010 standards
Best practices and evidence-based content
Clinical Decision Support (CDS) System
Patient safety
Improved quality of patient care
Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.
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Vendor-Certified versus Home-grown Healthcare Systems

Advantages of certified systems
Disadvantages of certified systems
Advantages of home-grown systems
Disadvantages of home-grown systems
EACH (Electronic Health Records [EHR] Alternative Certification for Hospitals) Program
Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.
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Advantages of Vendor Certified Systems:
Certification by CCHIT (Certification Commission for Healthcare Information Technology) validates that the commercial system has the ability to allow users to meet Meaningful Use.
Each vendor usually has customer-managed organizations to exchange ideas and use of the vendor’s products; e.g., INSIGHT for McKesson products.
Vendors have resources to quickly incorporated the ever-changing and increased government-issued mandates.

Disadvantages of Vendor-Certified Systems:
Usually more expensive
Vendors slow to incorporate changes that are not mandated by a certification organization like CMS, JCAHO, etc.
Interoperability problems – Difficult to interface products from different vendors

Advantages of Home-grown Systems:
More robust and customizable to meet unique needs
Do not have to wait for vendor to make desired changes or new features, or correct bugs.

Disadvantages of Home-Grown Systems:
Specialized staff to build and maintain system
More difficult to interface with commercial applications

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Decision Points: Net New Implementation versus an Upgrade
Sufficient resources
Staff
Financial
Physical or environmental restraints
Risk factors and strategies to minimize them
Upcoming visit from The Joint Commission (TJC)
Possibility of a union strike
New construction
Loss of key members of a project
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Decision Points: Net New Implementation versus an Upgrade (Cont.)
Scope creep
Best of breed versus fully integrated system
Advantages and disadvantages of each
Opportunities for improvement
CDSS
Evidenced-based medicine (EBM)
Alerts
Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.
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Implementation Success Factors
Determine how success will be measured before the project starts and what metrics will be used.
Establish a baseline measurement of the above metrics.
Examples of metrics:
Nonformulary medication orders
Amount of time between order entry and the first dose of medication
Amount of time between order entry and completion of “stat” orders

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Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.

See Table 17-2.
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Implementation Success
Factors (Cont.)
Receive support from top management and clinical leaders.
Receive input from representatives from every discipline.
Map all current preproject workflows and work-arounds and future workflows and processes.
Start a detailed go-live plan, with every task assigned to a specific individual or department.

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Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Implementation Success
Factors (Cont.)
TEST–TEST–TEST
TRAIN–TRAIN–TRAIN
System design
Minimal clicks and scrolling
Minimal interruptions
Alert fatigue
Location of common toolbars and shortcut buttons in the same location across the screens, if possible

8
Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Success Factors for a Successful Go-Live Plan
Providing a detailed go-live plan with tasks assigned to specific names
Publicizing go-live dates
Avoiding go-live dates on Mondays, Fridays, and weekends or near major holidays
Planning elbow-to-elbow support for users during the first week
Providing roaming superusers

9
Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Success Factors for a Successful Go-Live Plan (Cont.)
Planning for clinical coverage of clinicians who are providing support during the go-live
Scheduling regular rounds of senior leadership and clinical leaders to all departments
Acknowledging every user’s suggestions, comments, and complaints
Informing visitors about go-live via posters in the cafeteria, lobby, elevators, and newsletters

10
Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Command Center Readiness
Staff: Well-skilled personnel for each application
Shifts: Usually 10- to 12-hour shifts
Scheduled status meetings:
Review all issues, especially highly critical issues.
Schedule two or three status meetings everyday for the first 2 or 3 days; then decrease as needed.
Well-publicized hot line number: Bank of telephones for call-ins to roll over to the next available telephone

11
Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Command Center Readiness (Cont.)
Mechanism to report go-live issues
Call-ins to the hot line
Reports from roaming superusers
System to catalog and assign critical issues
Preprinted issue-reporting templates and forms
Establishment of levels of criticality
Direct communication with vendor support

12
Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Command Center Readiness (Cont.)
Physical environment:
Sufficient number of personal computers with all applications loaded for troubleshooting
Sufficient number of printers
Sufficient number of telephones with outside lines to communicate with vendor
Poster-sized sticky pads
White board with markers
Paper, pens, pencils, and staplers

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Celebrate Go-Live
Balloons and banners in lobby and cafeteria announcing go-live
Treats or food for staff across all shifts
Shared successful metrics with regular announcements regarding:
Computerized physician (provider) order entry (CPOE) application
Reduction in call backs
Reduction in nonformulary medications
Increased compliance with core measures
14
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Post Go-Live: User Input
Mechanisms for user feedback, questions, comments, and suggestions
Call ins
Suggestion boxes in public places such as in the cafeteria and the main lobby
Specially marked notebooks in the nurses’ lounges and the physicians’ lounges that are picked up and reviewed on a regular schedule
Frequently asked questions (FAQ) document to share with the staff

15
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Post Go-Live: Maintenance
Change Control Committee
Increase the frequency of scheduled meetings immediately after go-live to evaluate quickly all requested changes.
Patches
Upgrades
Change requests (bugs) identified and submitted to vendor
16
Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Post Go-Live: Maintenance (Cont.)
EHR education:
New staff and role changes of current staff
New functionalities or features with upgrades or patches
Refresher courses
Interfaces with new add-on ancillary systems such as a cardiology application
New interfaces with ancillary systems such as laboratory and radiation that change vendors
17
Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Post Go-Live: Maintenance (Cont.)
Order item master maintenance: Inactivating select orders, building new orders, and creating aliases
Introduction and refinement of EHR features that were not implemented with the initial go-live
Continual refinement of documentation screens, reports, workflows, security, and EHR-related policies
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Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Meaningful Use–Stage 2
Meaningful Use–Stage 2: January 1, 2014
Thresholds of Meaningful Use–Stage 1 criteria are increased.
Expansion of Meaningful Use–Stage 1 criteria: Eligible professionals (EPs) must use CPOE for 60% of ALL orders, not just for medication orders.
10% of the summary of care records must be electronically transmitted to healthcare providers outside of the network and those that have a different EHR system.
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Meaningful Use–Stage 2 (Cont.)
New criteria requiring patient engagement for EPs:
10% of patients must view, download, or share their medical records.
50% of patients must have access to visit summaries within 24 hours.
50% of patients must be able to receive electronic versions of their health information on request.
10% of patients must be able to receive health education materials.
10% of patients seen within the past 24 months must receive electronic reminders of upcoming appointments and preventive care.
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Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Chapter 17
Implementing and Upgrading an
Information System Solution
Copyright
©
2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.