This document discusses strategies for implementing health information technology (HIT) systems. It compares "big bang" implementations, where a system is launched system-wide at once, to "staggered" or phased implementations. While big bang implementations have faster rollout, they carry higher risk. Staggered implementations have lower risk but slower return on investment. The document also emphasizes the importance of user training and long-term support during and after implementation to ensure success. Contextual factors like organizational culture and individual user needs must also be considered in planning. Nested implementation teams and designated super-users or internal consultants can help provide support.
Medical Simulation Market to Reach US$ 2.50 Billion by 2022Amy Williams
The medical simulation market is expected to exceed more than US$ 2.50 Billion by 2022; Growing at a CAGR of more than 15% in the given forecast period.
Lance Millburg, Senior Lean Six Sigma Project Manager talks us through how Memorial Health System built their simulation team from the ground up into a nationally recognized program in 2 years.
Find out how BJC HealthCare shortened turnaround time for lab results by 37%, reduced walking time, and managed staffing levels effectively. This helped them to immediately reduce operational costs.
LeanHDX was the perfect tool to help BJC. Unique in its approach LeanHDX allowed BJC to consider the physical layout and the processes of the lab simultaneously.
Medical Simulation Market to Reach US$ 2.50 Billion by 2022Amy Williams
The medical simulation market is expected to exceed more than US$ 2.50 Billion by 2022; Growing at a CAGR of more than 15% in the given forecast period.
Lance Millburg, Senior Lean Six Sigma Project Manager talks us through how Memorial Health System built their simulation team from the ground up into a nationally recognized program in 2 years.
Find out how BJC HealthCare shortened turnaround time for lab results by 37%, reduced walking time, and managed staffing levels effectively. This helped them to immediately reduce operational costs.
LeanHDX was the perfect tool to help BJC. Unique in its approach LeanHDX allowed BJC to consider the physical layout and the processes of the lab simultaneously.
Technostress is one of many factors holding our healthcare system back. This presentation contains the results of research performed in healthcare settings and proposes a new approach to reducing the technostress induced by the electronic healthcare systems.
A presentation given at the Duke Margollis Health Policy meeting in 2015 and providing insights into the current challenges related to EHR data quality. Proposes a new approach - OneSource.
ICIS 2012: Information System Infusion: The Role of Control and EmpowermentJan-Bert Maas
Presentation of the paper 'Information System Infusion: The Role of Control and Empowerment' at ICIS 2012, Orlando. By Jan-Bert Maas, Paul van Fenema and Joseph Soeters
Researchers and care providers wanted to have access to all of the patients` vitals signs (temperature, blood pressure, heart rate, and respiratory rate) but most of this data wasn?t recorded, only a few readings a day were posted to the patients Electronic Medical Record (EMR). The EMR isn`t meant to store such volume of data, let alone to perform any data mining on it. This session will describe the architecture of the solution that was implemented to collect these vital signs automatically from Bedside Medical Devices (BDMI), and store them into a temporary storage, then load them into a Hadoop cluster. The session will also cover how the team married this vital signs data in the HDFS (Hadoop File System) with the rest of the EMR data for our Principles Investigators (PI) in our research institute to search for correlations between administered medications, diagnosis, and vital signs readings. The session will describe the reasons behind the design decisions that were made, such as using a Cloud Hadoop cluster versus on-premises while maintaining HIPAA.
Technostress is one of many factors holding our healthcare system back. This presentation contains the results of research performed in healthcare settings and proposes a new approach to reducing the technostress induced by the electronic healthcare systems.
A presentation given at the Duke Margollis Health Policy meeting in 2015 and providing insights into the current challenges related to EHR data quality. Proposes a new approach - OneSource.
ICIS 2012: Information System Infusion: The Role of Control and EmpowermentJan-Bert Maas
Presentation of the paper 'Information System Infusion: The Role of Control and Empowerment' at ICIS 2012, Orlando. By Jan-Bert Maas, Paul van Fenema and Joseph Soeters
Researchers and care providers wanted to have access to all of the patients` vitals signs (temperature, blood pressure, heart rate, and respiratory rate) but most of this data wasn?t recorded, only a few readings a day were posted to the patients Electronic Medical Record (EMR). The EMR isn`t meant to store such volume of data, let alone to perform any data mining on it. This session will describe the architecture of the solution that was implemented to collect these vital signs automatically from Bedside Medical Devices (BDMI), and store them into a temporary storage, then load them into a Hadoop cluster. The session will also cover how the team married this vital signs data in the HDFS (Hadoop File System) with the rest of the EMR data for our Principles Investigators (PI) in our research institute to search for correlations between administered medications, diagnosis, and vital signs readings. The session will describe the reasons behind the design decisions that were made, such as using a Cloud Hadoop cluster versus on-premises while maintaining HIPAA.
Slide deck from 2008 Symposium "Developing an Expert-System for Health Promotion: An Experimental E-Learning Platform" from the APA-NIOSH International Conference on Work, Stress, and Health
ICH Guidelines Effective for Regulating Quality of Medicines?Ajaz Hussain
ICH Guidelines: Effective tools for regulating the quality of medicines? Enabling regulatory considerations – the ICH Q8 – 12 are such considerations. Effective implementation of enabling regulatory considerations is a challenge. The challenge is what we know and what we can implement are two different things. Education, training, and experience linked to measures of professional development, as it relates to PQS, should bridge what we know and what we implement. What are such measures? Some corporations are already focused on making their PQS effective (e.g., Amgen) but most are not. In a global supply chain (with ~ 90% of Rx being generics) this can pose a major challenge to deliver assurance patients need. Why? #education #medicine #assurance #regulations #globalization #corporations #bridging #measurements
Common Practice Guidelines: A Significant Gap in Computational Modeling and S...BioGearsEngine
BioGears® is an open source, general-purpose human physiology simulation engine. The goal of BioGears is to provide consistent physiology for use by the medical modeling and simulation community. The accuracy of this whole-body model is assessed through a validation process which compares the simulation results to a range of observed values within the reference population. BioGears has been customized for integration with real-time training simulations to produce virtual patient responses in both software and hardware scenario-based applications. A software architecture that leverages a common data model was created to provide a well-defined interaction paradigm for models at different spatial and temporal scales. The framework can be applied for integration towards the development of predictive multiscale models for in silico clinical trials.
This talk describes:
· The motivation and purpose of the BioGears program
· The utilization of extensive user community engagement to inform design and implementation decisions
· The use of validation to provide assurance in results
· The process of translating physiology modeling and simulation research into clinical use
· The decision to allow physiology model extensions and improvements to be integrated by the user base over time
It will also include recommended best practices and lessons learned in getting BioGears adopted. Finally, perceived gaps and limitations in guidelines for establishing standardized simulation-based medicine will be presented, along with recommendations for future improvements.
This is an initiative started at the Interagency Modeling and Analysis Group and Multiscale Modeling Consortium
AI in Healthcare: Real-World Machine Learning Use CasesHealth Catalyst
Levi Thatcher, PhD, VP of Data Science at Health Catalyst will share practical AI use cases and distill the lessons into a framework you can use when evaluating AI healthcare projects. Specifically, Levi will answer these questions:
What are great healthcare business cases for AI/ML?
What kind of data do you need?
What tools / talent do you need?
How do you integrate AI/ML into the daily workflow?
Medical Technology Tackles New Health Care Demand - Research Report - March 2...pchutichetpong
M Capital Group (“MCG”) predicts that with, against, despite, and even without the global pandemic, the medical technology (MedTech) industry shows signs of continuous healthy growth, driven by smaller, faster, and cheaper devices, growing demand for home-based applications, technological innovation, strategic acquisitions, investments, and SPAC listings. MCG predicts that this should reflects itself in annual growth of over 6%, well beyond 2028.
According to Chris Mouchabhani, Managing Partner at M Capital Group, “Despite all economic scenarios that one may consider, beyond overall economic shocks, medical technology should remain one of the most promising and robust sectors over the short to medium term and well beyond 2028.”
There is a movement towards home-based care for the elderly, next generation scanning and MRI devices, wearable technology, artificial intelligence incorporation, and online connectivity. Experts also see a focus on predictive, preventive, personalized, participatory, and precision medicine, with rising levels of integration of home care and technological innovation.
The average cost of treatment has been rising across the board, creating additional financial burdens to governments, healthcare providers and insurance companies. According to MCG, cost-per-inpatient-stay in the United States alone rose on average annually by over 13% between 2014 to 2021, leading MedTech to focus research efforts on optimized medical equipment at lower price points, whilst emphasizing portability and ease of use. Namely, 46% of the 1,008 medical technology companies in the 2021 MedTech Innovator (“MTI”) database are focusing on prevention, wellness, detection, or diagnosis, signaling a clear push for preventive care to also tackle costs.
In addition, there has also been a lasting impact on consumer and medical demand for home care, supported by the pandemic. Lockdowns, closure of care facilities, and healthcare systems subjected to capacity pressure, accelerated demand away from traditional inpatient care. Now, outpatient care solutions are driving industry production, with nearly 70% of recent diagnostics start-up companies producing products in areas such as ambulatory clinics, at-home care, and self-administered diagnostics.
CHAPTER 1 SEMESTER V - ROLE OF PEADIATRIC NURSE.pdfSachin Sharma
Pediatric nurses play a vital role in the health and well-being of children. Their responsibilities are wide-ranging, and their objectives can be categorized into several key areas:
1. Direct Patient Care:
Objective: Provide comprehensive and compassionate care to infants, children, and adolescents in various healthcare settings (hospitals, clinics, etc.).
This includes tasks like:
Monitoring vital signs and physical condition.
Administering medications and treatments.
Performing procedures as directed by doctors.
Assisting with daily living activities (bathing, feeding).
Providing emotional support and pain management.
2. Health Promotion and Education:
Objective: Promote healthy behaviors and educate children, families, and communities about preventive healthcare.
This includes tasks like:
Administering vaccinations.
Providing education on nutrition, hygiene, and development.
Offering breastfeeding and childbirth support.
Counseling families on safety and injury prevention.
3. Collaboration and Advocacy:
Objective: Collaborate effectively with doctors, social workers, therapists, and other healthcare professionals to ensure coordinated care for children.
Objective: Advocate for the rights and best interests of their patients, especially when children cannot speak for themselves.
This includes tasks like:
Communicating effectively with healthcare teams.
Identifying and addressing potential risks to child welfare.
Educating families about their child's condition and treatment options.
4. Professional Development and Research:
Objective: Stay up-to-date on the latest advancements in pediatric healthcare through continuing education and research.
Objective: Contribute to improving the quality of care for children by participating in research initiatives.
This includes tasks like:
Attending workshops and conferences on pediatric nursing.
Participating in clinical trials related to child health.
Implementing evidence-based practices into their daily routines.
By fulfilling these objectives, pediatric nurses play a crucial role in ensuring the optimal health and well-being of children throughout all stages of their development.
The dimensions of healthcare quality refer to various attributes or aspects that define the standard of healthcare services. These dimensions are used to evaluate, measure, and improve the quality of care provided to patients. A comprehensive understanding of these dimensions ensures that healthcare systems can address various aspects of patient care effectively and holistically. Dimensions of Healthcare Quality and Performance of care include the following; Appropriateness, Availability, Competence, Continuity, Effectiveness, Efficiency, Efficacy, Prevention, Respect and Care, Safety as well as Timeliness.
The Importance of Community Nursing Care.pdfAD Healthcare
NDIS and Community 24/7 Nursing Care is a specific type of support that may be provided under the NDIS for individuals with complex medical needs who require ongoing nursing care in a community setting, such as their home or a supported accommodation facility.
Defecation
Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out
The Valsalva maneuver exerts pressure to expel faeces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool.
Normal defecation is painless, resulting in passage of soft, formed stool
CONSTIPATION
Constipation is a symptom, not a disease. Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. The signs of constipation include infrequent bowel movements (less than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feaces
IMPACTION
Fecal impaction results from unrelieved constipation. It is a collection of hardened feces wedged in the rectum that a person cannot expel. In cases of severe impaction the mass extends up into the sigmoid colon.
DIARRHEA
Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. It is associated with disorders affecting digestion, absorption, and secretion in the GI tract. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery, and the patient is unable to control the urge to defecate. Normally an anal bag is safe and effective in long-term treatment of patients with fecal incontinence at home, in hospice, or in the hospital. Fecal incontinence is expensive and a potentially dangerous condition in terms of contamination and risk of skin ulceration
HEMORRHOIDS
Hemorrhoids are dilated, engorged veins in the lining of the rectum. They are either external or internal.
FLATULENCE
As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends (flatulence). It is a common cause of abdominal fullness, pain, and cramping. Normally intestinal gas escapes through the mouth (belching) or the anus (passing of flatus)
FECAL INCONTINENCE
Fecal incontinence is the inability to control passage of feces and gas from the anus. Incontinence harms a patient’s body image
PREPARATION AND GIVING OF LAXATIVESACCORDING TO POTTER AND PERRY,
An enema is the instillation of a solution into the rectum and sig
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Lecture 8B
1. Quality Improvement
HIT Implementation Planning for
Quality and Safety
Lecture b
This material (Comp 12 Unit 8) was developed by Johns Hopkins University, funded by the Department of Health
and Human Services, Office of the National Coordinator for Health Information Technology under Award
Number IU24OC000013. This material was updated in 2016 by Johns Hopkins University under Award
Number 90WT0005..
This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International
License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/.
2. HIT Implementation Planning for
Quality and Safety
Learning Objectives — Lecture b
• Assess the quality implications of “big
bang” versus “staggered” approaches to
activation.
• Discuss “go live” support strategies that
minimize risk.
• Discuss “post live” maintenance support
strategies.
2
5. Implementation Strategies:
Differences
• Big Bang:
– Fast implementation.
– Short-lived anxiety.
– Quicker ROI.
– Shorter timeframe.
– Maintain momentum.
– Fewer hybrid systems.
– High risk, high anxiety.
– Large scope.
– Greater resource
needs.
• Incremental:
– Less likely to erupt.
– Less anxiety.
– Greater manageability
of incremental units.
– Slower.
– Longer time for ROI.
– Higher training costs.
– Potential for
stagnancy.
5
6. Contextual Implementation Model
(CIM)
• Implementations: ongoing, iterative.
• Three contextual levels of differences:
– Organizational context.
– Clinical unit context.
– Individual context.
6
7. Contextual Implementation Model:
Organizational Context
• Organizational context:
– Organizational culture.
– Resources.
– IT experience.
– Size and location.
– Implementation life cycle stage.
– Mission and strategic plan.
– Organizational structures.
– Roles of clinicians (doctors, nurses).
– Leadership.
7
8. Contextual Implementation Model:
Clinical Unit Context
• Clinical unit context:
– Team culture.
– Unit leadership.
– IT experiences.
– Clinical profile of unit.
– Size.
– User attitudes regarding use of IT.
8
9. Contextual Implementation Model:
Individual Context
• Individual context:
– Diverse ways of working.
– Diverse ways of thinking.
– Diverse ways of communicating.
– Diverse ways of collaborating.
– Computer literacy.
– Keyboard skills.
9
10. Complex Systems
• Diverse interactions and self-organization
are critical.
• A certain level of noise, creativity, and
exploration should be expected for
learning, changing, and adapting.
• Effective structures are essential.
10
11. Complex Systems Structures:
Health System
• Strategic oversight team.
• Centralized matrix leadership.
• Nested expert teams.
• Hospital oversight teams.
• Project management teams.
• Centralized trainers.
11
12. Complex Systems Structures:
Nested Teams — 1
• Operational teams:
– Operations oriented.
– Standardize operational processes/patient
safety practices.
• Clinical discipline teams:
– Membership of a single professional
discipline.
– Addresses professional standards.
12
13. Complex Systems Structures:
Nested Teams — 2
• Clinical consensus teams:
– Multidisciplinary.
– Standardize practices related to specific
patient populations or problems.
• Problem-oriented ad hoc teams:
– Short term, rapid action.
– Addresses specific problems or interests.
13
14. Implementation Support
• External consultants:
– Implementation specialists.
– Trainers.
• Internal consultants:
– Super-users/coaches/mentors.
– Support pools.
14
15. Implementation Support:
External Consultants
• Have expertise in use of the particular
software application.
• Have experience on go-live teams in a wide
variety of settings.
• Have the dedicated time to support the
implementation.
• Less familiar with the specific organizational
policies and workflows.
• More costly than using internal consultants.
15
16. Implementation Support:
Internal Consultants — 1
• Clinical personnel.
• Have training and knowledge beyond the
usual end user for the given software
application.
• Link the clinical world with the IT world.
• Have a variety of titles: super-users,
coaches, mentors.
• Informal or formal roles.
16
17. Implementation Support:
Internal Consultants — 2
• Serve as champions for the new system.
• Promote adoption.
• Assist with/reinforce training.
• Assist with developing policies and
procedures, including downtime.
• Liaison between clinical and IT staff.
• Perform competency testing.
• Provide quality oversight.
17
18. Implementation: Factors that
Affect Success — 1
• It is not possible to designate a single
implementation strategy that works in all
settings.
• End user support (or lack thereof) is a
significant factor in both successful (and
failed) implementations.
• Long-term attention to end-user training
and support is the key to data quality.
18
19. Implementation: Factors that
Affect Success — 2
• There should be skilled resource people:
– Present on the unit.
– Able to provide quick help.
– Serve as a driving force for change.
– Responsible for training.
• Formal post implementation support and
training.
19
20. HIT Implementation Planning for
Quality and Safety
Summary — Lecture b
• No single best way to implement HIT.
• Contextual factors are important for
implementation planning.
• End-user education and support are
critical to success.
• Long-term training and support drive
quality.
20
21. HIT Implementation Planning for
Quality and Safety
References — Lecture b — 1
References
Callen, J., Braithewaite, J., & Westbrook, J. I. (2008). Contextual implementation model
for assisting clinical information system implementations. Journal of the American
Medical Informatics Association, 15(2), 255–262.
Gruber, D., Cummings, G. G., Leblanc, L., & Smith, D. L. (2009). Factors influencing
outcomes of clinical information systems implementation: A systematic review. CIN:
Computers, Informatics, Nursing, 27(3), 151–163.
McNeive, J. E. (2009). Super users have great value in your organization. CIN:
Computers, Informatics, Nursing, 27(3), 136–139.
Owens, K. (2008). EMR implementation: Big bang or a phased approach? Journal of
Medical Practice Management, 23(5), 279–281.
Panorama Consulting Group. (2006). ERP’s Big Bang theory. Retrieved May 27, 2016,
from http://panorama-consulting.com/erps-big-bang-theory/
Scott, K., & Van Norman, J. (2009). Managing the complexity of a systemwide electronic
medical record design and implementation: Lessons for nurse leaders. Nursing
Administration Quarterly, 33(2), 109–115.
21
22. HIT Implementation Planning for
Quality and Safety
References — Lecture b — 2
Charts, Tables, Figures
8.04 Figure: Phase Diagram. Courtesy Alan J. McCombs. Johns Hopkins University.
Images
Slide 3: The Universe's “Baby Picture.“ Courtesy NASA. Retrieved May 27, 2016, from
http://science.nasa.gov/astrophysics/focus-areas/what-powered-the-big-bang
22
23. Quality Improvement
HIT Implementation Planning for
Quality and Safety
Lecture b
This material (Comp 12 Unit 8) was developed
by Johns Hopkins University, funded by the
Department of Health and Human Services,
Office of the National Coordinator for Health
Information Technology under Award Number
IU24OC000013. This material was updated in
2016 by Johns Hopkins University under Award
Number 90WT0005.
23
Editor's Notes
Welcome to Quality Improvement: HIT Implementation Planning for Quality and Safety.
This is Lecture b. The focus of this lecture is on providing you with effective “go live” support strategies.
The objectives for HIT Implementation Planning for Quality and Safety are to:
Assess the quality implications of “big bang” versus “staggered” approaches to activation.
Discuss “go live” support strategies that minimize risk. And
Discuss “post live” maintenance support strategies.
There is debate about whether it is better to take the big bang approach or to use a staged approach to introduce new technology and processes. When we speak about the big bang theory with respect to IT, we are not talking about the television sitcom or the scientific theory on the origins of the universe. Rather, we are discussing an approach to implementation of the electronic health record.
With the big bang IT strategy, the goal is to get it over with quickly. Small practices have the best odds of succeeding with the big bang approach. The big bang approach can be appealing because, while quite intense, it is short and calls for the organization’s energies and resources to be almost completely focused on the implementation of the EHR. This strategy minimizes long-term resource shortages and compresses the pain and difficulty of an IT project into a shorter period of time, unlike a phased approach that unfolds over time. Some initiatives require a big bang approach — a case in point being when a country decides to change from driving on the right-hand side of the road to the left-hand side of the road. This is not the time for a phased approach! A clean “cut to the new way of doing” via a big bang technique has its benefits.
The downside of the big bang implementation approach is that it is stressful, requires a great deal of pre-planning so that details are not overlooked and contingency plans are solid. Changes to processes can have far-reaching consequences, some of which are not evidenced until some time has passed. Therefore, a big bang approach can result in unexpected sequela that may have a negative impact on the organization and the patient population.
This type of strategy is inherently risky due to the potentially catastrophic consequences of a single flaw in the way the software has been configured or in the way processes have been re-engineered. In addition, it does not allow for problem identification and resolution to occur on a small scale, but rather, when problems arise, they affect all users.
On the other end of the spectrum is the phased approach, which is slower and staggered over time. Teams that use this approach transition to the new EHR incrementally, in a carefully staged approach. Larger practices and practices with multiple locations may benefit from this approach. This strategy allows project teams to continue with day-to-day operations while devoting more time in planning, customizing, and then pilot testing the new system. It also allows teams to stage the implementation to be consistent with clinical demands or workflow. The downside of this approach is that it often lacks the urgency and focus of a big bang project. It can also lead to "change fatigue” on the part of both the users and the project team.
In comparing the two approaches, one can readily see the differences. The big bang approach is fast, so anxiety is short-lived, and you have the potential to have a quicker realization of return on investment. The implementation is accomplished in a shorter timeframe, so you are able to maintain momentum. You don’t need to worry about the problems that having to use a hybrid paper and electronic systems presents. At the same time, there is higher risk, higher anxiety, larger scope, and the need for greater numbers of resources for training and implementation support. With incremental strategies, problems are less likely to erupt, there is less anxiety and greater ability to manage implementation of incremental units. At the same time, the implementation is slower, it takes longer to see the return on investment, there are higher training costs, and there is the potential for stagnation.
The Contextual Implementation Model, or CIM, is a way of examining how one should approach HIT implementations. Given that such implementations are ongoing and iterative, it is important to take into consideration three contextual levels of differences. These include organizational, clinical unit, and individual contextual differences. Before implementing an EHR, the implementation team should thoroughly analyze the context at organizational, departmental, and individual levels, which might have an impact on clinicians’ use of the system.
When analyzing the context at the organizational levels, implementation teams should look at the organizational culture, available resources, the experience the organization has with IT implementations, size and location of the organization, where they are in the implementation life cycle, the organization’s mission and strategic plan and where IT fits into that vision, existing structures and policies at the organizational level as these relate to the use of HIT, the roles of doctors and nurses in the organization, as well as the organization’s leadership.
Then the implementation team should analyze work practices at the clinical unit level. They should assess the culture of the team, the engagement level of unit leadership, any experiences the unit may have had with IT, the clinical profile of the unit, its size, and user attitudes related to use of IT. Differences in these areas can then be planned for and included in the implementation project plan.
Finally, the implementation team should look at the diverse ways of working, thinking, communicating, and collaborating of individual users, as well as their computer literacy and keyboard skills. During implementation, the implementation team should focus on contextual differences at individual and clinical unit levels and how these differences could be accommodated within the use of the information system. This requires detailed analysis of the functionality of the system and how different clinicians’ needs could be accommodated. Computer literacy and keyboard skills would require targeted training programs. Team cultures that are constructive and supportive of innovations should be a goal. Implementation teams should devise strategies to modify team cultures to ones that are receptive to change and supportive of the change process. Interventions can be devised to improve information sharing amongst team members, encourage support for innovation, provide a clear vision and objectives for staff, and thus promote a constructive culture that is receptive to innovations.
Implementation of HIT represents a major transformation of care in increasingly complex health care systems. There are three principles that are important to keep in mind. First, diverse interactions and self-organization are critical to success. The more we can involve clinical users in the implementation planning, the greater the chance for success. Diverse interactions create more options for action. Second, complex adaptive systems cannot be highly efficient and continue to survive in the dynamic environments that characterize these continually learning and adapting systems. Leaders must expect a certain level of noise, creativity, and exploration. Finally, effective structures are the key to system behavior.
The more complex the site, the greater the need for structures to ensure success. Banner Health, a large complex health care system in Arizona, has provided us with keys to successful system-wide implementation of IT. They have defined a structure that includes a strategic system oversight team with senior leadership members, a centralized leadership model with matrix reporting, multiple nested content- and process-expert teams and network layers for rapid design and redesign, hospital oversight teams with the executive leader sponsors, project management teams for each application implementation, and centralized trainers to deliver consistent training content at the facility level.
Let’s take a closer look at the nested teams and networks that they have created. There are operational teams, which are standing committees made up of individuals from across the health system who represent specific services areas, such as critical care or perioperative areas. These teams are responsible for standardizing operational processes and patient safety practices. Then, there are a number of clinical discipline teams, such as nursing, physicians, and social workers. These teams are made up of members of a single discipline, and they are responsible for ensuring that professional practice standards are defined and addressed.
Next, there are the multidisciplinary clinical consensus teams that develop practice standards related to specific patient populations or problems. Finally, there are problem-oriented ad hoc teams. These are short-lived teams that are formed to provide rapid action solutions for specific problems or interests.
There are many ways in which implementation support can be crafted. For smaller organizations, most software vendors either provide or can recommend external consultants to assist with implementation support or training support. Larger organizations generally find that it is better to cultivate internal consultants. You will find a variety of names and roles for these internal support people, such as super-users, coaches, or mentors. They can also be informally organized, or can be a part of more formal support pool structures.
Many organizations rely on external consultants to provide training and go-live support. These individuals have expertise in use of the particular software application being implemented, are experienced in implementing that system in a wide variety of settings, and have the dedicated time to support the implementation. The downside of using external consultants is their lack of familiarity with specific organizational policies and workflows and the fact that this option is usually more costly than using internal personnel.
Clinical personnel, usually nurses, who have training and knowledge beyond the usual end user for the given software application can be very valuable as a support for system implementation. These clinicians serve as “bridgers” or links between the clinical world and the IT world. They have a deep understanding of clinical workflows, since this is the world in which they live and provide care. They have credibility with other users, since they understand the problems that users face in the clinical environment, and they can help translate the needs of the end user to the IT technical teams. These internal experts are called a variety of names, depending on the particular role that they play in their organizations. These roles may be informal or formal.
Internal consultants are drawn from bedside users to assist with training and implementation, and many of them have ongoing roles well beyond system implementation. Most often, their primary responsibilities include serving as champions and promoting IT adoption, assisting with and reinforcing training, assisting with policy and procedure development, and serving as liaisons between clinical and IT personnel. In some instances, their roles extend to ongoing competency testing and quality oversight of use of the EHR.
Gruber and colleagues conducted a systematic literature review on factors that influence the outcomes of HIT implementation, and reached the following conclusions. First, it is not possible to designate a single implementation strategy that works in all settings. Next, “the highest number of factors influencing success or failure was reported during implementation and system ‘go-live.’ End user support (or lack thereof) was a significant factor in both successful (and failed) implementations.” Finally, long-term attention to end-user training and support is the key to data quality.
Andre and colleagues conducted a qualitative study of EHR implementation in palliative care settings and reported that all the respondents wanted a resource person; the expectations regarding this person differed. This person had to be present on the unit to provide at-the-elbow support. The person should be able to provide quick help and should be a driving force. This person should also be responsible for training and teaching. They concluded that, for implementations to be successful, there is a need for skilled and motivated key personnel. A formal plan for post implementation support and ongoing training should be implemented as soon as the system goes live. This often involves software vendor support and regular upgrades once the initial software is installed and functional.
This concludes Lecture b of HIT Implementation Planning for Quality and Safety.
In summary, there is no single best way to implement HIT. Organizational, clinical unit, and individual contextual factors are important for HIT implementation planning. End-user education and support is critical to success. Long-term end-user training and support drive quality.