Nursing Informatics Week-12-13

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Communication Skills in Health
IT, Building Strong Teams for
Successful Health IT Outcomes
Elizabeth (Liz) O. Johnson
• OBJECTIVES
1. Discuss the importance of communication in health IT to achieve adoption of
EHR technology.
2. Define the elements of effective communication plans.
3. Identify the stakeholders to consider in communications plans.
4. Describe the federal agencies, regulations, and other factors that affect health IT.
• KEY WORDS
Governance
Communication
Electronic health record
Physicians
Informaticists
Patient
for eligible physicians and healthcare providers who suc-

INTRODUCTION cessfully meet increasingly stringent requirements for
In America’s twenty-first century healthcare system, EHR implementation over the next five years.
landmark federal reform legislation enacted since 2009 is The journey to successful integration of health IT by
modernizing care-delivery organizations with new health providers industry-wide has been accompanied with chal-
information technologies (health IT) that regularly begin lenges. Tremendous complexities exist throughout health-
with the adoption of electronic health records (EHRs). care organizations working on health IT reform initiatives
Most notable of these laws are the American Recovery creating a critical need for effective communication cam-
and Reinvestment Act (ARRA) and its Health Information paigns that run throughout the lifecycles of acquiring,
Technology and Economic and Clinical Health (HITECH) implementing, and adopting EHRs in both inpatient and
Act provision, which established the Centers for Medicare ambulatory settings. Efforts such as these, with effective
and Medicaid’s (CMS) Meaningful Use of EHRs Incentive communication programs in place as a core strategy, sup-
Programs (Blumenthal & Tavenner, 2010). These programs port the goal of achieving the Institute of Medicine’s (IOM)
earmarked more than $22 billion in incentive payments six aims for improvement in care-delivery quality, making
293
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294 P art 4 • N ursing I nformatics L eadership
it safe, equitable, effective, patient centered, timely, and roles as new technologies are introduced. As a result, effec-
efficient (Institute of Medicine, 2001). tive communication programs have quickly become a high
As America’s healthcare system strives to be a “con- priority for hospitals and physician practices adopting EHR
tinuously learning” system, healthcare leaders and pro- and CPOE systems throughout the industry. The “continu-
viders realize that communication and improved patient ously learning” healthcare system in America depends
engagement are central to improving the value of health- on the involvement of all stakeholders—from patients to
care (Institute of Medicine, 2013a). Clinicians, clinical providers to management to vendors—to manage com-
informaticists, health organizations, and health IT policy- munications effectively and share them openly within the
makers serve as agents of change in the effort to involve entire healthcare community. The purpose of this chapter
patients not only in decision-making, but providing key is to provide an overview of communication strategies
pieces of health data. To enhance these efforts, IOM began that have proven effective in driving the implementation
the Evidence Communication Innovation Collaborative, of EHRs to support needs of patients, physicians, and the
which explores obstacles, solutions, and strategies to caregiver workforce. Sections in the chapter include (a) the
enhance patient involvement in healthcare (Institute of importance of communications in health IT initiatives; (b)
Medicine, 2013b). Two projects underway are “shared a focus on patient-centered, transparent care; (c) compo-
decision-making strategies for best care” and “patients’ nents of the communication plan; (d) industry consider-
attitudes on data sharing,” which should provide ways to ations (roles of federal agencies, federal regulations, and
encourage provider–patient communication and trans- the burgeoning role of mobile applications, social media,
parency in healthcare. and health information exchange); and (e) chapter review.
A number of studies have shown that good physician–
patient communication leads to improved patient satisfac-
tion as well as increased willingness of patients to share IMPORTANCE OF
pertinent data, adhere to medical treatment, and follow COMMUNICATIONS IN
advice. Under these circumstances, patients also are less
likely to lodge formal complaints or initiate malpractice
HEALTH IT INITIATIVES
suits (Ha & Longnecker, 2010). As Georgia Tech Professor William Rouse noted in a 2008
A strong communication campaign for physicians dur- article entitled “Healthcare as a Complex Adaptive System:
ing the EHR implementation is very important. Without Implications for Design and Management,” healthcare
such communication strategies, EHR adoption is far less organizations exist as complex adaptive systems with non-
likely. In 2002, for example, a major west-coast academic linear relationships, independent and intelligent agents,
medical center that heavily invested in the implemen- and system fragmentation (Rouse, 2008). While variation
tation of computerized provider order entry (CPOE) among them is gradually diminishing through increasing
encountered significant physician resistance. In large part, standardization of practices and systems, many provider
the clinician revolt occurred because physicians had been cultures still struggle with decentralization and reliance
insufficiently informed about and inadequately trained in on disparate legacy systems (Kaplan & Harris-Salamone,
the use of the clinical decision support (CDS) tool being 2009). The majority of healthcare organizations across the
implemented (Bass, 2003). According to David Bates, MD, nation have implemented EHRs, and providers are work-
in a 2006 Baylor University Medical Center Proceedings ing toward meaningful use in their health IT applications,
paper, failure to achieve leadership support or clinical creating the need for effective and tactical communication
buy-in from the large number of providers using the sys- plans. As the IOM’s Evidence Communication Innovation
tem resulted in strong resistance from an overwhelming Collaboration notes, “Communication is central to trans-
majority of physician effectively derailing the entire initia- forming how evidence is generated and used to improve
tive (Bates, 2006). the effectiveness and value of health care” (Halvorson &
Other provider organizations have encountered related Novelli, n.d.). The rapid changes in diagnostic and treat-
challenges with health IT implementations over the past ment options and the increased number of patients, with
decade (Kaplan & Harris-Salamone, 2009). Such costly, varying degrees of health literacy, turning to the Internet
high-risk experiences—especially in an increasingly for health information only serve to underscore the
patient-centric healthcare industry—have underscored the importance of clear and consistent communication. The
importance of effective, cross-enterprise, patient-focused following section provides insight into the importance of
communication plans and strategies that include physi- communications in health IT implementation programs:
cians and clinicians, administrators, clinical informaticists, in governance, the structure of a governance model, and
IT professionals, and the C-Suite—all of whom play critical rules for governance efforts.
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Chapter 19 • Communication Skills in Health IT, Building Strong Teams for Successful Health IT Outcomes 295
THE COMPLEXITY OF HEALTHCARE not want to share their practices with the other
competing group. Being cognizant of this expected
COMMUNICATIONS behavior should lead to the inclusion of collaboration
Healthcare systems face unique challenges in commu- opportunities as a part of the communication plan.
nications. Unlike corporations or other organizations, • “Agents are intelligent. As they experiment and
healthcare involves a variety of stakeholders, often with gain experience, agents learn and change their
competing goals and definitions of quality, in what is called behaviors accordingly. Thus overall system behav-
a complex adaptive system (Rouse, 2008). Complex adap- ior inherently changes over time.” Physicians, other
tive systems are described by William B. Rouse as follows: clinicians, clinical informaticists, administrators
are highly degreed professionals who are required
• “They are nonlinear and dynamic and do not
to comply with continuous education requirements
inherently reach fixed-equilibrium points. As a
result, system behaviors may appear to be random in order to maintain their certification. This pro-
or chaotic.” For example, healthcare in America vides a mechanism for sharing leading practices
is not governed by a single entity. The federal among their colleagues and changing their knowl-
government provides incentives to providers to edge, skill level, and attitudes. The challenge is that
implement EHRs, which have financial impact, but the rate of change varies across these groups where
the level and timing of compliance is still at the we find a continuum of “innovators, early adopt-
providers’ prerogative. Within a community, care ers, early majority, late majority, and laggards” as
providers have different owners and financial struc- described by Everett Rogers’ Technology Adoption
tures, i.e., for-profit, not-for-profit, single-owned Lifecycle model (Rogers, 1962).
entity, multi-provider organization, etc., which • “Adaptation and learning tend to result in self
affects how the EHR fits into their business plans. organization. Behavior patterns emerge; they are not
Communication approaches should be adaptable to designed into the system. The nature of emergent
environments which will not remain constant. behaviors may range from valuable innovations to
• “They are composed of independent agents whose unfortunate accidents.” When implementing an EHR,
behavior is based on physical, psychological, or we are not just implementing technology; we are also
social rules rather than the demands of system implementing standardized workflows. Although
dynamics.” The physician population best fits many system users adopt the new workflow, there are
this characterization. Most U.S. hospitals use also those who develop inappropriate “workarounds”
community-based physicians to service their to avoid changing their old behaviors. This requires
patients; these physicians are not employees of the the clinical leadership use clear messaging to hold
hospital and may serve patients in competing hos- their department members accountable for using the
pitals in the community. The hospital’s influence new technology in the appropriate manner.
over the compliance of these physicians to use the • “There is no single point of control. System behav-
EHR is limited to the physician-perceived ben- iors are often unpredictable and uncontrollable, and
efits of treating patients at that institution. Clear no one is ‘in charge.’ Consequently, the behaviors of
delineation and dissemination of benefits for all complex adaptive systems can usually be more easily
stakeholders is an effective approach for affecting influenced than controlled.” U.S. providers of care
independent agents. reflect a wide spectrum of structures—from small
• “Because agents’ needs or desires, reflected in their single proprietorships to limited partnerships to
rules, are not homogeneous, their goals and large multi-entity corporations. Some are privately
behaviors are likely to conflict. In response to these owned; others are government owned and operated,
conflicts or competitions, agents tend to adapt to such as the Veterans’ Administration healthcare sys-
each other’s behaviors.” Again, physicians provide a tem. Within healthcare systems decision-making is
good example of this scenario. Take the case where rarely a simple single threaded event. Creating suc-
two competing physician cardiology practice groups cessful campaigns for change require understanding
are serving a hospital that is implementing an EHR the influence structure and leveraging formal and
system that has built-in standardized decision informal communication approaches.
support to reflect leading clinical practices and to
reduce variation in care. However, the two practice Healthcare is, indeed, a complex adaptive system that
groups cannot agree on the standard of care or do cannot be directly controlled. Providers of care must be
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influenced to do the right thing and to aspire to a common the governance and communication plan to align with or
goal. Communications that are planned, strategic, broad- to evolve the culture of the organization.
based, and compelling are our best tool in effecting posi- Governance models in healthcare organizations pro-
tive changes in our healthcare environment. vide a structure that engages stakeholders to work through
critical decisions and ensure that risks associated with
changes in policy, technology, and workflow are mitigated
to maintain or improve the quality of patient care. A strong
LEADERSHIP AND GOVERNANCE example of a working model is provided by the author’s
The introduction of EHRs in healthcare organizations own health system—Tenet Healthcare Corporation.
drives transformational change in clinical and admin- Figure 19.1 illustrates the governance structure of Tenet
istrative workflows; organizational structure, i.e., that Healthcare’s IMPACT Program (IMPACT: Improving
which exists among physicians, nurses, and administra- Patient Care through Technology) and the importance of
tors; and relationships between the front-line workers, communications as it has been built into all layers.
physicians, administrators, and patients (Bartos, Butler, As shown here, a key to the success of this governance
Penrod, Fridsma, & Crowley 2006; Campbell, Sittig, Ash, structure is a three-tiered organizational structure that
Guappone, & Dykstra, 2006). Understanding the risks engages the corporation, regional operations, and the hospi-
posed by the disruptive facets of organizational and pro- tals themselves in a coordinated effort. Another key success
cess change is critical to ensuring the effective implemen- factor has been early commitment to key roles, including
tation of EHRs and mitigating risks of failure (Ash et al., clinical informaticists, physician champions, training and
2000). An essential part of risk mitigation in care-delivery communications leads, and health IT leads. Binding the
reform through health IT is the planning and implement- program together with unified, shared, and consistent mes-
ing of organizational communication initiatives that help saging continues to be a foundational strategy that supports
achieve the aims of an enterprise-wide governance team. all aspects of IMPACT’s execution (Johnson, 2012).
To succeed, responsibilities for such communications Barbara Hoehn, RN, MBA, summed up the importance
initiatives should be shared between health system lead- of communications in governance in her 2010 Journal
ers, champions, informaticists, and those charged with of Healthcare Information Management article entitled
oversight of the implementation of health IT systems, all “Clinical Information Technology Governance.” “Today, clin-
of whom should have a role to play in governance struc- ical IT is finally being universally viewed as a critical com-
tures whose processes are grounded in a strong commu- ponent of healthcare reform, and we are only going to get
nications strategy. A 2012 Hospital & Health Network one chance to do this right,” she wrote. “This means having
magazine cover story entitled “iGovernance” summarized everyone in the organization, from the Board Members to
the importance of such an approach for transforming the bedside clinicians, all focused on the same plan, the same
healthcare organizations as, “This IT governance func- tactical initiatives, and the same outcomes” (Hoehn, 2010).
tion, guided from the top but carried out by sometimes
hundreds of clinical and operations representatives, will
be evermore crucial to managing the escalation of IT in RULES FOR GOVERNANCE
healthcare delivery....” In fact, without such an informed Enabling governance committees requires a solid set of
governance process, the article states, “IT at many hos- rules, since hospitals are matrixed organizations com-
pitals and health care systems is a haphazard endeavor prised of multi-disciplinary staff and leaders from across a
that typically results in late, over-budget projects and, healthcare organization. A set of “rules to live by” in “iGov-
ultimately, many disparate systems that don’t function ernance” is identified in Table 19.1 (Morrissey, 2012).
well together” (Morrissey, 2012). Accountability begins at The following describes each role:
the hospital level and rises through the enterprise level.
Messaging through electronic, in-person, or video media 1. Hardwire the committees: Ensure that the chair of
options from chief executive officers and board mem- lower-level committees be participants on the next
bers of governance groups solidifies the importance of level of committees. Their role is to bring forward
enterprise-level health IT projects (College of Healthcare recommendations and issues needing higher-level
Information Management Executives [CHIME], 2010b). engagement for resolution.
However, both governance structures and the communi- 2. Set clear levels of successive authority: Committee
cations that support them require tailoring depending on responsibilities should be well defined so members
the nature of every health system. Communication leaders know issues they can address and issues beyond their
from the organization should be involved in developing level of authority (Hoehn, 2010).
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BOARD OF DIRECTORS
SUB-COMMITTEE
PMO/FMO
Accountability
Corporate
Global VP of Clinical Informatics EXECUTIVE

Delivery STEERING COMMITTEE
Business (EHR Implementation Lead)
Solutions
Functions
MEANINGFUL USE
COMMITTEE
HEALTH SYSTEM
Accountability
Operations
PARTNER COUNCIL
HOSPITAL STEERING OPERATIONS

COMMITTEES COMMITTEE Physician
Advisory
Council
Clinical
Leadership
Hospital Project Leads Council Clinical
Advisory
Accountability
Councils
Hospital
• FIGURE 19.1. EHR Implementation and Oversight Governance.
3. Do real work every time: Focus meetings on impor- who commands respect and possesses operational
tant issues in need of clinician engagement. If there authority to enact recommendations.
are no critical items, cancel the meeting and send
More specifically for health information technol-
out status reports electronically.
ogy, the Office of the National Coordinator for Health
4. Form no governance before its time: Recognize Information Technology (ONC), knowing that this area
that different organizations will not be prepared to requires consensus among many stakeholders, lays out
embrace a governance structure at the same time or milestones and expected outcomes for governance. In
to the same degree as others. their governance framework, ONC presents milestones
5. Put someone in charge that can take a stand: The and expected outcomes, rather than specific steps, for
leader of the top committee must be someone governance. These goals include organizational transpar-
ency and trust for all stakeholders (Office of the National
TABLE 19.1 Rules to Live by for Governance Coordinator for Health Information Technology, 2013).
Participants
1. Hardwire the committees. FOCUS ON CUSTOMERS
2. Set clear levels of successive authority. AND PLAYERS
3. Do real work every time.
Those who are engaged in EHR implementation initiatives
4. Form no governance before its time. should also be involved in communications associated
5. Put someone in charge who can take a stand. with these multi-year programs. Figure 19.2 illustrates the
spectrum of customers and players.
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that is promoted by the governing body and integrated
Patients &
Communities into practice by leadership and management working with
the organization’s health care teams” (Federal Register
II(B)(5), 2011).
Health System
Physicians
Leadership
Focus of Physicians
Communications
Nursing
As discussed in the introduction, adoption of EHRs by
IT Departments health systems or practices cannot be expected to suc-
Workforce
ceed without the endorsement and ownership of the
Multi- physician community, whose working environment must
disciplinary inevitably adapt to changes to long-established workflows.
Project Teams
Furthermore, when included from the outset of any health
IT transformation initiative, the deployment of “physician
• FIGURE 19.2. Focus of Communications. champions” can become powerful and effective commu-
nicators, assisting colleagues through health IT adoption.
In fact, a Government Health IT story reported that
In the provider setting, each of these groups has a dif- ONC itself, through its regional extension centers, has
ferent type of communications engagement. The media recruited “physician champions” who are well on their
and vehicles used may be different, but the strategic focus way to becoming meaningful users of EHRs to help oth-
is the same: improving the quality of patient care through ers in their area get over the hurdles of digitizing their
strategic adoption of health IT that is in turn enabled by medical records (Mosquera, 2011). Therefore, the need
smart communications. for communications that supports not only training ini-
tiatives and the management of new procedural require-
ments, but also an understanding of the dynamics of
Patients and Communities
legislated healthcare reform itself, is important from the
In its 2001 report, Crossing the Quality Chasm: A New earliest stages of health IT adoption.
Health System for the 21st Century, the IOM established However, such needs are often unmet. An April 2012
the need for patient-centered communications and sup- iHealthBeat article reported, for example, that the results
port as part of the six aims for improving healthcare, as of a recent survey of more than 250 hospitals and health-
noted in the introduction (Institute of Medicine, 2001). care systems demonstrated that significant percentages of
Since then, patient-centric healthcare and the emergence respondent physicians had inadequate understanding
of care-delivery models such as the Patient-Centered of Stage 1 meaningful use requirements; others cited a
Medical Home (PCMH) have become central to health lack of training and change-management issues (Providers
reform. Integral to the PCMH concept are seven joint prin- Make Progress in EHR Adoption, 2012). As a result of
ciples established in 2007, one of which calls for a “whole- improved programs and communications in organizations
person orientation.” This means each personal physician is such as regional extension centers, 72% of office-based phy-
expected to provide for all of a patient’s lifetime health ser- sicians had used an EHR by the end of 2012, and 66% were
vice needs. Lifetime engagement related to health drives planning to or had applied for meaningful use (Bendix,
the requirement for comprehensive physician-to-patient 2013). These statistics spotlight the continued need to
communications and shared decision-making (Patient- directly engage physicians in health IT implementations
Centered Primary Care Collaborative, 2007). through comprehensive communications initiatives.
Such communications are also required to support
healthcare reform at the community level, as demon-
Nursing Workforce
strated in CMS’s 2011 establishment of the Three Part
Aim for the Medicare Shared Savings Program, e.g., the For patients in both inpatient and ambulatory settings,
Medicare ACO, with its focus on “better care for individu- nurses constitute the front line of patient care. But for
als and better health for populations” (Federal Register. health systems everywhere, they are also on the front line
I.(C), 2011). In its final rule for the Medicare ACO, CMS of health IT reform. As Joyce Hahn, Executive Director
mandated the requirement for advancing patient-centered of the Nursing Alliance for Quality Care, said, “Nurses
care through accountable care organizations (ACOs), stat- represent the largest potential users of electronic health
ing, “an ACO shall adopt a focus on patient-centeredness records” (Hahn, 2011). As with their physician colleagues,
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therefore, the role of communications is not limited to IMPACT program news, features stories from successful
training nurses in the use of EHR systems, but rather hospital CPOE implementations so that upcoming hos-
preparing them to engage fully in the design, testing, and pitals can take advantage of the lessons learned (Johnson
implementation of EHRs to support improved care coor- and Browne, 2012). This has resulted in improved training
dination and continuity of care. Throughout the health- processes and has better prepared the hospitals across the
care industry, health systems CIOs are finding that “the board for changes in the system’s EHR system applications.
success of large IT implementations will depend not only The success stories also fostered healthy competition across
on the willingness of floor nurses to accept new technol- the health system to surpass previous CPOE adoption
ogy, but also on the strength of the IS-nursing manage- metrics at go-live. Newsletters should be distributed on a
ment connection” (Mitchell, 2012). Therefore, engaging consistent basis, have a recognizable template of content
nurses through communications both as champions and that is always included, and provided in a variety of com-
users of new health IT is a strategic necessity. munications mediums such as e-mail, print, and company
The clinical nurse informaticist has become a key role intranet.
in ensuring the adoption of EHR technology and the sus-
tainment of benefits. This role serves as a key change agent
Patients and Consumers
and communicator to all clinical disciplines by facilitat-
ing interdisciplinary workflows and using metrics to drive One imperative in the Patient Protection and Affordable
improvements in patient care. Care Act (PPACA) is that providers must encourage patients
Nursing Advisory Teams (NAT) can function as deci- to engage in their own care and communicate electronically
sion-making bodies—and NAT’s decisions will become with providers. This is seen as an important step in reduc-
the standard for the implementation of core clinical ing hospital re-admissions for patients who have certain
EHR applications. The consistent way that these leaders medical conditions, such as diabetes. However, hospitals
communicate their decisions has proved to be integral face some resistance from patients, who would rather speak
to promoting safe, quality patient care and improving directly with their physicians or do not understand the ben-
outcomes for patients and families while supporting the efits of reviewing and maintaining their own health records.
clinical quality initiatives (Johnson, 2012). Nurses and To combat such challenges, hospitals are creating
nursing informaticists can be key persons in the commu- patient-friendly portals where patients can check their
nication approach with physicians. Using their established appointments, see their lab results, pay bills, and send
relationships, nurses are able to remove the barriers and secure messages to their physicians. Some hospitals also
concerns physicians initially express in using EHRs, par- are interacting directly with private physician offices to
ticularly computerized physician order entry. Provision of ensure follow-up care, which often reduces the need for
key talking points and documented benefits should be for- readmission, and using telehealth services for high-risk
mally incorporated into the communication plan. patients. In addition, organizations, such as home nurs-
ing agencies, are text messaging to check in on pregnant
women and new mothers (Versel, 2013). It should be noted
IT Departments and Multi-disciplinary
that to ensure success, the language and content of patient
Project Teams
communication will be different for that used among cli-
IT departments and project teams are responsible for nicians. All of the components of health literacy such as
meeting the challenges of new-system introductions as reading level, language preference, local naming conven-
well as managing the continuous upgrades to existing tions for health conditions are critical considerations when
ones. To support this work, the teams’ roles in commu- crafting communications for the patients and consumers.
nications efforts involve engaging clinicians in staff posi- Another resource that should be considered an effective
tions, confirming commitments, managing change, and communication tool and methodology related to patient
setting EHR deployment strategies, per The CIO’s Guide engagement is the ONC Regional Extension Centers
to Implementing EHRs in the HITECH Era, a 2010 paper (RECs). These RECs serve as a communication and support
from the College of Healthcare Information Management resource for providers as they choose, implement, and use
Executives (CHIME) (CHIME, 2010a). EHRs. The centers assist in workflow analysis and help pro-
Organizational newsletters are effective communica- viders connect with their patients using tools like patient
tion vehicles for sharing best implementation practices, portal which is a window to their information in their
success stories and fostering team cohesiveness across EHR. As of July 2013, more than 147,000 providers were
the healthcare organization. For example, The IMPACT enrolled with a regional extension center. Of these, more
Insider, Tenet’s weekly cross-enterprise e-newsletter for than 124,000 had a live EHR and more than 70,000 had
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demonstrated meaningful use. Some 85% of REC-enrolled who function as subject matter experts, and champions to
providers were live on an EHR vs. 62% live on an EHR in secure buy-in for system adoption.
the general provider population (Office for the National A 2009 article by Chad Eckes, CIO, and Edgar Staren,
Coordinator of Health Information Technology, n.d.-a). MD, entitled “Communication Management’s Role In EHR
Success” offers other ideas, such as (Eckes & Staren, 2009):
Healthcare System Leadership • Fact Sheets, newsletters, and posters: collateral

tailored to clinician audiences
As noted in the section on governance, communica-
tions led by an executive-level steering committee, often • Road shows: pre-implementation educational
demos of forthcoming system capabilities
chaired by a health system’s chief executive or operating
officer, represent the beginning and the end of successful • Town hall meetings: opportunities for senior
health IT implementation processes. The top of the orga- leaders to hold question and answer sessions
nization not only establishes the size of the investment • Standard meeting reports: detailed status notes
the organization is prepared to make, but also commu- of schedules, budget, risks, and progress
nicates “the broad strategies for IT in advancing business
An e-newsletter can be used to communicate suc-
goals and, ultimately, acting on the result of a consistently
cess stories from hospitals that are further down the road
applied proposal and prioritization regimen” per the 2012
and have successfully implemented EHR systems. Such
“iGovernance” article cited earlier (Morrissey, 2012).
a vehicle is especially effective for integrated health sys-
tems whose hospitals are spread geographically across the
country.
Another perspective is provided by a 2005 JHIM article
BUILDING A COMMUNICATIONS PLAN by Detlev Smaltz, PhD, FHIMSS, and colleagues, in which
Kaiser Permanente noted in the 2011 HIMSS Davies they discuss the importance of project communication
®
Award application for their KP HealthConnect EHR that plans focused on stakeholder groups and meeting their
they credited their communication initiatives for “creating needs. Table 19.2 provides a sample of this plan for three
awareness, building knowledge, managing expectations, stakeholder groups (Smaltz et al., 2005).
motivating end users, and building proficiency” (Health Communicating an EHR implementation plan to phy-
Information Management Systems Society [HIMSS], sicians, nurses, and providers is essential for EHR suc-
2011). As part of their communications plans, they cess. Unlike many other hospital initiatives, changes that
included vehicles such as a central Intranet site, leader- directly affect the responsibilities of providers may be met
ship messaging, weekly e-newsletters, regional commu- with ambivalence, passivity, or as in the west-coast medi-
nication tactics, and videos. Other health systems also cal center mentioned in the introduction, active resistance.
employ e-mail updates, end-user training, super-users Therefore, communication about such changes should
TABLE 19.2 Sample of Health IT Project Communication Plan

Stakeholder Objective Media Content
Executive Management Update on cost, benefits, service • In-person meeting and briefing Status update and
quality, and milestones impact on outcomes
Nursing Maintain awareness of progress; • Nurse educators • Project methodology
engage in design effort • Nursing leadership • Design participation
• Collateral • Educational info
• Unit meetings • Outcomes impact
• Intranet Web site
Medical Staff Maintain awareness of progress; • Medical executive committee • Project methodology
engage in design sessions • Clinical chairs • Design participation
• Targeted newsletter • Educational info
• Outcomes impact
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include the following four steps, according to Michael Patients also should be included in EHR communica-
Crossnick, HITECH Answers (Crossnick, 2012): tions. Blackstone Valley Community Healthcare, working
with a regional extension center in Rhode Island, created
1. Create process teams: Create process teams within
a patient portal named HealthKey, with which patients
the staff to define the new workflow processes. These
could schedule appointments and e-mail questions
teams get the rest of the staff involved and help edu-
(HealthIT.gov, 2011). Patients coming in for appointments
cate them as the practice prepares to adopt an EHR.
provided their e-mail addresses, which generated invita-
These teams should meet at well-defined intervals on
tions to HealthKey. While initial use of the patient portal
a regular and consistent basis.
was modest, those who did use it viewed it favorably. A
2. Communicate the logic for EHR adoption: Explain key issue has been getting patients to complete the second
all the benefits of EHR adoption, how each member step, which is completing enrollment on the portal. As a
of the staff will benefit, and how the patients will result, Blackstone is purchasing kiosk terminals for wait-
ultimately benefit by improved quality of care. Be ing rooms so patients can complete the enrollment onsite
careful to avoid “because we said so,” or “it’s a gov- and are planning a patient survey to evaluate HealthKey.
ernment mandate” statements. While this may be Communications strategies may also need some cre-
true in some instances, it does not capture the true ativity; in late 2013, patients who enrolled in the patient
spirit of EHR adoption. portal were eligible to win a mini iPad (Blackstone Valley
3. Define measurable success factors: Clearly state Community Healthcare, 2013).
what the critical success factors are surrounding
the new EHR workflows and processes and follow Communication Metrics
this with a reporting system to evaluate success and
improve the processes once the EHR has been fully The best metrics to measure communication program
deployed. effectiveness are arguably the same used to present the sto-
ries of successful health IT implementations themselves.
4. Clearly communicate results: Establish a communi- In Tenet’s case, strong governance programs supported by
cation plan to communicate the definition of success. a pervasive and adaptable communications strategy have
These communications should happen frequently at helped drive EHR/CPOE Meaningful Use go-lives in 49
pre-defined intervals on a regular basis. Be certain to hospitals across the country by the end of the first quarter of
include all successes, as well as areas for opportunity, 2014. These results were supported by weekly e-newsletters,
in these communications. Nothing aligns people hospital site–specific communications campaign, future
faster than gaining success, even if they are initially state workflow localization, change readiness assessments,
small accomplishments. at-the-elbow support for providers from super-users and
subject matter experts throughout the go-live processes,
physician partnering, post–go-live support, and 24 × 7
PROJECT PHASES AND THE command centers for 10 days post–go-live.
COMMUNICATION FUNCTIONS
Health IT projects often unfold over multi-year periods
with pre-adoption (selection), pre-implementation, imple-
KEY INDUSTRY CONSIDERATIONS
mentation (go-live), and post-implementation (outcomes) While much of the communications focus supporting the
comprising the four major phases (Rodriguez & Pozzebon, implementation of new EHR systems and related health
2011). It is important that communication plans be built IT is directed inside a health system, those responsible for
and integrated within these phases, because the informa- building communication strategies must do so in the con-
tion needs of stakeholders will vary as projects evolve and text of industry change beyond any hospital’s walls. With
mature. Furthermore, a variety of formal and informal the arrival and rapid entrenchment of the digital age over
communication media will be needed to reach different the last decade, innovations in mobile devices and social
health-system groups, a point made in a 2009 Journal media platforms have broadened, enriching communica-
of AHIMA article entitled “Planning Organizational tions options to support successful health IT integration.
Transition to ICD-10-CM/PCS” (D’Amato, et al., 2009). Furthermore, the actions of the Federal Government to
The article further states that because points of urgency ensure increasing volumes of trusted, secure health infor-
and risks to be mitigated are also critical to key stakehold- mation exchange are constantly redefining how and what
ers, they should also be considered among the key ele- the healthcare industry can expect to communicate across
ments of an effective communication strategy. the continuum of care in the coming days, months, and
c19.indd 301 05-02-2015 12:30:33

years. Therefore, communications planning in support of that have emerged in the Health 2.0/Medicine 2.0 era as
health IT initiatives must reflect the forces driving such defined by Van De Belt and colleagues in their 2010 Journal
change: an expanding world of media, the roles of Federal of Medical Internet Research article (Van De Belt, Engelen,
healthcare agencies, and the adoption of regulatory stan- Berben, & Schoonhoven, 2010). Keys to enabling produc-
dards as they are driving the evolution of health informative communications with today’s new interactive tools
tion exchange itself. recognizes that “(a) health has become more participa-
tory, (b) data has become the new ‘Intel Inside’ for systems
supporting the ‘vital decisions’ in health, and (c) a sense
SOCIAL MEDIA AND eHEALTH of ‘collective intelligence’ from the network would supple-
INITIATIVES—MEETING THE ment traditional sources of knowledge in health decision-
HEALTH COMMUNICATION making” as summarized by Hesse and colleagues in their
2011 article entitled “Realizing the Promise of Web 2.0:
NEEDS OF COMMUNITIES Engaging Community Intelligence” (Hesse et al., 2011),
Physicians and clinicians across the industry are increas- Social media sites bring new opportunities to improve
ingly communicating among themselves and with their provider-to-provider communications within physician-
patients due to an explosion of mobile health device centric channels. These include sites like Sermo and
technology. A recent article entitled “Doctors’ Tablet QuantiaMD, which cater only to the physician community.
Use Almost Doubles in 2012” confirmed through a sur- Other social networking sites support patient communi-
vey of 3015 physicians that nearly 62% are using some ties that bring new opportunities for marketing of services
type of tablet platform—with the dominant choice being and disseminating best practices, as noted by David Nash,
Apple’s iPad. Such technologies are rapidly evolving, and MD, MBA, in a May 2010 article, entitled “Social network-
clinicians are increasingly depending upon them to docu- ing impact on patients, doctors, and non-profits” (Nash,
ment patient visits, manage clinical workflows, conduct 2010). As with mobile devices, the many positive effects
research on technical and clinical issues, and receive alerts to be gained from participation in social media must be
regarding patient conditions (Vecchione, 2012). considered alongside concerns for the privacy and secu-
While the upside to this rapid increase in commu- rity of protected health information. Supported by the
nication technologies is tremendous, the deployment HIPAA Privacy and Security Rules passed in 1996, health-
of such devices in the marketplace may be surpassing care organizations have become more vigilant in estab-
the pace for which security precautions can keep up, as lishing rules and policies governing participation in social
noted in a February 2012 Forbes article, aptly entitled media. Such heightened awareness was recently noted in
“How Healthcare’s Embrace of Technology has Turned the April 2012 Federation of State Medical Boards, “Model
Dangerous” (Lai, 2012). The article acknowledged the Policy Guidelines for Appropriate Use of Media and Social
“huge potential in helping medical providers diagnose Networking in Medical Practice.” Even so, as these com-
patients more quickly and accurately, improving the munication platforms evolve in the future, addressing
patient-provider relationship, and reducing extra paper- issues of privacy and security will be a key concern for
work – and the medical errors that are sometimes caused the industry, physicians, health systems, patients, and the
by them.” But it also called on hospitals to help “draft up healthcare reform movement as a whole (Lewis, 2011).
an industry-wide set of best practices governing the use of
mobile devices in hospital settings.”
To address security issues, the FDA released final ROLE OF FEDERAL
guidelines for mobile technology use in September 2013
(Food and Drug Administration, 2013). While these are
HEALTHCARE AGENCIES
non-binding guidelines that address mobile medical apps, Healthcare reform during the past decade has been
they provide a roadmap for current use and the devel- defined, spearheaded, and guided by Federal Government
opment of future medical mobile apps. They may also agencies armed with ARRA and HITECH legislation to
play a role in other eHealth initiatives as more and more providing funding, oversight, and industry-level guid-
consumers turn to their mobile devices to interface with ance on the implementation and adoption of health IT
patient portals to communicate with their providers and throughout the United States (Robert Wood Johnson
maintain their personal health records. Foundation [RWJF], 2009). Leading the government’s
Beyond devices, new digital media vehicles encom- healthcare initiatives is the U.S. Department of Health and
pass a multitude of healthcare specific social media Web Human Service (HHS) (Department of Health and Human
sites such as PatientsLikeMe, Sermo, and Diabetesmine Services, n.d.).
c19.indd 302 05-02-2015 12:30:33

Two key divisions of HHS are CMS and ONC. In addi- able to share information, including electronic copies
tion to Medicare (the federal health insurance program for and visit summaries for patients. As of October 2013,
seniors) and Medicaid (the federal needs-based program), 85% of eligible hospitals and 60% of eligible providers
CMS oversees the Children’s Health Insurance Program have received incentive payments, which means that
(CHIP), the Health Insurance Portability and Accountability they have adopted, implemented, and met the crite-
Act (HIPAA), and the Clinical Laboratory Improvement ria for EHR use (Reider & Taglicod, 2013).
Amendments (CLIA), among other services. Also, under Stage 2: To be implemented in 2014 under the current
HITECH, CMS is charged with advancing health IT through proposed rule and extend to 2016, “Stage 2 meaning-
implementing the EHR incentive programs, helping define ful use” includes new standards such as online access
meaningful use EHR technology, drafting standards for for patients to their health information and electronic
the certification of EHR technology, and updating health health information exchange between providers.
information privacy and security regulations under HIPAA
Stage 3: Expected to begin in 2017, “Stage 3 meaning-
(Centers for Medicare and Medicaid Services [CMS], n.d.).
ful use” is projected to include criteria that dem-
Much of this work is done in close conjunction with
onstrate improvement in the quality of healthcare
ONC and the two critically important federal advisory
(Reider & Taglicod, 2013).
committees that operate under its auspices. The first of
these committees is the Health IT Policy Committee, which
makes recommendations to ONC on development and
adoption of a nationwide health information infrastruc- ROLE OF REGULATORY STANDARDS
ture, including guidance on what standards for exchange of AND THE EVOLUTION OF HEALTH
patient medical information will be required (Office of the
National Coordinator for Health Information Technology
INFORMATION EXCHANGE
[ONC], n.d.-b). The Policy Committee has a number of In today’s era of healthcare reform, an increasing num-
workgroups that address specific issues, such as governance ber of standards in the area of health, health information,
for a nationwide health information exchange, consumer and communications technologies are helping guide the
involvement, and privacy and security measures for EHRs. healthcare industry toward interoperability between
The second is the Health IT Standards Committee, independent entities and systems. The goal is to support
which focuses on recommendations from CMS, ONC, and the safe, secure, and private exchange of PHI in ever-
the Health IT Policy Committee on standards, implemen- increasing volumes to improve the quality of care.
tation specifications, and certification criteria for the elec- As advised by ONC, CMS, and the Health IT Policy
tronic exchange and use of patient health information (PHI) Committee, the Health IT Standards Committee is the
(Office of the National Coordinator for Health Information primary federal advisory committee working to fulfill this
Technology [ONC], n.d.-c). Many of its workgroups aim to mandate. It is also a committee upon which this author
set specific criteria and standards to ease the implementa- is proudly serving at the appointment of HHS Secretary
tion of new programs and to measure their effectiveness. Kathleen Sebelius. Table 19.3 provides a summary of the
Understanding the roles of these agencies and duties of this committee as provided by a 2009 Robert
committees—and keeping abreast of their actions—is an Wood Johnson Foundation Report, “Health Information
important responsibility for those engaged in planning Technology in the US: On the Cusp of Change and the
and delivering communications that support health IT American Recovery and Reinvestment Act” (Robert Wood
adoption. Individually and collectively, they help drive the Johnson Foundation [RWJF], 2009).
definition of incentive payment requirements across the The Health IT Standards Committee has established
three stages of EHR Meaningful Use. Each stage not only over the course of its deliberations a number of important
creates new health IT performance requirements inside a workgroups as sub-committees to the parent committee.
given health system, but also defines the kinds of informa- These workgroups meet periodically to discuss their topics,
tion exchange—in themselves forms of communication— present their findings at Health IT Standards Committee
that will be required between healthcare entities across meetings, and make recommendations to this Committee.
the entire continuum of care, including those directly The agency’s sub-committees are formed around subjects
focused on the patient and the community. such as Clinical Operations, Clinical Quality, Privacy &
Security, Implementation, Vocabulary Task Force, Consumer
Stage 1: Beginning in 2011 as the incentives program Technology, and the Consumer/Patient Engagement Power
starting point for all providers, “Stage 1 meaningful Team (Office of the National Coordinator for Health
use” consists of transferring data to EHRs and being Information Technology [ONC], n.d.-c).
c19.indd 303 05-02-2015 12:30:33

TABLE 19.3 Duties of the HIT Standards the accelerated use of health IT. CMS, ONC, and its HIT
Committee Policy and Standards Committees are driving communi-
cations at the industry level to provide all stakeholders
Duties with a common set of rules to follow for selection, design,
implementation, and adoption of EHRs. Challenges still
Harmonize or update standards for uniform and consistent
implementation of standards and specifications.
persist, however, when effective communication plans are
not developed and followed in complex health IT projects
Conduct pilot testing of standards and specifications by the
that can affect physicians, nurses, administrators, and
National Institute of Standards and Technology.
patients alike.
Ensure consistency with existing standards. This chapter has addressed issues regarding the impor-
Provide a forum for stakeholders to engage in development tance of communications and the development of effec-
of standards and implementation specifications. tive communication strategies in strengthening initiatives
Establish an annual schedule to assess recommendations of ranging from governance efforts to physician-to-patient
HIT Policy Committee. partnerships—all as part of successful EHR implementa-
Conduct public hearings for public input. tions. Key takeaways to consider in the conclusion of this
Consider recommendations and comments from the chapter include the following:
National Committee on Vital and Health Statistics (NCVHS)
in development of standards. • Coordinated, cross-enterprise communications
strategies are critically important parts of health
IT implementations, including the development of
The Implementation Workgroup is dedicated to ensur- governance structures supporting the introduction
ing that what is being asked of the greater health-system and adoption of EHR systems.
and physician-practice communities is actually feasible • The customers and players engaged in communi-
in terms of adoption and meaningful use. A strong public cations include patients and communities, physi-
communications strategy is core to the work of this work- cians, nurses, clinical informaticists, project teams
group, which holds hearings with broad healthcare indus- and IT departments, and health system leadership.
try representation—including health systems, physicians, Remember that patient-centricity, the Meaningful
EHR and other health IT vendors and developers, among Use program, and physician and nurse engagement
others—and maintains active liaison relationships with are all critical points in the communication initia-
the sister Health IT Policy Committee. tives for these participants.
As a result, the Implementation Workgroup will con-
tinue to bring forward “real-world” implementation experi-
• Vehicles in a communications plan can include
an Intranet, print media, road shows, Town Hall
ence into the Standards Committee recommendations with meetings, and standard meetings to be used
special emphasis on strategies to accelerate the adoption of through all phases of a project and the success of
proposed standards, or mitigate barriers, if any (Office of the such projects can be the best measure of the com-
National Coordinator for Health Information Technology, munication plan’s effectiveness.
n.d.-d). Currently, the Implementation Workgroup is updat-
ing the goals and objectives for Meaningful Use Stage 3. • Some of the most powerful forces driving change
As are the meetings of the Health IT Policy and include social media, mobile devices, and contin-
Standards Committees, all workgroup meetings are held ued healthcare reforms and should be considered
in public, and notices for each meeting appear on the when developing communications plans.
ONC Web site and in the Federal Register (Office of the • The ONC’s committees, the HIT Policy and
National Coordinator for Health Information Technology, Standards Committees, and sub-committees, such
n.d-d). Public comment is always welcome. as the Implementation Workgroup, are key drivers
of national communications important to all stake-
holders involved in working toward the meaningful
CHAPTER REVIEW: FUTURE OF use of EHRs.
COMMUNICATIONS IN HEALTH IT America’s healthcare system is a complex, expensive sys-
ARRA, HITECH, and incentives programs supporting tem that needs to learn and adopt continuously to improve
the meaningful use of EHRs are helping the healthcare the quality of care and outcomes, protect patient safety, and
industry make a paradigm shift in care delivery through reduce inefficiencies (Institute of Medicine, 2013a). One of
c19.indd 304 05-02-2015 12:30:33

the major ways these goals can be accomplished is through considering new role players for your EHR implementation.
the increased use and development of health IT. Health IT The CIO’s guide to implementing EHRs in the HITECH era.
can increase providers’ abilities to share and retain patient CHIME Report. CHIME, Ann Arbor, MI. pp. 13, 31.
information and can support initiatives in patient engage- College of Healthcare Information Management Executives
(CHIME). (2010b). Chapter 9: Communication dispels
ment, care coordination, Meaningful Use, and eHealth. As
fear surrounding the EHR conversion. The CIO’s guide to
the healthcare industry grows increasingly interconnected implementing EHRs in the HITECH era. CHIME Report.
through health IT and other technologies, effective com- Retrieved from http://www.cio-chime.org/advocacy/
munication plans will remain essential parts of the process. CIOsGuideBook/CIO_Guide_Final.pdf
With a commitment to the development and execution of Crossnick, M. (2012). EHR implementation process requires
communications strategies around the implementation of communication. HITECH Answers. Retrieved from http://
emerging health IT, higher levels of ownership and com- www.hitechanswers.net/ehr-implementation-process-
mitment by professionals will help ensure the success of the requires-communication/. Accessed on March 27, 2012.
U.S. healthcare reform movement in years to come. D’Amato, C., D’Andrea, R., Bronnert, J., Cook, J., Foley, M.,
Garret, G., … Yoder, M. J. (2009). Planning organiza-
tional transition to ICD-10-CM/PCS. Journal of AHIMA/
American Health Information Management Association,
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20
Assessing the Vendors
Mark D. Sugrue
• OBJECTIVES
1. Describe an approach to evaluate the vendor marketplace for health information
technology solutions.
2. Discuss the evolution of the healthcare technology market place.
3. Distinguish the custom development or “build” approach from the purchasing of
commercially available solutions or “buy” approach.
4. Identify two or more criteria that may be used to differentiate one vendor from
another.
5. List the key Guiding Principles of a Vendor Analysis Methodology.
• KEY WORDS
Best of breed
Change management
Return-on-Investment (ROI)
Request for Information (RFI)
Request for Proposal (RFP)
Single vendor
INTRODUCTION support their own electronic health record software. The

idea of developing in-house applications, often referred
Assessing the Healthcare Information Technology market to as the “build” approach, was necessary at a time when
can be a daunting task. It is estimated that the global health commercial options were limited. The benefits of the build
IT market will reach $56.7 billion by 2017, an increase approach included the ability to program specifications to
from the 2012 market value of $40.4 billion (Pedulli, 2013). the organization’s unique requirements and the flexibility
In the United States alone, more than 1000 vendors exhibit to apply future updates or enhancements whenever they
at the Health Information Management Systems Society were needed.
(HIMSS) annual conference. Navigating the field of poten- The cost of the build approach, however, was great
tial vendors and assessing solution require a skilled and and many organizations could not compete within their
experienced leader and a team committed to a fair, unbi- market for the technical resources required to develop
ased, and thoughtful analysis. and support home grown solutions. There was also
great institutional risk associated with this approach.
Mission critical applications, for example, programmed
Build vs. Buy
by an employee could result in a single point of fail-
In the early days of Healthcare Information technology, ure should that individual no longer be available to the
many pioneering organizations elected to develop and organization.
309
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The commercial healthcare information technology 4. Use the Data; Trust your Gut
vendor market began to flourish in the middle of the 5. Make a Commitment
twentieth century with many of the early solution offer-
ings focused on financial and back office functions. As
technology continued to evolve so too did the market.
Demand for solutions increased steadily and over time VENDOR ASSESSMENT
vendors began to diversify their portfolios to include more METHODOLOGY
and more applications across different settings.
Whether large or small the introduction of new technol-
Today, there are many categories of vendors in the
ogy into an environment will have an impact on users and
market offering a wide variety of solutions. The competi-
potentially patients. Effectively managing this change at
tion has helped make purchasing or buying a solution the
both the individual and institutional levels will be a critical
more popular choice by far. This “buy” option as it is com-
success factor (Sugrue, 2010).
monly referred to has created a robust and thriving health
In many ways the selection project itself is an opportu-
IT marketplace.
nity to engage users and begin the process of introducing
change. As the team begins to assemble its plan to assess
Vendor Assessment Methodology vendors it should remember that communication with all
stakeholders is important. While it is not possible to have
Effectively assessing the vendor marketplace requires a
every stakeholder or employee of the organization actively
data-driven methodology and approach that will guide
participating in each step of the process, it is possible and
the organization through a vendor analysis process. The
highly recommended for teams to effectively communi-
graphic in Fig. 20.1 represents a Vendor Assessment
cate status and inform all of progress.
Methodology. Throughout the methodology Key Guiding
Principles are embedded to ensure that proven best prac-
tices are adhered to.
Understanding the steps of the methodology along with GUIDING PRINCIPLE #1—Manage the Change;
the Key Guiding Principles and incorporating these into a Communicate
well-developed and well-managed project plan will help
ensure that the organization is applying a fair and unbi-
ased approach to assessing potential vendor solutions. Guiding Principle #1 is “Manage the Change; Comm
unicate” and this cannot be stressed enough.
Key Guiding Principles Large-scale transformation efforts such as new technol-
ogy implementations may begin with an Organizational
The Key Guiding principles include: Change Readiness Assessment prior to a Vendor Assess
ment. In today’s rapidly changing healthcare environment
1. Manage the Change; Communicate
the pace and degree of change can be overwhelming for
2. Maintain and Document Objectivity the organization and for individuals. An Organizational
3. Think Process; Not Department Change Readiness Assessment provides a mechanism to
understand the organization’s appetite and capacity for
change and can help inform the Vendor Assessment effort.
For an example of a Readiness Assessment for a physi-
cian practice environment see http://www.HealthIT.gov
(HealthIT.gov: EHR Implementation Steps March, 2014).
It has been said that successful implementation of tech-
A. B. C. D. E. nology begins with early end-user engagement. A Change
Strategy Define Identify Evaluate Partner Management Strategy grounded in solid communication
that is incorporated throughout the project is the best
defense against resistance to change that may occur in any
organization. Examples of communication strategies used
during a vendor assessment include:
1. Newsletter publication on project goals and status
• FIGURE 20.1. Vendor Assessment Methodology. 2. E-mail or intranet communication about the project
c20.indd 310 20-02-2015 17:58:12

Chapter 20 • Assessing the Vendors 311
3. Town hall meetings led by organization leaders to 2. Future State (“What are we going to look like in the
provide status and answer questions future?”). It is important for organizations making invest-
4. Posters communicating the anticipated timeline and ments in technology solutions to consider the long-term
reasons for change outlook and impact. Most organizations will have a stra-
tegic plan which can provide some insight into the future
5. Contests to name or internally brand the project
direction of the enterprise. Leadership must fully consider
the technology implications of various business strategies.
A. Strategy Consider, for example, the potential technology impacts for
the following healthcare-related strategic initiatives:
The first major step in the Vendor Assessment Metho
dology is “Strategy.” This phase of the methodology is a. Becoming an Accountable Care Organization:
typically led by leadership and is intended to provide the Increased need to manage data on populations and
structure and strategic alignment and direction necessary predictive analytics to support transitions of care
to support the entire effort. The Strategy phase typically b. Merger and acquisitions activity: Data migration
focuses on four key strategic considerations. These are: and integration of technology platforms across an
enterprise
• Business Drivers
c. Changing payment models focused on quality: Data
• Future State Operational and IT Vision
and quality reporting needs
• Independence and Compliance
d. Clinician talent acquisition strategies: Technology
• Financial and Return-on-investment and tools to enable and support leading clinical
practice
1. Business Drivers (“Why are we doing this?”). An
e. Patient Engagement Initiatives: Technology tools such
important first step in assessing the vendor market place
as patient portals and data and information to effec-
is to ask “why?” or what are the business or clinical drivers
tively engage patients and families
behind the organization’s need to evaluate vendor solu-
tions in the first place? Establishing the need for change The operational vision helps describe what the future
and having it clearly articulated by leadership is also an operational environment of the organization may look
important element of an effective people and organiza- like. In addition to the operational vision it is important
tional change management strategy. to also understand the overall Information Technology
There may be a number of reasons why an organiza- strategy and vision during the initial phase of the Vendor
tion needs to assess the health IT vendor market. Some of Assessment Methodology. Among other things, the IT
these reasons may include: strategy will often describe the organization’s overall
approach to vendor solutions and products in the context
a. New or pending regulatory requirements unmet by of an existing or future IT portfolio.
current vendor, such as meaningful use or ICD10 In recent times, there has been an effort to minimize
b. Current solution outdated, no longer supported (e.g., the number of vendors included in an IT environment. In
Application retired) the past, organizations that embraced the best-of-breed
c. Changing business needs not met by current model found that managing communication and inte-
solution gration between multiple vendors was challenging. On
the other hand, it is well understood that there is not a
d. Merger with another institution on a different platform
single vendor who meets all of the functional and techni-
e. New enabling technology required to support cal needs of a healthcare enterprise. Today, most organiza-
improved care delivery/practice tions are attempting to minimize the number of vendors
f. Leadership decisions to change or introduce new in their portfolio in the hope of achieving better interop-
technology erability between key systems. Where an organization is
g. Current solution no longer meets business/clinical and most importantly where they want to be in the future
requirements, such as personalized healthcare along this continuum between best of breed and single
vendor is an important strategic element to understand.
h. Poor service or instability of current vendor
Both the Operational and IT strategies are impor-
Understanding the organization’s unique business dri tant inputs for the Vendor Assessment Methodology.
vers for assessing the market and documenting these as Anticipated solution benefits should be clearly defined and
part of a Vendor Assessment project charter is essential. aligned with the organization’s overall strategic direction.
c20.indd 311 20-02-2015 17:58:12

Leadership involvement is essential in order to ensure this that all project documents will come under some degree
alignment of the institutional goals and objectives with of scrutiny by those outside of the project in the future.
expected solution benefits.
3. Independence and Compliance (“Is the process fair

GUIDING PRINCIPLE #2—Maintain and Document
and defensible?”). One of the key strategic principles
Objectivity
of a well-structured vendor analysis is independence.
Merriam-Webster dictionary defines independence as
“freedom from outside control or support” (Merriam
Webster Online Dictionary: Independence, 2014). An Some of the indicators of a fair and objective system
independent vendor analysis process would be free of bias selection process are:
and would result in an objective decision for the organiza-
tion. It is important for all members of the team to abide • All vendors respond to the same RFI/RFP format.
by guidelines established to ensure strict independence. • There is a single point of contact for vendor questions.
These guidelines might include: • Vendors are asked not to interact with others in the
organization.
a. Acknowledging any real or apparent personal
conflicts of interest. Team members who have • RFI/RFP released to vendors at the same time with
relationships with representatives from one of the same deadlines.
vendors under consideration or members holding a • Any questions asked by and responded to are
financial interest in one of the companies would be shared with all vendors.
examples of a personal conflict.
• Demonstration scripts are provided at pre-deter-
b. Having a well-defined and adhered to vendors’ “no mined intervals in advance so that each vendor is
gift” policy. provided the same amount of preparation time.
c. Agreeing to no outside contact policy during the • Demonstration environment and timing is as con-
procurement such that vendors cannot circumvent sistent as possible for all vendors.
established communication channels.
• Demonstrations are managed and facilitated fairly
d. Strictly managing internal and external communi- and consistently.
cation and ensuring that information is shared with
vendors in a timely, consistent, and professional In some instances there may be local or regional
manner. requirements that must be considered from a compli-
ance perspective. A Certificate of Need (CON) process,
Oftentimes organizations pursuing large-scale vendor for example, is required in some states under certain
assessments will look to external consulting firms to assist conditions. According to the National Council of State
in guiding the organization through the process. The con- Legislatures CONs “…are aimed at restraining healthcare
sulting firm selected as well as the resources assigned to facility costs and allowing coordinated planning of new
the team should be held to the same standards relative to services and construction” (Certificate of need state health
independence and bias. laws and programs, 2013). These laws authorizing such
With healthcare organizations’ spending and investing programs are one mechanism by which state governments
tens and even hundreds of millions of dollars on technol- seek to reduce overall health and medical costs (Fig. 20.2).
ogy solutions there is an increase in oversight and scrutiny
from multiple stakeholders. Public and private boards, for 4. Financial and Return-on-investment (“What are
example, may require detailed information regarding the the costs and benefits?”). Lastly, and equally as impor-
selection of a particular vendor. It is necessary for those tant, the leadership team must provide some parameters
who lead these efforts to maintain and document objec- around anticipated solution costs and benefits. Oftentimes
tivity throughout the process. This documentation would with large-scale investments the organization’s Board of
include a project charter, a work plan, timelines, status Directors including the Finance and Investment com-
reports, correspondence, and meeting minutes to name a mittees may be involved to help provide some strategic
few. Project documents should be maintained in a secure guidance for the leadership and the Vendor Assessment
place, they should provide a detailed chronology of all project team as it relates to financial matters. This may
activity and they should be written with sufficient detail also include the need to seek funding from external
to stand alone upon review. The team should anticipate sources including capital and bond markets.
c20.indd 312 20-02-2015 17:58:12

State Certificate of Need (CON) Health Laws, 2013
WA NH
VT ME
AK MT ND
OR MN
MA
ID SD WI NY
WY MI RI
PA CT
NE IA NJ
NV OH
IL
UT IN DE
CA CO WV
KS MO VA MD
KY
NC
OK TN
AZ AR
NM SC
HI
MS GA
LA AL
TX
American
Samoa FL
Guam
U.S. Virgin
Islands
CON law; state approval may be required
PR
CON law repealed or not in effect
Compiled by NCSL November 2013; based on data from AHPA & State Agencies.
• FIGURE 20.2. State Requiring CON and those that Do Not. (Reproduced, with Permission. Copyright ©
National Conference of State Legislatures.)
The leadership team and the Board of Directors are 1. Conduct Market Research and Understand Key
often focused on the anticipated Return-on-investment Market Differentiators. Conducting a market scan of
(ROI) model of the proposed solution. To the extent that potential vendors is an important first step of the Define
they exist the Vendor Assessment project team should phase. An effective high-level market scan is as much an
fully understand any preliminary assumptions made rela- art as it is a science. While there are many resources avail-
tive to solution costs and benefits. It will be vitally impor- able within the industry, the best and most reliable way
tant for the team to secure data early in the effort that to attain an appreciation of any vendor and solution is
help support and compare the projected financial impact through networking and relationships.
analysis to an actual estimate based on data directly from Reaching out to colleagues or networking with peers
the vendors. Cost estimates will be discussed further in who have “been there; done that” is a recommended first
the Define phase. step in a successful market scan. Participating in trade
shows or industry conferences at a local or national level
B. Define can also provide an opportunity to connect with col-
leagues and to speak candidly with vendors who attend or
The Define phase of the Vendor Assessment Methodology exhibit. Lastly, there is a lot of information available on the
is intended to create the list of prospective vendors, to Internet with varying degrees of reliability. Searching tar-
document the functional and technical solution require- geted vendor Web sites and/or user groups is often helpful
ments, and to formally request information or a formal in obtaining baseline information but should be reviewed
proposal from targeted solution providers. with an eye toward bias, reliability, and credibility.
The major tasks in this phase are: It is also recommended to conduct a formal literature
review. As health information technology continues to
• Conduct market research and understand key mar-
evolve there is an ever-increasing body of knowledge in
ket differentiators.
the formal, peer reviewed literature. While the literature
• Develop functional and technical requirements. may not have vendor-specific information, it may pro-
• Develop and Submit RFI/RFP. vide some insight into solutions and anticipated benefits.
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A team considering a new acute care Electronic Health vendors, on the other hand, are focused on providing
Record (EHR), for example, may search the formal litera- management consulting, staff augmentation, or other
ture on Computerized Prescriber Order Entry (CPOE). high demand skills and expertise and do not usually
This research will provide a sound basis not only for the develop software product. Hardware vendors gener-
selection but for the identification of key benefits of the ate revenue primarily from the sale and support of the
new technology. hardware component of a solution offering and often
This review may also alert the selection team to poten- partner with other firms for software or services.
tial unintended consequences of new technology. Together It should be noted that these business differentiators
these documented benefits and unintended consequences are dynamic and can change as a vendor’s business
help inform the understanding of the market and the solu- evolves. It is also true that a single vendor may
tion being considered. differentiate across multiple dimensions. There
For a fee, industry and market research firms offer are software vendors, for example, who also offer
another way to gain information about vendors and their services and hardware. Just as there are hardware
solutions. Several examples of industry resources are pro- vendors who market, sell, and support software
vided in Table 20.1. applications. During a vendor analysis, it is impor-
As the team begins to understand the market they will tant to understand the potential vendors’ primary
find that the vendors in the health information technol- business differentiators and motivators so that an
ogy market differentiate themselves across several dimen- informed decision can be made.
sions. Among others, there are business, technical, and
Industry focus: Another important business differentia-
solution differentiators that should be considered as part
tor to consider is industry alignment. There are ven-
of the Define phase of a vendor assessment.
dors who focus 100% on the healthcare marketplace
and others who include industries outside of health-
Business Differentiators care in their portfolio. There are pros and cons for
Privately held vs. Public companies: Some health IT each. A healthcare focus offers assurance that a ven-
vendors are privately held businesses and in some dor appreciates the unique challenges the healthcare
cases wholly owned by the founders. These types of industry faces. On the other hand, the diversity of a
organizations typically make decisions about their company that serves multiple industries could offer
business and their solutions based on the company’s innovative solutions to bring forward into healthcare.
internal management and leadership. Other vendors Understanding which industries the vendors focus on
in the health IT market are publically traded orga- by asking probing questions and looking at their
nizations who ultimately report to external share- market penetration and research and development
holders. Decisions in these organizations are often investments can provide insightful information
highly focused around quarterly earnings targets. about the organization’s past as well as its long-
Software vs. Services vs. Hardware: There are vendors term commitment to providing innovative solu-
who function purely as software developers. That tions to the healthcare industry.
is, they develop software solutions but are not as
interested in generating revenue from other solution Technical Differentiators. There are multiple categories of
components such as hardware or services. Services technical differentiators to consider. Some of these include
TABLE 20.1 Health IT Market Resources

Resource Description URL
KLAS Vendor performance data based on http://www.klasresearch.com/

customer feedback
Gartner Industry research firm http://www.gartner.com
Forrester Industry research firm http://www.forrester.com
HIMSS Analytics Industry research firm http://www.himssanalytics.org
U.S. Department of Health and Human Services Certified Health IT product list http://www.healthit.gov
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those related to the development of software products, vendors, for example, may provide solutions for
product-line growth strategies, or the solution delivery the ambulatory market while others focus exclu-
mechanisms the vendor supports. sively on the needs of the acute, inpatient setting.
Further narrowing can be seen with what is typi-
Development Model: When evaluating vendors it is
cally referred to as “niche” vendors who service a
necessary to understand the underlying solution
very specific need. Peri-operative, Maternal Child
development model that is used. The develop-
Health, Behavioral Health, Radiation oncology,
ment model for software vendors, for example,
Emergency services are all examples of environ-
may involve open source software (OSS) or a
ments where niche vendors offer solutions.
proprietary, vendor-controlled approach. For
more information on OSS, please refer to Chap. 5. With the continued consolidation within the industry
While there is no right or wrong answer for one and the movement toward new models of care
development model over another it is important to delivery, it is important to consider current and
understand the vendors’ approach to development future business and clinical needs when analyz-
and to recognize how that approach is or is not ing vendors. An organization that operates as an
aligned with the organization’s current and future acute care facility today may find that its future
IT strategy. includes becoming part of an Accountable Care
Organization (ACO) model, for example, where
Product Line Growth: A vendor’s overall strategy environments such as post-acute, long term, reha-
to building its product line is another techni- bilitation, and others will need to be considered.
cal differentiator to consider. Some vendors
develop all of their solutions internally while Product evolution: Understanding the historical
other rapidly acquire technologies from others perspective of a vendor’s product is an essential
sources and essentially act as a system integrator. element of a comprehensive vendor analysis. One
Understanding the technical architecture on which Electronic Health Record vendor, for example,
the solution is built as well as the history of all solu- may have established roots by developing inpatient
tion components can provide valuable information clinical solutions while another may have started
to the team considering a vendor’s solution. out as a vendor focused on radiology systems.
Understanding this historical perspective is impor-
Solution Delivery: Today there are many options for tant in developing an appreciation of the vendor’s
the delivery of technical solutions to organiza- core competencies and a better understanding of
tions. Software solutions and electronic health how the solution has evolved over time.
records, for example, may reside on computers or
Integration: While some vendors claim to offer an
servers on the physical premises or they may be
“integrated” solution what they really provide is a
hosted remotely. In addition, many solutions are
franchise model where they purchase or acquire
now being offered by application service providers
various legacy applications and attempt to inte-
(ASP) via the Internet through such mechanisms as
grate them and sell them as a single solution
Software-as-a-service (SaaS). The team evaluating
offering. (See “Technical Differentiators” above.)
vendors will need to consider the delivery mode
It is vitally important to track each product or
that makes the most sense for the organizations. It
application back to its genesis to understand more
is not unusual for vendors to offer multiple delivery
fully whether a solution was developed as part of
options and all should be considered by the team as
a single, integrated platform or is a patchwork of
appropriate.
interfaced legacy systems.
Functionality: All solutions that enter a commercial
Solution Differentiators. Solution differentiators are those market go through a maturity cycle. In the begin-
characteristics of the vendors’ products that distinguish ning, there are wide differences in the features
them from competitors. These differentiators include the and functions and a limited number of vendors
market segments served, product evolution, integration, offering the solution. Over time, however, as the
functionality, and future product development plans. product matures and more vendors enter the mar-
Market segments served: While many vendors claim ket, competition creates a leveling of functional
to offer a “comprehensive” portfolio of solutions differentiators.
most serve relatively small market segments and An assessment of the now mature electronic health
have a narrow product line. In healthcare, some record market in the United States would show that
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the vendors who have led the market all have prod- the “How to implement EHR’s” section of the HealthIT.
ucts that are similar in their features and functions gov Web site. See Step 3: Select or upgrade to a certified
but differentiate on other elements. This Darwin- EHR (HealthIT.gov: Step 3 Select or Upgrade Certified
like survival of the fittest phenomenon is one of the EHR, March, 2014; AHRQ, n.d.).
key benefits of having a competitive, commercial Technical requirements focus less on workflow and
market for solutions. more on technical capabilities within the solution. These
Nonetheless, functionality is a key element of any might include “Ability to interface to Laboratory system,”
Vendor Assessment. Functional requirements “Supports Window Active Directory,” “Ability to send
will be explored in more detail in the “Develop and/or receive HL7 messages,” “Complies with HIPAA
Functional and Technical Requirements” section Technical Security standards,” etc.
that follows. Requirements can be very specific and detailed or they
can be high level. When the team develops requirements
Future Product Development plans: One of the most
consideration is generally given to the current state as well
important differentiators to understand about a
as the potential or desired future state workflow.
vendor is where they are headed with their product
A Key Guiding Principle that applies to requirements
line. In many cases, the partnership with vendors
development is to “Think Process; Not Department.” While
can last years or decades. As such, it is important
this principle, like all others, can be applied throughout
to develop a sense of where the vendor plans to
the Vendor Assessment Methodology, it is particularly
focus development efforts in the next 5 to 10 years.
important for requirements development.
As mentioned previously in the Strategy phase,
alignment of the vendors’ strategy with an orga-
nization’s strategic plan is an important step in
assessing a vendor’s compatibility to partner with GUIDING PRINCIPLE #3—Think Process; Not
an organization over the long term. This is espe- Department
cially true with understanding the vendors’ short-
and long-term product development plans.
As such, functional requirements should be developed
2. Develop Functional and Technical Requirements. from a process perspective and not a departmental or silo
Requirements definition is a very important step in the perspective. It is important, for example, when developing
Vendor Assessment methodology. Requirements can requirements for medication administration to consider
serve multiple purposes. First of all, they help define cur- the implications from the patients’ perspective as well as
rent state workflows requirements. They also help orga- the physicians’ (ordering), pharmacists’ (verification and
nize the desired future state features and functions. Often dispense), and nurses’ (administration and evaluation)
referred to as the “wish list,” future state requirements perspectives. Approaching requirements from a single
provide an opportunity for the Vendor Assessment team discipline, a single department or one step of the workflow
to see if a vendor’s solution can support the desired future would only partially define what is needed.
state environment. Nursing represents the largest segment of the health-
Requirements may also serve a purpose during the con- care workforce. In the United States, it is estimated that
tract negotiations phase. Gaps in functionality, for exam- there are 3.1 million Registered Nurses (Nursing by the
ple, may inform any custom modifications that may be numbers fact sheet, 2013). Table 20.2 highlights some
contractually obligated. In addition, some institutions may sample requirements organized around the Nursing
contractually bind the vendor’s response to requirements. Process. Again, it is important to consider the process and
As discussed, solution requirements can be divided not the department or in this case the nursing perspective
into functional and technical capabilities. Functional alone. Assessment requirements, for example, may lead to
requirements refer to those features and functions that an impact for nutrition, respiratory, or rehabilitation ser-
support workflow of end users. Examples of functional vices. Keeping this broader, process-focused perspective
requirements in a healthcare software application might will ensure that functional requirements are comprehen-
include: “Ability to log onto the system,” “Ability to register sive (see Table 20.2).
a patient,” “Ability to enter an order,” “Ability to generate Technical requirements can be complex. Requirements
a claim,” etc. The U.S. federal government offers a host of in this section generally pertain to the technical aspects
templates, best practices, and examples of functional and that your system must fulfill, such as performance-related
technical requirements and many other great resources in issues, system reliability, and availability issues. This
c20.indd 316 20-02-2015 17:58:13

TABLE 20.2 Sample Functional Requirements TABLE 20.3 Sample Technical Requirements
Nursing Hardware Describe the hardware support model
Process Sample Functional Requirement Implementation Will the system be available 99.99% of
the time for any 24-hour period?
Assessment Ability to capture admission assessment data
Regulatory Is the system Meaningful Use
Supports Braden Skin Scale Assessment
Compliance certified?
Diagnosis User can enter and modify Nursing
Report Writing Is the report writer native to the core
Diagnoses
application?
System supports multiple Nursing
Interfaces Do you support HL7?
terminologies
Technical System supports alphanumeric
Plan Supports Nursing and inter-professional
Security passwords?
plans of care
Backups and Can a single record be recovered?
Capture user-defined outcomes
Downtime
Implement Nursing work lists generated by system
Support Do you offer 24 × 7 × 365 technical
System displays status of all tasks support?
Evaluate Supports analytics related to nursing
sensitive quality
Ad hoc reporting capabilities
It may be helpful to start with a pre-defined list of
requirements and validate those against your existing
workflows. Colleagues who have been through similar efforts
may be able to provide sample requirements. An orga-
section may include multiple categories of questions that nization may also gather requirements from an external
may or may not be able to fit into the structured response source. The Health Resources and Services Administration
(see above) requirement. It is important to develop these (HRSA), for example, offers a number of resources to con-
requirements in collaboration with subject matter experts sider including Electronic Health Record system require-
from the organization who understand the requirements ments (HRSA, n.d.). In large-scale efforts it is not unusual
(Agile Modeling, n.d.). to seek out the services of a consulting partner to help
manage some of the key steps of a Vendor Assessment.
Sample Technical Requirements (Table 20.3) Consultants often have libraries of requirements that they
Structured Responses. It is important to structure the can leverage as part of their work. Regardless of the source
response to functional and technical requirements where of the requirements, it is always recommended to validate
possible to alleviate ambiguity and facilitate requirements these with the operational areas. This not only ensures the
analysis. Best practice is to phrase requirements such that
they can be answered in a Yes/No response format. This
can be difficult for some requirements but will provide for TABLE 20.4 Sample Structured Response
a more effective response analysis. Definitions
Soliciting a Yes/No response is not as simple as it may
Response Description
seem. Recognizing that they are being scored and competi-
tion exists, vendors will want to respond to requirements YC Yes, Current release fulfills
with a “Yes” response. This may introduce some ambiguity, YF Yes, Future release fulfills (note version # and
however, and responses should be structured to add clarity. release mm/yy)
To help alleviate concerns about this ambiguity, ven- NM Not standard, custom Modification available if
dors should be instructed to respond more accurately agreed upon by vendor
through a structured response approach. This may look
ND Not standard, requires further Discussion
like those described in Table 20.4.
The scope of the Vendor Assessment project will deter- NN Not standard, custom modification Not available
mine the work effort involved in developing requirements. OI Other third-party software, supports via
A focused assessment of a Laboratory solution, for exam- Interface
ple, would involve a narrower set of requirement than a full ON Other third-party software, No interface
Electronic Health Record and Revenue Cycle evaluation.
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requirements are correct but it can be an important step in b. Requires the organization to specify what it proposes
the user engagement process as well. to purchase. If the Requirements Analysis has been
prepared properly, it can be incorporated quite easily
3. Develop and Submit RFI/RFP. A Request for Information into the Request document (see below).
(RFI) is generally used to gather initial information about
c. Alerts vendors that the selection process is
a vendor and solution offerings and may be used to qualify
competitive
certain vendors to participate in further analysis. The RFI is
often used as a precursor or in conjunction with more for- d. Allows for wide distribution and response
mal requests such as a Request for Proposal (RFP), Request e. Ensures that suppliers respond factually to the
for Tender (RFT), or Request for Quotation (RFQ). RFQ is identified requirements
used oftentimes by the government when the product is f. Follows a structured evaluation and selection
approved for purchase, but the local authority must spend procedure, so that an organization can demonstrate
the money to purchase and install the software. An RFT, impartiality—a crucial factor in public and private
on the other hand, is usually an open invitation for suppli- sector procurements
ers to respond to a defined need as opposed to a request
g. May be used as part of future contract negotiations
being sent to selected potential suppliers.
An RFP is a generally considered a more formal docu- Table 20.5 shows a sample RFI/RFP outline.
ment of solicitation made, often through a formal and struc-
tured bidding process. An RFP may be issued by an agency
or company interested in procurement of a product, ser- C. Identify
vice, or other valuable asset. In the case of a federal or state During the Identify stage each vendor’s eligibility for fur-
agency the RFP may be posted to a procurement Web site. ther participation is determined and the vendor finalists are
The use of an RFI or an RFP offers several benefits. An identified. While the RFI/RFP may have been sent to a large
RFI/RFP: number of vendors the goal is to limit the field to three to
a. Informs vendors that an organization is looking to five qualified vendors for the upcoming and more resource
purchase products and/or services and encourages intense Evaluation phase. A review of the RFI/RFP responses
them to participate is conducted and inclusion criteria are established.
TABLE 20.5 Sample RFI/RFP Outline

Section Description
1 Executive Overview A high level summary of the request

2 Organizational Background Vital statistics and rationale for selection
3 Response Instructions for the vendors to follow
4 Evaluation Criteria Describes what the vendors will be evaluated on
5 Vendor Response This section explains to the vendor how to respond
Executive Summary Response to executive-level questions
General Information Response to background information on the vendor

Application Functions/ Response to functional requirements (one for each functional area in scope with structured
Features responses)
Technical Requirements Response to technical requirements (may be several pages and may not be in Yes/No or free
text format)

System Provide timelines and resources for deployment
Implementation
System Documentation Provide supporting documentation
Other Additional information the vendor would like to provide
Costs Response to detailed system cost information (usually provided in a structured format)
6. Attachments Templates for the vendor to use or additional information
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Quantitative and qualitative analyses are conducted on Rather high-level scripts can be developed that guide the
the RFI/RFP responses, including the functional and tech- vendor, allow for some flexibility, and provide a mechanism
nical requirements. to capture quantitative and qualitative data. The U.S. govern-
Eliminating vendors from the process can be difficult ment’s HealthIT.gov Web site offers sample demonstra-
but should be conducted with transparency and open tion scripts (Health IT.gov: EHR Demonstration Scenario,
communication. Once the decision to eliminate a vendor Evaluation and Vendor Questions, January, 2013).
has been made, the vendor should be notified verbally
and through a formal written response. Vendors may be 2. Site Visits. Site visits are generally conducted with a
holding resources in preparation for demonstrations and limited number of organizations due to the commitment
should have the opportunity to re-deploy those resources of time and expense for both the host facility and the orga-
should they not be invited to demonstrate their solution. nization considering the solution. It is important for site
visits to be planned in advance with specific goals and
objectives identified. Site visits are time limited and vary
D. Evaluate
in duration based on the extent of the solution being con-
During the Evaluation phase, the remaining field of ven- sidered. Vendor participation in site visits varies as does
dors and solutions are looked at more closely. During this the number of participants. In general, it is better to keep
phase vendor demonstrations, site visits, and reference the group small but also important to be inclusive with
calls may occur to further inform the team and identify good representation from key stakeholders. The primary
the vendor of choice. objective is to see the solution deployed in an operational
environment and to hear direct and candid feedback from
1. Demonstrations. Conducting demonstrations is a sig- the host facility.
nificant investment in time and resources for the organi- Typically, a site visit agenda will include the following:
zations and vendors. When conducting demonstrations, it
a. Introduction and Overview
is important to strike a balance between the organizations’
need to objectively evaluate each vendor and the vendors’ b. Solution Discussion
desire to show the best features of their product. All of this c. Facility Tour
needs to be considered in the context of time and resource d. Questions and Answers
availability as well as competing priorities for both the
organization and the vendor. The introduction and overview is intended to intro-
It is recommended to establish demonstration dates duce the host site and visitors to each other and to reiterate
very early in the process; even before final vendors are the goals and objectives of the visit. A solution discussion
known. Depending on the size of the effort and resources typically follows which describes the host organization’s
demonstration dates should be set, rooms reserved, and experience with the solution from the beginning. This
communication to hold the dates delivered to vendors in discussion should include the issues the organization was
the RFI/RFP. looking to resolve, the decision process used to identify the
It is important that the demonstrations are fair for all selected vendor, the implementation of the solution,
participants. Where possible the same or similar facility the relationship with the vendor, and whether or not
should be used at the same time of day for the same dura- expected benefits have been achieved. The mix and num-
tion and with a consistent list of participants. This level of ber of participants is governed in a large part by the scope
rigor is required to provide an “apples to apples” compari- of the solution being considered. Key stakeholders should
son of demonstration results. be well represented. It is recommended for the partici-
Scripts or scenarios developed by the organization are pants to debrief immediately following the site visit and
often used to help guide the demonstration and to capture not wait for the return home. Debriefing together and doc-
quantitative and qualitative data for evaluation. Having umenting observations immediately ensure that the team
process-oriented scripts that highlight key system require- accurately captures their thoughts. Observations related
ments provides an opportunity to see how the system is to the workflow integration as well as general observations
used to achieve organizational goals. Scripts for clinical about the host facility are important to document. When
systems should be oriented around the patient experience multiple site visits occur and time passes it can be difficult
and care delivery. It is a common mistake to overengineer to remember details from facility to facility.
the script which makes it challenging for the vendor to
demonstrate to an overly prescriptive process and hard for 3. Reference Calls. Reference calls should be conducted
participants to evaluate. in order to appreciate the perspective of customers who
c20.indd 319 20-02-2015 17:58:14

have successfully implemented the vendor solution. When between the organization and its potential future busi-
requesting references, it is important to find organizations ness partner.
that are as similar as possible so that a comparison can
be completed. It is recommended that at least three (3)
reference calls are conducted. References are completed GUIDING PRINCIPLE #5—Make a Commitment
with those organizations that the vendor has provided as a
qualified reference. A reference call questionnaire should
be developed so that the same questions are captured for
As in any relationship, once a partner is identified it
each reference.
is important for both parties to make a commitment to
each other’s success. Contract negotiations may begin as
4. Due Diligence. Due diligence refers to a process of
soon as the preferred vendor is identified. At this stage, it
further and deeper investigation of a company prior to
is common for organizations to include legal representa-
contract signing. Much of the information required
tives who are familiar with health information technology
to support due diligence should have been requested in
contracts as part of the team.
the RFI/RFP. In some instances, it may be necessary to
In some cases, early planning activities will occur
engage a third party to conduct due diligence and to more
in parallel with contract negotiations. Data gathered
thoroughly investigate the financial status of a potential
throughout the analysis may be used to inform planning
vendor partner.
and contract discussions. Some organizations, for exam-
The quantitative and qualitative data collected
ple, may include the vendor’s response in the require-
throughout the process are used to support and inform
ments as part of the contract in order to hold the vendor
the vendor of choice decision. As with most major deci-
accountable for their answers.
sions, however, there is a need to do a “gut check.” If
Stakeholder communication is vital throughout the life
despite the data collected the vendor does not “feel” like
cycle of a vendor selection. Oftentimes the team will be
the right partner during the selection and pass the teams
expected to provide a summary of the analysis and current
gut check it is unlikely that they will meet the organiza-
status. The audience for these presentations can range all
tions’ needs once a contract is signed. While the data are
the way from front-line staff to the organization’s board of
helpful in the end, the instincts of the team and leaders
directors or creditors. Effective communication and pre-
involved in the process are the most valid indicator of
sentation skills are essential. The team should anticipate
future success.
questions and be prepared to respond with short notice to
any and all stakeholders. A well-thought-out communica-
tion plan during the selection effort will set the stage for
GUIDING PRINCIPLE #4—Use the Data; Trust ongoing communication during the planning and imple-
your Gut mentation phases.
A major deliverable of the Evaluation phase is the

Summary Analysis. The Summary Analysis brings SUMMARY AND BEST PRACTICES
together data from all parts of the methodology in a clear In conclusion, it is immense responsibility to lead or par-
and concise format that is ready for executive review. A ticipate in the selection of a new vendor partner for an
sample Summary Analysis appears in Fig. 20.3. organization. Following a data-driven and evidence-based
Vendor Assessment Methodology provides the opportu-
E. Partner nity for a thoughtful and objective analysis of the vendor
marketplace.
In a well-structured vendor selection process, the win- The Key Steps of the Vendor Assessment Methodo
ner or “Vendor of Choice” often emerges as the clear logy are:
answer.
In the past, some organizations elected to enter into A. Strategy
contract negotiations with multiple potential solution B. Define
providers in order to increase leverage and provide for
C. Identify
a more competitive bidding environment. In practice,
however, this strategy seldom achieves the intended D. Evaluate
results and more often creates unnecessary tension E. Partner
c20.indd 320 20-02-2015 17:58:14

Overall Weighted Scores Per Vendor
100.00%
90.74% 89.00% 88.70% 88.14% 88.07% 87.68%
90.00%
84.43% 83.25%
80.00%
70.00%
63.54%
60.00%
50.00%
40.00%
30.00%
20.00%
Vendor A Vendor B Vendor C Vendor D Vendor E Vendor F Vendor G Vendor H Vendor I
Vendors
Vendor A Vendor B Vendor C Vendor D Vendor E Vendor F Vendor G Vendor H Vendor I

1) Live POE solution β β β β
2) Live Pharmacy solution β NP
3) a. POE Software License Cost $15,172,299 $23,866,807 $19,780,000 $16,025,000 $4,424,000 $9,229,000 $5,850,000 $9,503,000 $10,658,000
b. Pharmacy Software License Cost I I N/A $1,433,900 $980,000 $3,902,250 $1,604,000 I NP
c. Total Proposed Start-up Cost $18,449,745 $25,054,748 $34,439,268 $25,771,424 $10,600,000 $44,973,980 $24,117,936 $110,568,870 $72,000,000
4) POE Key Functional Requirements
iv.a.1.f Ability to enter orders via PDA F F N F N F N N
Dose Calculator based on
v.a.2.f documented patient weight F N
Supports Adult TPN ordering with
v.a.2.r templates F F N N
v1.1.n Flag orders entered remotely N N N N
Require countersignature based on
N N
vii.1.d intervention
vii.5.l Escalation Rule F N N N N
ix.a.l Ability to modify drug database N N
5) Largest Relative Bedsize >500
6) Pharmacy system is stand-alone β
Legend
Operational
β Beta
NP No Product/System
I Included in POE cost
F Future: Available prior to Q4 2003
Not Available or Future without
N date
• FIGURE 20.3. Sample Summary Analysis.
Remember to consider and apply the Key Guiding 4. Use the Data; Trust your Gut
Principles throughout the lifecycle of the Vendor 5. Make a Commitment
Assessment:
REFERENCES
1. Manage the Change; Communicate
Agile Modeling (n.d.). Technical (non-functional) require-
2. Maintain and Document Objectivity ments: An agile introduction. Retrieved from http://www.
3. Think Process; Not Department agilemodeling.com/artifacts/technicalRequirement.htm
c20.indd 321 20-02-2015 17:58:14

NURSING INFORMATICS – VIDEO LECTURES (Weeks 12 & 13) NOTES
COMMUNICATION IN MULTIDISCIPLINARY TEAMS The best form of information transfer occurs during face-to-face • But within healthcare hierarchy often prevents people from
Communication is the key to effective teamwork and the delivery of conversations. This form of communication is especially important for speaking up. The ability to speak up to express concerns is a
safe patient care. It is fundamental for decision making, team expressing concerns and finding resolutions to conflict. key safety behaviour we should all have.
coordination and in maintaining situational awareness. Human factors • Not speaking up, especially in junior team members, has been
science tells us that: Models of Communication shown to be a contributing factor to many patient safety
• the inherent limitations of our memory, • Communication can be difficult due to both internal and errors.
• the effects of stress and fatigue, external barriers. • Using the PACE tool (Probe, Alert, Challenge, Emergency)
• the risks associated with distractions and interruptions, and o Internal barriers are those which affect us as could allow any healthcare professional to challenge any action
• our limited ability to multitask individuals such as language differences, our culture, or behaviour they may feel is inappropriate or unsafe.
ensure that even skilled experienced providers will make mistakes. our expectations of the situation and our past Example: Sarah is a midwife and has called the
experience. neonatology doctor to attend a Category 2 Caesarean
Effective communication methods create a well understood plan of care o External barriers are those around us such as Section. The baby has been born and the
and this can greatly reduce the chances of error and consequently background noise and distractions. neonatologist is attempting to resuscitate the baby.
patient harm. • One-way communication is a form of communication is The heart rate remains below 100 beats per minute
relatively quick, however, there is no immediate feedback and and the neonatologist is unable to inflate the lungs,
Communication can be divided into four components: the receiver may not pay adequate attention to the with no chest rise visible. Sarah is helping the
1. WHAT instructions given. neonatologist by listening in to the baby's heartbeat
o This is the information to be communicated. • Two-way communication involves both the receiver and the and checking the oxygen saturations. Sarah is
o "The fact that we have been pushing now for two sender, forming a closed feedback loop. This form of becoming increasingly concerned about the baby, as
hours and there is no descent..." communication allows for checking and correction of details, the neonatology doctor has become task focused and
2. HOW allowing both parties to work together to achieve a mutual believes that they are successfully resuscitating the
o How are you going to communicate? understanding and prevent any misinterpretation of the baby. What would you do in this situation?
o "...Would you mind just grabbing a theatre pack with original meaning of the information. PROBE: "Is the chest rising?"
a consent form while I do that and then coming back • Open questions should be used by both parties using 'what' or ALERT: "James, I really cannot see the chest
with it?" 'when' questions rather than those which invite 'yes' or 'no' rising"
3. WHY answers which are likely to lead to an automatic response and CHALLENGE: "James, the chest is not rising,
o Why are you communicating this? be potentially biased. the heart rate is not improving, can I take
4. WHO 1. Using open questions involves the recipient and over?"
o Who are you communicating with? means they must think about their response. EMERGENCY: "James, this is not working.
The chest is not rising, the heart rate is not
There are different types of communication that we use every day. Graded Assertiveness improving, I am putting out a 2222 call.
• Written communication • As any healthcare professional working within the NHS, we are Please can I take over?"
o This form of communication needs to be clear, legible, exposed to increasing stress and workload. The intrinsic By using the PACE tool to challenge the unsafe actions
precise and informative as otherwise the information limitations of our memory, our environment, and the impact and behaviour of the doctor, Sarah has been able to
can be open to misinterpretation. of stress and fatigue can all influence our communication with stop the situation, allow for reassessment and ensure
• Verbal communication others. the patient's safety.
• Non-verbal communication • Safe and effective delivery of health care requires
o Our facial expressions, tone of voice, gestures and eye communication between individuals with different roles, Handovers and SBAR
contact help us to convey emotion and reinforce our training, experience and perspectives on care. • Working frequently in shifts results in dynamic teams, with
verbal communication. members not being constant. Handover of care is therefore
essential in developing a shared mental model and effective
continuity of care.
majjyap ‘21
• Poor communication at handover is a leading cause of patient "I will perform the vaginal examination in the agents and the top-down macroscale system of organization both of
harm. next four hours after regular contractions which are often driven by different agendas but are ultimately
• Handover should be multidisciplinary, formal and follow a unless I have got earlier concerns". interdependent.
consistent format. You should have adequate time without
distractions or interruptions. Top Tips on Communicating in Teams It is this interaction between bottom-up differentiation of agents with
• Have a clear leader. This should be the person who has • Be explicit. Clearly state the desired action and who should do different agendas going in different directions and top-down
maintained situational awareness throughout the previous it, using both verbal and non-verbal communication. integration in order to maintain the global pattern of organization that
shift, and therefore has the knowledge to provide an accurate • Use names to directly communicate to someone. creates the core dynamic of complexity within these systems.
handover. The leader should highlight patients who are at risk • Ask them to report back (closing the loop) to you when they
or with concerns. have completed the action. There are many examples of complex adaptive systems from ant
• Clear and unambiguous plans should be stated. • Think of your timing. “Do I need to communicate this now or colonies to financial markets to the human immune system to
• At handover, exchange of sufficient and relevant information can it wait?” democracies and all types of ecosystems, but we will start on the micro
using standardized communication tools should be used. • Do not communicate if someone is task focused, unless the level by talking about the agents and adaptation.
• SBAR is a communication tool which allows healthcare information is urgent.
professionals to communicate effectively and assertively; with • “Can you find someone else you can help you?” Speak up and An agent is an actor that has the capacity to adapt to their state
the right level of detail communicated in any clinical setting. It be assertive if you are concerned about another colleagues meaning that given some change within their environment, they can in
can empower those who may feel less confident or less behaviour or decision making. Be careful not to disregard the response adjust their own state. So, say our agent is a player within a
experienced than a senior to make a recommendation. SBAR is other person or come across as being aggressive. Asking sports game. If we throw a ball to the person, he or she can catch that
comprised into four prompts: questions to acquire more information may be all that is ball. They are able to do this because they have what is called a
1. Situation required to resolve a problem. Avoid interrupting, trying to regulatory or control system.
"Morning! I am Raquel, the midwife looking work out what the person will say next or changing the subject.
after Lucy Brooks." • Remember to actively listen to others especially if they are A control system of this kind consists of a sensor, controller, and an
"She is a primigravida at 37+1 being induced trying to speak up. This is key in demonstrating effective actuator. The person is using their optical sense to input information to
for small for gestational age..." communication skills. their brain (the controller) that is then sending out a response to their
2. Background muscles (the actuator) and through this process, they can adjust to
"Lucy has a BMI 42. She had serial scans in generate the appropriate response to this change in their environment
COMPLEX ADAPTIVE SYSTEMS
pregnancy and a small for gestational age and it is the same process through which a bird in an ecosystem or a
A complex adaptive system is a special class of complex system that has
baby has been diagnosed." trader within a market is receiving information, processing it and
the capacity for adaptation, thus like all complex systems, they consist
"She is being induced for that reason." generating a response.
of many elements what are called agents. With these agents interacting
"The estimated fetal weight is 2.4 in a nonlinear fashion, creating a network of connections within which
kilograms." Typically, these agents can only intercept and process a limited amount
agents are acting and reacting to each other's behavior.
"She had an ARM at 6:30 at 3 cm dilated, of local information like a snail following a trail on the ground, it does
started oxytocin at 6:45." not have a global vision of the whole terrain around it and it must simply
Through adaptation, agents have the capacity to synchronize their
"Oxytocin is currently running at 8 mls per respond to the local information available to it.
states or activities with other agents locally. Out of these local
hour." interactions, the system can self-organize with the emergence of
"She is contracting two in ten and the With this capacity of adaptation, agents have some degree of autonomy
globally coherent patterns of organization developing.
CTG's..." through which they can choose to synchronize or desynchronize their
3. Assessment state with that of other agents within their local environment, we might
This macroscale organization then feeds back to the micro level, as the
"My assessment is that we need to increase also call this cooperation or competition. They typically do this based
system has to perform selection upon the agents based upon their
the oxytocin as per our current guidelines upon the costs and payoffs for choosing one of either option and this
contribution to the whole system's functioning, and thus there develops
and she is not yet in established labor." cost-benefit ratio varies depending on the scenario or what we might
a complex dynamic between the bottom-up motives of the individual
4. Recommendation call the game they are engaged in with other agents.
majjyap ‘21
within an ecosystem, the human body, a democracy, or a corporation • Health Information Technology system (HIT) stores multiple
Some scenarios such as playing chess have very low incentives for within a market. The whole macro system is periodically subject to records in protected databases. These databases can sort the
cooperation while favoring competition. These are called zero-sum perturbations and change within that environment. In order for it to information into statistically usable data to facilitate quality
games while other scenarios have a much lower cost and a higher optimize its state, there must be some mechanism for performing improvement.
payoff for cooperation such as driving your car on the correct side of selection upon the agents within the system. Those creatures within an • Information technology (IT) is used to obtain lab results and
the road. These different types of games create attractors that result in ecosystem that can best respond to the environment are replicated. other diagnostic tests in a more timely manner. It can be used
default positions for agents to cooperate or compete. Added to this our Those employees that have proven their value to the company will be to send prescriptions more quickly and more accurately
feedback loops, where what one agent does influences what another promoted while others will be fired. Those products that best fulfill the to pharmacies by utilizing e-prescribing, or writing and sending
agent chooses to do. If you owned a certain stock and upon hearing demand are selected by the consumer while others go by the wayside, prescriptions electronically. Pharmacies use their own
some negative news about that company, all of your fellow traders the result being that the whole system evolves to exhibit more of the databases to cross-reference established patient information
around you started selling it, this would create a positive feedback loop desired characteristics as they become more prevalent with the system. like allergies, medical history, as well as potential interaction
attracting you to also sell and if you did that, you would again amplify to current prescriptions. Pharmacies also use IT to check
the positive feedback placing a stronger attraction on others to also do In this way, this global pattern of organization will feed back to affect insurance formularies and to determine how much to charge
likewise. the agents on the local level, both enabling them and constraining the patient for the medication. Quality is improved in these
them. It enables them as it is a mechanism for them to coordinate their examples through increased efficiency and reduced errors.
In such a fashion, some phenomena can cascade through a population activities and thus receive the benefits from forming part of a complex • Evidence Based Practices (EBPs) are the most up-to-date and
synchronizing their state's rapidly. This process previously described is organization in the form of security, shared knowledge, technology, and statistically proven research data to implement. With IT,
a form of what is called self-organization from the interaction of the so on. But it will also constrain them, as following regulations and being hospitals can study the effect of new EBPs on patient outcomes
individual agents arises some kind of global pattern which typically subject to some form of selection is part of maintaining this global to identify the exact amount of quality improvement.
could not have been predicted from the behavior of the agents in organization. But of course agents have their own agendas that may or • Physicians must make referrals to specialists or clinics outside
isolation. For example, in the brain, consciousness is an emergent may not be aligned with those of the whole system and this is where of the hospital. In the hospital, a physician has to enter a
phenomenon which comes from the interaction between the brain cells the real complexity comes into the dynamic as there is now a core consult to send to a patient to another location. When the
thus the global property of consciousness results from the aggregate tension between the micro and macro levels. The system as a whole, consult is entered into the EHR, it is marked as pending. The
behavior of individual elements. Within this macroscale system that that is how it appears within its environment, will be primarily defined referral itself has all the required data, as well as other
emerges, control and regulation is typically distributed out. There is no by how this core tension is resolved. That is to say is the system driven additional data necessary to convey its purpose. It will
master neuron or set of neurons that tell the whole brain what to do. by the interests of the agents at the expense of the whole, or by the subsequently be noted when scheduled and when completed.
No one is in control and no one in the system has complete information interest of the whole at the expense of the interests of the individuals, The physician can check on the status of the referral with only
of it. This distributed nature to complex adaptive systems may make or has it managed to find some resolution to this conflict? If we take an a simple click in the EHR.
them very robust, where the system can adapt to some large example of an economy, we can have a free-market economy which is • Sadly, the physician must revert to old fashion phone calling
disturbance. The internet might be an example of this, dynamically driven primarily by the interest of the agents in a bottom-up fashion or and faxing to send a referral outside of the hospital, due to a
updated routing tables keep track of how long it takes to send we might have a communist economy driven by a top-down dynamic at lack of interoperability or the ability for healthcare IT systems
information along any path on the network. If there is a failure in one the expense of individual motives, or we may have some economic to communicate with each other.
part of the network, packets are rerouted through another channel. system that manages to integrate the two? • Health Information Exchange (HIE) is the electronic exchange
Control over the flow of IP packets is distributed out over many of health information between providers. The government is
different routers and service providers with a large amount of INFORMATION TECHNOLOGY: CLINICAL PRACTICE developing new standards to facilitate communication
redundancy, making it robust to failure. But equally complex adaptive • Information technology is a term that summarizes the way between all HITs.
systems can self-organize into a critical state where feedback loops can healthcare providers store, use, and share clinical data to • Nationally, large hospitals have realized between 30 and nearly
work to amplify some small perturbation into a large systemic effect as improve healthcare. It includes electronic health records and 60 million dollars in gains over a five-year period due to the use
witnessed during financial crises. e-prescribing. of IT. Transcription costs and fees associated with maintaining
• Electronic Health Records (EHRs) are used to store all the and storing paper records have been eliminated. It has also
This emergent macroscale system of organization then operates within information associated with a given patient. gotten easier to provide recruiting, improve disease
some environment whether we are talking about a herd of animals
majjyap ‘21
management, and comply with enhanced regulatory 2. Business/financial systems. The business/financial systems of 6. Medical support. Regardless of the careful, astute nature of
guidelines. a hospital include tracking the payroll of hospital employees, physicians and nurses, it is easy to make mistakes when
as well as tracking the payment and billing of patient accounts. working in a busy, chaotic, stressful healthcare environment.
HOSPITAL INFORMATION SYSTEMS Whether we like it or not, hospitals need money to survive. Medical support systems can help with this. There are
• A hospital information system (HIS) is a comprehensive There is no way that we can accurately keep track of the flow computerized systems that give us alerts and messages to help
technology system that allows hospitals to manage all aspects of money in and out of the system without computerized help. prevent errors. Many systems are equipped with allergy alerts,
of their operation, not just patient information. It can be When we think about payroll, having a computerized system medication contraindications, and care reminders that prompt
viewed as a system that helps all hospital departments manage helps us to ensure accuracy with wages and helps us to file providers to take the time to ensure safe care is given.
their information in order to allow them to effectively do their taxes correctly. Many systems are built with the need for only
jobs. Hospital information systems not only manage patient a small amount of data to be entered and the system will REGULATORY REQUIREMENTS FOR HEALTHCARE INFORMATICS
information, but also financial and business information. As we automatically calculate the appropriate withholdings. Most Regulations Overview
know, data drives decisions. The overall computerized will even automatically be updated when new tax laws come • Since the 1960s, there has been a rapid development of
coordination of this data allows senior-level leaders to gain out. computer software that can provide electronic
access to all of the information that portrays the hospital's 3. Communication and networking. When we take care of documentation, information, communication, and decision
current situation and determine if they are meeting patients, we must be able to communicate with all members support for staff and providers of healthcare. The growth
organizational goals. of the healthcare team to ensure the patient has what he or of healthcare informatics, a specialty role combining clinical
• We know that in a hospital, patients are the primary reason she needs. Although we greatly value face-to-face knowledge and information science, has produced a
why we are there. We want to impart high quality care to those communication, sometimes it is not possible when working in technology base in the clinical setting. Health information
who come to us for help. A hospital information system can such a busy environment. This is why computerized systems technology, or HIT, formed the product called the electronic
help us do this by streamlining patient information in one are effective. Many systems allow physicians to enter new health record, or EHR. Nursing informatics is a special role for
central electronic place, which improves the ability for orders for a patient so nurses and other departments can see nurses who help design workflow for the EHR, taking the care
physicians and direct care staff to access patient data. The them in real time. This prevents many delays in patient care of patients into technology.
easier and quicker health providers can access information and treatment. Additionally, patient results can be placed into • Regulatory bodies in government have been tasked with
about the patients, the more effectively they can determine the system and can be seen quicker by providers. This smooth addressing the healthcare informatics world in an effort to
the care to be given. exchange of patient information is vital to timely care. improve quality, safety, and security of patient care and
4. Department management. Electronic department records.
Friedman and Martin Functional Model management systems allow each individual department in a
Friedman and Martin have developed a model that depicts a hospital to be effectively managed and a smooth workflow to Health Insurance Portability and Accountability Act (HIPAA)
comprehensive list of hospital functions that need to have a solid exist in order to operate effectively. Many individual hospital
Legislation was passed in 1996 to allow insurance coverage to continue
system in place for appropriate management. Their model describes six departments have their own electronic system that they use to
in case of job loss or changes. Parts of this law are specific to healthcare
elements of hospital management that we should closely examine to manage and communicate staff work schedules. This allows
technology as patients can now have access to their electronic health
see how information systems can help. adequate coverage to be provided for day-to-day operations.
records. Confidentiality is a large part of this law as it addresses the
1. Core systems. The core systems of a hospital include patient 5. Medical documentation. Having data and information about
security and handling of the patient's record.
scheduling and a process for tracking patient admissions, patients is a central component of being able to provide care.
discharges, and transfers to different levels of care. Many This is why medical documentation systems are important.
Health Information Technology for Economic and Clinical Health
computerized systems that track these components are built Most hospitals have a single, standardized computer charting
(HITECH)
with automatic alert functions that send a message to system that allows patient data to be input, organized, stored,
In 2009, this law was passed to create a national healthcare
physicians and others involved in care management to alert and retrieved in a systematic way to allow physicians and staff
infrastructure. This law includes:
them to the admission, transfer, or discharge of a patient. to access what they need to provide care. Additionally, having
• Greater HIPPA enforcement with strict compliance and large
Having these real-time alerts can improve the timeliness of a system that is set up this way allows for audits to be
penalties for breaches in confidentiality
addressing patient needs and make the care coordination conducted to ensure quality.
• Health information technology expansion
process of a patient flow much smoother.
majjyap ‘21
• Interoperability, which is the exchange of patient data through testing function of technical products and devices used in healthcare for • Compares
secure networks connecting many providers and healthcare quality and safety. Interoperability is still on the forefront as the • A document that solicits proposal, often made through a
organizations nation's healthcare networks are growing. bidding process, by an agency or company interested in
• Standards for certification of the electric health record procurement of a commodity, service, or valuable asset, to
programs in each facility RFI, RFQ, AND RFP potential suppliers to submit business proposals.
• Incentives to those that implement healthcare technology with RFI and Benefits • Benefits:
accountability • Request For Information o Clearly defined parameters
• Notification of health record breaches • Educates o Well-documented process
• A common business process whose purpose is to collect o Equal opportunity for each participant
Affordable Care Act (ACA) written information about the capabilities of various suppliers, o Clear snapshot of the market provided to purchasers
This legislation provides affordable insurance coverage for those who depending on our materials requirement. Normally, it follows
are uninsured and has brought rapid changes for healthcare at all levels. a format that can be used for comparative purposes. An RFI is Process Flow of RFI, RFQ, and RFP
Regulations linked with this legislation are numerous. Healthcare primarily used to gather information to help make a decision
technology is also a large part of this bill and informatics is responding to buy best products.
to meet the demands from providers, staff, and the ACA. Accurate data • Benefits:
collection, measuring the work being done for the patient, and tracking o Information is gathered in a formal, structured, and
the outcomes of the care given are high on the list. comparable way.
o Suppliers understand that there is a competition
The ability for providers to have access to electronic health records, going on.
communicate with other providers, and exchange information directly o You show that you try to act without a prejudice or
related to the patient are also in process now through healthcare with a preferred supplier.
interoperability. o You get a formal reply from the supplier.
Meaningful use is another goal of technology being driven by ACA. RFQ and Benefits
Healthcare systems may be eligible for initiatives from Medicare and • Request For Quotation
Medicaid if they implement, upgrade, and use certified electronic • Quantifies
health record software. But, the following goals must be met: • A business process in which a company requests a quote from
• Improve quality and safety using technology a supplier for the purchase of specific products or services. RFQ
• Support patient care and access to health record generally means the same thing as Call For Bids and Invitation
• Improve coordination of patient care between staff and For Bid. An RFQ typically involved more than the price per Difference Between RFI, RFQ, and RFP
providers item. RFI RFQ RFP
• Foster patient and family engagement in the care • Benefits: Purpose Develop Determine Compare costs
• Expand healthcare technology for improved data collection, o Low prices based on higher volumes. An RFQ is a strategy or feasibility of between
adding to accountability straightforward and organized way to request a quote learn more each potential competing
from multiple suppliers. about supplier’s bid vendors
Food and Drug Administration Safety and Innovation Act (FDASIA) o Low prices based on competition supplier’s
This regulation was passed in 2012 to provide a more standardized o Steady, locked in prices capabilities
framework and oversight for healthcare information technology that o Reserved and available inventory Level of Effort Medium High (Client) / Low (Client) /
was given to the FDA (Food and Drug Administration). Software used by (Client) / High (Vendor) Medium
facilities must be reliable, supporting safety and quality improvement. RFP and Benefits Medium (Vendor)
It must also include recognized standards or best-practices for care, • Request For Proposal (Vendor)
majjyap ‘21
Format Open-ended Open-ended, Close-ended most common framework is scrum, and you will also encounter Kanban,
but with The iterative and incremental model employs a cyclical approach. It XP (Extreme Programming), Crystal, and Lean Development. Again,
formal starts with an initial planning phase and ends with deployment, with Agile's goal is to reduce cost, increase collaboration and customer
parameters cyclic interactions taking place in between. The approach is incremental satisfaction.
Best Suited Customized Customized Commoditized since it divides the functionality into small increments, which are
For solutions solutions products developed and tested over one or more iterations. Rapid Application Development
One approach to software development that has gained a lot of interest
SYSTEMS DEVELOPMENT LIFE CYCLE The software prototyping model relies on creating and testing in recent years is rapid application development, or RAD. This
System development is the process of defining, designing, testing and prototypes of software applications. A prototype is a simple, incomplete approach uses an iterative process and relies heavily on the use of
implementing a software application. This includes the internal version of the software being developed. An initial prototype is prototypes. Developers and end users are closely working together
development of customized systems as well as the acquisition of developed that meets some of the very basic requirements but lacks during all stages of system development.
software developed by third parties. A system development project many of the details. The initial prototype is tested and reviewed, and
includes all the activities from the time a potential requirement has the feedback is used to improve the prototype. RAD uses prebuilt components from various programming languages to
been identified until the system has been fully implemented. build prototypes very quickly. The system is built one segment at a time,
The spiral model combines elements of various other models, the and these segments are tested while the entire system is being built.
The systems development life cycle, or SDLC, is the process of creating waterfall and prototyping models in particular. It is typically used for The use of prototyping makes it easier to find out whether segments
systems and the models used to develop these systems. A typical SDLC large and complicated projects. The approach starts with a small are working in the early stages of development.
includes a number of different phases, such as requirements analysis, prototype, which is followed by a short version of the waterfall process.
software design, software coding, testing and debugging, installation This is mostly to gather requirements. The first prototype is reviewed, In a more traditional approach, the analysis and design stage can take
and maintenance. This life cycle is implemented using a software and in subsequent loops, additional requirements are identified, and a up a fair amount of time and effort. In contrast, the analysis and design
development process. There are a number of models of software more detailed design is developed and implemented. stage in RAD is very quick, and the details of the design are developed
development, each with a somewhat different approach to during various prototype cycles. A number of variations on RAD have
implementing the various phases of the life cycle. Prototypes been developed, including Agile software development, scrum software
A number of models rely on the use of prototypes. A prototype development and extreme programming. These approaches combine
Models of Software Development demonstrates the main features of the system without all of its detailed elements of rapid prototyping, iteration through cycles and
The waterfall model of software development follows a very sequential functionality. Prototyping can be used in a number of different ways; responsiveness to requirements.
design process. It is also referred to as a linear-sequence life-cycle for example to identify requirements, to demonstrate the technical
model. In this model, progress is seen as flowing downwards through feasibility of a proposed system and to convince people a particular WHAT IS AGILE METHODOLOGY?
various phases, like a waterfall. The phases include initiation and system is worth developing. Definition of Agile
conception, requirements analysis, software design, construction (or Agile is a blanket term covering several project management
coding), testing and debugging, installation and maintenance. The A prototype approach to software development places a strong approaches that allow teams to respond to changing requirements and
basic premise of the waterfall model is that you only move to the next emphasis on users. When a prototype is built, a user can decide customer unpredictability through incremental, iterative project work.
phase when the preceding phase is completed successfully. This whether she likes it or not. Feedback from the user is applied in the next
approach works well for projects that are relatively simple. version of the prototype. Overview of Agile
Agile methods came about because rigid, sequential software
The V-model is an extension of the waterfall model. Instead of moving Agile Methodology development methods could not keep up with rapidly changing
down in a linear way, the process steps go upwards after the coding A popular development methodology is the Agile model. The premise requirements and priorities. Agile methods began appearing in the early
phase to form a V shape. This shape demonstrates the relationship of the Agile model is a reduced development cycle. An Agile approach 1990s as the software industry exploded. In 2001, software
between each early phase of development and the associated testing consists of early and frequent software delivery, frequent development leaders met to discuss shared ideas and various
phase. In this approach, testing procedures are developed early in the communication, continuous change, and simplicity. Agile does not approaches to software development. By the end of that meeting, they
life cycle, even before any coding is done. Testing holds a much greater necessarily mean faster, but it does mean that the customer and work had written the Agile Manifesto.
emphasis here compared to the waterfall model. teams see results quicker. Within Agile, there are methods of work. The
majjyap ‘21
The Agile Manifesto describes four values common to all Agile is specific to the new floor plan and allows the project team to
methods. While Agile agrees with the values in traditional methods, it concentrate on this iteration cycle.
believes more value is found in: • In the test step of the floor plan iteration, the project team
• Individuals and interactions verifies the new layout matches the design, tests any new
• Working software electrical outlets, and ensures all building inspections are
• Customer collaboration done.
• Responding to change • The final step of the floor plan iteration is the release. In this
step, the RenoVate Now project team turns over the newly
Today, Agile methods are used in industries besides software. Its appeal constructed floor plan to the customer. The customer reviews
lies in its focus on customer collaboration and producing working the completed work and accepts it or makes additional Benefits of Agile
products. Diverse businesses, such as construction, information changes. Agile is flexible, a huge benefit when the customer requirements or
technology, and manufacturing, are using Agile methods with a high • The release step signals the end of an iteration, and the next priorities frequently change. Agile also gets the product to the market
degree of success. iteration cycle begins. What's done during that cycle is faster and has better team communication than traditional methods.
determined by the define step. For example, if the customer • More Flexible. Agile adapts to change better than traditional
Steps to Using Agile does not accept the product of the floor plan iteration, the new project management approaches. Requirements can be
Step 1: Define Determine what work will be cycle focuses on the floor plan again and every step is added, deleted, or changed at the beginning of each iterative
done in the current iteration repeated. If the customer accepts the new floor plan, the cycle, guiding the project team on the work for the next
Step 2: Design Plan how to build the RenoVate Now team moves on to the hard design elements of iteration. The customer can also shift priorities at the
requirements into a product the renovation, such as cabinetry and appliances. This iteration beginning of each cycle, allowing the project team to keep up
Step 3: Build Make the design a reality cycle is repeated, with each iteration focusing on a specific with the customer's business needs.
piece of the renovation until the final complete renovation is
Step 4: Test Verify the product functions as • Product Gets to Market Faster. The product gets to market
designed delivered. faster using Agile because the focus is on working deliverables,
Step 5: Release Give the product to the customer not finished products. The requirements defined during a
AGILE METHODOLOGY: BENEFITS AND DISADVANTAGES particular iteration are built into a working model.
Example: What is Agile? • Better Communication. Because the project team works
• The first priority in a renovation is a new floor plan. The truth • Agile is an umbrella term for several methodologies that all closely with the customer to revisit requirements and
is, decisions involving appliances and paint colors can wait. So, use iterative work packages. Each work package has a 'mini- priorities, Agile has better communication than traditional
the first iteration is the new floor plan, and lets the customer phase' to define, build, test, and release the software, or methods. The cyclic nature of iterative cycles drives continual
focus on those decisions. whatever the project deliverable is. feedback, ensuring the team has high levels of communication.
• During the define phase of the floor plan iteration, the project • The benefits of Agile are that it is more flexible, it offers a faster
team gathers the requirements for a new room layout, delivery to the customer, and it provides better Disadvantages of Agile
understands how the customer intends to use the room, and communication. Even with its benefits, Agile has characteristics that can be
inspects the existing architecture. • The disadvantages of Agile are that can be hard to predict, the disadvantages that the customers need to be aware of. The flip side of
• The design step of the floor plan iteration puts the new layout final product is not released first, and the documentation is left the very benefits of agile can be a disadvantage.
into a visual format. The design has no decorative elements so for last. • Hard to Predict. Agile is so flexible that it becomes
the customer can focus on the layout. Feedback from the unpredictable. The customer can change requirements and
customer is incorporated into the new layout, and the design priorities after every iteration. Sometimes, that makes it hard
is approved. to know what work will be done next, so managing schedules
• The next step, build the new floor plan, ensures the design is and resources can be hard.
built as described in the design. Since the customer is not • Final Product Is Not Released First. Agile’s focus is delivering a
focusing on the decorative aspects of the renovation, feedback working product with every iteration, and there may be several
majjyap ‘21
iterations before the final product is built. This means that the 2. Scrum master. The servant-leader to the delivery team. His or • Scrum master has to consistently teach members that
final product is not the first release and multiple releases are her main responsibility is to remove any roadblocks that are this meeting is not a status meeting and that they only
needed to get a finished product. preventing the team from completing work and to protect the need to answer three questions:
• Documentation Gets Left for Last. In Agile, documentation team from all outside interference. The scrum master also o What did you finish yesterday?
gets left for last. It does not make sense writing comprehensive teaches others, including the product owner and other o What do you plan on finishing today?
documentation that is likely to change. Early documentation organization employees, about scrum and ensures that o Do you have any impediments or blocks to
only covers the immediate requirements. Extensive everyone adheres to its principles. completing your work?
documentation is typically done near the end of the project. As 3. Product owner. Responsible for creating and prioritizing the 3. Refinement or grooming
the project reaches its end, the team will catch up on the work listed in the product backlog, which is a list of work that • The delivery team and the product owner discuss the
documentation so that it is detailed and thorough. needs to be completed. This person serves as the one voice for product backlog items and evaluates them by
the product and works closely with the development team on assigning them points. A point is a value that does not
SCRUM: PROCESS AND EXAMPLES a daily basis. measure time, but doubt, effort, and complexity.
What is Scrum? • The refinement ceremony helps to prepare the
• Scrum is a framework that guides small teams to break The Five Ceremonies backlog for planning. The point values are used to
complex products into small, functional pieces of work that can Scrum teams engage in five standard ceremonies or events, determine a team's velocity, which is the average
be coded and delivered in small increments of time known as traditionally known as meetings. These include: number of points a team completes over the course
iterations or sprints. The benefit is that working software is 1. Sprint planning of a few sprints. This helps to guide the team during
delivered to customers quickly. • Happens on the first day of the sprint. sprint planning to determine if they are over- or
• Scrum is a term borrowed from the sport rugby and is short • Purpose of this ceremony is to choose which high- under-committing.
for scrummage, which is a way of starting play again. The goal priority product backlog items will be developed in 4. Sprint review
of rugby is to play continuously without any time-outs or other the sprint. • Last day of the sprint; the scrum team participates.
interference. • The product owner then describes the top-priority • The product owner will also invite people to attend.
• As in rugby, in scrum, a delivery team must deliver working, product backlog item, and the delivery team discusses • A 'show and tell' that gives everyone a chance to
quality software by the end of the sprint. A sprint is usually two and plans out what needs to be completed in order to provide feedback on the completed work. The
weeks in length, but can be shorter or longer. The delivery consider the product backlog item completed. The product owner is responsible for collecting feedback
team continues to work in sprints until the end of the product product owner then describes the next item and the and adding new work items to the backlog.
or project. Team members work together, without any outside team continues to discuss and commit until they are 5. Retrospective
interruptions, while the sprint is in process. no longer able to commit to any more work in their • Also attended by the scrum team and happens on the
sprint. last day of the sprint.
Scrum Team Roles 2. Daily stand-up • It gives the team a chance to review how well they are
The scrum team incorporates three roles: • Lasts no longer than 15 minutes and happens each or are not doing and how they can make
1. Delivery team morning at the same time. improvements for the next sprint.
• Accountable for choosing which work it will deliver at • The scrum team attends the daily stand-up, and
the end of the sprint. Team members are self- everyone stands up and answers three questions.
organizing and empowered to make all decisions on Standing up helps to keep everyone from getting too
how they'll complete their work. They're also fully comfortable in their seats, plus it helps to keep the
dedicated to the product. ceremony short.
• Sometimes referred to as a development team. The • The purpose of this ceremony is to keep the daily
team size is kept small, usually only five to seven focus on the sprint work.
people, so that collaboration and communication is
easier.
majjyap ‘21

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19

for eligible physicians and healthcare providers who suc-

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Global VP of Clinical Informatics EXECUTIVE

HOSPITAL STEERING OPERATIONS

• FIGURE 19.1. EHR Implementation and Oversight Governance.

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Healthcare System Leadership • Fact Sheets, newsletters, and posters: collateral

TABLE 19.2 Sample of Health IT Project Communication Plan

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INTRODUCTION support their own electronic health record software. The

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3. Independence and Compliance (“Is the process fair

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TABLE 20.1 Health IT Market Resources

KLAS Vendor performance data based on http://www.klasresearch.com/

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TABLE 20.5 Sample RFI/RFP Outline

1 Executive Overview A high level summary of the request

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A major deliverable of the Evaluation phase is the

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Vendor A Vendor B Vendor C Vendor D Vendor E Vendor F Vendor G Vendor H Vendor I

5) Largest Relative Bedsize >500

6) Pharmacy system is stand-alone β

• FIGURE 20.3. Sample Summary Analysis.

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