CHAPTER

7
SYSTEM IMPLEMENTATION AND SUPPORT
LEARNING OBJECTIVES
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To be able to discuss the process that a health care organization typically goes through in implementing a health care information system. To be able to appreciate the organizational and behavioral factors that can affect system acceptance and use and strategies for managing change. To be able to develop a sample system implementation plan for a health care information system project, including the types of individuals who should be involved. To gain insight into many of the things that can go wrong during system implementations and strategies health care managers can employ to alleviate potential problems. To be able to discuss the importance of training, technical support, infrastructure, and ongoing maintenance and evaluation of any health care information system project.

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Once a health care organization has finalized its contract with the vendor to acquire an information system, the system implementation process begins. Selecting the right system does not ensure user acceptance and success; the system must also be incorporated effectively into the day-to-day operations of the health care organization and adequately supported or maintained. Whether the system is built in-house, designed by an outside consultant, leased from an application service provider (ASP), or purchased from a vendor, it will take a substantial amount of planning and work to get the system up and running smoothly and integrated into operations. This chapter focuses on the two final stages of the system development life cycle, implementation and then support and evaluation. It describes the planning and activities that should occur when implementing a new system. Our discussion focuses on a vendor-acquired system; however, many of the activities described also apply to systems designed in-house or by an outside developer or acquired through an ASP. Implementing a new system (or replacing an old system) can be a massive undertaking for a health care organization. Not only are there workstations to install, databases to build, and networks to test but there are also processes to redesign, users to train, data to convert, and procedures to write. There are countless tasks and details that must be appropriately coordinated and completed if the system is to be implemented on time and within budget—and widely accepted by users. Along with attending to these activities, or tasks, it is equally important to address organizational and behavioral issues. Studies have shown that over half of all information system projects fail. Numerous political, cultural, and behavioral factors can affect the successful implementation and use of the new system (Ash, Anderson, & Tarczy-Hornoch, 2008; Ash et al., 2007). We devote a section of this chapter to the organizational and behavioral issues that can arise and other things that can go wrong during the system implementation process and offer strategies for avoiding these problems. The chapter concludes by describing the importance of supporting and maintaining information systems.

SYSTEM IMPLEMENTATION PROCESS
System implementation begins once the organization has acquired the system and continues through the early stages following the go-live date (the date when the system is put into general use for everyone). Like the system acquisition process, the system implementation process must have a high degree of support from the senior executive team and be viewed as an organizational priority. Sufficient staff, time, and resources must be devoted to the project. Individuals involved in rolling out the new system should have the resources available to them that will ensure a smooth transition. The time and resources needed to implement a new health care information system can vary considerably based on the scope of the project, the needs and complexity of the organization, the number of applications being installed, and the number of user groups involved. There are, however, some fundamental activities that should occur during any system implementation, regardless of its size or scope:

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Organize the implementation team and identify a system champion. Determine project scope and expectations. Establish and institute a project plan.

Failing to appropriately plan for and manage these activities can lead to cost overruns, dissatisfied users, project delays, and even system sabotage. In today’s environment, where capital is scarce and resources are limited, health care organizations cannot afford to mismanage implementation projects of this magnitude and importance. Organize the Team and Identify a Champion One of the first steps in planning for the implementation of a new system is to organize an implementation team. The primary role and function of the team is to plan, coordinate, budget, and manage all aspects of the new system implementation. Although the exact team composition will depend on the scope and nature of the new system, a team might include a project leader, system champion(s), key individuals from the clinical and administrative areas that are the focus of the system being acquired, vendor representatives, and information technology (IT) professionals (Figure 7.1). For large or complex projects, it is also a good idea to have someone skilled in project management principles on the team. Likewise, having a strong project leader and the right mix of people is critically important. Implementation teams often include some of the same people involved in selecting the system; however, they may also include other individuals with knowledge and skills important to the successful deployment of the new system. For example, the implementation team will likely need at least one IT professional with technical database and network administration expertise. This person may have had some role in the selection process but is now being called on to assume a larger role in installing the software, setting up the data tables, and customizing the network infrastructure to adequately support the system and the organization’s needs. The implementation team should also include at least one system champion. A system champion is someone who is well respected in the organization, sees the new system as necessary to the organization’s achievement of its strategic goals, and is passionate about implementing it. In many health care settings the system champion

FIGURE 7.1.

Sample Composition of Implementation Team

Physician

Nurse Manager

Lab Manager

Radiology Director

CIO

IT Analyst

Business Manager

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is a physician, particularly when the organization is implementing a system that will directly or indirectly affect how physicians spend their time. The physician champion serves as an advocate of the system, assumes a leadership role in gaining buy-in from other physicians and user groups, and makes sure that physicians have adequate input into the decision-making process. Other important qualities of system champions are strong communication, interpersonal, and listening skills. The system champion should be willing to assist with pilot testing, to train and coach others, and to build consensus among user groups (Miller & Sim, 2004). Numerous studies have demonstrated the importance of the system champion throughout the implementation process (Miller, Sim, & Newman, 2003; Wager, Lee, White, Ward, & Ornstein, 2000; Ash, Stavri, Dykstra, & Fournier, 2003). When implementing clinical applications (such as computerized provider order entry [CPOE] or medication administration using bar coding) that span numerous clinical areas, such as nursing, pharmacy, and physicians, having a system champion from each division can be enormously helpful in gaining buy-in and in facilitating communication among staff. Determine Project Scope and Expectations One of the implementation team’s first items of business is to determine the scope of the project and what the organization hopes the project will achieve. To set the tone for the project, a senior health care executive should meet with the implementation team to communicate how the project relates to the organization’s overall strategic goals and to assure the team of administration’s commitment to the project. The goals of the project and what the organization hopes to achieve by implementing the new system should emerge from early team discussions. The system goals defined during the system selection process (discussed in Chapter Six) should be reviewed by the implementation team. Far too often health care organizations skip this important step and never clearly define the scope of the project or what they hope to gain as a result of the new system. At other times they define the scope of the project too broadly or scope creep occurs. Let’s look at two hypothetical examples, from two providers that we will call Mason Hospital and St. Luke’s Medical Center. The implementation team at Mason Hospital defined its goal and the scope of the project and devised measures for evaluating the extent to which the hospital achieved this goal. The implementation team at St. Luke’s Medical Center was responsible for completing phase 1 of a three-part project; however, the scope of the team’s work was never clearly defined.

Mason Hospital Mason Hospital decided that it wanted to implement a CPOE system. An implementation team was formed and charged with managing all aspects of the CPOE rollout. Mason Hospital’s mission is to be ‘‘the premier academic community hospital in the United States.’’ Considering how to achieve this mission, the team identified CPOE as the ‘‘building block’’ needed to improve quality of care, reduce errors,

CASE STUDY

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and create a far safer and more effective work environment for hospital medical staff. In addition to establishing this goal, the team went a step further to define what a successful CPOE implementation initiative would consist of. Team members then developed a core set of metrics (for example, physician CPOE adoption rate, use of telephone and verbal orders in nonemergency situations, reduction in adverse drug events, reduction in duplicate orders, improved quality of documentation, and increased compliance with practice-based guidelines) that were subsequently used to track the project’s success in the defined areas. St. Luke’s Medical Center St. Luke’s Medical Center set out to implement an electronic medical record (EMR) system, planning to do so in three phases. Phase 1 would involve establishing a clinical data repository, a central database from which all ancillary clinical systems would feed. Phase 2 would consist of the implementation of CPOE and nursing documentation systems, and Phase 3 would see the elimination of all outside paper reports through the implementation of a document imaging system. St. Luke’s staff felt that if they could complete all three phases, they would have, in essence, a ‘‘true’’ EMR. The implementation team did not, however, clearly define the scope of its work. Was it to complete phase 1 or all three phases? Likewise, the implementation team never defined what it hoped to accomplish or how implementation of the EMR fit into the medical center’s overall mission or organizational goals. It never answered the question: How will we know if we are successful? The ambiguity of the implementation team’s scope of work led to disillusionment and a sense of failing to ever finish the project.

Establish and Institute a Project Plan Once the implementation team has agreed on its goals and objectives, the next major step is to develop and implement a project plan. The project plan should include
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Major activities (also called tasks) Major milestones Estimated duration of each activity Any dependencies among activities (so that, for example, one task must be completed before another can begin) Resources and budget available (including staff whose time will be allocated to the project) Individuals or team members responsible for completing each activity Target dates Measures for evaluating completion and success

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These are the same components one would find in most major projects. What are the major activities, or tasks, that are unique to system implementation projects? Which

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tasks must be completed first, second, and so forth? How should time estimates be determined and milestones defined? System implementation projects tend to be quite large, and therefore it can be helpful to break the project into manageable components. One approach to defining components is to have the implementation team brainstorm and identify the major activities that need to be done before the go-live date. Once these tasks have been identified, they can be grouped and sequenced based on what must be done first, second, and so forth. Those tasks that can occur concurrently should also be identified. A team may find it helpful to use a consultant to guide it through the implementation process. Or the health care IT vendor may have a suggested implementation plan; the team must make sure, however, that this plan is tailored to suit the unique needs of the organization in which the new system is to be introduced. The subsequent sections describe the major activities common to most information system implementation projects (see the following list) and may serve as a guide. These activities are not necessarily in sequential order; the order used should be determined by the institution, based on its needs and resources.
Typical Components of an Implementation Plan

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Workflow and process analysis
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Analyze or evaluate current process and procedures Identify opportunities for improvement and, as appropriate, effect those changes. Identify sources of data, including interfaces to other systems. Determine location and number of workstations needed. Redesign physical location as needed. Determine system configuration. Order and install hardware. Prepare computer room. Upgrade or implement IT infrastructure. Install software and interfaces. Customize software. Test, retest, and test again . . . Train staff. Update procedure manuals. Convert data. Test system.

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System installation
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Staff training
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Conversion
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Communications
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Establish communication mechanisms for identifying and addressing problems and concerns. Communicate regularly with various constituent groups.

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Preparation for go-live date
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Select date when patient volume is relatively low. Ensure sufficient staff are on hand. Set up mechanism for reporting and correcting problems and issues. Review and effect process reengineering.

Conduct Workflow and Process Analysis One of the first activities necessary in implementing any new system is to review and evaluate the existing workflow or business processes. Members of the implementation team might also observe the current information system (if there is one) in use. Does it work as described? Where are the problem areas? What are the goals and expectations of the new system? How do organizational processes need to change in order to optimize the new system’s value and achieve its goals? Too often organizations never critically evaluate current business processes but plunge forward with implementing the new system while still using old procedures. The result is that they simply automate their outdated and inefficient processes. Before implementing any new system, the organization should evaluate existing procedures and processes and identify ways to improve workflow, simplify tasks, eliminate redundancy, improve quality, and improve user (customer) satisfaction. Although describing them is beyond the scope of this book, many extremely useful tools and methods are available for analyzing workflow and redesigning business processes (see, for example, Whitten & Bentley, 2007). Simply observing the old system in use, listening to users’ concerns, and evaluating information workflow can identify many of the changes needed. Involving users at this early stage of the implementation process can gain initial buy-in to both the idea and the scope of the process redesign. In all likelihood the organization will need to institute a series of process changes as a result of the new system. Workflow and processes should be evaluated critically and redesigned as needed. For example, the organization may find that it needs to do away with old forms or work steps, change job descriptions or job responsibilities, or add to or subtract from the work responsibilities of particular departments. Getting users involved in this reengineering process can lead to greater user acceptance of the new system. Let’s consider an example. Suppose a multiphysician clinic is implementing a new patient scheduling system. Patients will be able to schedule their own appointments on line via the Internet, and receptionists will also be able to schedule patient appointments electronically. The clinic might wish to begin by appointing a small team of individuals knowledgeable about analyzing workflow and processes to work with staff in studying the existing process for scheduling patient appointments. This team might conduct a

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series of individual focus groups with schedulers, physicians and nurses, and patients and ask questions such as these:
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Who can schedule patient appointments? How are patient appointments made, updated, or deleted? Who has access to scheduling information? From what locations? How well does the current system work? How efficient is the process? What are the major problems with the current scheduling system and process? In what ways might it be improved?

The team should tailor the focus questions so they are appropriate for each user group. The answers can then be a guide for reengineering existing processes and workflow to facilitate the new system. During the workflow analysis, the team should also examine where the new system’s actual workstations will be located, how many workstations will be needed, and how information will flow between manual organizational processes and the electronic information system. Here are a few of the many questions that should be addressed in ensuring that physical layouts are conducive to the success of the new system:
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Will the workstations be portable or fixed? If users are given portable units, how will these be tracked and maintained (and protected from loss or theft)? If workstations are fixed, will they be located in safe, secure areas where patient confidentiality can be maintained? How will the user interact with the new system? Does the physical layout of each work area need to be redesigned to accommodate the new system and the new process? Will additional wiring be needed?

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Install System Components The next step, which may be done concurrently with the workflow analysis, is to install the hardware, software, and network infrastructure to support the new information system and build the necessary interfaces. IT staff play a crucial role in this phase of the project. They will need to work with the vendor in determining system specifications and configurations and in preparing the computer room for installation. It may be, for example, that the organization’s current computer network will need to be replaced or upgraded. During implementation, having adequate numbers of computer workstations placed in readily accessible locations is critical. Those involved in the planning need to determine beforehand the maximum number of individuals likely to be using the system at the same time, and accommodate this scenario. Typically when a health care organization acquires a system from a vendor, quite a bit of customization is needed. IT personnel will likely work with the vendor in setting up and loading data tables, building interfaces, and running pilot tests of the hardware and software using actual patient and administrative data. We recommend piloting the system in a unit or area before rolling out the system enterprise-wide. This test enables the implementation team to evaluate the system’s effectiveness, address

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issues and concerns, fix bugs, and then apply the lessons learned to other units in the organization before most people even start using the system. Consideration should be given to choosing an appropriate area (for example, department or location) or set of users to pilot the system. Some of the questions the implementation team should consider in identifying potential pilot sites are these:
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Which units or areas are willing and equipped to serve as a pilot site? Do they have sufficient interest, administrative support, and commitment? Are the staff and management teams in each of these units or areas comfortable with being system “guinea pigs”? Do staff have the time and resources needed to serve in this capacity? Is there a system champion in each unit or area who will lead the effort?

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Plan, Conduct, and Evaluate Staff Training Training is an essential component of any new system implementation. Although no one would argue with this statement, the implementation team will want to consider many issues as it develops and implements a training program. Here are a few of the questions to be answered:
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How much training is needed? Do different user groups have different training needs? Who should conduct the training? When should the training occur? What intervals of training are ideal? What training format is best (for example, formal, classroom-style training; one-on-one or small-group training; computer-based training; a combination of methods)? What is the role of the vendor in training? Who in the organization will manage or oversee the training? How will training be documented? What criteria and methods will be used to monitor training and ensure that staff are adequately trained? Will staff be tested on proficiency?

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There are various methods of training. One approach, commonly known as train the trainer, relies on the vendor to train selected members of the organization who will then serve as super-users and train others in their respective departments, units, or areas. These super-users should be individuals who work directly in the areas in which the system is to be used; they should know the staff in the area and have a good rapport with them. They will also serve as resources to other users once the vendor representatives have left. They may do a lot of one-on-one training, hand-holding, and other work with people in their areas until these individuals achieve a certain comfort level with the system. The main concern with this approach is that the organization may devote a great deal of time and resources to training the trainers only to have these trainers leave the institution (often because they’ve been lured away by career opportunities with the vendor).

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

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areas. The specific conversion procedures used will depend on the nature of the old system and its structure as well as on the configuration of the new system. Finally, the new system will need to be tested. The main purpose of the testing is to simulate the live environment as closely as possible and determine how well the system and accompanying procedures work. Are there programming glitches or other problems that need to be fixed? How well are the interfaces working? How does response time compare to what was expected? The system should be populated with live data and tested again. Vendors, IT staff, and user staff should all participate in the testing process. As with training, one can never test too much. A good portion of this work has to be done for the pilot testing. It may need to be repeated before going live. And the pilot lessons will guide any additional testing or conversion that needs to be done.
Communicate Progress or Status Equally as important as successfully carrying out the activities discussed so far is having an effective plan for communicating the project’s progress. This plan serves two primary purposes. First, it identifies how the members of the implementation team will communicate and coordinate their activities and progress. Second, it defines how progress will be communicated to key constituent groups, including but not limited to the board, the senior administrative team, the departments, and the staff at all levels of the organization affected by the new system. The communication plan may set up both formal and informal mechanisms. Formal communication may include everything from regular updates at board and administrative meetings to written briefings and articles in the facility newsletter. The purpose should be to use as many channels and mechanisms as possible to ensure that the people who need to know are fully informed and aware of the implementation plans. Informal communication is less structured but can be equally important. Implementing a new health care information system is major undertaking, and it is important that all staff (day, evening, and night shifts) be made aware of what is happening. The methods for communication may be varied, but the message should be consistent and the information presented up-to-date and timely. For example, do not rely on e-mail communication as your primary method only to discover later that your organization’s nurses do not regularly check their e-mail or have little time to read your type of message. Prepare for Go-Live Date

A great deal of work goes into preparing for the go-live date, the day the organization transitions from the old system to the new. Assuming the implementation team has done all it can to ensure that the system is ready, the staff are well trained, and appropriate procedures are in place, the transition should be a smooth one. Additional staff should be on hand and equipped to assist users as needed. It is best to plan for the system to go live on a day when the patient census is typically low or fewer patients than usual are scheduled to be seen. Disaster recovery plans should also be in place, and staff should be well trained on what to do should the system go down or fail. Designated IT staff should monitor and assess system problems and errors. When organizations are implementing information systems with clinical decision support, we recommend that they adhere to these “ten commandments” for effective clinical decision support.”

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Ten Commandments for Effective Clinical Decision Support
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Speed is everything— this is what information system users value most. Anticipate needs and deliver in real time—deliver information when needed. Fit into user’s work flow—integrate suggestions with clinical practice. Little things can make a big difference— improve usability to “do the right thing.” Recognize that physicians will resist stopping— offer alternatives rather than insist on stopping an action. Changing direction is easier than stopping— changing defaults for dose, route, or frequency of a medication can change behavior. Simple interventions work best—simplify guidelines by reducing to a single computer screen. Ask for additional information only when you really need it—the more data elements requested, the less likely a guideline will be implemented. Monitor impact, get feedback and respond—if certain reminders are not followed, readjust or eliminate the reminder. Manage and maintain your knowledge-based systems—track users’ response to decision support and update to coincide with changes in medical knowledge [Bates et al., 2003].

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A great deal of planning and leadership is needed in implementing a new health care information system. Despite the best-made plans, however, things can and do go wrong. The next section describes some of the common organizational challenges associated with system implementation projects and offers strategies for anticipating and planning for them.

MANAGING THE ORGANIZATIONAL ASPECTS
Implementing an information system in a health care facility can have a profound impact on the organization, the people who work there, and the patients they serve. Individuals may have concerns and apprehensions about the new system. They may wonder: How will the new system affect my job responsibilities or productivity? How will my workload change? Will the new system cause me more or less stress? Even individuals who welcome the new system, see the need for it, and see its potential value may worry: What will I do if the system is down? Will the system impede my relationship with my patients? Who will I turn to if I have problems or questions? Will I be expected to type my notes into the system? With the new system comes change, and change can be difficult if not managed effectively.

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The human factors associated with implementing a new system should not be taken lightly. A great deal of change can occur as a result of the new system. Some of the changes may be immediately apparent; others may occur over time as the system is used more fully. Many IT implementation studies have been done in recent years, and they reveal several strategies that may lead to greater organizational acceptance and use of a new system:
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Create an appropriate environment, one where expectations are defined, met, and managed. Do not underestimate user resistance. Allocate sufficient resources, including technical support staff and IT infrastructure. Provide adequate initial and ongoing training. Manage unintended consequences, especially those known to affect implementations such as CPOE.

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More research is needed to explore the extent to which these and other strategies can lead to more widespread adoption of health care information systems, particularly clinical applications such as the CPOE and EMR systems. Create an Appropriate Environment If you ask a roomful of health care executives, physicians, nurses, pharmacists, or laboratory managers if they have ever experienced an IT system failure, chances are over half of the hands in the room would go up. In all likelihood the people in the room would have a much easier time describing a system failure than a system success. If you probed a little further and asked why the system was a failure, you might hear comments like these: “the system was too slow,” “it was down all the time,” “training was inadequate and nothing like the real thing,” “there was no one to go to if you had questions or concerns,” “it added to my stress and workload,” and the list goes on. The fact is the system did not meet their expectations. You might not know whether those expectations were reasonable or not. Earlier we discussed the importance of clearly defining and communicating the goals and objectives of the new system. Related to goal definition is the management of user expectations. Different people may have different perspectives on what they expect from the new system; in addition, some will admit to having no expectations, and others will have joined the organization after the system was implemented and consequently are likely to have expectations derived from the people currently using the system. Expectations come from what people see and hear about the system and the way they interpret what the system will do for them or for their organization. Expectations can be formed from a variety of sources—they may come from a comment made during a vendor presentation, a question that arises during training, a visit to another site that uses the same system, attendance at a professional conference, or a remark made by a colleague in the hallway.

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Furthermore, the main criterion used to evaluate the system’s value or success depends on the individual’s expectations and point of view. For example, the chief financial officer might measure system success in terms of the financial return on investment, the chief medical director might look at impact on physicians’ time and quality of care, the nursing staff might consider any change in their workload, public relations personnel might compare levels of patient satisfaction, and the IT staff might evaluate the change in the number of help desk calls made since the new system was implemented. All these approaches are measures of an information system’s perceived impact on the organization or individual. However, they are not all the same, and they may not have equal importance to the organization in achieving its strategic goals. It is therefore important for the health care executive team not only to establish and communicate clearly defined goals for the new system but also to listen to needs and expectations of the various user groups and to define, meet, and manage expectations appropriately. Ways to manage expectations include making sure users understand that the first days or weeks of system use may be rocky, that the organization may need time to adjust to a new workflow, that the technology may have bugs, and that users should not expect problem-free system operation from the start. Clear and effective communication is key in this endeavor. In managing expectations it can be enormously helpful to conduct formative assessments of the implementation process, in which the focus is on the process as well as the outcomes. Specific metrics need to be chosen and success criteria defined to determine whether or not the system is meeting expectations (McGowan, Cusack, & Poon, 2008). For example, if wide-scale usage is a priority, collection of actual numbers of transactions or usage logs may be meaningful information for the leadership team. Other categories of metrics that might be helpful are clinical outcome measures, clinical process measures, provider adoption and attitude measures, patient knowledge and attitude measures, workflow impact measures, and financial impact measures. The Agency for Healthcare Research and Quality recently published the Health Information Technology Evaluation Toolkit, which can serve as a guide for project teams involved in evaluating the system implementation process or project outcomes (Cusack & Poon, 2007). Do Not Underestimate User Resistance During the implementation process it is important to analyze current workflow and make appropriate changes as needed. Earlier we gave an example of analyzing a patient scheduling process. Patient scheduling is a relatively straightforward process. A change in this system may not dramatically change the job responsibilities of the schedulers and may have little impact on nurses’ or physicians’ time. Therefore these groups may offer little resistance to such a change. (This is not to guarantee a lack of resistance— if you mess up a practice’s schedule, you can have a lot of angry people on your hands!) In contrast, changes in processes that involve the direct provision of patient care services and that do affect nurses’ and physicians’ time may be tougher for users to accept. The physician ordering process is a perfect example. Most physicians today are accustomed to picking up a pen and paper and handwriting an order or calling one in to the nurses’ station from their phones. With CPOE, physicians may be expected to keyboard their

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orders directly into the system and respond to automated reminders and decision-support alerts. A process that historically took them a few seconds to do might now take several minutes, depending on the number of prompts and reminders. Moreover, physicians are now doing things that were not asked of them before—they are checking for drug interactions, responding to reminders and alerts, evaluating whether evidence-based clinical guidelines apply to the patient, again the list goes on. All these activities take time, but in the long run they will improve the quality of patient care. Therefore it is important for physicians to be actively involved in designing the process and in seeing its value to the patient care process. Getting physicians, nurses, and other clinicians to accept and use clinical information systems such as CPOE or EMR can be challenging even when they are involved in the implementation. At times the incentives for using the system may not be aligned with their individual needs and goals. On the one hand, for example, if the physician is expected to see a certain number of patients per day and is evaluated on patient load and if writing orders used to take thirty minutes a day with the old system and now takes sixty to ninety minutes with the new CPOE system, the physician can either see fewer patients or work more hours. One should expect to see physician resistance. On the other hand, if the physician’s performance and income is related to adherence to clinical practice guidelines, using the CPOE system might improve his or her income, creating a greater chance of acceptance. The physician’s workload or productivity goals might, however, be beyond the organization’s control. They might be individual goals the physician has set for himself or herself. Can or should organizations mandate the use of clinical information systems like CPOE? In effect, the organization is stating that resistance is unacceptable. Several health care facilities have instituted policies mandating physician use of CPOE, with mixed results. Physicians’ acceptance of such a mandate may have a lot to do with the organizational culture, the training they received, their confidence (or lack of confidence) in the system, how the mandate was imposed, and a host of other factors. Mandating use is most common in academic medical centers where residents and fellows are expected to enter orders in a computerized system. Mandating physician use can be taxing for community hospitals or other facilities that are not the physicians’ employers. Community-based physicians often admit patients to more than one hospital and spend limited time at each facility. Trying to get these fairly independent physicians to buy into a facility’s CPOE system and participate in the necessary training can be difficult. To address this and related acceptance issues, the California HealthCare Foundation, in collaboration with First Consulting Group, conducted an in-depth study of ten community hospitals, throughout the United States, that have made significant progress in implementing CPOE (Metzger & Fortin, 2003). The study found that CPOE leaders tended to avoid the term mandate and instead recommended that health care executives work toward an enterprise-wide policy for universal CPOE. Key staff in participating hospitals recommended starting with a strong commitment to CPOE, delivering a consistent message that CPOE is the right thing to do, and working within the culture of the medical staff toward the goal of universal adoption. This goal might take years to achieve. Readiness for universal adoption occurred once (1) a significant number of physician CPOE adopters showed their peers what was possible, (2) sufficient progress

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was made toward achieving patient safety objectives, and (3) the medical staff came together with one voice to champion CPOE as the right thing to do. Similarly, a study of five community hospitals in Massachusetts that had implemented CPOE found although all five hospitals started out with the intention that all physicians would use CPOE, only two had a formal policy to that effect (Saving lives, reducing costs: CPOE lessons learned in community hospitals, 2006), but all physicians were highly encouraged to do so. Tactics used for inducing or encouraging physician adoption included providing one-on-one training anywhere and anytime, making it easy to establish remote access from home and office, assigning high priority to enhancements that benefited ease of order completion, empowering nurses to serve as super-users and to encourage physician direct entry, investing in order sets and helping physicians build a personal favorites list and removing all paper order sheets from the floor (Saving lives . . . , 2006). In cases where the hospital had residents and employed physicians such as intensivists or hospitalists, these physicians were expected to use CPOE for all their orders. Every hospital, regardless of how it framed physician adoption, portrayed CPOE as a necessary change and made an enormous investment in ensuring the system was easy to learn and use. Whether, and when, to mandate use or adopt a universal acceptance policy is a decision that should come with time. Experience has shown that a mandate should not be imposed until the organization has achieved a certain level of system use and medical staff overall have confidence in the system’s functionality and have bought into the system. There may be a point in time where all orders will have to be entered directly by physicians or when paper medical records will no longer be pulled or maintained. However, that point in time should be clearly communicated, all efforts should be made to ensure users are trained and ready to make the change, and backup procedures should be in place when the day arrives. System champions, particularly when they are also physicians, can be extremely helpful in preparing for the day of universal adoption. They can serve as coaches, listeners, teachers, and advocates for facility physicians and for the system. It is through their role and example that others will come along. Some medical staff may choose not to and may leave the organization; however, the great majority will stay and work toward the common goal. It perhaps goes without saying that user acceptance occurs when users see or realize the value the health care information system brings to their work and the patients they serve. This value takes different forms. Some people may realize increased efficiency, less stress, greater organization, and improved quality of information, whereas others may find that the system enables them to provide better care, avoid medical mistakes, and make better decisions. In some cases an individual may not experience the value personally yet may come to realize the value to the organization as a whole. Allocate Sufficient Resources Sufficient resources are needed both during and after the new system has been implemented. User acceptance comes from confidence in the new system. Individuals want to know that the system works properly, is stable, and is secure and that someone is

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

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be replaced as advances are made in technology, the organization’s goals and needs change, and the health care environment changes. Provide Adequate Training Earlier we discussed the importance of training staff on the new system prior to the go-live date. Having a training program suited to the needs of the various user groups is very important during the implementation process. People who will use the system should be relatively comfortable with it, have had ample opportunities to use it in a safe environment, and know where to turn should they have questions or need additional assistance. It is equally important to provide ongoing training months and even years after the system has been implemented. In all likelihood the system will go through a series of upgrades, changes will be made, and users will get more comfortable with the fundamental features and will be ready to push the system to the next level. Some users will explore additional functionality on their own; others will need prodding and additional training in order to learn more advanced features. When implementing a new system, it important to view the system as a long-term investment rather than a one-time purchase. The resources allocated or committed to the system should include not only the up-front investment in hardware and software but also the time, people, and resources needed to maintain and support it. Manage Unintended Consequences Management expertise and leadership are important elements to the success of any system implementation. Effective leaders help build a community of collaboration and trust. However, effective leadership also entails understanding the unintended consequences that can occur during complex system implementations and managing them. Unintended consequences can be positive, negative, or both, depending on one’s perspective. Ash and colleagues (2007) recently conducted interviews with key individuals from 176 U.S. hospitals that currently have CPOE. CPOE is one of the most complex and challenging of clinical information systems to implement. From their work, they identified eight types of unintended consequences that implementation teams should plan for and consider when implementing CPOE: 1. More work or new work. CPOEs can increase work due to the fact that systems may be slow, nonstandard cases may call for more steps in ordering, training may remain an issue, some tasks may become more difficult, the computer forces the user to complete “all steps,” and physicians often take on tasks that were formerly done by others. Workflow. CPOEs can greatly alter workflow, sometimes improving workflow for some and slowing or complicating it for others. System demands. Maintenance, training, and support efforts can be significant for an organization, not only in building the system but also in making improvements and enhancements to it.

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Communication. CPOE systems affect communication within the organization; they can reduce the need to clarify orders but also lead to people failing to adequately communicate with each other in appropriate situations. Emotions. Clinician reactions to CPOE can run the gamut from positive to negative. New kinds of errors. Although CPOE systems are generally designed to detect and prevent errors, they can lead to new types of errors such as juxtaposition errors, in which clinicians click on the adjacent patient name or medication from a list and inadvertently enter the wrong order. Power shifts. Shifts in power may not be viewed as as much of a problem as some of the other unintended consequences, but CPOE can be used to monitor physician behavior. Dependence on the system. Clinicians become dependent on the CPOE system, so managing downtime procedures is critical. Even then, while the system is down, CPOE users view the situation as managed chaos (adapted from Ash et al., 2007).

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Health care executives and implementation teams should be aware of these unintended consequences, particularly those that can adversely affect the organization, and carefully plan for and manage them.

SYSTEM SUPPORT AND EVALUATION
Information systems evolve as an organization continues to grow and change. No matter how well the system was designed and tested, errors and problems will be detected and changes will need to be made. IT staff generally assume a major role in maintaining and supporting the information systems in the health care organization. When errors or problems are detected, IT staff correct the problem or work with the vendor to see that the problem is fixed. Moreover, the vendor may detect glitches and develop upgrades or patches that will need to be installed. Many opportunities for enhancing and improving the system’s performance and functionality will occur well after the go-live date. The organization will want to ensure that the system is adequately maintained, supported, and further developed over time. Selecting and implementing a health care information system is an enormous investment. This investment must be maintained, just as one would maintain one’s home. Like any other device, information systems have a life cycle and eventually need to be replaced. Health care organizations typically go through a process whereby they plan, design, implement, and evaluate their health care information systems. Too often in the past the organization’s work was viewed as done once the system went live. It has since been discovered how vital system maintenance and support resources are and how important it is to evaluate the extent to which the system goals are being achieved. Evaluating or accessing the value of the health care information system is increasingly important. Acquiring and implementing systems requires large investments, and stakeholders, including boards of directors, are demanding to know both the actual and future value of these projects. Evaluations must be viewed as an integral component

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of every major health information system project and not an afterthought. In fact we believe that assessing the value of a health IT investment is enormously important and thus have devoted Chapter Fifteen entirely to the subject.

SUMMARY
Implementing a new information system in a health care organization requires a significant amount of planning and preparation. The health care organization should begin by appointing an implementation team comprising experienced individuals, including representatives from key areas in the organization, particularly areas that will be affected by or responsible for using the new system. Key users should be involved in analyzing existing processes and procedures and making recommendations for changes. A system champion should be part of the implementation team and serve as an advocate in soliciting input, representing user views, and spearheading the project. When implementing a clinical application, it is important that the system champion be a physician or clinician, someone who is able to represent the views of the care providers. Under the direction of a highly competent implementation team, a number of important activities should occur during the system rollout. This team should assume a leadership role in ensuring that the system is effectively incorporated into the day-to-day operations of the facility. This generally requires the organization to (1) analyze workflow and processes and perform any necessary process reengineering, (2) install and configure the system, (3) train staff, (4) convert data, (5) adequately test the system, and (6) communicate project progress using appropriate forums at all levels throughout the organization. Attention should be given to the countless details associated with ensuring that backup procedures are in place, security plans have been developed, and the organization is ready for the go-live date. During the days immediately following system implementation, the organization should have sufficient staff on hand to assist users and provide individual assistance as needed. A stable and secure IT infrastructure should be in place to ensure minimal, ideally zero, downtime and adequate response time. The IT department or other appropriate unit or representative should have a formal mechanism in place for reporting and correcting errors, bugs, and glitches in the system. Once the system has gone live, it is critical for the organization to have in place the plans and resources needed to adequately maintain and support the new system. Technical staff and resources should be available to the users. Ongoing training should be an integral part of the organization’s plans to support and further develop the new system. In addition, the leadership team should have in place a thoughtful plan for evaluating the implementation process and assessing the value of the health care information system. Beyond taking ultimate responsibility for completion of the activities needed to implement and to support and evaluate the new system, the health care executive should assume a leadership role in managing the organizational and human aspects of the new system. Information systems can have a profound impact on health care organizations, the people who work there, and the patients they serve.

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Acquiring a good product and having the right technical equipment and expertise is not enough to ensure system success.

Health care executives must also be attuned to the human aspects of introducing new IT into the care delivery process.

KEY TERMS
Implementation team System champion System implementation Train the trainer Unintended consequences User resistance Workflow and process analysis

LEARNING ACTIVITIES
1. Visit a health care organization that has recently implemented a health care information system. What process did it use to implement the system? How does that process compare with the one described in this chapter? How successful was the organization in implementing the new system? To what do staff attribute this success? Search the literature for a recent article on a system implementation project. Briefly describe the process used to implement the system and the lessons learned. How might this particular facility’s experiences be useful to others? Explain. Physician acceptance and use of clinical information systems is often cited as a challenge. What do you think the health care leadership team can or should do to foster acceptance by physicians? Assume a handful of physicians in your organization are actively resisting a new clinical information system. How would you approach and address their resistance and concerns? Assume you are working with an implementation team in installing a new nursing documentation system for a home health agency. Historically, all its nursing documentation was recorded in paper form. The home health agency has little computerization beyond basic registration information and has no IT staff. What recommendations might you offer to the implementation team as it begins the work of installing the new nursing documentation system? Discuss the risks to a health care organization in failing to allocate sufficient support and resources to a newly implemented health care information system. Assume you are the CEO of a large group practice (seventy-five physicians) that implemented an EMR system two years ago. The physicians are asking for an evaluation of the system and its impact on quality, costs, and patient satisfaction. Devise a plan for evaluating the EMR system’s impact on the organization in these three areas.

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