A Risk Assessment Model of Interoperable Electronic Health Records Solutions Panel: The Challenges...
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Transcript of A Risk Assessment Model of Interoperable Electronic Health Records Solutions Panel: The Challenges...
A Risk Assessment Model of Interoperable Electronic Health Records Solutions
Panel:
The Challenges of Interoperability in e-Health
Claude Sicotte
Département d’administration de la santé
Faculté de médecine
Université de Montréal
Feuille de route
Presentation of the Risk Assessment Model
Brief survey of the two cases under study
Analysis of the major risks involved in both EHR interoperable implementations
The Lessons
Questions & Comments
Risk Management Framework
IT Implementation
Stages
ProjectManagementObjectives &Expectations
Risk Exposure
Management Strategies
FitProject
Success
© Claude Sicotte, Université de Montréal
Risk Assessment Model
Technologic
Organizational
Managerial
Human
Strategic
© Claude Sicotte, Université de Montréal
Five types of risk
Technological Risk: Hardware & Software Complexity & Network interoperability complexity
Human Risk: Resistance to change & Users’ unrealistic expectations
Usability Risk: Potential of use in real workplace context
Managerial Risk: Quality of Project Team, Resources availibility & Unrealistic project schedule
Strategic/Political Risk: Misalignment of groups of professionals and organizations’ objectives and stakes
© Claude Sicotte, Université de Montréal
Brief survey of the two EHR implementations cases
The vision: A clinical data sharing network system
The goal: To enhance access, quality and coordination of healthcare
The objectives: To increase the speed of transmission and the exchange of clinical data & To reduce intervention delays
The technology: A Network Electronic Health Record (EHR) - Data Warehouse
© Claude Sicotte, Université de Montréal
The Technology: An interoperable EHR
Shared Electronic Health Record (EHR) Common Patient Index - Unique network identifier Shared Medical Thesaurus Common Patient Inscription Module Common Patient Consent Management Module Clinical Data: Labs Results, Medical Imaging Reports No physicians’ electronic ordering; only data display
Network Infrastructure: Proprietary High-band secure intranet - Previously deployed
Technical Interfaces: Legacy Systems - EHR Data Warehouse
© Claude Sicotte, Université de Montréal
Brief survey of the first case,the less successful one
Users: 39 Pediatricians - 1 Pediatric Teaching Hospital, 2 Regional Community Hospitals, 4 Medical Clinics
Data Providers: 3 Public Hospitals
Project Length: Three years and 4 months (2000 - 2004)
Length of IT use assessment: First 7 months (2004)
Total Project Budget: 11 million $ (Cdn)
The partners: Pediatric Teaching Hospital (Maître d’oeuvre) - 2 Regional Community Hospitals - 4 Pediatric Clinics - IBM - Several firms of Legacy systems - Technocentres Régional & National, GTQ - Sogique & IBM - Bell Canada, Vidéotron.
© Claude Sicotte, Université de Montréal
Brief survey of the second case, the more successful one
Users: 105 General Practitioners - 10 Medical Clinics
Data Providers: Public Hospital & Private Labs Setting
Project Length: Two years and 2 months (2001 - 2003)
Length of IT use assessment: First 10 months (2003)
Total Project Budget: 14.8 million $ (Cdn)
The partners:
Laval Planning Regional Agency (Maître d’oeuvre) - Omni-Med - AMOL - 10 Medical Clinics - Hôpital Cité de la santé & Labo MDS - MédiSolution, Nexxlink, Artefact, Lanier - Technocentres Régional & National, GTQ - Sogique & IBM - Bell Canada, Vidéotron.
© Claude Sicotte, Université de Montréal
Level of implementation success(Source: Electronic Log History Journals)
Case # 2 (2003) Feb April June Sept Nov
% MDs-Users
/week28% 55% 53% 64% 69%
Mean Nb of access/week
6 3,2 2,7 5,2 4,7
Mean session length (mnt)
134 116 124 116 139
© Claude Sicotte, Université de Montréal
Case # 1 Teaching Hosp Hosp A Hosp B Clinics
Use Boycott, Anemic use
1 MD None Administr. Personal
Differences between the initial and the final levels of Risk
Technolo-gical Human Usability Managerial
Strategic & political
Very High
HighCase #1
Moderate Case #2
Weak
Very Weak
© Claude Sicotte, Université de Montréal
Risk
Level
Dimensions
Initial risk Level
Technological Risk Assessment
Risk
Factors
Newness of network software and infrastructure
Interoperability - Infrastructure: Use of incompatible
hardware
Interoperability - Infostructure: Lack of common data standard for the transfer of clinical data (HL7)
Risk
Management
Enlistment of outside IT experts (EHR firm)
Data Warehouse solution
Development of home-made technical interfaces/
Several Vendors
Management of Users’ expectations
© Claude Sicotte, Université de Montréal
Technological Risk Assessment
Outcomes
Case 1:
Underestimation of the time needed to develop
the technical interfaces
12-month delay
Missed deadline
Decline of users’ confidence
Case 2:
More realistic schedule - Better management of users’ expectations
Users’ commitment to the project remained unaffected
© Claude Sicotte, Université de Montréal
Human Risk Assessment
Risk
Factors
Physicians’ voluntary participation: less risk
Initial expectations and attitudes were positive
No resistance to change
Physicians were realistic about the large efforts needed to learn to use the EHR
Risk
Management
Case 1: Weak efforts to build relations with users
Case 2: Impressive and continuous implementation efforts to build strong relations with the physicians; Project champions; Experimental use of the system interface; …
True users’ influence on the implementation process
© Claude Sicotte, Université de Montréal
Human Risk Assessment
Outcomes
Case 1: An increase of the human risk because of:
(a) weak efforts in users’ relation building before the go live
(b) the delays to develop the technical interfaces
Case 2:
A decrease of the human risk despite serious technological problems (System response time)
The physicians became increasingly confident in the success of the new system
© Claude Sicotte, Université de Montréal
Usability Risk Assessment
Risk
Factors
Low awareness in this matter
Taken for granted Physicians’ perceived uselfulness
Only system’s user friendliness = a significant risk
Information usability = EHR Information Content
Work usability = alignment between EHR use and work routines
Risk
Management
Data Warehouse: Volume and data quality
Case 1: Weak recruitment of patients (- -)
Case 2: High responsiveness the Users’ needs (++) & Better recruitment of patients
© Claude Sicotte, Université de Montréal
Usability Risk Assessment
Outcomes
Case 1: An increase of the usability risk because of (a) late efforts in patient recruitment (Information Usability)(a) no effort to align the EHR use with work routines
(Work Usability)
Case 2: A decrease of the usability risk due to a high perceived EHR usefulness (High Information Usability) - Despite an initial poor EHR system response time, physicians continued to participate because they saw that no efforts were being spared to find solutions to their problems
- Despite a lower than expected work usability
© Claude Sicotte, Université de Montréal
Managerial Risk Assessment
Risk
Factors
Quality of the project management team (Skills & Knowledge
Team size, variety and time constraints
Availibility of resources
Risk
Management
Case 1: Smaller team, possessed less expertise both in IT and project management; far less time to devote to the management of the project
Case 2: More intensive managerial efforts & more responsive to Users’ needs and Project Risk
© Claude Sicotte, Université de Montréal
Managerial Risk Assessment
Outcomes
Case 1:
Because of its smaller size, team’s efforts were overload by technological problems at the expense of other important risks, namely the human and usability risks
Case 2:
Larger scope of problems’ awareness and capabilities to intervene
Strategic Risk Assessment
Risk
Factors
Network’s diverse composition rather than network size
Larger misalignment of partners’ objectives and stakes in Case #1 (Teaching academic center/Medical Clinics; Children/adult patients)
Risk
Management
Rather small number of organizations
One type of users = Physicians
Case #2: Higher Network Homogeneity (composed solely of GPs + One Health Region) and early network building efforts
© Claude Sicotte, Université de Montréal
Strategic Risk Assessment
Outcomes
Case 1:
Interorganizational conflicts were not really a problem
Gradual disinterestedness was more of a problem
Case 2:
Continuous increase of confidence between the diverse partners including the regional association of physicians, the EHR firm and the team project team
The main lessons
Six key factors of success:
1. The vision
2. The Network strategy
3. Flexible Execution
4. Design of a hybrid electronic - paper system
5. Clinical processes engineering both at network and individual levels
6. Quality of the project management team© Claude Sicotte, Université de Montréal
Key success FactorsLesson # 1: The vision
There is a need to widen the project vision
to give more space to the Clinical dimension to offset the unavoidable weigth given to the technologic dimension
A Two-way vision is necessary to create a synergy between the technology and the clinic
Key elements: Responses to users’ needs & Management of users’ expectations
© Claude Sicotte, Université de Montréal
Key success FactorsLesson # 2: The Network
strategy
There is a need to conceive what is the meaning of “Interorganizational Partnership“ beyond a Telecommunication networkThere is a need to simultaneously further a Collective/Network logic and Local logics at diverse levels: clienteles, programs, groups of healthcare professionals and organizationsWhat are the incentives?
© Claude Sicotte, Université de Montréal
Key success FactorsLesson # 3: Flexible Execution
There is a need to continuously change the initial plan to solve emerging problems and capture opportunitiesIt seems to be an especially difficult thing to accomplish especially after the go liveFlexible execution is necessary both at the operational and strategic levels
© Claude Sicotte, Université de Montréal
Key success FactorsLesson # 4: Hybrid System
A frequent mistake: To conceive the project on the sole functionalities offered by the electronic solutionIt is rarely possible to completely eliminate the old paper system. It is thus important to build a hybrid system corresponding to the true users’ needs
© Claude Sicotte, Université de Montréal
Key success FactorsLesson # 5: Clinical
Engineering
A reconfiguration of clinical work processes remains unavoidable.
It needs to be done in such a way to offer benefits to the users
It is the Achilles’ heel in many projects
© Claude Sicotte, Université de Montréal
Key success FactorsLesson # 6: Quality of the Team
There is a need to widen the composition, the size and the action scope of the project management teamThree key human resources:
The IT SpecialistThe Clinical ChampionThe Change Manager
© Claude Sicotte, Université de Montréal