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TOWARDS AN IT ROADMAP FOR

BELGIAN HOSPITALS

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Title

Towards an IT Roadmap for Belgian Hospitals

Authors

Prof. Dr. Brecht Cardoen – [email protected]

Prof. Dr. Bjorn Cumps – [email protected]

Mathias Boënne – [email protected]

Table of Contents

Executive summary ............................................................................................... 2

Introduction .......................................................................................................... 4

IT challenges for hospitals ................................................................................................. 4

Focus on digital transformation .......................................................................................... 7

Research question ................................................................................................. 9

A view on a hospital’s capabilities ...........................................................................10

Business architecture ...................................................................................................... 11

IT architecture ................................................................................................................ 14

A closer view on some Belgian hospitals ..................................................................16

Case 1: large non-university hospital ................................................................................ 16

Case 2: large university hospital ....................................................................................... 19

Case 3: large non-university hospital ................................................................................ 22

Case 4: medium-size non-university hospital ...................................................................... 24

From heat map to roadmap ...................................................................................28

Conclusion and next steps .....................................................................................32

Bibliography ........................................................................................................33

Reference

This report is electronically available on www.vlerick.com/healthcare and can be cited as

“Cardoen B., Cumps B. and Boënne M. 2017. Towards an IT Roadmap for Belgian Hospitals.

Vlerick Business School, HMC White Paper”.

Acknowledgement

This report was supported by the Belgian Association of Hospital Directors (ABDH/BVZD)

and made possible by an unconditional grant provided by Xperthis.

Our solution to your specific needs

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Executive summary

With technology developing at the speed of light, hospitals are embracing the era of digital

transformation and are substantially rethinking how information technology (IT) should

progress within the healthcare setting. The evolution in the domain of healthcare is

increasingly calling for IT proficiency to face the many challenges, including the need for

improved registration, standardisation, integration and exchange of data and information,

the fostering of patient centricity and the push towards a better quality and efficacy of cure

and care. To date, the business requirements of the hospital are not always aligned with

the current state of IT accomplishments. The aim of this study is to identify the main

business and IT capabilities of hospitals in the Belgian healthcare context and to summarise

them into an intuitive and transparent capability map, of which the result is shown in Figure

1. This map will help individual hospitals to rethink and challenge their current IT strategy

in line with the hospital’s general strategy, and to dynamically prioritise which capabilities

need further development and should be specified in the hospital’s IT roadmap.

Figure 1: View on the hospital capability map, with key (sub) capabilities expressed in dark

grey (light grey) blocks


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The research trajectory did comprise two phases. In a first phase, we made ourselves

familiar with the recent context and evolution in the field of hospital information

technology, and interviewed many different stakeholders to learn from their view on recent

IT developments and needs. In a second phase, these insights, together with a view on

recent business literature, led to the creation of a capability map that was iteratively refined

in discussions with hospital executives, mainly on the level of CEO and CIO. We

acknowledge that the choices leading to the capability map of Figure 1 aren’t exact science

and will always leave room for interpretation, adaptation and future changes.

By means of multiple hospital case studies, we illustrate that the capability map can be

used as a heat map to quickly screen the different capabilities and their state of

development within a specific hospital setting. We point out, however, that our model is

not to be confused with a maturity assessment model and therefore does not list specific

scales to measure every (sub) capability. From the case studies, and without aiming to

generalise for the entire Belgian hospital scene, we notice that there is a large variability

by which the capabilities are developed. On the level of the individual hospital, this

variability shows between (i) the key capabilities of a hospital and (ii) the various sub

capabilities that constitute a particular key capability. When comparing the results over the

different cases, we also observe that results substantially differ between the hospitals, thus

indicating that substantial room for improvement exists.

An interesting question is whether all hospitals should develop the same capabilities and if

we therefore should put a joint IT roadmap forward. From the interviews and cases, we

conclude, e.g., that the implementation of the electronic patient record (EPR) is receiving

utmost attention nowadays and constitutes an IT project that many hospitals share. This

seems a sound choice, since the EPR impacts directly or indirectly almost all of the

capabilities that are listed. We do see, though, from the cases that some hospitals are

already actively thinking about the EPR implementation on a network level, while others

are still working hard to get an integrated EPR within their own hospital entity. Apart from

the EPR project, though, it is less clear which capability needs to be prioritised. Given the

differences in the current state of IT among hospitals, and the differences in general

strategy defined by the hospitals, we argue that a one-size-fits-all IT roadmap might

eventually not be desirable. Instead, we recommend hospitals to use the capability map

and pinpoint their own capabilities of interest for the near future. The capability map will

allow them to add relationships between capabilities and reason on the necessary

development of other supporting capabilities given their prioritisation, therefore making it

a dynamic instrument.


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Introduction

Before jumping to the research question (next section), this introduction should provide a

brief overview of the hospital’s information technology (IT) challenges. We also verify

whether these challenges are in line with the general (non-hospital) reality about digital

transformation.

IT challenges for hospitals

Hospitals are facing an overwhelming multitude of challenges. While the amount of

diseases globally continues to grow as a result of the ageing population, health inequality

or people’s lifestyle, the spending of

hospitals keeps rising at unsustainable

rates (Tooke, 2015). Hospitals are

therefore increasingly being pressed by

governments and other stakeholders to

deliver high quality care to patients at the

lowest cost possible. The effective sharing

of relevant information within and

between hospitals has not only proven to

significantly lower hospital costs by

avoiding the duplication of cure and care

practice, it can also substantially lower

the amount of incorrect drug

administrations, the amount of

miscommunications, illnesses and

deceases that could and should be

prevented (Grossman, 2013; Robben,

2015; Vanaudenaerde, 2015). In other

words, information and communication

technologies and processes have the

power to boost the value that hospitals

can deliver to their patients, while

simultaneously lowering the costs to do

so. To reach this double aim, IT should

not only be perceived as a supportive

tool, but as an integral part of the entire

healthcare process.

But even though the healthcare industry

is among one of the most transaction-

intensive industries, Belgian hospitals

have traditionally been lagging in terms

of the implementation and alignment of

their IT, which is one of the reasons why

the Belgian federal government and other

stakeholder institutes are pressing hospitals to put IT as one of the highest priorities on

Methodology

To identify today’s most relevant challenges

about information and communication technology

in hospitals, we did apply a stakeholder

perspective. We interviewed first a series of

relevant non-hospital stakeholders who

frequently and directly interact with hospitals or

are seen as professional specialists in the field of

IT in the healthcare industry. The stakeholders we

interviewed include the NIHDI/RIZIV/INAMI (Ri

de Ridder), the Federal E-health platform (Frank

Robben), the Advisor of the Minister of Social

Affairs and Public Health (Frank Ponsaert), the

Advisor of the Minister of Health of Walloon

Region (Philippe Henry de Generet, written

communication), the Advisor of the Minister for

Welfare, Public Health and Family of Flemish

Region (Caroline Verlinde, Regine Van Ackere,

Wim Vanslambrouck), the Belgian Association for

Doctors' Syndicates (Marc Moens), the CIN-NIC

(Bernard Bolle), the Red Cross (Dominiek

Vanaudenaerde) and the Flemish Patients’

Platform (Roel Heijlen). The authors are very

grateful for these opportunities and would like to

thank all interviewees for their contribution.

Insights derived from the interviews are

complemented by a literature review of recent

business studies (see Bibliography). The insights

derived from the interviews and the literature

were presented and discussed during a workshop

exclusively for hospital directors. The

complementary learnings and discussion of this

workshop are integrated in this section of the

report. Furthermore, the opinion of hospitals is

addressed in detail later in this document by

means of case studies.


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their agenda via policy initiatives such as the action plan1 concerning ehealth listing 20

action points to grow IT in the healthcare sector. One action point that is recently

accelerated because of it’s central role to achieve many other action points concerns the

implementation of the electronic patient record (EPR), for which recently a set of Belgian

Minimum Use Criteria2 (BMUC) and according stages of development have been identified.

Overall, we should be fostering the move towards increased patient centricity in the

decision-making processes of hospitals via transparency and exchangeability of patient

information (Groves et al., 2013; Ponsaert, 2015; Robben, 2015; Verlinde et al., 2015).

The reasoning behind this is that all decisions, including those concerning IT, should

predominantly be based on the benefit for the patient, which is more than often not yet

the case. At this moment, IT and their related processes within and between Belgian

hospitals are unstructured, fragmented, not sufficiently integrated or standardised, and

not supported with sufficient resources. Addressing and overcoming these barriers would

simultaneously boost the quality of care to patients and significantly lower the costs

incurred by Belgian hospitals. The next paragraphs specify the barriers that ought to be

tackled to yield a more efficient hospital environment in Belgium.

FRAGMENTATION: The complexity of the organisational design of hospitals has traditionally

made it very challenging to implement healthcare IT and processes effectively. When

comparing the process of care with a typical manufacturing process, it quickly becomes

apparent that the amount of people, units and technologies involved to ‘process’ one

patient is significantly larger and more variable in comparison with other industries (Wager

et al., 2013). This complexity has resulted into the fragmentation of organisational

structures that now operate as silos within and between hospitals. To enable the sharing

of information between healthcare providers, payers and patients, the development of IT

infrastructures within and between hospitals is a fundamental necessity. The responsibility

to limit and remove fragmentation of IT technologies and processes within hospitals mainly

lies with the hospital management. To overcome fragmentation of IT and processes

between hospitals, the reorganisation into mergers and collaborative networks of hospitals

have been brought forward as solutions (Weil, 2000; Moens, 2015). Recently, Belgian

hospitals are already becoming connected by starting to organise themselves mainly as

networks. Efficient, digital hospitals take the lead in this step by positioning themselves as

extensive metahubs where health information is centralised (PwC, 2013; Verlinde et al.,

2015). However, there is still a long way to go before this barrier is overcome. For instance,

general practitioners in Belgium often still operate independently, rather than being part

of a network.

INTEGRATION AND STANDARDISATION: Multidisciplinary, integrated and interchangeable patient

files with both technological and semantic standards are not yet present within or between

hospitals, even though it would lower hospital costs while improving healthcare quality

(Robben, 2015). Integration links the efforts of organisational units through shared data.

The benefits of integration include increased efficiency, coordination, transparency and

agility (Ross et al., 2006). To a large degree, medical information exchange has been

1 For more information on the ehealth action plan, please visit http://www.plan-egezondheid.be/ or

http://www.plan-esante.be/

2 The BMUC can be retrieved from https://www.health.belgium.be/en/node/28865. We also invite the reader to consult www.ziekenhuisEPD.be for latest details reported by the federal government on the EPR evolution and, e.g., retrieve results of the questionnaire on EPR status and alignment of

hospitals with the BMUC (2016).

http://www.plan-egezondheid.be/

http://www.plan-esante.be/

https://www.health.belgium.be/en/node/28865

http://www.ziekenhuisepd.be/


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hindered by the lack of standards for data and transactions used by hospitals. Yet, with an

increase in chronic care and multimorbidity, the call for integration will only increase (De

Ridder, 2015). Standardisation would deliver efficiency and transparency across hospitals

while driving down costs (Ross et al., 2006; IBM, 2013). Standardisation has also been

slowed down as the health status and medical condition of a patient is difficult to describe

using comprehensive, coded data (Wager et al., 2013). By no means, though, IT should

be allowed to hinder therapeutic decision making (Robben, 2015; De Ridder, 2015).

Currently, there is no sufficient alignment between standards in primary, secondary and

tertiary care (Verlinde et al., 2015). Standardisation and integration of patient information,

moreover, is not straightforward as many issues arise around data privacy, security and

control (PwC, 2013; Moens, 2015; Robben, 2015). For instance, physicians only require

access to the information needed to support their clinical decisions in the context of the

task being performed, not all the information about a patient should be made available in

all cases. Integration and standardisation also brings up the issue of a potential rise of a

monopoly of a health IT provider in Belgium, which is advised by all stakeholders to be

averted. But the integration and standardisation of IT systems without monopoly can only

be feasible if IT technologies of the software providers are programmed to be able to share

information with each other (Robben, 2015; Verlinde et al., 2015). Interoperability of

health information and communication systems is therefore a necessary condition to

succeed. Another reason that health IT systems are not standardised is because hospitals

often develop and/or customise their health IT to create switching costs for their highly-

knowledgeable workforce. If a physician would switch to another hospital, they would have

to get used to and learn how to work with different software (Robben, 2015). The question

that arises here is whether it is ethical that IT systems and processes are used as switching

barriers to bind the physicians to the hospital while it would be more beneficial to the

patient if they would become more standardised. All interviews pointed out that there is a

clear and urgent need for standardisation concerning the electronic patient record (EPR),

in which the BMUC might be a first step. Denmark is often pointed out as successful

example of adopting an integrated EPR (e.g. Kierkedgaard, 2013). The difference in

political landscape, however, makes an exact imitation of the centralisation of IT for Belgian

hospitals improbable (Ponsaert, 2015). A more reasonable proposed solution for Belgian

hospitals would be to centralise the data in hubs, while the ownership and source of patient

information is kept decentralised. Nevertheless, all interviewees agreed that the

development of the EPR is one of the top priorities for hospitals in Belgium at this time.

RESOURCES: There has historically been an underinvestment of resources, both with respect

to human and capital, in hospital information systems. The resulting restricted/limited

adoption of information and communication technologies still constitutes the source of

many of the issues that hospitals are facing today. This has to do with the inadequate

budgets that have been granted to Belgian hospitals and/or the meager amount of budget

that is distributed towards IT projects within hospitals. When questioning our interviewees,

many indicated to have no view on current IT budgets within hospitals, though.

WORKFORCE: Change management within hospitals is also seen as a substantial barrier that

needs to be overcome. Hospital workforces are often not willing to alter their activities and

behaviour in response to changes in the IT systems (Deloitte, 2015). Autonomy and

transparency of health activities are two main issues that lay at the cause of this reluctance

to adopt new IT systems (Ponsaert, 2015). In addition, physicians nowadays do not receive

any IT training during their education or professional career, so they often do not realise

the strategic value that IT can offer to them (PwC, 2013). Government incentives and


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initiatives stay recommended to stimulate change in hospitals, but are not sufficient on

their own to bring change in the behaviour. The hospital workforces must have a clear

understanding and take the initiative themselves to change their activities and behaviour

in function of the benefit for the patient. Realising success in digital transformation also

requires senior clinical professionals and health IT leaders to define in common an

achievable vision that addresses the relevant challenges (Deloitte, 2014). Thinking about

IT should not only be a task for IT people (De Ridder, 2015). In essence, we really need

to manage change (Robben, 2015; Ponsaert, 2015).

PATIENT ROLE: The expectations of the patients are shifting and the ‘my patient’ view during

treatment needs to fade (De Ridder, 2015; Heijlen, 2015). Patients are becoming

increasingly more informed and therefore will start to make their decisions less and less

based on which hospital is closest, but instead based on the quality of the specific physician

or health service (Verlinde et al.; 2015). In the future, patients might also contribute more

to the care they receive, i.e. they will also provide information to the care institution by

means of mobile technology. Having a more participative patient might also call for working

towards a more responsible patient and being more clear on what can and will be expected

from his/her side.

M-HEALTH: Currently, m-health is often not yet cost-competitive as compared to other

digital health processes since the eco-system around m-health still needs to be developed,

which takes time. In order to capture data from m-health, an eco-system of knowledge

centres, administrators, legislators and big data systems should be set up (Deloitte, 2015;

Robben, 2015). The added value of m-health on the health care process is expected to be

substantial as smartphones offer new ways of engaging with patients (PwC, 2014), but

should not be overrated (Ponsaert, 2015). The healthcare is becoming increasingly more

digitised, as electronic systems are replacing the paper-based systems, opening a gateway

for innovation. More and more sophisticated mechanisms are reaching the market but they

are often hindered as they remain unregulated (PwC, 2013).

It has become clear that Belgian hospitals are facing a multitude of intertwined challenges

in terms of information and communication technologies. In summary, our interviewees

indicate that major challenges lie ahead w.r.t. the EPR, integration, standardisation,

change management, and all of this while putting the patient forward.

Focus on digital transformation

A question that might arise is whether the challenges hospitals have concerning digital

transformation (i.e. the end-to-end integrated business transformation where digital

technology plays a dominant role) are to some extent similar to, or at least in line with,

those of many other industries. In other words, do we also find similar spearheads and

focus points in other industries and settings. To have a view on this, we connect to the


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ExConomy3 framework (Viaene and Danneels, 2015): what are the realities that are

currently driving the digital economy in a broad and general context?

REALITY 1 - Customer Experience is Value: In the digital space, customers will take the lead

and companies need to think more from outside-in instead of inside-out. For healthcare,

this implies that the patient will (finally) take its central position in the healthcare eco-

system, and that services should be built around the patient instead of the healthcare

institution.

REALITY 2 - Customers are moving targets: Companies cannot assume that value

propositions that work today will still be effective tomorrow. Therefore, they need to more

actively and intensely track and follow what the customer is doing and what he/she wants

to achieve (entering the field of big data). For healthcare, it implies that we need to better

monitor the (perhaps even healthy) patient to better answer upcoming and changing

needs. Patient loyalty will disappear in the digital space.

REALITY 3 - Collaboration reshapes strategy and business models: The company on its own

will not have enough strength and offering to fulfill the customer’s needs. Therefore, it

needs to partner with others who excel in complementary capabilities and skills and go

together in targeting the customer. In healthcare, this can be seen as the search for

alliances between hospitals and the formation of care networks to build a strong eco-

system that offers a continuity of care.

REALITY 4 – Eco-system platforms boost value co-creation: The eco-system will only flourish

if there is a performing underlying platform that allows for making the collaboration

happening. This means that your data needs to be combined with data of others, in an

integrated and equally important flexible way. For healthcare, this points to the need for

an easy and safe integration of data with the partners in the healthcare alliance and eco-

system. Enterprise Architecture (EA) helps to build this platform, and especially the use of

APIs (Application Program Interfaces) comes to the forefront for sharing data externally

(with nowadays already many applications in ,e.g., the travel and banking sector).

In essence, it is not so hard to see that these four realities easily transfer to the healthcare

setting, which shows that at least the core of the challenges seem to be universal and

learnings can be taken from general insights on digital transformation too.

3 Listen to what Prof. Dr. Stijn Viaene has to say about the ExConomy framework on

https://www.youtube.com/watch?v=OIx5IDK-WPo

https://www.youtube.com/watch?v=OIx5IDK-WPo


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Research question

The many IT challenges make that it is not straightforward for hospitals to decide upon

focus points in the development of an appropriate IT strategy. The objective of this study

is twofold.

First, we aim to construct a high-level capability map that should help hospitals to identify

strengths and deficiencies in their current IT support of the required set of business

capabilities. It is important to state that we do not aspire to develop an IT maturity

assessment model. A well-known maturity model for the electronic medical record is, e.g.,

provided by the EMRAM4 model of HIMSS. For a general and recent view on the state of

maturity models for hospital information systems, we refer to Carvalho et al. (2015) who

state that maturity models for hospital information systems can be significantly improved.

In their research, they indicate that “the models pertaining to the health field are poorly

detailed, do not provide maturity measuring tools and do not structure the characteristics

of maturity stages according to influencing factors”. More in the interest of this research

study, we want to develop a concise and visual structure that supports professionals who

are looking to quickly overview the digital offering of their hospital from different angles

and in line with the major capabilities that are expected from a hospital setting.

Second, by applying this capability map to some hospitals residing in the Belgian healthcare

landscape and developing small case studies, we hope to identify some patterns that will

hint directions for future digital development. We want to show how the capability map

can be used to move from a static tool, in better understanding the current status, to a

dynamic tool that helps identifying which capabilities to develop given the strategic choice

a hospital is making, leading to the start of designing an IT Roadmap. Since hospitals might

substantially deviate in the current status of their capabilities, as will be shown by the

cases and which was also put forward by the interviews (e.g. Ponsaert, 2015), we do not

intend to generalise one advice for all hospitals. It is in our opinion more useful to show

how choices of capability development impact different capabilities and initiate different

calls for IT development.

4 EMRAM is a maturity model developed by HIMSS with eight stages (0-7) to measure the level of

electronic medical record (EMR) capabilities ranging from limited ancillary department systems to a paperless EMR environment. At Q4 of 2016, about 16 Belgian hospitals took the assessment, and two hospitals reached level 6 (UZ Brussel and CHU Liège). More information to be retrieved from

http://www.himss.eu/healthcare-providers/emram



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A view on a hospital’s capabilities

From the introduction, it shows that in general IT currently does not meet the business

expectations and aspirations of a healthcare organisation or eco-system. Enterprise

Architecture (EA) is often put forward as a methodology to bridge this gap, focusing on the

proper arrangement of elements into a reasoned structure. One could define EA as “the

fundamental organisation of a system embodied in its components, their relationship to

each other, and to the environment, and the principle guiding its design and evolution”

(IEEE Standard 1471-20005). Yet, there is a vaste choice of definitions in the literature,

mainly focused on the outcome of architecting, but equally important one should consider

the process of architecting. We refer to Cumps et al. (2013) for an overview and the

evolution in the field of EA.

Enterprise Architecture is generally considered to comprise both Business Architecture and

IT Architecture. Business Architecture traditionally covers the capabilities of an

organisation (what do we want to do), the organisational structure into different domains,

and the processes that are installed to reach the goals and objectives (how do we want to

realise the capabilities). While processes can more easily change over time, the capabilities

are seen to be more stable. Therefore, decomposing the services and activities of an

organisation in terms of capabilities -

essential basic building blocks - helps to

provide a high-level structure. This

decomposition can be visually summarised

by means of a capability map. The IT

Architecture should consequently be built

to support an organisation in reaching and

developing its capabilities in particular,

and to fit the Business Architecture as a

whole. Therefore, an effective capability

map creates a foundation for execution

and ensures alignment between business

processes and IT (Ross et al., 2006).

Digitisation of hospitals is advised to be

driven by architecture that delivers

capabilities to support services and

processes (Deloitte, 2015).

Figure 1 provides an overview of the

capability map we developed for this

study. It follows the EA structure and

makes a difference between the Business

Architecture and the IT Architecture.

These two main parts show a (non-exhaustive) breakdown in key capabilities (such as

internal care orchestration, external care orchestration, etc.) which on their turn will list

some important sub capabilities (such as admission planning, discharge planning, etc.). In

5 http://standards.ieee.org

Methodology

To build a capability map that fits the Belgian

context and that balances conciseness with

sufficient level of detail, we did use an iterative

process of refinement. In an initial step we did

base ourselves on our own experience of the

operating model of Belgian hospitals, recent

trends, and on frameworks retrieved from

recent business studies, listed in the

bibliography. In a second step, the capability

map was taken to discussion with a number of

practitioners and professionals in the field of

IT/hospital/healthcare. Consequently, we have

been testing and validating the capability map

with four hospitals by means of semi-structured

interviews. After every case we did refine the

map based on feedback or requests for

clarification. Developing a capability map is

difficult as it forces management to frame a

simple vision of a complex organisation. We are

therefore very grateful to the participating

hospitals of the case studies, and in particular to

the interviewees for sharing their insights and

constructive suggestions along the discussions.

http://standards.ieee.org/


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the remainder of this section, we will briefly clarify and situate the different (sub)

capabilities to create a joint understanding and to enhance reasoning with the capability

map.

Figure 1 (bis): View on the hospital capability map, with key (sub) capabilities expressed

in dark grey (light grey) blocks

Business Architecture

INTERNAL CARE ORCHESTRATION: The careful planning, arranging and automation of

composite care services and processes for the patient from the moment he/she enters the

hospital until he/she leaves the premises of the hospital.

ADMISSION PLANNING: The careful planning and managing of the act of admitting

patients or allowing them to enter in the care services of the hospital. This capability

typically involves the inpatient setting and therefore also relates to proper bed

management capabilities.


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DISCHARGE PLANNING: The formulation and planning to release a patient from the care

services of the hospital, here limiting the focus to connecting all information and

stakeholders from inside the hospital entity (<> external care orchestration).

TREATMENT PLANNING: The planning and managing of the actions and methods of

treating patients medically (ambulatory visit/consultation) or surgically.

CARE TRANSITION MANAGEMENT: The planning and managing of transferring a patient

to another (clinical, organisational or nursing) unit within the hospital.

EXTERNAL CARE ORCHESTRATION: The careful planning, arranging and automation of

composite care services and processes for the patient with healthcare institutions and

stakeholders that are not formally part of the hospital entity.

CONTINUITY OF CARE (HOSPITALS): Managing the information exchange and transition

of care for the patient with other hospitals in healthcare eco-system (e.g. those not

being a member of the hospital’s collaborative network, etc.).

CONTINUITY OF CARE (NON-HOSPITALS): Managing the information exchange and

transition of care for the patient with agents other than hospitals in the healthcare

eco-system (e.g. general practitioners, patients, clinical remote ancillary services

(labs), elderly care, etc.).

CARE ADMINISTRATION: Encompassing the activities that relate to the administration of

care (so patient perspective) and the respective registration of input and output (also

outcome-related).

CLINICAL DECISION MAKING: The act of making informed medical decisions that might

be supported or even hinted by automated and predictive IT support.

REGISTRATION: The act of registering information in the hospital information system,

such as active or past diagnoses, patient identification, informed consent,

medication usage, nursing information, etc.

CLINICAL RESEARCH: Supporting the clinical trials by means of technology, e.g. for

aggregating results, sharing datasets or selecting patients.

QUALITY & RISK MANAGEMENT: Capability of preserving and guaranteeing qualitative

and safe healthcare, encompassing hospital accreditation or drug-drug interaction

screening, but also outcome-based analysis turning to the field of value-based

healthcare.

BUSINESS INTELLIGENCE: Technology-driven capabilities for analysing data and presenting

actionable information to help hospital executives, managers and other end users to make

better informed decisions.

PERFORMANCE MANAGEMENT: The assessment of employees, processes, resources or

other factors to gauge progress towards predetermined strategic objectives of the

hospital (e.g. dashboards).

PREDICTIVE MODELLING: The identification, analysis, assessment, control and

avoidance or elimination of unnecessary risks via data-mining technologies that are

used to analyse historical and current data in order to help predict future outcomes

or behaviour. While the emphasis here is on the business perspective, also clinical


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predictive modelling might be an important capability (but resides under care

administration - clinical decision making).

INTEGRATED REPORTING & COMMUNICATION: This is the embedded and detailed reporting

and communication of a clear, concise and integrated overarching picture of a

hospital’s ability to produce value over time for different stakeholders. It

incorporates the reporting and communication of data analysis results of the real-

time data hospitals generate and gather from their day-to-day operational

activities.

BUSINESS MANAGEMENT: Activities associated with effectively and efficiently running,

controlling, leading, monitoring and organising a hospital.

ENTERPRISE RESOURCE PLANNING (ERP): The accounting oriented, relational database

based, multi-module but integrated software activity for identifying and planning

the resource needs of a hospital. ERP provides a user-interface for the entire

organisation to manage product planning, materials and parts purchasing,

inventory control, distribution and logistics, production scheduling, capacity

utilisation, order tracking as well as planning for financial and human resources.

FINANCE & INVOICING: The planning, directing, monitoring, organising and controlling

of the monetary resources of a hospital, including the billing process.

STAFF IT LITERACY AND CHANGE: The level of familiarity and expertise of the hospital’s

workforce with the basic hardware and software concepts and the willingness to

adopt changes in the implementation of the basic hardware and software.

PATIENT ENGAGEMENT: Actions and interactions hospitals make with their patients to obtain

greater benefit from the healthcare services they provide. These actions might take place

on both the administrative and clinical level.

ACCESSIBILITY: The easy to approach, reach, enter and use of services by patients

within and outside of the hospital, e.g. accessibility of the patient towards his/her

own medical record.

CUSTOMISATION: Tailoring of the services to the patient’s particular and individual

needs, e.g. information sharing or handling questions.

SELF SCHEDULING & EMPOWERMENT: The extent to which the hospital enables the patient

to undertake actions and decisions themselves, instead of hospital staff or a

scheduler. By empowering the patient, the hospital often seeks cost reduction while

increasing customer value and experience.

WELL-BEING: Act of following and considering a healthy ‘patient’ instead of focusing

on the curative aspect of care, therefore moving the organisation in the direction of

preventive healthcare.

DEPARTMENTS: Activities and services provided by the hospital’s main medical-technical

departments or units, including the pharmacy, laboratory, radiology, wards and nursing

units, operating theatre and sterilisation unit, emergency department and intensive care

unit.


14

IT Architecture

DATA: Information in raw, structured or unstructured form that represents conditions,

ideas or objects relevant to the hospital.

INTERNAL DATA INTEGRATION: The combination of technical and business processes

used to combine data from different sources within the hospital.

EXTERNAL DATA INTEGRATION: The combination of technical and business processes

used to combine data from different sources from the outside the hospital with the

hospital.

BIG DATA HANDLING: Is the analysis, sequencing and monitoring of high-volume, high-

velocity and/or high-variety information that is recorded on a (semi-)continuous

basis. We differentiate big data from big data sets.

DEVICES: We refer to devices as instruments, appliances or equipment, whether used alone

or in combination, including the software intended by its manufacturer to be used for

administrative, diagnostic and/or therapeutic purposes by health professionals to support

patient care.

INTERNAL DEVICE INTEGRATION: The capability of integrating and connecting devices

owned by the hospital to the hospital information system and IT services.

EXTERNAL DEVICE INTEGRATION: The capability of integrating and connecting devices

owned by other stakeholders than the hospital (e.g., bring your own device tablets

or personal computers, smartphones, etc.) to the hospital information system and

IT services, regardless whether the devices are physically present in the hospital or

remote.

APPLICATIONS: Programs that are developed to perform specific functions, either stand-

alone or as input for other programs/applications.

ELECTRONIC PATIENT RECORD: An EPR (or equivalently electronic health record)

contains the standard medical and clinical data gathered by the healthcare provider

(i.e. the electronic medical record), next to ,e.g., nursing data and medication

information so to include a more comprehensive patient history.

COMPUTERISED PHYSICIAN ORDER ENTRY - CPOE: An application to fulfill the e-

prescription of medication, but in the broader sense also for non-medication orders

as those performed by the lab or radiology. The CPOE is often seen as part of the

EPR.

TRACK & TRACE: Applications that foster tracebility and/or localisation of

patients/instruments/equipment/medication/etc. and contribute to health safety

and efficiency.

TELE-HEALTH: Remote communication about and/or surveillance of clinical issues by

means of multi-media technology. Examples include teaching sessions, virtual

physician consultations, tele-ICU, etc.

M-HEALTH: Mobile health applications that often relate to the usage of wearables or

smartphone usage and link to the concept of big data.


15

SOCIAL MEDIA: Refers to the usage and exploitation of new media applications such

as facebook, twitter and alike in the healthcare organisation and communication.

PORTAL: Gateway or internet site that provides access or links to other sites, either

for internal use within the healthcare organisation or for external use directed

towards patients and other stakeholders.

ARTIFICIAL INTELLIGENCE: Applications in the field of algorithmic design and machine

learning applied to health data to support clinicial decision making.

INFRASTRUCTURE: IT infrastructure is the underlying base or foundation of all components,

facilities, services and installations that play a role in overall IT and IT-enabled operations

of a hospital. It refers to the composite hardware, software, network resources and services

required for the existence, operation and management of an enterprise IT environment. It

allows a hospital to deliver IT solutions, support and services to its employees, partners

and patients.

SECURITY & PRIVACY: The confidentiality, integrity and availability of data and the

ability of the hospital and patient to determine what data in a computer system can

be shared with third parties.

SERVERS & STORAGE: These are servers that are used to store, access, secure and

manage digital data, files and services. Its purpose is to store and provide access

to data over a shared network or through the internet.

BACK-UP SYSTEMS: The activity of copying, archiving and securing files and databases

in systems so that they will be preserved in case of equipment failure or a

catastrophe and to restore the orginal. It is usually a routine part of the operation

of a hospital.

NETWORK INFRASTRUCTURE (CLOUD): The capability to transfer data, especially huge

size data files, through the network. It also covers the technical features ensuring

the connectivity to the network for all stakeholders.


16

A closer view on some Belgian hospitals

The goal of this section is to apply the framework of previous section to several hospital

cases and assess for every item of the capability map its current development status. To

do so, we interviewed the CEO and/or CIO and/or IT department head of the participating

hospitals and jointly discussed every building block of the framework. Since interviews are

a subjective means to acquire information and respondents might be less/more critical in

appraising the items, we tried to align for this during the talks. In the next subsections,

we briefly report on the general findings of every case and visualise the assessment by

colouring each item of the capability map, resulting in a heat map that allows for a quick

glance of the findings. The colour scaling has five stages and considers the following five-

scale range:

( ) - red: We are not actively working or thinking about this item; we are extremely

dissatisfied with our current status;

( ) - orange: The level of development we have is far below the standard and calls for

substantial improvement;

( ) - yellow: We achieve a level of development that fits the goals of today, but this

might not be in line with the challenges of tomorrow so that next steps should be taken;

( ) – light green: We reach a very acceptable and high level of development, which is

however not yet the ideal scenario we would like to realise;

( ) – dark green: This area cannot be further improved and is an area in which we for

sure excel.

Case 1: large non-university hospital

The first case is about a large (general) non-university hospital with multiple sites, located

in the Flanders region. The hospital has made it’s primary goal to provide the best possible

care for its patients, with the patient as a central focal point around which all activities and

decisions evolve. The hospital currently strives to operationally align its processes and

technologies after the merger in order to become a fully modern and paperless hospital

within a period of 5 years. Yet, at this moment, senior management points out that their

IT is not up for this task. That is why they have committed themselves to fundamentally

change their IT strategy by implementing a number of actions, formulated in an elaborate

IT policy plan.

As can be derived from the capability heat map of Figure 2, the overall picture shows

substantial room for improvement in terms of IT. Especially the processes concerning the

orchestration of care of the patients seem poor at first sight. The senior management

indicates that an electronic patient record with standard typology is present, in which at

least patient information from the lab, radiology and pharmacy departments are digitally

stored and made available to external partners, but no more. The goal of senior


17

management is to enhance the IT systems substantially in the following 5 years, centred

around the introduction of a new integrated EPR. To do this, 5 strategic action points are

formulated and being implemented as we speak:

1. Supporting care by better integrated IT

2. Supporting workflow with IT

3. Increasing patient engagement through IT

4. Supporting the healthcare network with IT

5. Adopting medical and IT innovations in the hospital

The senior management of the hospital has made the integration of their care processes

and systems their foremost priority in their strategic action plan, as they see this as a

major obstacle that explains the current undesired low state of digitisation. This hurdle

should be overcome first before other issues can be addressed/tackled. The internal care

orchestration is currently digitally underdeveloped. Admission and discharge planning is

mostly manual because there is no sufficiently detailed digital patient information available

as input for these activities. Currently registration of data is focused on what needs to be

provided to the government, not necessarily what’s needed for governance and

management. Moreover, the hospital management wants many of the registrations

(especially quality), instead of following the governmental reporting cycle, to become

continuous. The care transition management is described as rather archaic: e.g. hospital

staff needs to manually screen output to check whether the right patient is in the right

room. The configuration of the IT supporting treatment planning is not adequate enough,

but has at least stepped away from outlook, which made it a very time-consuming process

for the hospital staff. The lack of efficacy is also reflected in the business intelligence

activities of the hospital, for which they indicate that integrated reporting &

communications can be significantly improved, e.g. by moving to ‘self-service reporting’

instead of filing for reports in the respective department. The external continuity of care

for the patient now only happens occasionally with other hospitals. They show that there

isn’t sufficient information sharing between them and general practitioners outside of the

hospital: there is no prior information whatsoever on 95% of incoming patients in the

hospital who are not known to the hospital and do not bring their own letter with medical

information. The only information that is shared so far between hospitals and general

practitioners are the discharge papers and letters specifying medical content. To address

this issue, the hospital is deciding between two strategies in the 4th point of their action

plan: how to connect the network. Either they will opt for sharing patient information by

connecting and interfacing with existing yet scattered IT systems, or they will opt for one,

integrated system to be shared with all external partners. A difficult question remains about

who needs to take the orchestrator-role in the emerging field of networked healthcare:

patients, general practitioners or the hospital? If general practitioners want to take this

responsibility, the hospital states that they should then also get organised accordingly.

Actually, shouldn’t the patient be in the driver seat?

An additional reason for the lack of integration is that the departments inside the hospital

are still organised as silo’s. They should also be integrated in terms of their systems. Senior

management acknowledges that integrating care systems between departments can be

more difficult due to the lack of standards in semantics, typology and so forth, but they

agree that the patient care and administration planning should definitely become

integrated into one system. When comparing departments, they note that all the


18

information in the intensive-care unit is still stored and communicated on paper. CPOE is

currently not integrated with the implemented planning systems, but seen as a crucial

application to integrate in the short term. Clinical research is seen as a silo as well in the

organisation and therefore disconnected from the rest of the hospital in terms of IT.

Figure 2: Capability heat map of Case 1

Quality management is conducted ad hoc, as the necessary digital data is not always

available to do this effectively. The same applies for predictive modelling and risk

management, part of the business intelligence of the hospital. The reason for this is that

without available digital data these activities cannot be effectively conducted. This is also

reflected in the data capability list in the IT architecture of the hospital. Data integration,

both internal and external, score low. The handling of big data (and equally mining of non-

structured data) is non-existent at the moment as there is few to almost no data captured

to fuel the big data handling process, nor to be used as input for artificial intelligence. We

therefore conclude and agree with senior management that integration of IT systems and

data is a primary concern.

A second strategic point of action put forward in the IT policy plan is supporting the

workflow in the hospital with IT. Clinical decision making is barely supported by IT at this


19

moment. Only on the pharmaceutical side digital warnings will be displayed when negative

side-effects would arise for patients when prescribing combinations of medication.

Enterprise resource planning is currently digitally supported, but disconnected from the

other IT systems within the hospital. The aim of the senior management is to get these

systems interconnected by 2018. Invoicing is a separate unit that is partly supported by

IT. Senior management agrees that this should also be integrated into the entire hospital

IT system and become fully automated (e.g. integrate planning so that copying of activities

becomes superflues), but it is currently a lesser priority in comparison with the integration

of the care processes.

The third strategic point of action is to increase the patient engagement with supporting

IT. The hospital has already taken it’s first steps by experimenting with a ‘diabetes journal’

for the self monitoring of patients and by exploring the opportunity of a portal for online

self scheduling by patients. However, it still depends on the department whether online

self scheduling and self registration can be used by patients. This would add to the on-site

registration by means of ekiosks, which is already in place. Senior management wants to

furthermore advance the IT applications to track and trace the patient geographically in

the hospital. However, at this moment, wifi is not free for patients. In order to fully benefit

from the track and trace application via wifi, the hospital considers to distribute it for free.

Partly as a consequence of the increase in self-tracking systems and applications available

to patients, senior management believes that the self scheduling, self registration and self

monitoring will become increasingly more utilised over the near future. Currently, the

hospital is setting up and implementing their first pilot projects in tele-health and m-health.

This is aligned with their 5th strategic point of action in their IT policy plan: adopting

medical and IT innovations in the hospital such as remote assistance and artificial

intelligence. They state that getting access to patient information from these innovative

trends such as self monitoring applications is essential for them to deliver better care to

their patients, at a lower cost and with shared responsibility.

Senior management also observes a great need for staff development and training in

working with IT. Major hurdles are twofold: “I’m not able to…” and “I do not want to…”.

They note that the hospital staff who understand that IT can be an enabler instead of a

barrier or nuisance are proactively following skill courses and training (on their initiative)

in order to adopt IT into their daily worklife. Terms of action on this matter are however

not yet formulated in the IT policy plan.

Case 2: large university hospital

The hospital of the second case concerns a large university hospital with multiple sites,

located in the Brussels region. About five years ago, this hospital already felt the sense of

urgency of being in need of a high performing EPR and has actively been searching for a

software package that would address the specific needs: high performance and ease of

use. A market study including both national and international EPR providers showed that

the market did not yet provide the solution they were looking for (i.e. the offer on the

national level was limited, and the international providers showed reluctance to customise),

and a decision was made to install a temporary solution that should cover the needs of a


20

ten years timespan, before re-evaluating the market and making the transition to a new

EPR.


With respect to the internal care orchestration, a better IT support of the pre-admission

activities might be needed. Major advances are made on the level of discharge

management. By showing the impact of systematically and correctly indicating the time of

discharge in the IT system, operational results significantly improved. With respect to the

external care orchestration and thus the continuity of care, the Abrumet system in the

Brussels regions clearly helps the exchange of information, though the standardisation of

data should be further improved and move into the direction of more structured data. The

hospital’s current EPR also exhibits a lot of unstructured data, which makes data exchange

more difficult. However, switching to structured data is difficult, and does not only involve

the hospital but also policy makers as many standards still need to decided upon. The

hospital expects that the lack of structured data will shortly also show at the level of

network communication. Also, the absence of structured data currently does not allow for

substantial clinical decision support. The systems that are in place to orchestrate the care

are delivering information upon request (pull), while it might be useful to think about


21

systems that push information without ending with an overload of (not useful) information.

The hospital is furthermore not sure who should be the gatekeeper when dealing with

continuity of care. The most obvious professional here would be the general practitioner.

Quality and risk management is currently focused on tracking and resolving incidents. A

systematic view on the feedback of patients, or medical outcome is yet to be developed.

Next to the IT challenge of producing integrated reports on quality and performance, an

even more important question raises on how outcome and performance should be reported.

With respect to the latter, the hospital points to a multitude of registrations and

opportunities, yet predictive modelling seems to be minimal.

Although the hospital provides an opportunity to request appointments online (which still

need to be confirmed and booked though by staff), the hospital is not yet empowering the

patient to a large extent.

The systems of the departments of the hospital (and those to support clinical research)

substantially differ in the level of digitisation and use of paper. This difference also shows

over the different sites. The management acknowledges that the transition from paper to

IT, or just changes in IT practice, are not always easy to implement and that more attention

should go to change management. In the transition, it is key to show the added value of

the new IT application or system (cf. example on discharge management), though this is

often perceived to be a challenge. The ultimate idea is to have a fully integrated IT system

that connects all currently often fragmented pieces of information in the hospital. The

hospitals points to the subtle but important difference between ‘integrating’ and

‘interfacing’, where interfacing merely points to connecting the bits and pieces, while

integrating is creating added value through the system. For instance, value is created when

medication is automatically added to the invoice of the patient, medication stock levels are

updated, replenishment is triggered and if needed new procurement orders with the

supplier are instantaneously sent out. With respect to some other key applications in the

hospital, mixed results are obtained. Whereas the CPOE is well-developed for the e-

prescription of medication, it needs further attention when assessed in the broader sense

of orders. Tele-health is restricted to remote sessions for medical education. Big data, M-

health and artificial intelligence are not yet the order of the day. The hospital, though,

actively manages its social media.

The IT infrastructure is up-to-date. From a technical point of view, the evolution to having

more data centrally available (e.g. think about PACS and imaging) might push the limits

of the storing and network technology, which actually should allow for easy access

regardless the file size.


22

Case 3: large non-university hospital

The third case concerns a large (general) non-university hospital with multiple sites,

located in the Flanders region. Since the hospital resulted from a merger, it has already

set up projects to align the IT systems and work towards standardisation. In the near

future, following the recent changes towards network formations, the hospital aims to

install a shared EPR system with the hospitals participating in their network. The main

focus of this collaborative project is to further integrate patient information over all systems

both within and across hospitals and units. According to the hospital this is best enabled

through the implementation of the same package. A lack of interconnectedness and

standardisation (unequal technical capabilities) between IT systems, are brought forward

as one of the main reasons why the current legacy EPRs are not fit for purpose.


Overall, as indicated in Figure 4, digitisation and automation seem to be well-embedded in

this organisation. The internal care orchestration is digitally well-supported as the

admission, treatment and discharge of patients are planned through standard procedures


23

from which is only deviated if the patient situation changes or the doctor in charge decides

to deviate from the standard pathway. Planning in terms of pathways helps to think ahead

and have a proactive policy that eases the transition of care.

One of the main deficiencies brought forward is the connection of the hospital IT and

systems with external stakeholders such as patients, elderly care institutions, general

practitioners or other hospitals. There is barely any communication or sharing of

information outside the boundaries of the hospital, mainly due to a lack of standards for

communicating data. After the discharge, there is no further electronic communication with

the patient, neither is the post-treatment health of patients being tracked. Apart from

being connected to hubs and ehealth, there is little to no automated exchange of

information.

Sufficient sources of information and data are currently present to support cure, care and

management. However, decision support systems exploiting this knowledge to support

clinical decision making are limited, except for the checks for interaction of multiple

medication for a patient. The registration of data is almost entirely paperless, though the

data is not always structured, which might impact the extent to which it can be used in

reports and visuals. The hospital actively uses platforms to support clinical research and is

piloting to see how datasets can be shared among institutions. Over the recent years, there

has been an increase of evaluation capturing systems to actively collect data in order to

control and manage the quality level of the hospital. The outcome-based assessment of

treatments, as prescribed to move towards value-based healthcare, is not yet in place.

Risk and performance management are well-established within the hospital organisation

to ensure patient safety and continuity of business. With respect to track and trace, the

hospital does not yet feature a closed loop medication process. All organisational reporting

is integrated and centralised in one online portal. Predictive modelling, both organisational

and clinical, is very limited to non-existent. Overall, many operations have become fully

automated and supported by IT over the years. The ERP covers the chain from procurement

over stock management to pay.

Clinical experts and physicians within the hospital take the initiative to recommend new IT

and systems to the hospital senior management on a proactive basis. Readiness for change

is therefore deemed present. With respect to the back-office, however, a more traditional

image appears and reluctance to change might be a challenge that calls for a well-

considered approach to increase the adoption of novel IT.

In terms of patient engagement, the hospital has not implemented anything beyond the

basic functionalities such as access to the wifi network. The accessibility of information

towards the patient and business partners is open for improvement, but pilots are running.

Towards the patient, e.g., the hospital is finding a way to install an online platform through

which patients can consult their information and communicate with the hospital. Also

customisation is currently under revision, for instance by means of a pilot examining how

patients can be targeted with precise information regarding their treatment by means of

multi-media. The hospital provides ekiosks for self registration on site, but no applications

are currently in place to foster self scheduling, although also on this topic a project is

running.

Although many departments work digitally and paperless, fragmentedness of IT systems

might still be present as they often have different IT systems (dedicated and some even


24

self developed) based on their needs. Different sites might also have different systems,

such as the ICU. When implementing new IT systems, integration into the overall EPR and

hospital information system is set as a paramount criterion. The efforts of the hospital to

build towards a strong EPR result in an enhanced internal data integration. From the

external point of view, integration is directed towards governmental bodies, but can be

significantly improved w.r.t. general practitioners among other. The integration of devices

can be further improved, both internally (e.g. older equipment calls for transferring the

data manually into the IT system) and externally (e.g. integrating apps data of patients -

mobile health or tele-health to be further explored by the hospital but currently no

immediate focus).

The infrastructure is self-managed and considered advanced. Servers & storage are

deemed as state-of-the-art and backup-systems are in place and tested at a regular basis

with black-out exercises.

In sum, the hospital has made significant progress in the automation and digitisation of its

capabilities over the years. Following the strategy of the hospital, efforts will be aimed on

integrating and standardising all distinct applications & systems into a holistic, integrated

EPR, keeping in mind the upcoming transition toward a hospital network. Also, the hospital

aims to boost and empower patient engagement by setting up a “my-hospital” online

platform. Besides communicating and sharing information across the entire ‘care chain’,

enhancing clinical decision support is another key focus area of the hospital.

Case 4: medium-size non-university hospital

The fourth case is about a medium-size (general) non-university hospital operating from a

single site, located in the Flanders region. The hospital was the result from a merger and

a relocation of the facilities to a modern architectural building. Following the upgrade in

facilities, it seems that now the IT systems are generally open for improvement and

therefore will undergo major changes in the near future with the introduction of a new EPR.

While automation of the planning of activities is finding its way into the internal care

orchestration, with a well-developed admission and bed planning tool, it is brought forward

that information of the care process of the patient is still registered on paper moving along

with the patient, which isn’t helpful towards care transition management and internal care

orchestration. The communication of the hospital to external stakeholders remains limited

and unstructured. Since the medical record is connected to a hub, other hospitals can

access upon request information assuming there is a therapeutic relationship with the

patient who also confirmend the informed consent. With respect to nursing information, no

sharing is taking place. It happens that information is provided by exchanging CD-ROM

media or by phone. Communication and information sharing with non-hospital players

occurs via traditional media such as the ehealthbox, e.g. for exchanging secured letters

with the general practicioner. Other stakeholders, like home care agencies or elderly care

institutions apparently are not targeted within the external continuity of care

communication of the hospital.


25

Clinical decision making of medical doctors is currently unsupported by IT, even at the

level of warnings signalling interaction effects of medication. Clinical research is conducted

based on the recorded patient information but is limited or unstructured. The hospital has

no view whether physicians use own or dedicated IT applications to support the clinical

research. Although many data are registered, especially through the effort of the nursing

team, it does not translate to the fullest w.r.t. quality and risk management, where the

main focus is oriented towards managing incidents. This, however, is considered to be

sufficient for the hospital’s current needs.


Performance of the hospital is measured in terms of metrics reporting on bed utilisation,

length of stay, etc. and are aggregated into dashboards reading from the data warehouse

of the hospital. Predictive modelling is currently unpractised at the hospital. While many

operational KPIs seem to be present, it is challenging to drill down reports and insights to

the staff. Reporting is mainly communicated via the intranet portal of the hospital, but

shows potential for improvement. The ERP system that is currently in place causes

dissatisfaction because it is does not integrate with many other IT and software packages,

e.g. those dealing with purchasing originating from the pharmacy, or the maintenance


26

planning of medical equipment. Also the ERP system has not witnessed sufficient updates.

Financial management and invoicing are brought forward to proceed without any

irregularities. The hospital installs automated checks for irregularities in the invoices based

on listed medical activities. Staff and workforce are constantly being educated to manage

and adapt IT change through e-learning modules, multi-media applications and on-site

training. Also, the hospital strictly follows for every IT project a methodology for managing

the transition phase of IT renewal.

The accessibility of the IT systems by the patients is limited as well in so far that they can

only consult their own information through the hub. Customisation of services towards the

patient via IT applications is minimal, though an enriched website should allow patients

shortly to have a better view on the kind and structure of the invoice they can expect,

taking into account their particular treatment. No applications for self scheduling are

available, though it is mentioned that the hospital provides some kioks in which the

patients can assess by themselves some vital parameters.

Mixed results are seen for the IT support of the departments. For the wards, the medication

prescriptions are digital, though the nursing information is stated on paper. The operating

theatre is identified to be among the better IT supported departments, partly thanks to its

automated link with sterilisation services.

The internal data integration is expected to significantly improve with the introduction of

the new EPR. The hospital’s view on integration entails, e.g. for discharge, that the

immediate and automated update on the medication scheme or ambulatory visits is

mentioned in the discharge letter. In line with the findings on the continuity of care,

external data integration is poor. The hospital is following trends on big data, but currently

does not engage in any application. It is mentioned that apart from the technological side,

also staffing is a prerequisite to achieve results in this field, which is currently not matched

with the IT financing. With respect to device integration, the hospital states to be

theoretically ready for staff to bring their own device, or to connect apps, yet in practice

there seems limited to no request for these services.

The CPOE is part of the EPR and is open for improvement as it only targets medication

orders. Track and trace of patients is currently not in place, except for patients who have

the tendency to leave their designated location without permission and who are

consequently RFID-tagged. Also surgicial instrument sets follow a track and trace protocol.

The hospital does not have a fully closed medication loop, but is piloting within this regard.

Mobile health and tele-health initiatives are currently not on the map within the hospital,

except for participating in remote medical training sessions. The IT department, however,

closely follows these trends by attending information sessions as they believe in the future

impact. As mentioned, the hospital provides a portal which can be seen as a static rather

than collaborative tool. IT infrastructure is considered to be adequate and follows good

practice guidelines, including regular audits on safety and resilience, for which

improvement plans are continuously developed.

The main strategic project defined by the hospital is the adoption of the new electronic

patient record, which is expected to improve a number of problems and barriers that the

hospital wants to overcome such as the limited integration of current IT systems, the need

for consolidation of the ERP system, the empowerment of patients and the introduction of

standardardised information that can be communicated to other hospitals and non-hospital


27

players. In essence, the major goals are to not only consolidate and integrate information

throughout the hospital, but also make useful use of the information that is captured to

further improve the care orchestration, both internally and externally. Next to and following

from the EPR renewal, a second aim is to move more toward an engaged and empowered

patient, who might be able to contribute more in the organisation of the healthcare process

and alleviate workload currently performed by hospital staff.


28

From heat map to roadmap

From the introduction and case results, we can conclude that IT is often not aligned with,

or even fails to meet, the business expectations of the hospital. Yet, there is agreement

that IT should not be allowed to hinder the medical profession and the provision of care,

resulting in a set of actions impacting the state and usage of IT. In this context, one can

think of an IT roadmap as a plan to match the goals on business capabilities with

technological solutions, therefore describing the steps to be taken for a successful

transition. Often, a differentiation is made between the short term and the long term to

further pinpoint the actions in an appropriate time frame. However, there might be an

evolution over time in how roadmaps should be perceived and used. In the former days, a

roadmap was often seen as a more rigid plan that would connect the “as is” situation with

a “to be” sitation and would deliver a transition of the IT architecture to be followed in the

next, let’s say 10 years. Nowadays, we see that roadmaps are more and more restricted

in the time horizon they span, up to 3 years. Also, the all-encompassing rigid

transformation path has to move for a set of multiple paths based on scenarios so to allow

for flexibility, agility and resilience (cf. the ExConomy framework) and paths which should

be open to change and new opportunities that perhaps are yet to be discovered. In times

of uncertainty6, and for the hospital sector this easily translates to the many political and

legislative decisions that are still to be made in accordance with uncertain technological

evolutions, this makes sense. Furthermore, even though hospitals will act within a joint

and shared political and economical space, it might not be useful to define a generic, all

fitting, IT roadmap that would help them in making a structured transition to a next stage.

While some focal points might be shared among many hospitals, others will not and call

for different actions.

Without any doubt, the IT application project that is top of mind in the Belgian hospital

scene is centred around the EPR7. Either hospitals are dealing with the selection up to the

implementation of a (re)new(ed) EPR for their own institution, or a bit more advanced,

they start thinking about the selection and implementation of an EPR for the hospital

network in which they are about to participate. The huge focus on the EPR does not come

as a surprise, as this application is identified to be the main ‘connector’ or ‘integrator’ that

bridges many applications and capabilities. To have a better understanding, let’s take a

look at Figure 6. In this figure, we highlight the elements of the Business Architecture and

IT Architecture that will be directly impacted by and benefit from an enhanced EPR

functioning in the hospital. If we start from the Belgian Minimum Use Criteria (BMUC) to

scope the base expectations of an EPR towards the near future, we can retrieve and

position the 15 ‘core criteria’ (such as drug drug interaction, e-prescription medication,

automated communication with hubs and eHealth, discharge letters, etc.) under the gray-

scaled building blocks of the capability map. It clearly shows the integrative power of the

6 Cardoen B., Peeters C., Van Dyck W. and Schoonaert L. 2017. Impact of Uncertainty in Times of

Network Formation. Vlerick Business School, HMC White Paper. This white paper can be retrieved from www.vlerick.com/healthcare

7 For some recent examples of hospitals announcing or reporting on the implementation of a new

EPR, see, e.g., UZA (https://www.uza.be/uza-legt-de-fundamenten-voor-een-virtueel-ziekenhuis), AZ Delta (http://www.actualcare.be/nl/nl-management/nl-management-ict/az-delta-kijkt-uit-naar-geintegreerd-epd/), UZ Gent (http://www.zorganderstv.be/nieuws/uz-gent-bouwt-aan-een-nieuw-

toekomstgericht-elektronisch-pati%C3%ABntendossier)

http://www.vlerick.com/healthcare

https://www.uza.be/uza-legt-de-fundamenten-voor-een-virtueel-ziekenhuis

http://www.actualcare.be/nl/nl-management/nl-management-ict/az-delta-kijkt-uit-naar-geintegreerd-epd/

http://www.actualcare.be/nl/nl-management/nl-management-ict/az-delta-kijkt-uit-naar-geintegreerd-epd/

http://www.zorganderstv.be/nieuws/uz-gent-bouwt-aan-een-nieuw-toekomstgericht-elektronisch-pati%C3%ABntendossier

http://www.zorganderstv.be/nieuws/uz-gent-bouwt-aan-een-nieuw-toekomstgericht-elektronisch-pati%C3%ABntendossier


29

application. When we would also add what is described as the ‘menu items’ (such as OR

planning, clinical decision support systems, M-health, ICU module, localisation of the

patient, etc.) to the capability map, the impact of having a high-performance EPR becomes

ever apparent, which is creating a world of opportunities for the hospital, the patient and

the healthcare eco-system in general. One should be aware, though, that having a well-

developed EPR might not be a guarantee as such for having a flawless system, especially

in light of high customisation. In their recent paper, Davis and Khanse (2016) examine by

means of an in-depth hospital case study involving 30 interviews why the Epic EPR was

suffering from discrepancies between the intended use and workarounds installed by

clinicians and why there was a dichotomy in perspectives between the hospital’s technology

department and the end user in terms of intended functionality and usability (i.e. between

what they think is happening and what is really happening), which makes that technology

and its use needs to be managed.

Figure 6: Visulalising the impact and relationship of the EPR on the EA in light of the EPR’s

BMUC (grey blocks cover core criteria and potentially menu items, white blocks cover menu

items) as defined by the federal government to date.


30

From the interviews (e.g. Ponsaert, 2015) it was already mentioned that hospitals do not

always align and share the same IT development goals (such as the EPR) and therefore

might exhibit substantial differences in their IT projects that are running or will be be

initiated shortly, showing in the IT maturity of the organisation. Maturity models, like

EMRAM, show that in Europe8 (Q4/2016 results, n=1462) only 12% of the hospitals are

situated in stage 3 or 4 (i.e. the middle stages), where one actually would expect the bulk

of the hopsitals. This shows that hospitals are moving forward at different speeds, with

either a high-end or a low-end IT maturity. Again, without having the goal to assess

maturity, be exhaustive nor to generalise, this might be also become apparent from the

case studies and heat maps. Figure 7 summarises the key capabilities of the Business and

IT Architecture as specified in the capability map, and visualises this variation, both within

a particular key capability and between the different key capabilities.

Figure 7: Summary of the key capabilities of the heat maps from the hospital case studies

Even if hospitals are situated within a similar stage with respect to a particular capability,

this does not imply that they also share the same need and intention for further

development of that particular capability. For instance, when focusing on the field of patient

engagement, we notice that all cases feature orange, showing the potential for significant

improvement. From the interviews, though, only two of the hospitals explicitly pointed out

that working on better empowered and engaged patient was a top priority in the upcoming

future, and therefore should be part of their IT roadmap. Let’s again illustrate how the

capability map can be used as a dynamic support tool to visualise the impact of different

choices, for instance when the focus is put to work on and keep track of the well-being of

patient, turning healthcare from a curative view to a more preventive view. Figure 8 brings

a view on the relationships between the capabilities that need to be developed. Imagine

8 HIMSS Analytics Database, see http://www.himss.eu/healthcare-providers/emram



31

the hospital wants to continuously follow-up on a patient who had a successful surgery and

post-surgery treatment, this to be done using an app. The reasoning behind this decision

could be that when irregular, or unexpected patterns would emerge, the necessary actions

can be taken to prevent that this patient would end up in a critical health condition (so e.g.

focusing on the very timely detection of potential deterioration or bad compliance of the

patient). To do this, a lot of data is needed, entering the field of big data and m-health

which needs to be stored and shared, having an impact on the IT infrastructure and data

and device integration. This huge amount of data needs to be transformed into information

and patterns, which connects to artificial intelligence applications that support clinical

decision making. In case of irregularities, a note should be added to the EPR of the patient,

and for instance a message should be pushed to the patient and/or general practitioner to

follow-up. Even better would be the situation where irregularties can be predicted without

having a clear manifestion of them showing in the data. The patient appreciates that the

results and key messages of the continuous monitoring can be consulted and accessed

whenever and wherever he/she is.

Figure 8: Visulalising the impact and relationship of improving the well-being capability on

the EA


32

Conclusion and next steps

With the development of a pragmatic capability map, we hope to support hospitals in the

development of their IT strategy and the according choices to be made to evolve to a future

digital-proof state. The model should help to dynamically assess how capabilities relate to

one another and how aspired changes to one capability might also require effort on

different dimensions.

We acknowledge that the capability map leaves room for interpretation and is not

exhaustive in listing all capabilities. Also, the capability map is not to be confused with an

IT maturity model, nor with a detailed IT roadmap. Next steps for the hospitals therefore

consist of making a detailed and by definition also technically oriented plan of action to

build the prioritised capabilities, including a well-fitted time horizon and project plan, which

all together will constitute the IT roadmap. In this regard, we want to remind the reader

that the era of a rigid roadmap with long term projections seems to be outdated and

replaced by much more agile, flexible and short-term roadmaps, showing readiness to

adapt to rather unexpected evolutions and change.


33

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