Thinking Beyond CPOE to Integrated IT Strategy and Management

Transcription

1 Thinking Beyond CPOE to Integrated IT Strategy and Management ABSTRACT There is a tremendous amount of pressure driving organizations to implement computerized provider order entry. To unlock the greatest value, a more enterprise-wide strategic approach to healthcare IT is needed. Eric Finch and Christine Mayne E veryone knows how much pressure there is to improve patient safety and reduce medical errors. The messages from the Institute of Medicine, 1 the Leapfrog Group, 2 and others make it clear that one way healthcare organizations should approach this is to accelerate the adoption of IT solutions, such as computerized provider order entry, electronic medical records, bar coding, and others. When faced with the alphabet soup of healthcare IT possibilities CPOE, EMR, EPI, LIS, CIS, etc. it is tempting for an organization to pick a much-talked-about solution like CPOE and get down to work. While there are benefits and challenges associated with CPOE, the greatest value comes from thinking about a CPOE project as more than just an IT implementation exercise. CPOE Benefits Before thinking beyond CPOE to integrated IT strategy and management, it is important to understand the benefits and challenges associated with CPOE. It is easy to see why many are pushing for greater adoption of CPOE within healthcare organizations. IT is one of the primary contributors to quality of care and there are certainly benefits that can be gained from a successful CPOE implementation. Studies suggest that more than 50 percent of medical errors could be eliminated from CPOE alone. 3 True CPOE functionality, which goes beyond order entry to include clinical decision support with evidence-based rules, alerts, and treatment guidelines, offers many benefits that contribute to improved quality of care and reduced medical errors. The primary benefits include: KEYWORDS Computerized provider order entry (CPOE) Portfolio management Strategic IT management IT roadmaps Risk impact assessment 24 Journal of Healthcare Information Management Vol. 18, No. 1

2 Reduced drug-drug interactions and allergic reactions Reduced handwriting errors Reduced duplicate orders In addition to these primary benefits, these reductions also help lower costs in the form of: Reduced adverse drug event costs Reduced lawsuit payouts due to medical errors Reduced wasted cost from duplicate orders Time savings is another benefit, although it is often debated. While there may be a little savings from the data entry time, the real benefit is the savings in the cross-departmental and interdepartmental communication time. One example of this is immediately notifying the nurse and the lab when the doctor orders blood work. This enables the blood draw and procedures to begin sooner. Another benefit seen by healthcare organizations is faster physician notification of test results. This improved communication leads to greater efficiencies within healthcare organizations....the cost savings and benefits are heavily dependent on a good set of clinical support rules, which generally must be developed or customized by each healthcare organization. CPOE Challenges Despite these benefits and the impressive promise of reducing medical errors, less than 5 percent of U.S. hospitals have implemented enterprisewide CPOE capabilities. 4 Why? The decision to invest large sums of money in a CPOE implementation is not one that is taken lightly. The full intent of CPOE, in terms of crossdepartmental communication and efficiency, is still in its infancy and this creates certain challenges. Unrealistic expectations and vendor promises do not make life any easier. While the kinks are being worked out, it can be tough to decide if CPOE is on the verge of becoming the next big bang for healthcare IT or is about to fizzle out. One thing known for certain is that implementations like this cost big money. While CPOE holds potential cost savings in the long term, that does not eliminate the challenge of finding the money it takes to implement it now. When an organization does implement CPOE, the cost savings and benefits are heavily dependent on a good set of clinical support rules, which generally must be developed or customized by each healthcare organization. Efforts are under way to change this, but it is the current reality. Once an organization decides how to address these challenges, there is also the question of where to start. The electronic medical record (EMR), which makes patient information available at the point of care, and CPOE, which enables order placement with clinical decision support, are complementary solutions. Both are cash- and resourceintensive implementations. Which comes first? The truth is that there is no silver bullet and certainly no single-point solution that will meet all healthcare IT needs. Overall, the healthcare industry allocates about 2 to 3 percent of its budget on IT, compared with between 5 and 10 percent for industries such as financial services and retail. 5 While one could argue that the potential benefits justify higher IT spending in healthcare, what is more important is spending the money wisely. Despite rocketing IT spending in other industries, many organizations remain dissatisfied with the return on their IT investments. One does not have to look very hard to find stories of IT projects gone awry in healthcare. A mismanaged IT implementation can result in a loss equal to 10 times the implementation cost. As IT becomes increasingly important as a way to gain efficiencies and improve patient care, healthcare organizations cannot afford to neglect IT challenges. IT management challenges often manifest themselves as what appear to be project management problems, including schedule slippage, insufficient ROI, general dissatisfaction, flawed decision making, and dysfunctional inter-organizational behavior. Often, the root cause of these problems is that organizations do not properly manage high-complexity, high-risk investments. It is less of a technology problem and more of a management problem. Unlocking Greater Value By understanding how to integrate IT and business planning, organizations can improve their IT effectiveness. The key is to start managing IT expenditures as strategic investments, not as costs. Best-in-class organizations manage IT investments as a portfolio and focus on fewer, high-value initiatives. A holistic approach to IT strategy and management gives executives a management framework that they can use to improve the performance of their organization. A Strategic IT management (SITM) approach helps organizations harness their information technology capability to achieve strategic and operational advantage. See figure 1, A Strategic IT Management Approach, for an overview that includes: Enterprise Excellence Portfolio Excellence Technology Excellence Solution Excellence Operations Excellence Enterprise Excellence. The good news is there are ways to overcome IT challenges. Just last year, the Institute Journal of Healthcare Information Management Vol. 18, No. 1 25

3 of Medicine noted that despite some laudable examples of integrated care, the delivery system consists of silos. 6 When IT decisions are made in different silos or departments, it severely impacts the ability to access a single view of patient information across the organization and exchange information between departments. Yes, one can build interfaces and most organizations do, but interfaces alone are not enough to create an enterprise-wide solution. There are several reasons why the decision to purchase a laboratory information system (LIS) should not be a lab-only decision. The decision should be made after broader consideration involving IT and the CxOs (chief executive officer, chief financial officer, chief information officer, chief medical officer, etc). A broader decision means looking at the other systems in use or being considered for future use. While it is difficult to find one complete healthcare IT solution to meet all the needs of an organization, there is the option to purchase best-of-suite solutions that reduce the interface work and get some departments exchanging information and coordinating care delivery more efficiently. This is not to say that best-of-suite solutions are the right answer, but it is 26 Journal of Healthcare Information Management Vol. 18, No. 1

4 helpful to know what other vendors are being used and think through the tradeoffs of one option over another. Involving IT in the decision-making process is a given, but the point to note here is that CPOE or other healthcare IT options should not be treated just as IT initiatives. Organizations need to focus on deploying healthcare solutions, not just applications or IT projects. Granted there is an IT component and IT direction is needed, but it is broader than that. An effective way to get this broader perspective is to align IT initiatives and spending with CxO strategy. But what does that mean in practice? Portfolio Excellence. First, it means managing IT projects differently than how they are typically treated today. Rather than treating IT as a cost center that supports the requests from various departments, it should be managed as a strategic investment. This means the CIO should work with the other executives to translate the organization s strategies into a supporting mix of IT projects. The CxOs should function as an IT Portfolio Management Team making tradeoff decisions in terms of funding, resources, risk, and return across the portfolio of IT projects. A key element of this is periodic reviews and monitoring the performance of the entire portfolio, at both an aggregate level and for each major project. Best-in-class organizations manage IT investments as a portfolio and focus on fewer, high-value initiatives. See figure 2, Portfolio Management Intent versus Realities, for some examples of things to watch out for with portfolio management. The executive level is the right governance level to balance business priorities and allocate resources and funding to the most strategic initiatives. Managing a portfolio of IT projects also implies thinking about CPOE in the context of the EMR, and other healthcare IT options. This enables the organization to think cohesively about solutions and still choose to implement them a piece at a time. Technology Excellence. Along with setting up the executive-level Portfolio Management Team to integrate IT planning with business strategy, supporting tools are also needed to drive technology excellence. These include metrics, an IT roadmap, and a risk impact assessment. Metrics. As with any good process, metrics are important as a way to look at the aggregate progress and results. Metrics provide a quantitative, objective measure of process performance, which helps to identify areas requiring immediate intervention where the process is not functioning as expected. Tracking too many metrics can make it difficult to know What workflows and behaviors should change as part of the solution? What can the organization gain by thinking beyond the departmental walls? how and when to respond. Simply tracking a dashboard of metrics, such as schedule slippage, resource variance, and scope creep, can identify problems earlier when adjustments can be made. In order to do this, a consistent set of metrics must be defined and collected at the project level so it can be rolled up in the aggregate. Monitoring the performance of the portfolio is important, not just to keep things on track, but also to drive continuous improvement. Metrics enable the organization to continually raise the bar as increasing levels of performance are achieved, so they are an important tool for the Portfolio Management Team. IT Roadmap. An IT roadmap is usually proposed by the IT organization to the Portfolio Management Team. An IT roadmap is a prioritized implementation plan designed to lead an organization to maximum returns on IT investments. It clarifies where the organization is going with respect to automation priorities and how to get there in the most efficient manner. Key questions answered by an IT roadmap include: What are the organization s technical operations risks? Is there the proper focus on scalability and critical outage issues? What are the high-level business and clinical process requirements that must be supported over the next two to four years? What are the competitive differetiators, core competencies, and business operations risks? What does the current applications blueprint look like? What do the systems, processes, key data objects, and interactions look like? What should the future applications blueprint look like? What processes, key data objects, and interactions are needed? How does the organization get from the current to the future blueprint? What are the candidate package applications that meet business and clinical needs? What portions of the blueprint should the organization address and when? An IT roadmap is a tool to help balance technical needs with business and clinical needs. It establishes the vision to support the business objectives and shows how to get there. Risk Impact Assessment. Once an organization knows where it is going with respect to IT, next come the processes to help it get there. One of the traditional IT challenges is the interconnections and dependencies from one IT solution to another. This challenge is particularly tough in a fragment- Journal of Healthcare Information Management Vol. 18, No. 1 27

5 ed IT area such as healthcare. Getting different systems to talk to each other and share data is a full-time job. A risk impact assessment is a tool the IT organization can use to understand these interconnections and manage interface planning. It concentrates on the critical features/functions and the interaction of those functions between the systems. Leveraging risk impact assessment requires the business and IT to use a structured and coordinated approach, which includes: Organizing the system layers in a framework that is flexible and scalable Organizing business functional layers in a framework that is aligned with a company s operations Connecting the systems and business frameworks in a manner that can be understood by both groups Ensuring that both business and IT have confidence in the completeness and accuracy of the data and commit to using the impact assessment techniques Defining a standard approach for the risk valuation of each systems-related component Creating the tools and techniques whereby the business and IT can quickly and easily leverage these concepts and apply them to real-world projects Determining the mechanisms required to ensure the underlying data is kept up-to-date and the processes can be enhanced over time. The implementation of risk impact assessment can provide immediate, tangible benefits to the business and IT. The evaluation of concepts early on for potential systems...healthcare IT can feel like a knee-jerk response to the hot topic of the moment and the pressures to keep up. risk provides business owners with valuable information to guide their interaction with specific IT resources. The visibility of systems risk can guide business owners in the elimination, grouping, or prioritization of features/functions. The control of the communication to business of the types of risk associated with changes to production systems elements can be achieved through IT s management of risk profiles. Solution Excellence. A good portfolio management process that aligns IT initiatives with executivelevel strategy helps ensure the organization is focusing its resources in the right areas. The next step is managing projects on time and within budget. Best-inclass organizations use cross-functional teams to manage projects. This is particularly important in a fragmented and departmentalized industry such as healthcare. The typical team structure is a Core Team composed of a lead representative from each key functional area. These team members drive the project and coordinate the effort of additional resources from their respective areas that make up the Extended Team. Knowing the horror story of the organization that implemented a CPOE solution and then turned it off within a matter of days, the suggestion to include physician representation on the project Core Team should come as no surprise. It is important to have the internal users of the system involved right from the beginning to help define requirements for the system. Deploying healthcare solutions means thinking beyond system implementation and integration to thinking about business and clinical practices. To do 28 Journal of Healthcare Information Management Vol. 18, No. 1

6 this effectively, the team needs representation from the business and clinical areas. Automating the status quo is overlooking a huge potential value from the project. What workflows and behaviors should change as part of the solution? What can the organization gain by thinking beyond the departmental walls? This is where non-it resources can help. They help move from Technology Excellence to ensuring that organizations deliver IT solutions that meet the business and clinical needs. Clearly this is easier said than done. Clinicians are busy with their primary jobs so there is a need to show them the value of participating. Part of this comes from framing the project as a healthcare solution, not just an IT project, and part comes from the visibility and alignment with the enterprise-wide strategy. Beyond workflow considerations and clinical needs, clinicians can serve as lead users in later phases of the project to review proposed applications and test early installations while there is still time to adjust. Operations Excellence. Even once the system is implemented, there needs to be an ongoing process for maintaining Operations Excellence. Operations Excellence includes: Optimizing operating cost (unit cost, service level, volume) Managing service delivery (internal market economy and policies) Sub-processes Define>Measure> Analyze>Improve>Control (DMAIC) It also includes a focus on the human aspect of change management associated with the system and helping the organization to work with the new practices. Once installed, it s important to assess the benefits gained and make adjustments if the users are not using the system as anticipated. This leads to increased customer satisfaction by collecting feedback and adjusting the system based on its use once implemented. Conclusion With a wide variety of IT packages and vendors, the implementation choices for a healthcare organization can be overwhelming. At times, healthcare IT can feel like a knee-jerk response to the hot topic of the moment and the pressures to keep up. While the decision to invest large sums of money in CPOE or other healthcare IT solutions is not taken lightly, they are all too often made one solution at a time. Certainly there are benefits that can be realized from such a decision, but to unlock greater value a more strategic approach to healthcare IT is needed. See figure 3, Benefits of SITM, for a summary. Value is left on the table when organizations make system selection decisions within a silo or make IT decisions that are not part of a broader clinical strategy. To realize the greatest benefits from CPOE or any other healthcare IT solution, the decision to invest should be made as part of a broader enterprise-wide strategy. Strategic IT management can yield substantial results: 15%-30% improved payback and ROI 10%-30% reduction in operating expenses 60%-80% increase in IT project success rate 50%-80% improvement in critical system availability For cash-strapped healthcare organizations, the potential returns on IT investments are too important not to fully realize. About the Authors Eric Finch is a partner at Pittiglio Rabin Todd & McGrath (PRTM), a management consultancy to technology-based companies. At PRTM, he specializes in helping clients successfully complete IT projects on time and within budget. Christine Mayne is a manager at PRTM and a member of HIMSS. Prior to joining PRTM, Christine was a Core Team member at Cerner Corp., contributing to the design, development, and initial release of its HNA Millennium software. References 1. Institute of Medicine, Crossing the Quality Chasm: A New Health System for the 21st Century, March Goff, V. Advancing Patient Safety: The Leapfrog Group, December See reference Briggs, B. CPOE: Order from Chaos, Health Data Magazine, February Gravitz, D. Health Care and the Net, Red Herring, October Institute of Medicine, Fostering Rapid Advances in Health Care: Learning from System Demonstrations, Journal of Healthcare Information Management Vol. 18, No. 1 29