a risk assessment model of interoperable electronic health records solutions panel: the challenges...

A Risk Assessment Model of Interoperable Electronic Health Records Solutions

Panel:

The Challenges of Interoperability in e-Health

Claude Sicotte

Département d’administration de la santé

Faculté de médecine

Université de Montréal

Feuille de route

Presentation of the Risk Assessment Model

Brief survey of the two cases under study

Analysis of the major risks involved in both EHR interoperable implementations

The Lessons

Questions & Comments

Risk Management Framework

IT Implementation

Stages

ProjectManagementObjectives &Expectations

Risk Exposure

Management Strategies

FitProject

Success

© Claude Sicotte, Université de Montréal

Risk Assessment Model

Technologic

Organizational

Managerial

Human

Strategic


Five types of risk

Technological Risk: Hardware & Software Complexity & Network interoperability complexity

Human Risk: Resistance to change & Users’ unrealistic expectations

Usability Risk: Potential of use in real workplace context

Managerial Risk: Quality of Project Team, Resources availibility & Unrealistic project schedule

Strategic/Political Risk: Misalignment of groups of professionals and organizations’ objectives and stakes


Brief survey of the two EHR implementations cases

The vision: A clinical data sharing network system

The goal: To enhance access, quality and coordination of healthcare

The objectives: To increase the speed of transmission and the exchange of clinical data & To reduce intervention delays

The technology: A Network Electronic Health Record (EHR) - Data Warehouse


The Technology: An interoperable EHR

Shared Electronic Health Record (EHR) Common Patient Index - Unique network identifier Shared Medical Thesaurus Common Patient Inscription Module Common Patient Consent Management Module Clinical Data: Labs Results, Medical Imaging Reports No physicians’ electronic ordering; only data display

Network Infrastructure: Proprietary High-band secure intranet - Previously deployed

Technical Interfaces: Legacy Systems - EHR Data Warehouse


Brief survey of the first case,the less successful one

Users: 39 Pediatricians - 1 Pediatric Teaching Hospital, 2 Regional Community Hospitals, 4 Medical Clinics

Data Providers: 3 Public Hospitals

Project Length: Three years and 4 months (2000 - 2004)

Length of IT use assessment: First 7 months (2004)

Total Project Budget: 11 million $ (Cdn)

The partners: Pediatric Teaching Hospital (Maître d’oeuvre) - 2 Regional Community Hospitals - 4 Pediatric Clinics - IBM - Several firms of Legacy systems - Technocentres Régional & National, GTQ - Sogique & IBM - Bell Canada, Vidéotron.


Brief survey of the second case, the more successful one

Users: 105 General Practitioners - 10 Medical Clinics

Data Providers: Public Hospital & Private Labs Setting

Project Length: Two years and 2 months (2001 - 2003)

Length of IT use assessment: First 10 months (2003)

Total Project Budget: 14.8 million $ (Cdn)

The partners:

Laval Planning Regional Agency (Maître d’oeuvre) - Omni-Med - AMOL - 10 Medical Clinics - Hôpital Cité de la santé & Labo MDS - MédiSolution, Nexxlink, Artefact, Lanier - Technocentres Régional & National, GTQ - Sogique & IBM - Bell Canada, Vidéotron.


Level of implementation success(Source: Electronic Log History Journals)

Case # 2 (2003) Feb April June Sept Nov

% MDs-Users

/week28% 55% 53% 64% 69%

Mean Nb of access/week

6 3,2 2,7 5,2 4,7

Mean session length (mnt)

134 116 124 116 139


Case # 1 Teaching Hosp Hosp A Hosp B Clinics

Use Boycott, Anemic use

1 MD None Administr. Personal

Differences between the initial and the final levels of Risk

Technolo-gical Human Usability Managerial

Strategic & political

Very High

HighCase #1

Moderate Case #2

Weak

Very Weak


Risk

Level

Dimensions

Initial risk Level

Technological Risk Assessment

Risk

Factors

Newness of network software and infrastructure

Interoperability - Infrastructure: Use of incompatible

hardware

Interoperability - Infostructure: Lack of common data standard for the transfer of clinical data (HL7)

Risk

Management

Enlistment of outside IT experts (EHR firm)

Data Warehouse solution

Development of home-made technical interfaces/

Several Vendors

Management of Users’ expectations


Technological Risk Assessment

Outcomes

Case 1:

Underestimation of the time needed to develop

the technical interfaces

12-month delay

Missed deadline

Decline of users’ confidence

Case 2:

More realistic schedule - Better management of users’ expectations

Users’ commitment to the project remained unaffected


Human Risk Assessment

Risk

Factors

Physicians’ voluntary participation: less risk

Initial expectations and attitudes were positive

No resistance to change

Physicians were realistic about the large efforts needed to learn to use the EHR

Risk

Management

Case 1: Weak efforts to build relations with users

Case 2: Impressive and continuous implementation efforts to build strong relations with the physicians; Project champions; Experimental use of the system interface; …

True users’ influence on the implementation process


Human Risk Assessment

Outcomes

Case 1: An increase of the human risk because of:

(a) weak efforts in users’ relation building before the go live

(b) the delays to develop the technical interfaces

Case 2:

A decrease of the human risk despite serious technological problems (System response time)

The physicians became increasingly confident in the success of the new system


Usability Risk Assessment

Risk

Factors

Low awareness in this matter

Taken for granted Physicians’ perceived uselfulness

Only system’s user friendliness = a significant risk

Information usability = EHR Information Content

Work usability = alignment between EHR use and work routines

Risk

Management

Data Warehouse: Volume and data quality

Case 1: Weak recruitment of patients (- -)

Case 2: High responsiveness the Users’ needs (++) & Better recruitment of patients


Usability Risk Assessment

Outcomes

Case 1: An increase of the usability risk because of (a) late efforts in patient recruitment (Information Usability)(a) no effort to align the EHR use with work routines

(Work Usability)

Case 2: A decrease of the usability risk due to a high perceived EHR usefulness (High Information Usability) - Despite an initial poor EHR system response time, physicians continued to participate because they saw that no efforts were being spared to find solutions to their problems

- Despite a lower than expected work usability


Managerial Risk Assessment

Risk

Factors

Quality of the project management team (Skills & Knowledge

Team size, variety and time constraints

Availibility of resources

Risk

Management

Case 1: Smaller team, possessed less expertise both in IT and project management; far less time to devote to the management of the project

Case 2: More intensive managerial efforts & more responsive to Users’ needs and Project Risk


Managerial Risk Assessment

Outcomes

Case 1:

Because of its smaller size, team’s efforts were overload by technological problems at the expense of other important risks, namely the human and usability risks

Case 2:

Larger scope of problems’ awareness and capabilities to intervene

Strategic Risk Assessment

Risk

Factors

Network’s diverse composition rather than network size

Larger misalignment of partners’ objectives and stakes in Case #1 (Teaching academic center/Medical Clinics; Children/adult patients)

Risk

Management

Rather small number of organizations

One type of users = Physicians

Case #2: Higher Network Homogeneity (composed solely of GPs + One Health Region) and early network building efforts


Strategic Risk Assessment

Outcomes

Case 1:

Interorganizational conflicts were not really a problem

Gradual disinterestedness was more of a problem

Case 2:

Continuous increase of confidence between the diverse partners including the regional association of physicians, the EHR firm and the team project team

The main lessons

Six key factors of success:

1. The vision

2. The Network strategy

3. Flexible Execution

4. Design of a hybrid electronic - paper system

5. Clinical processes engineering both at network and individual levels

6. Quality of the project management team© Claude Sicotte, Université de Montréal

Key success FactorsLesson # 1: The vision

There is a need to widen the project vision

to give more space to the Clinical dimension to offset the unavoidable weigth given to the technologic dimension

A Two-way vision is necessary to create a synergy between the technology and the clinic

Key elements: Responses to users’ needs & Management of users’ expectations


Key success FactorsLesson # 2: The Network

strategy

There is a need to conceive what is the meaning of “Interorganizational Partnership“ beyond a Telecommunication networkThere is a need to simultaneously further a Collective/Network logic and Local logics at diverse levels: clienteles, programs, groups of healthcare professionals and organizationsWhat are the incentives?


Key success FactorsLesson # 3: Flexible Execution

There is a need to continuously change the initial plan to solve emerging problems and capture opportunitiesIt seems to be an especially difficult thing to accomplish especially after the go liveFlexible execution is necessary both at the operational and strategic levels


Key success FactorsLesson # 4: Hybrid System

A frequent mistake: To conceive the project on the sole functionalities offered by the electronic solutionIt is rarely possible to completely eliminate the old paper system. It is thus important to build a hybrid system corresponding to the true users’ needs


Key success FactorsLesson # 5: Clinical

Engineering

A reconfiguration of clinical work processes remains unavoidable.

It needs to be done in such a way to offer benefits to the users

It is the Achilles’ heel in many projects


Key success FactorsLesson # 6: Quality of the Team

There is a need to widen the composition, the size and the action scope of the project management teamThree key human resources:

The IT SpecialistThe Clinical ChampionThe Change Manager


Comments

&Questions

[email protected]

a risk assessment model of interoperable electronic health records solutions panel: the challenges...

Documents

montral slide

risk management framework

stakes claude sicotte

medical clinics data

interoperable ehr

exchange of clinical

mdecine universit

ehr implementations