Hospital Information Systems Integration Leadership ...

Connecting Medical Informatics and Bio-Informatics R. Engelbrecht et al. (Eds.) ENMI, 2005

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Hospital Information Systems Integration Leadership Strategy for a Portuguese Central and University Hospital Luís Velez Lapão, Luís Valadares Tavares, Manuel João Pereira Instituto Superior Técnico-Civil Engineering Department and INA-Civil Service College, Portugal

Abstract The Hospital de Santa Maria is a central and University Hospital with a full capacity of 1110 beds and with 4700 staff has been adopting a Leadership Strategy to transform the HIS. The methodology followed a Roadmap framework based on Project Management paradigm, which allows linking the HSM’s strategy with HIS’s strategy. The HSM’s added value is clearly shown by the appropriated budget allocation to build a HIS which helps healthcare professionals to serve the citizens better. It has been observed a clear advantage in parallel project tasks development in reducing time delay dependence from different tasks. The roadmap paradigm was addressed for linking short to medium term strategy. The selection process included the development of (parallel) pilots. This approach was determinant to disseminate HL7 standard in Portugal among technology suppliers. It was also given special attention to the users and to the decision-making processes by the setting up several workshops with most of the stakeholders. Keywords Hospital Information Systems Portfolio, Leadership Strategy, and Information Systems Strategy Roadmap

1. Introduction The debate over the introduction of Information Systems in healthcare in Portugal at the beginning of the XXI century follows the growing concern that the costs of healthcare are increasing too fast and have already surpassed the acceptable level to society. The pressure for government budget contention from EU is the strongest factor. It all began in the 1990s with major shifts happening from administrative hospital information systems (HIS) to systems that started to be used by physicians, nurses, and other healthcare providers as part of the delivering process [1]. But there are also medical reasons to look for the development of an integrated HIS. Western countries, more sensitive to this issue, are witnessing a movement towards the integration of information systems in Hospitals (or preferably integrating the entire healthcare network). In the United States this has been mainly driven by HIPAA, an information privacy and security standard promoted by the US Government, although management reasons are the most relevant due to the opportunity to reduce costs out of inefficiencies [2]. Even in well-advanced countries like The Netherlands [3], and the U.K. [4], there was a perceived lack in actual integration of information systems working as the best practice examples to be followed. There were two fundamental objectives to tackle HSM information system. First, only recently the Management Boards became aware of the Hospital management ineffectiveness because they did not have the opportunity to look for proper indicators before. The motivation for investing in these systems is now clearly economic and strategic. Physicians and nurses have been encouraged to help the hospital to manage the allocation of Section 11: Online Health Information & Patient Empowerment


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resources by a proper cost-benefit analysis of problems. Second, it is also important to acknowledge that Hospital information systems (HIS) are still quite a complex structure [5] that comprehends vast information technologies, several application systems and information management. The purposes of the HIS became clear as being the support of hospital services goals. Hospital de Santa Maria (HSM) is a central and University Hospital built in 1954 in the modern part of Lisbon, nowadays it has a full capacity of 1110 beds and 4700 staff (1100 doctors, 1600 nurses and approximately 2000 other staff) processing approximately 2500 patients every day [6]. As a central hospital it offers all the clinical services required, meaning 52 medical units, several laboratories, complementary means of diagnosis and all the support departments (from logistics to cafeteria). Most of these units and departments have developed (or acquired) a specific information system solution adapted to their own needs in the last 20 years, therefore one might find anachronic systems side by side the most modern and sophisticated ones [7]. Thus, the HSM IS was a set of separated islands developed at request but without a strategy or any Information System policy that would have driven and oriented the process. It was established a partnership between HSM, Instituto Superior Técnico (Lisbon Institute of Technology) and INA with support from technology suppliers to address the applications heterogeneity problem that would drive the building of a HIS and promote the change and the improvement in HSM’s management.

2. Materials and Methods: A Strategic Roadmap for HSM’s HIS Strategy The methodology developed by the team IST/INA aimed at two objectives: A detailed analysis of the initial HSM situation and the definition of a HIS strategy roadmap, representing an organizational change that should put the citizen and their needs in the centre of the process as well the conditions of healthcare professionals (following the defined business strategy)[8]. The process started with the HSM’s mission and objectives definition, both as short and medium term goals. Hence, the board defined that “The HSM’s mission is to provide quality care to all citizens served by the Hospital region at optimised costs“[9]. Secondly, it is necessary to complete a full-scale characterisation of the HSM’s information systems that helps to understand the dimension of the task required to reach the goal. Thirdly, regarding the objectives defined for the implementation it is required to address the HIS’s strategic alternatives for the integration of the information system considering the HSM’s specifics. The alternatives were: a) Implement a holistic Solution; b) Adopt a phased implementation after proper prioritisation; c) Focused only on the most urgent systems; d) Develop internally a system solution that covers all sub-systems requirements; A very important aspect concerns the solution provider involvement in the process and the leadership throughout the whole process. The provider should be regarded as a partner, meaning that the provider should be involved in the process right from the beginning and be co-responsible for the outputs. Mostly because the HIS implementation is part of a crusade to promote the utilisation of the HL7 protocol as the standard to be used. To overcome the problems imposed by the existing HIS parts, the Board decided that the HIS strategic plan has to be defined to fit the mission statement. All the relevant stakeholders must be involved. Therefore a stakeholder-oriented approach was preferred to cope with the complexity of the problem. Considering the Hospital Board objectives, three task forces teams were defined to address those objectives: Clinical information system; Management information system; and Networking and Data warehouse. To manage each of these groups was defined a co-ordinator. Each workgroup defined the policies within their area of responsibility, prioritised projects and allocated budgets. To address the strategic planning that would support the HIS it has been followed an adaptation of the Winter at al. [8] methodology that comprise “the hospital strategic goals assessment”, “the identification of the current state of the HIS” and “an analysis on how far the current information system fits the goals”. The methodology for a strategic HIS plan encompasses the following five steps: a)- Strategic goals of Hospital Santa Maria [10]; b)- Description of the HSM IS current state. c)- Analysis and assessment of the current state of the HIS [7]; d)- Description of the planned state of the HIS; e)- Roadmap definition: Path from the current to the planned state: This plan assigned resources and concrete deadlines (although flexible) for partial results, as well as assigning priorities to individual tasks and the dependencies between tasks. Representatives of the different stakeholders were involved in the definition of the future state process. The McFarlan [11] Matrix was used. Section 11: Online Health Information & Patient Empowerment


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3. System Selection and Implementation Leadership Strategy The IS integration is a very difficult task due to the complexity and the number of different actors involved. An integration process can be technically accomplished through two different ways [12] by means of a direct link or by means of message exchange. Since the HIS is composed by five different suppliers forming a “best-of-breed” framework it was advisable to opt for the second one. The freedom to exchange some of the applications in the future was among the criteria considered. A good communication infrastructure is essential so that it ensures in all cases messages to be correctly delivered to the addressees in the proper sequence and that standard message protocols are used. There are several advantages in adopting a phased implementation strategy [13]. Moreover phasing the implementation would allow for a better financial resources management, as time delay would diminish considerably the financial risk. Phasing is also the best way to address learning, because one can learn with early projects and adopt new measures in the following ones thus augmenting the probability of fitting with the users’ requirements and therefore diminishing the risk of failure. The development of subsystems or changes in existing systems was carefully planned within a finite period of time but allowing some flexibility due to financial restrictions. Decisions on budget and personnel allocations must be made, and priorities in relation to other, competing projects must be set. One must also understand the introduction of IS imposes changes on an organisation process. Organisations usually follow several stages in their growth toward a situation in which information systems are fully integrated. Nolan [14] growth model was used to address maturity HSM IS understanding. Galliers at al [15] observed that most organisations pass maturity stages one by one, and that the transformation into the formalisation and maturity stages especially requires explicit leadership by the Board. This is precisely what is happening in the HSM. At HSM, the next Nolan stage implied the rethinking and redesign of the whole organisational structure. The selection process was to be developed through a set of test prototypes that would reduce both risks and the strategic gap [9]. To support the selection decision-making process an operational methodology was used. Like SMARTER [16] or the TRIDENT [17] both allow for a balanced approach. In the TRIDENT Methodology the problem is addressed with a five-phase process balanced by three parameters (quality, cost and implementation):1 – Needs Assessment and Planning [7]; 2 – Gathering Information [7]; 3 – Vendor Demonstrations; 4 – Negotiation; 5 – Pilot Projects implementation. The process analysis considered the technology supplier’s that responded to the call. Two pilot projects were selected and their implementation started within weeks. The evolution from the non-integrated “best of breed” system to an integrated HIS should follow three phases: 1 – Starting with the definition of an “integrator engine”, 2 – The definition of the data model and the “Data Warehouse” system adjusted to the HSM needs, 3 – The definition of management system and the electronic patient record system to follow the production process. When defining the HIS one must also consider its time evolution. Whatever the Information System considered it will need, sooner or later, an up-grade or maintenance. Recent trends enhance the importance of processes, workflow management and web-based applications as best pratice [12]. With these conditions satisfied, HSM could then proceed towards the HIS. The initial analysis and diagnosis of the HSM IS concluded that: 1-The IS is a very complex system, with several different sub-systems and different actors; 2-Most application were not linked and coherently integrated together. There were in fact only few point-to-point connections between applications from the same supplier; 3-Enormous difficulty accessing timely precise information; 4-Some problems regarding specific applications due to lack of knowledge and a troubled dependency from technology suppliers; 5-Difficulties in correctly training the healthcare professionals; Theses conclusions and department objectives were considered at a workshop that defined the roadmap.

4. First Project Results: The Roadmap and Integration For a flexible development of a strategic planning for the HSM information System a “Roadmap” was defined [7], based on the HSM strategy and with the aim of modernising IS infrastructure consisting by the following macro-processes: 1-HSM Network Development and up-grade, 2- Clinical applications, 3- Data base structure and data warehouse, and 5- Management Information System.

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HSM ’s HISM RO ADM AP ST RAT EG Y

PR O C ESS ES

PL ANNING

IM PL EM ENT AT IO N

O PT IM IZ AT IO N

HSM Strategy Definition HSM M ission

Netw orking Infra-structure

Balanced Scorecard

Up-gra de

Plannig

Im plem e ntation (Phase I)

Im plem enta tio n (P hase II)

Integrator Analysis

(softw are engine) “interfaces” developm ent

Procurem e nt.

Neg otia tio n

Negotiation

Pilot La unch

Im plem entation

Im plem e ntation

New Applications Proc urem e nt

Electron ic Patient Record

Analysis

Pilot N egociation

Pilot Im plem e ntation

Análysis/Decision

M IS availability

M anegem ent Inform ation System (M IS)

Analysis

KPI

Procurem ent

Pilot Im plem e nta tio n

Definition

System E valuatio n

Im plem entation (P has e II)

Evaluaton

The Roadmap describes the planned evolution of HIS. Following a “top-down” strategy, the Roadmap allows for the development of an IS strategy in the context of the hospital business plan. The phasing of the implementation was also included in the “Roadmap”. The function of a HIS is to support hospital activities on operational, tactical, and strategic levels. The HIS have four fundamental aims: a more efficient use of the restricted resources available for patient care, a qualitative service improvement to the patient, a support of research and teaching (the last two apply mainly in university hospitals). A HIS should contain the following systems: An infra-structure for the storage of data (i.e., a database), Facilities to enter data into the database and to retrieve or edit the data (i.e., applications), Communication infra-structures, and Facilities that enable the user to use the system (i.e., terminals). A distinction was made in the roadmap between functions that are specific for some clinical department and functions that support processes in more than one department. The following are the main functions that were defined for the HIS: Support of day-to-day activities (CRP), Support of the planning and organisation of these day-to-day activities (HIS), Support of the control and correction of planned activities and their costs, in view of agreements on medical and financial policies (this is usually called management control), and Support of clinical research through use of the HIS database, which is particularly important for university hospitals. McFarlan [11] Matrix was used to analyse the HSM’s applications Portfolio, see next page: Contribution for future objectives of the organization

+

Strategic (Intangible)

Future (Future Benefits)

EIS: Balanced Scorecard (in project)

Electronic Patient System (in project) CRM (in project)

Nuclear (Production: Cost/Benefit) Pharmacy pital management (outpatient c Emergency, inpatient)

Support (Efficiency) Intranet/email RHV ERP Finance Logistics Billing/GDH Material management

PACS/PICIS

-

Laboratories

Level of Today’s organisation dependency +

Applying the McFarlan matrix to HSM applications’ portfolio shows a well-balanced portfolio. Hence, the integration of applications might go forward. HSM had all the conditions to develop the HIS that would help to focus on strategy. The first accomplishment was the wide availability of Intranet and email services that resulted in a reduction of paper consumption and the increasing of internal communications respectively. The major positive results so far are the following: Section 11: Online Health Information & Patient Empowerment


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• • •

Definition of a security policy; Definition of a set of policy rules for the friendly use of communications resources; Financial ERP Enhancement with the integration of Finance and Procurement; ‐ The Procurement and the Finance department used different applications; one was actually already of an obsolete architecture. The option was to install the stocks module from the Financial application supplier which allowed the integration of both systems. This supplier is now working on the development of a HL7 interface. • Cost reduction estimate for the distribution of an information diary (“e-BI”) via intranet; ‐ The implementation of “e-BI” allowed for the daily reduction of approximately 200,00 € in paper costs and reduction in personnel (~5) that stopped doing the daily distribution with an additional advantage of reducing the space to store all the issues. • The generalised use of the email, as it was limited to the top managers. The decision to extent its use has already allowed for further reduction in distribuiting mail costs. The Emergency Lab application has already been installed to manage the production of laboratory tests, allowing for both the request and the result to be available in every emergency department PC. This implementation permitted the laboratory tests process automation, meaning the elimination of paper flow, important waiting-time reduction (from 2 hours to 15 min.) and 50% increase in

billing. 5. Conclusion The idea is to give to physicians an information system that adds value, so he/she can become somewhat positively dependent on the use of the system. With valid data the Board might gain as far as possible a clear perspective over the physician’s behaviour as he/she writes orders to allocate resources. This sort of resources-use control is desirable as it allows a highly autonomous group of professionals to allocate resources according to a specific best practice available with the system. Although one must recognise that this is a dramatic change in the relationship between administrators and health professionals that need proper leadership. The option for the “integrator” had in mind the efficiency and clinical gains in the communications between applications, i.e. the benefits for patient service itself. The future implementation of an electronic patient record system also needs the support of the integrator, in order to combine all the data that is needed to sustain the increasing demand for quality, alert and clinical knowledge systems and, if possible, clinical decision-support systems. It is usually unsuccessful to implement an electronic clinical system without guarantying integration beforehand. The methodology followed a Roadmap framework, which allowed associating both HSM and HIS strategy. The added value to HSM is clearly shown by the appropriated budget allocation for the investment needed to build a HIS that will help healthcare professionals to serve the citizens better. There was also a clear advantage in parallel process development because each task force could either develop them individually without depending on the others or address difficulties independently. The roadmap had the objective of mapping the short-medium term strategy into actions. It was also given special attention to the users and to the decision making processes by the setting up of a workshop, which was based on the definition of management indicators that would cope with the HSM strategy. At the present moment HSM has almost all core and support applications. If all these applications were working properly they would be guarantying the efficiency of the Hospital’s productive process. Regarding the future HSM’s strategy, The IST/INA-Civil Service College have been working with HSM to complete the Roadmap: The MIS is under development to help support decision making to reduce resources waste and to position the HSM as an influential and differentiated University Hospital that offers better healthcare services to the citizen.



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6. Acknowledgement The authors would like to thank the Board of HSM and CIO Carlos Ferreira, for the openness and contributions for this work and also to Carla Nunes MD for the fruitful discussions on the subject.

7. References [1] Healthcare in Portugal: A Strategy for a new Century 1998-2002. Ministry of Health (in Portuguese), 1999. [2] Glaser, John P., The Strategic Application of IT in the Healthcare Organizations, Jossey Bass 2002; [3] Hasselbring W, Peterson R, Smits M, Spanjers R, Strate; Strategic Information Management for a Dutch University Hospital. Stud Health Technol Inform. 2000; 77:885-9. [4] Martin McKee and Judith Healy, Hospitals in a Changing Europe. Open University Press 2002. [5] Winter, A.F. et al; Strategic Information Management Plans: the basis for systematic information management in hospitals; International Journal of Medical Informatics 64 (2001) 99-109. [6] Hospital de Santa Maria Activity Report 2003; [7] Lapão, L.V.; Valadares Tavares, L. and Pereira, M.J.;“HSM’s HIS Assessment and Analysis” – INA 2004 [8] Winter, A.P. et al; Purpose and Structure of Strategic Plans for Information Management in Hospitals. Medical Infobahn for Europe. Amsterdam: IOS Press. S. 880-884. [9] Document “Portaria 448/2001”, of 3rd of May; [10] G. Hogbin & D. Thomas, Investing in Information Technology, The IBM McGraw-Hill Series, 1994. [11] McFarlan, “Information Technology changes the way you compete”, HBR May-Jun 1984; [12] R. Lenz & K. Kuhn, Integration of Heterogeneous and Autonomous Systems in Hospitals, Data Management & Storage Technology 2002. [13] T. Spil, H. Meeberg and K. Sikkel, “The definition, selection and the implementation of a new hospital information system to prepare the hospital for the electronic future: an example of a project based education”, Proceedings of the 32nd Hawaii International Conference on System Sciences 1999. [14] Nolan, R. , “The Crisis in Data Processing”, HBR Mar-Apr 1979, 115; [15] Galliers, R. D., e A. R. Sutherland "Information systems management and strategy formulation: the 'stages of growth' model revisited", Journal of Information Systems, 1, 2 (1991); [16] Graeber, Stefan; How to Select a Clinical Information System, AMIA 2001 [17] Valadares Tavares, L; “The TRIDENT approach to rank alternative tenders for large engineering projects”, Foundations of Control Engineering, 1984;

Address for correspondence Luís Velez Lapão , [email protected] Instituto Nacional de Administração – Palácio dos Marqueses de Pombal, 2578-875 Oeiras – Portugal-
