Clinical Information System Implementations: A ‘Three-Way’ Street

The centerpiece of many current healthcare information technology (HIT) outsourcing initiatives is the buyer’s decision to implement a new clinical information system (CIS) as a principal part of HIT outsourcing. Unfortunately, buyers have traditionally gone down one of two roads with their IT outsourcing supplier in accomplishing their CIS objectives.

However, neither of these is the best route to a successful CIS implementation.

Proceeding on Either of the Commonly Taken One-Way Streets

On the first road, the buyer decides that it will “take the lead” on the Clinical Information System implementation (because, ostensibly, only the buyer can decide what’s best for the buyer), and then “hand over” the CIS to the supplier upon the implementation. The buyer selects the CIS software provider (vendor), makes the determinations regarding necessary hardware, negotiates all of the prices, contracts, and licenses with the vendor and third-parties, and pays all of the bills.

This ignores several important details, however. First, when it comes to HIT or CIS, the buyer probably doesn’t know what’s best. Second, the buyer probably has less expertise, experience, and possible buying leverage with vendors than its supplier. Third, the supplier, not the buyer, is the one that must manage, operate, and maintain the CIS within the existing and changing IT environment.

At best, a CIS implementation done “outside” of HIT outsourcing will require significant supplier contract changes–i.e., price increases. At worst, it may create significant interoperability problems and system performance issues.

On the second road, the buyer decides that it will put its supplier in the driver’s seat and make the supplier responsible for all contractual, operational, and financial obligations for the CIS implementation as part of the HIT outsourcing— i.e., the proverbial “one throat to choke” model.

However, this also ignores several important details. First, the buyer has no (or very little) interface, working relationship, or contractual privity with the vendor: never a good idea for an HIT component which so many of the buyer’s own staff will use on a daily basis. Second, it assumes that the buyer’s and supplier’s interests with respect to the CIS implementation are aligned. Depending on how the supplier’s HIT outsourcing contract is structured, there could very well be many cross-purposes and disincentives regarding performance and cost. Third, it may seriously complicate unwinding your HIT outsourcing contract upon expiration and non-renewal or earlier termination for whatever reason.

CIS Implementations Should Follow the “Three-Way” Street

The supplier and buyer, in consultation and “partnership” with one another, should share the contractual, operational, and financial responsibilities for and control of the CIS implementation, including, but not limited to:

• Negotiating and contracting with the selected vendor
• Communicating with end users
• Identifying issues and obstacles
• Completing the CIS implementation on time and within budget
• Satisfying functional requirements, to be described in a “Preliminary CIS Implementation Plan” within the HIT outsourcing contract

On the three-way street with the CIS vendor, the supplier and the buyer should have the following respective responsibilities regarding the CIS implementation:

1. Project Initiation
   • Supplier and buyer will define respective CIS implementation project leaders.
   • Supplier and buyer CIS implementation project leaders will work together to define the project team, define decision-making bodies, develop the project charter, and conduct the project kick-off meeting.
   • Supplier and buyer will establish the “Final CIS Implementation Plan.”
   • Buyer will identify sponsors appropriate to champion and participate in strategic decisions relative to the CIS implementation and to assist in resolving internal roadblocks.
   • Buyer will identify the CIS vendor contract negotiation team, including legal counsel, to participate in contract negotiations.
   • Buyer will identify departmental subject matter experts and super users.
2. Project Management
   • Supplier will assume project management responsibility to include:
     • Management and control of process definition
     • Definition of key team member responsibilities
     • Management of key team members
     • Coordination of project team meetings
     • Risk mitigation (e.g., change control and tracking mechanisms)
     • Facilitation of design decisions
     • Orchestration of design sessions
     • Monitoring and communication of project progress
     • Management of vendor-provided services
     • Identification and resolution of day-to-day projected-related issues
     • Escalation of issues
     • Budget tracking
     • Development of buyer staffing requirements
   • Buyer will assume responsibility for:
     • Providing appropriate sponsorship to ensure the internal non-IT resources (e.g., department managers, subject matter experts, and departmental super users) are available throughout the project
     • Identifying “super users”
     • Reviewing and (if acceptable) signing off on design documents
3. Vendor Contract Negotiations
   • Supplier will review the CIS vendor contract presented to buyer from a business and technical perspective and identify areas of concern or issues that require review and response. Supplier will not provide legal advice regarding contract terms and conditions. Buyer will use legal counsel as it deems prudent throughout the contracting process.
   • Buyer will review the CIS vendor contract and identify areas of concern or issues that require review and response. The review will include financial arrangements, contract terms, and conditions.
   • Buyer’s legal counsel will review the CIS vendor contract and identify areas of concern or issues that require review and response.
   • Supplier will coordinate the necessary meetings to inform all constituencies on the issues and confirm buyer’s position on each issue. Supplier will consolidate identified issues into a position paper for submission to the vendor for response.
4. Pre-Implementation Planning
   • Supplier will assume responsibility for:
     • Evaluation and recommendation of opportunities to improve patient outcomes, financial performance, and employee productivity through process redesign
     • Selection of resources and skills for implementation
     • Examination of current operating organization structure
     • Gap analysis and impact analysis for organization process and technology changes
   • Buyer’s appropriate sponsor will ensure participation of the department managers and super users in the analysis to be conducted by supplier.
   • Buyer’s CIS “steering committee” will participate in reviewing the evaluations and recommendations provided by the supplier.
   • Buyer’s appropriate sponsor will assist in implementing organizational process changes.
5. Clinical Transformation
   • Supplier will merge its technical system competency with operational and process improvement expertise to lead the organizational change management, including physician-to-physician education, to encourage application of best practices, communications and adoption strategies, resulting in an early adoption by and satisfactory utilization of the CIS by buyer’s users.
   • Buyer will provide appropriate sponsorship and assist in encouraging adoption of supplier’s recommendations.
6. Implementation
   • Application design
     • Supplier will assume responsibility for screen, table, and work list definition; identification of required reports; and review and development of the training strategy.
     • Buyer will provide training facilities.
     • Supplier and buyer (steering committee, department managers, department subject matter experts, and super users) will work together to identify staff to be trained.
   • Application building
     • Supplier will assume responsibility for building master files, tables, order sets, and work lists.
     • Supplier and buyer (department managers, super users, and training department) will work together to develop training agendas, curriculum material, certification tests, and job aids.
   • Integration testing
     • Supplier will lead the integration testing by defining and coordinating required interfaces and conversions, providing integration test plan(s), providing application and operational testing reports, and conducting operation testing.
     • Supplier and buyer (department subject matter experts and super users) will work together to conduct and document integrated testing.
   • Training
     • Supplier will lead the development of training materials, development of the training plan, and execution of the training program.
     • Buyer’s training department will assist the supplier in developing and executing the program, and the executive sponsor will ensure end user participation in the training sessions.
   • Operational Readiness
     • Supplier will provide the final “cut” of the database build and system design and confirm technical operational readiness.
     • Buyer (department subject matter experts and super users) and supplier will work together to conduct final system validation.
   • Coordination of user acceptance testing (production testing)
     • Supplier will provide testing plans, coordinate testing activities, implement change control processes, perform and test the historical upload, and conduct volume and performance testing.
     • Buyer will review and (if acceptable) sign off on user acceptance testing; department subject matter experts and super users will assist with execution of acceptance tests.
   • Conversion (Go-live readiness)
     • Supplier will conduct conversion, technical, and application readiness assessments; prepare and execute operations test plans; conduct, develop, and validate conversion plan.
     • Buyer will review and (if acceptable) approve conversion acceptance criteria.
   • Conversion (Go-live)
     • Supplier will finalize go-live plans and timeframes; prepare the production environment; confirm that system, peripheral devices, and interfaces are prepared to support the conversion; lead execution of go-live activities; develop command center plan; finalize support team requirements for go-live; and resolve go-live issues.
     • Buyer will review and (if acceptable) approve go-live plans and assist with staffing the command center (departmental super users).

Of course, no one strategy is the right one for all scenarios. From time to time, there may be situations where it is appropriate for a buyer to take on a CIS implementation “solo.” And there may be situations where the supplier should be solely “on the hook” to deliver the CIS as part of a comprehensive HIT outsourcing. It’s my experience, though, that the right road to take is the three-way street: one on which buyer, supplier and CIS vendor are inextricably connected.

Lessons from the Outsourcing Journal:

• The buyer and the supplier must work together in a “partnership” like no other partnership between a customer and a vendor of services regarding the Clinical Information System.
• Although normally difficult to do in a traditional customer-vendor relationship, the interests of the buyer and the supplier must be absolutely aligned on a Clinical Information System implementation if it is to be successful.
• Finally, success does not occur upon merely the technically acceptable implementation of the Clinical Information System. Success occurs upon the measurable adoption of the CIS by the buyer’s users.

Bruce Leshine is a partner in the law firm of Jorden Burt LLP. With over twenty years of experience as a lawyer, business executive and systems engineer, Leshine represents and advises clients in the areas of information technology, telecommunications, and IT and business process outsourcing. His email: [email protected].