Health information system (HIS) implementations are massive efforts that pull on the energy, tolerance, and stamina of all involved. Everyone is looking forward to a break at the end of the project, but a break may be hard to find. Much like having gestated and delivered a child, the result of an implementation is a dependency that will last for years. The hope is, in short order, that a degree of maturity will be reached so the system delivers more than it consumes. Understanding the typical sequence of events and causes of discomfort – and properly preparing for them – can ease transitions and enhance the end-user experience.
Post-implementation begins when critical workflows have been established and a sense of normalcy arrives in day-to-day activities. IT department teammates start to disappear for vacations or less stressful jobs. Capacity feels limited and users are insatiable. IT desires praise and prioritization and is not getting it. End users have yet to understand that any change they wish to make in services or processes requires IT, competing against others' requests. Implementation governance transitions to operations, and operations is not prepared to function in this new environment. Old ways of changing are not working as they used to, and no one understands why.
Several steps are necessary to navigate this terrain. The first step is recognizing the new dependency. Then attention can turn to defining new governance, managing resources, adjusting processes, and planning for continual change.
Turning the ball and chain into a three-legged race
A common misconception is that once workflows have been adjusted to embrace electronic systems, the change is done. It can come as a surprise when clinical changes that used to be independent of IT, now require a change in IT systems. For example, onboarding a new end user, such as a nurse practitioner for a new service, may require additional requirements gathering to build the proper access and workflow. This could be a month of work for IT analysts already committed to other initiatives. This is only one of many unexpected, emergency change requests that could present themselves.
When these situations build up and delay care, the dependency of clinical care on the HIS hits home. This awareness can lead to conflict and dissonance, or it can open opportunities for collaboration and coordination between the IT and clinical teams. The relationship should be recognized as a three-legged race instead of a ball and chain.
To mitigate the pain of this stage, in advance of implementation, healthcare leaders need to recognize the new dependency on the IT department, communicate the expectation widely, and ensure that organizational strategy development requires all initiatives to be assessed for IT resource requirements in the post-implementation world. Every strategic initiative should be accompanied by the question, “And how will our new dependency on information systems impact the work required to achieve this objective?” The leadership team should be prepared to appropriately staff the IT department in accordance with strategic initiatives, earmark new IT needs such as enhanced cybersecurity and software management systems, and allocate an increased baseline maintenance budget to support the continued adoption and education of new systems. Alternatively, they will need to decrease and prioritize their ambitions if the price tag is too high.
Easing the capacity crunch
Limiting the number of changes, prioritizing them, and being strategic with IT resources are essential parts of managing capacity well. Even after recognizing that the newly implemented system is a dependency, it takes time to align resources and pace. Clinical care teams are used to independently adjusting to improve situations and maximize the use of their clinical resources. Likewise, IT will have had no prior visibility into the abundance of clinical changes that occur and will likely be understaffed and overly fatigued. Adding IT resources may help ease the pressure, but it will also minimize the opportunity for the clinicians to learn strategic use of their new systems.
Alignment is the key to managing the capacity crunch. The first step needs to be an adjustment in governance. In the context of a new dependency between clinical action and IT resources, there needs to be leadership to ensure that strategic direction aligns to organization goals, to prioritize changes, and to bridge the gap between clinicians and IT. If an organization did not have a chief medical information officer (CMIO, CxIO) and chief nursing information officer (CNIO, CxIO) prior to the implementation, post-implementation is an ideal time to onboard them.
Thinking carefully about reporting structure is important. Immature systems frequently have CxIOs reporting to IT as the clinical champions of implementations. However, the primary function of a CxIO is to leverage technology to drive improvement in the quality and safety of clinical care, and this responsibility falls under the purview of the CMO/CNO. If the CMO/CNO does not have the appropriate knowledge or enthusiasm for technology-enabled care to support a meaningful reporting relationship, then the organization likely needs more than one adjustment in leadership.
CxIOs are essential for mitigating the pain of the crunch. CxIOs educate their respective leadership on how to identify the IT requirements for clinical changes, the innovative possibilities of leveraging technology, the resources available, and the need for prioritization. These efforts mark the beginning of the decentralization of standards and requirements gathering and the transition of ownership from an implementation team to the operations team. The CxIO, as the lynchpin for the architectural integrity of the HIS, will own and align clinical standardization efforts amid the decentralization process. In other words, they police to ensure individual directors are not straying from the standard or duplicating efforts across the board.
Ensuring strong relationships between operational directors and their IT counterparts while having predictable IT resourcing for maintenance and optimization within each clinical area aids self-policing of workloads. Consider the example of a successful post-implementation transition in a pharmacy department that established a weekly meeting with their assigned IT analysts. The analysts and clinical representatives went through pharmacy requests and discussed the clinical impact, options for improvement, and prioritization. Those items identified as a top priority with acceptable solutions were addressed by the analysts between meetings. Changes that required more than the time of the designated analysts, or that required consensus from multiple stakeholders, were vetted as projects through a formal institutional process. In this case, a sense of autonomy, connectivity, and visible improvement led to a positive relationship even amid scant resourcing.
Changes requiring project gating will need an approval body to coordinate prioritization and resourcing. Pre-implementation, project approval bodies may not have had appropriate clinician representation to manage these requirements. Additionally, synergies between approval bodies may not have existed to the extent necessary to manage the global dependency. Reassessing all committees for appropriate stakeholder representation and alignment with organization-wide initiatives or escalation processes will need to occur with the fresh eyes of post-implementation dependency.
These operational changes need to be reflected in policies and procedures. Included in these procedures should be formulas for sizing, gating, and educating the change, as well as clear frameworks as to who has the authority to decline a request. Saying “no” will be essential to wise action and peace of mind, however, it best comes from leadership than at the junction of end users and support personnel.
The nudge (not the shove)
Continuous palpable change can cause fatigue, but continuous imperceptible change can lead to deathly slow transformation. When is it kinder to implement change as a big push versus a slow nudge? In managing IT projects, keep in mind the importance of stakeholder readiness and the size of the change. If the average end user can take the change in stride, or requires a brief nudge to adopt, then the change should happen as soon as it is tested and ready to go. If a greater support effort is needed, it may be best to save the implementation until pre-determined larger change moments. Most organizations have preferences as to what time of year these significant changes can be made. This takes into consideration vacation schedules, typical seasonal flows, and adequate time for training. Consider scheduling regular big efforts at predictable times during the year. This allows end users to incorporate these more significant shifts into their flow and encourages a continual evolution mindset.
Adopt a continuous improvement mindset
Any change is a beginning of a new way of being, not a conclusion. As our dependency on technology increases, our need for alignment, strategic prioritization of initiatives, and teamwork increases. Planning for continual change and establishing a predictable flow or rhythm in improvement efforts help to ease the transition. The beauty of change in a post-implementation world is that you now have data to help you determine your direction of change and to support your adoption efforts.