December 2012IT MANAGEMENTDEpArTMENTAl JourNAl

As the IT environments of healthcare orga-

nizations have grown more complex, the

quality of help desk support may be subject

to closer scrutiny. Health organizations are

fundamentally different than other enter-

prises, since failures of clinical information

systems can have serious consequences

for patient care. In addition, the workflows

of clinicians do not lend themselves to

remaining on hold for long periods of time

or waiting for help desk technicians to fol-

low up on service requests.

For these and other reasons, optimizing

IT help desk performance has become a

critical objective for healthcare leaders. In

some cases, it may make sense to employ

external partners for some level of help

desk support. One organization that

has had success with outsourcing some

help desk functions is Cancer Treatment

Centers of America (CTCA), which includes

five hospitals across the U.S., as well as a

clinic, a corporate office, and an operations

center. In mid-2011, CTCA selected an IT

help desk provider to assume responsibil-

ity for Level 1 support requests.

“We’ve been very pleased with them, they

are very customer-centric,” says IT Account

Management Director Christopher Downs.

“We’ve built a strong partnership with

them. We’re also looking at expanding

their role.”

Evaluating Help Desk Outsourcing

CTCA currently has over 4,500 IT stakehold-

ers throughout the organization. It initially

staffed an internal help desk that operated

between 7:00 am to 7:00 pm. As CTCA grew

into a multi-state, multi-time zone entity,

the needs of its users changed accordingly.

Ensuring Customer Satisfaction with External Help Desk

As telemedicine solutions continue to

become more resilient and viable options

for organizations with large service areas,

children’s hospitals in particular have

shown interest in the technology. Since

parents in some communities may not be

able to easily transport themselves or their

children, pediatric facilities will often expe-

rience a demand for their services across

a wider area than other organizations. It is

for this reason—in addition to the prohibi-

tive cost of sending pediatricians to remote

sites on a regular basis—that some of the

most challenging deployments and great-

est strides in telemedicine have been on

behalf of children’s hospitals.

Nationwide Children’s Hospital, for one,

sees patients from across the country, but

frequently provides care for patients who

must drive up to three hours to be seen by

the organization’s specialists. Nationwide

Children’s has maintained outreach sites

over the past 20 years where physicians can

travel from Nationwide Children’s main

campus in Columbus, Ohio to provide spe-

cialty care in rural communities. Demand

for specialists continues to grow and over

the past two years, the organization has

expanded to 26 outreach clinics.

Our goal with our telemedicine services

is to provide pediatric expertise to rural

communities that don’t have convenient

access to subspecialists,” says Gil Peri,

Vice President of Regional Development.

“This was not meant to replace that strat-

egy or focus—it was meant to complement

it. Instead of traveling up to six hours, the

physician could potentially see another

20+ patients via telemedicine.” The tele-

medicine strategy compliments the organi-

zation’s outreach efforts, enabling services

to be provided close to the patient’s home.

Nationwide Children’s telemedicine pro-gram has been in place for more than five years and was launched with a pediatric neonatology collaborative between six rural hospitals. Neonatologists can use a camera and actually see the patient and the remote nurse. This allows the physician to provide a consult that is more applica-ble to that family, discuss the current care and potential transport of the patient, and check in to provide piece of mind for rural physicians. The telemedicine technology simply allows Nationwide Children’s to do more with its pediatric specialists than previous remote consults allowed.

Because of the importance of being able to zoom and scan for neonatology cases, Nationwide Children’s specifically targeted solutions that are both resilient and pro-vide high quality image fidelity. Building on the successful deployment of telemedicine in neonatology, the organization began moving forward with implementations for GI and psychiatry purposes. In both of these care environments—in addition to neurology in the coming months—physi-cians are able to consult with patients from the Columbus campus.

Establishing a Strategic Deployment Strategy for Telemedicine Initiatives

SEE HElp DESk ON PAGE 2

SEE TElEmEDICInE ON PAGE 3

With fewer than half of organizations that offer telemedicine actually billing for those ser-vices, Nationwide Children’s offers a valuable perspective on implementing such initiatives.

Billing Practices of Organizations that Provide Telemedicine Services

Source: Academy Survey Data

Bill for Telemedicine

42%

Do Not Bill for

Telemedicine 58%

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In particular, the necessity of 24/7 help desk support became apparent. One key indicator was a decrease in customer sat-isfaction scores.

“I think [the decision to outsource] comes with the size of your organization, as well as when you do a true transparent survey of your stakeholders and determine if they are pleased,” says Downs.

Over time, customer satisfaction surveys began to reflect recurring concerns about the length of time for calls to be answered and for tickets to be resolved. In some cases, users reported that they did not feel help desk technicians were adequately meeting their needs. Once user dissatisfac-tion becomes apparent, it can be a signi-fier that an organization that may need to explore alternative held desk options.

The need to achieve cost savings is natu-rally a significant consideration when evaluating the feasibility of outsourcing. Accounting for the pace of organizational growth, leaders can project the need for additional help desk personnel, and related compensation costs. Based on such an analysis, leaders may find that engaging an external partner provides the opportunity to reduce expenses.

“From a cost perspective, we found we were able to provide better service while reducing our costs,” says Downs.

Establishing a Help Desk model

As noted above, CTCA’s external help desk provides support primarily on Level 1 issues. When users call into the central call center, help desk technicians will determine if they can resolve the issue. If the request is related to advanced clinical applica-tions, help desk technicians will attempt

to diagnose if it is a hardware or software issue prior to escalation to the next level. CTCA’s internal IT personnel are respon-sible for most Level 2 support at this time. Service requests can be initiated through an online portal as well as by phone and email. Currently, approximately one-third of CTCA support requests originate online.

CTCA has three dedicated Incident Managers—one for each shift—who are familiar with the CTCA’s staff and service level agreements. Under those managers is a group of analysts that are not neces-sarily dedicated to CTCA’s account, but are sufficiently familiar with the organiza-tion’s needs.

CTCA’s help desk receives about 3,700–3,800 contacts each month. On a daily basis, Downs reviews a 24-hour report that provides a snapshot of the previous day’s activity. He also analyzes any surveys that have been completed, and if there is any negative feedback, it can be immediately addressed. Some examples of key indica-tors CTCA monitors on a routine basis are pictured at right.

CTCA’s help desk reporting tools also enable the analysis of trends. Downs has the capa-bility of analyzing data by site and by group (e.g., desktop support) to identify if there are issues developing at certain locations or with specific categories of support.

Another key aspect of this model is that CTCA’s partner provides an onsite Relationship Manager who oversees the daily issues related to ticket resolution, and acts as a point of contact to resolve any problems that may arise.

“You need to have an onsite manager,” emphasizes Downs. “Don’t [outsource]

without one. When we started, we didn’t have one and it was bumpy. Once we added that person, the process smoothed very quickly.”

key lessons

Due to the success of this partnership over the past year, CTCA leaders are investigat-ing how to engage its help desk provider in Level 2 support. A pilot is also cur-rently being planned for next year involving onsite clinical support personnel.

“If a physician is with a patient and there’s a problem with the system, in many cases picking up the phone and calling the help desk is not really a viable solution,” explains Downs. “What we hope to do is put two or three people in the clinic, so if a clinician is having an issue, somebody would be there to help them immediately.”

When leaders consider such help desk arrangements, one potential drawback is less control since technicians are not employees. CTCA has not had any nota-ble issues in this area, in large part due to having a local Relationship Manager, which Downs strongly recommends. He also advises that organizations exploring IT help desk partnerships include explicit accountability mechanisms if service level agreements are not met. Although CTCA has had a productive relationship with its partner, specific penalties for missing goals can provide an extra layer of assurance.

To date, outsourcing Level 1 IT help desk support has proven beneficial for CTCA. In addition to cost savings, it has consistently exceeded its monthly customer satisfaction goals—the lowest it has ever been is 89.8%, and it is routinely over 94%. For leaders investigating alternative help desk options, CTCA provides an example of how success can be attained with an external model.

FROM HElp DESk ON PAGE 1

CTCA is able to analyze other indicators, but these provide a helpful overview of help desk performance.

Key Metrics for CTCA Help Desk

Indicator Goal

Customer Satisfaction (users rate service on five-point scale from “strongly disagree” to “strongly agree”)

85%

First Call Resolution (In-Scope) 90%

Call Abandonment Rate Over 18 Seconds 5%

Calls Answered in Less Than 30 Seconds 80%

Industry research indicates many healthcare IT leaders believe outsourcing can help reduce expenses, as well as provide critical knowledge that internal staff may not possess.

Top Reasons for Healthcare Organizations Outsourcing IT Services

Source: Waller Lansden Dortch & Davis

Cost Savings

90%

Expertise of Vendor

63%

Monthly customer satisfaction targets are rou-tinely exceeded by CTCA’s help desk partner.

CTCA Help Desk Satisfaction Scores

Lowest Score

Average Score

94.0%Goal

85.0%

89.8%

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For telepsychiatry specifically, patients will visit the Nationwide Children’s campus for their initial evaluation. This allows the psy-chiatrist to conduct their evaluation, and follow-up can be conducted remotely.

“This technology allows our physicians to sit locally and do the exact same consult that they would do in person, but with our telepsychiatry system,” says Peri. Moreover, in the near future Nationwide Children’s may receive reimbursement for psychiat-ric telemedicine services, which will allow the organization to take a more aggressive approach to deploying telemedicine.

More importantly, proper reimbursement would allow Nationwide Children’s to offer remote consultations more often as appro-priate, because physicians would have the incentive to dedicate the time to do so. For now, the organization’s pediatric psychia-trists are able to do anything that he/she would do in person. Medication manage-ment is handled in this way and there is always an attendant at the patient’s side of the consult to escort patients, obtain vital signs, manipulate technology as necessary, and provide the patient with as close to the same experience of being onsite as possible.

Additionally, Nationwide Children’s staffs a pediatric gastroenterologist—a position that is also quite rare and lacks represen-tation in many communities. As with the pediatric psychology service, the GI tele-medicine group triages patients who are eligible for remote care and then works with previously appointed physicians who are certified for treating patients for gastro-enterology-based consultations.

preparing for the Transition

While stakeholders initially required con-siderable educational resources to under-stand the capabilities of telemedicine, Nationwide Children’s was able to over-come deployment hurdles with effective strategic management.

“We have an internal telemedicine steer-ing committee focused around estab-lishing processes to deliver telemedicine virtual visits,” explains Peri. “We work with the rural communities to determine which telemedicine services would provide the

most value. We then assess each service to determine the appropriate fit for tele-medicine technology.”

As an organization, Nationwide Children’s always begins such processes with a needs assessment to identify the requirements of the community. Additionally, the organiza-tion’s strategy focuses on improving access to its pediatric specialists throughout every stage of the process. This has required communication through the steering com-mittee and tightly regulated pilot phases to ensure that there would be no unforeseen challenges when the process was rolled out to the organization’s outreach clinics.

For one, this involved the organization addressing limited bandwidth in its rural communities—a challenge that was addressed via a partnership with the Ohio Supercomputer Center (OSC), which had the funding to provide bandwidth. OSC and Nationwide Children’s collaborated when they found that they were working in the same region and could potentially benefit each other. The two organizations obtained grant funding to provide tele-medicine technology to rural communities.

There is monthly onboarding that is con-ducted with each participating site, which involves a testing process with the physi-cians, nursing team, and any onsite IT per-sonnel. This allows everyone to remain informed regarding the technology and any relevant changes. The onboarding process starts with an onsite educational event, which is supplemented by monthly calls to ensure users are maintaining competency in the technology. Additionally, the same telemedicine technology is used to con-duct grand rounds with the rural and com-munity organizations.

“Our use of the platform is well beyond just patient consultation,” says Peri. “If someone were to ask me what was one of the most important components, it’s to have a strong assessment and implemen-tation process. There are a lot of logistics

required to launch a telemedicine clinic. Communication internally and externally is a critical success factor.”

keys to Telemedicine Success

Other lessons learned from Nationwide Children’s strategic telemedicine deploy-ment experience include:

• When building the telemedicine ser-vice, maintain centralized and attain-able goals

• Focus on efficacy when working with community physicians

• Evaluate whether it makes sense to pro-vide service to rural organizations on a case by case basis

• Remain adaptable and flexible when working with community partners’ con-straints, visions, or missions

In addition to these points and taking this more staged approach to the implementa-tion of a telemedicine service line, Peri rec-ommends conducting a detailed community needs assessment and holding discussions with regional stakeholders to define work plans for deployment. Such an approach allows for individualized deployments, which has proven helpful when working with community providers. Organizations that wish to implement their own telemedicine departments may benefit from consider-ing Nationwide Children’s experiences and lessons learned during its planning and implementation processes.

FROM TElEmEDICInE ON PAGE 1

“[Our partnership with the OSC] was a great collaboration because we already knew where the need was, but it was going to be cost-prohibitive for us to work alone in that space and we needed partners—not just rural hospital partners, but collaborative partners such as OSC and other funding sources to make this network a reality.”

– Gil Peri Vice President of Regional Development

In addition to the persisting challenge of billing for telemedicine services, many organizations are expressing concerns regarding infrastruc-tural investments.

Technological Barriers to Implementing Telemedicine

Source: National Center for Biotechnology Information

Remote Data Access

Reliability

Usability

Technical Support

18.1%

16.2%

Internet Connectivity

23.8%

22.9%

28.6%

Documentation and Billing 45.7%

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IT MANAGEMENTStrategies & Tactics • Industry Trends & Analysis – for IT Strategic Management published monthly by Healthcare Business Insights

ita-research@hbinsights.com • 888.418.7153

Establishing EHR Governance Groups to Ensure Project Success

As more and more organizations begin electronic record deployments and others continue to use their applica-tions in accordance with federal stan-dards and regula-

tions, a standardized governance structure is imperative. An EHR Governance Group can play a key role by providing enterprise- and executive-level oversight to ensure strategic EHR projects are properly identi-fied, prioritized, and deployed. The primary objective of such a group will be to manage the installation of technology, the comple-tion of each phase of the project, the inte-gration with in-line solutions, the creation of functional workgroups, and the delivery of support for end users.

Establishing Functional Analyst Development Strategies

It is frequently chal-lenging to identify ideal development schedules for IT per-sonnel, particularly with organizations that employ limited FTEs or with newly established roles. For

those that have just started building out their data management strategy and have begun hiring analysts, it can be particularly diffi-cult to identify the appropriate benchmarks by which to measure individual growth. It is for these reasons that The Academy pro-vides detailed personnel development strat-egies, tailored to any functional role within an organization’s IT workforce. With regard to data warehouse analysts, this commonly involves detailing the necessary data man-agement competencies.

Providing Effective Notifications for CPOE Transitions

Organizations across the country are going

live with CPOE, and many leaders have experienced chal-lenges with clearly explaining the non-negotiable nature of the transition. For

this reason, some have found it beneficial to standardize communication templates for effective go-live notifications, even while bearing in mind how the challenging implementation might be received by clini-cal stakeholders. Such communication will need to explain that all physicians will be required to directly enter orders into the CPOE, except under specific exceptions that have been preapproved by the orga-nization’s clinical leadership where phone/verbal orders are justified.

Academy Research Highlights: Data Warehouse Analyst Development, EHR Governance, and CPOE Notification

Functional Requirements for Analyst Promotion Strategy

Detailed Requirements GatheringOrganizations will commonly expect that analysts have expressed an aptitude in analyzing operational information needs, clinical activities, and translating require-ments gathered from constituents into design specifications.

Technical ComplianceDuring both daily operations and testing procedures for production software, analysts will need to demonstrate that they can comply with departmental and technical standards for programming, design, analysis, and coding extract and summarization routines.

Maintaining Core CompetenciesData Warehouse Analysts will be expected to maintain—and demon-strate—an understanding of working with data marts during support and integration, development, source sys-tem analyses, and data manipulation.

Core Roles for EHR Governance Group Charters

Establish Vision StatementFirst and foremost, it will be impor-tant for critical governance groups to establish the quality goals and mission statements to clearly outline how this significant undertaking fits into the cultural vision and care commitments of the organization.

Outline Group StructureThe EHR Governance Group will act as a liaison for technologists and senior leadership throughout the implementa-tion and support processes. It will be important to outline the structure of the group as it will coordinate the interde-partmental project portfolio.

Support Ongoing DeploymentsAn EHR Governance Group will also work to create standardized project timelines, engage key constituents within the organization, and implement core EHR infrastructure.

Key Aspects of Communicating CPOE Requirements

Communicate the BenefitsCPOE implementations will often improve turnaround time for directly integrating orders into the core informa-tion system, which can ensure that all orders will be available for review imme-diately after patient discharge, and that orders do not suffer from poor legibility.

Provide Procedural ClarificationAn effective go-live notification will ideally provide insight from respected medical staff into procedural points—such as whether the use of printed paper orders for worksheets will be acceptable.

Clarify Phone/Verbal ExceptionsThere will invariably be some circum-stance during which the mandated use of CPOE may not be the most appropriate means of documentation. This could include code blue patient emergencies, or a temporary lack of access to a computer.

Data Warehouse Analyst Development Strategy General  Summary  Data Warehouse Analysts shall be eligible for promotion when once they have successfully demonstrated each of their role’s core competencies and have served the full term of the one-year probationary period. During this time, the Data Warehouse Analyst will have complied both with the [ORGANIZATION NAME] mission and with the core expectations for personnel filling such a role. This includes thinking critically and confronting complex challenges while operating in an active healthcare analytics environment, as well as continuously seeking and identifying opportunities for process improvement and cost savings. Required  Demonstration  of  Core  Functions  Data Warehouse Analysts shall be eligible for progression within their function, once they have demonstrated experience with:

Analyzing operational information needs and clinical activities to gather requirements for improvement

Translating requirements into design specifications, verifying accuracy

Providing input and recommendations for software implementations, process improvements, design enhancements, and support

Guiding operational projects through each phase of development cycles, including planning, development, deployment, and support

Developing project scope documentation for strategy and resource requirements to maintain enterprise visibility into project status/design

Programming software to accommodate user specifications in addition to revising in-line programs to support new requirements and configurations

Conducting comprehensive testing of production software

Complying with departmental and technical standards for programming, design, analysis, and coding extract and summarization routines

Creating stored procedures for data scrubbing, and optimizing data structures or data marts to support complex analysis

Creating and presenting metadata for data warehouse/data marts

Designing and implementing automated warehouse processes and report/batch processing programs

Evaluating effectiveness of programs and systems to propose new development opportunities, making decisions based on a detailed understanding of applications or improvements

Supporting standards and guidelines through data definitions, diagrams, and data modeling tools

Troubleshooting production solutions as required, optimizing performance, resolving problems, and providing timely follow-up for issue reports

Developing interfaces to support use of data warehouse to better understand/use decision support systems

Analyzing technical issues with relation to the in-line suite of applications, hardware, and operating systems, taking corrective action to minimize adverse operational impacts

Electronic Health Record Governance Group Charter Purpose  This mission- and quality-focused Electronic Health Record (EHR) Governance Group will play a key role in the IT Governance process by providing enterprise- and executive-level oversight to ensure strategic EHR-related projects are properly identified, funded, prioritized, and deployed across [Organization Name]. An EHR is a medical record or any other information relating to past, present, and future physical and mental health, or condition of a patient which in an electronic data format is captured, transmitted, received, stored, retrieved, or linked for the primary purpose of providing clinical care and health-related services. The objective of the EHR Governance Group and the EHR implementation project will be to install a working version of the selected EHR in both production and test environments, complete each phase of the project outline below, interface with in-line information systems, create a functional workgroup to coordinate the scanning and indexing of paper records and documentation to be stored on the selected EHR, and providing end user support for the transition. This support will take the form of training for pilot groups, active requirements and feedback gathering from core user groups, and training of all clinicians and ancillary staff. EHR  Governance  Group  Steering  Committee    The functional role of the EHR Governance Group requires multidisciplinary representation for the core vision and mission of [Organization Name]. The EHR Governance Group Steering Committee’s primary purpose is to make the guiding decisions that uphold [Organization Name]’s and the EHR implementation project’s best interests, ensuring that the project adheres to the organization’s foundational principles and the project’s objective, scope, and core deliverables. This Steering Committee will help to spread strategic input and end user buy-in throughout [Organization Name] and its care community. This will require that the EHR Governance Group and its core Steering Committee meet regularly to evaluate project progress and fidelity to core implementation goals.

– Director, Information Technology – Co-Project Manager (Procedural) – Co-Project Manager (Technical) – Business Office Representative (Scheduling) – Business Office Representative (Billing) – Clinical Executive Representative – Physician Group Representative – Nurse Leader Representative

All EHR Governance Group members are committed to the following:

Vision [Organization Name] and all EHR Governance Group stakeholders will provide:

The best patient care experience for every patient, every time The best place to work for employees, volunteers, and medical staff

Mission [Organization Name] will provide community-based quality health services delivered with compassion and respect. Commitment [Organization Name] serves the greater __ area of [State]. The organization’s commitment to providing exceptional care for its community means having a modern facility with the latest in medical technology and recruiting the finest physicians to be part of [Organization Name]’s clinical staff. The medical staff includes more than 100 board-certified physicians, active in both primary care and many specialties.

CPOE Transition – Effective Date Notif ication

Information Technology is pleased to announce that, effective [DATE], [ORGANIZATION NAME] will be participating in a major new initiative to directly enter all diagnostic/treatment orders and prescriptions into a computerized physician order entry (CPOE) system. Members of the medical staff must complete training and demonstrate competence prior to utilizing the CPOE system. All members of the staff will be required to directly enter diagnostic and treatment orders as well as prescriptions into the CPOE system as appropriate, except under the following four (4) exceptions:

The patient’s emergent situation temporarily precludes the physician from directly entering his/her orders. The information system is not available—due to downtime, for instance—or is not deployed. The physician is physically remote from the hospital and does not have access to the information system via

remote computer. The physician is in the process of performing a clinical procedure (e.g., cardiac catheterization, surgery,

invasive procedure, interventional radiology) that temporarily precludes direct order entry. Limited emergency verbal or telephone orders from authorized prescribers will be electronically signed, reviewed, and documented by the prescriber in a timely manner according to [ORGANIZATION NAME]’s inpatient practices. Electronic signatures require that each authorized prescriber is the only individual who can reproduce his/her electronic signature, the authorized prescriber cannot later repudiate that he/she signed the prescription, and only the authorized prescriber may change a verified/certified order. This transition will improve the turnaround time for directly integrating orders into the core Horizon system; this change will improve: [Add any additional benefits that you would like to communicate]

Timeliness of Care: All orders will now be available for review immediately after discharge. Legibility of Orders: [ORGANIZATION NAME] will no longer be affected by poor printer cartridges or scanning errors commonly encountered during the manual process.

To ensure that this transition is successful and that the above improvements are realized across the organization, utilization reports will be generated daily for the first two to four weeks following the system go-live. Reporting frequency can be scaled down as needed and the data will be used to identify departments and physicians in need of additional assistance or process improvements. Please be sure to review the following important points: [Procedural Suggestions – Optional]

Paper copies of orders can still be printed as worksheet documents and be used as communication tools while the patient is in-house.

The worksheet documents will be placed in a confidential bin for shredding upon the patient’s discharge and cannot be used as a permanent part of the documentation. Anything written on these orders will not be placed in the permanent chart.

Handwritten order forms not in the CPOE system, such as chemotherapy orders, general handwritten orders, restraint orders, etc., will continue to be scanned manually after discharge and must not be discarded.

Information Technology would like to gratefully acknowledge the tremendous efforts of our Physician and Nursing clinical leaders to help make this important transition a reality. If you have any questions, please contact [Primary Project Contact] at [Contact Information].