The stories in this guide were based on case studies about a specific intensive care IT system that integrates information from bedside monitors into a single intuitive display to provide better real-time information for clinicians

Bates, D

Goldmann, D

Pagel, A

English

UCL Discovery

COMMENTARYThe stories in this guide were based on case studies about a specific intensive care IT system that integrates information from bedside monitors into a single intuitive display to provide better real-time information for clinicians.Why Did We Develop This Guide?The potential benefits of health information technology (HIT) for delivering better health care are so obvious1-3 that the pressure to develop and implement HIT and clinical decision support (CDS) systems continues to build, even though the anticipated benefits are rarely fully realized, at least early on.4-13 Implementing new information systems within hospitals is almost always harder than anticipated by decision makers, clinical teams, and software companies.14-17Many of the barriers to success occur at the final stages of implementation,15,17-19 in the nitty-gritty ofhow a system is implemented,whose work and goodwill are required to make it happen, andhow a system is incorporated into existing workflows. Much research exists on the barriers to implementation and how these barriers can be overcome.4,17,20-23 However, it is much less clear how this valuable information should reach busy frontline clinician leaders or senior hospital executives who often oversee the purchase and implementation of new HIT systems, particularly in the case of smaller, more bespoke systems for individual specialities or wards.We hope that these cartoons and accompanying tips can help bridge that gap.The Evidence This Guide Is Based OnThe stories in this guide were based on case studies about a specific intensive care IT system that integrates information from bedside monitors into a single intuitive display to provide better real-time information for clinicians.How to Avoid Common Pitfalls of Health IT ImplementationChristina Pagel, PhD, David W. Bates, MD, MSc, Donald Goldmann, MDVol.  No.  | October 2, 2020DOI: 10.1056/CAT.20.0048NEJM Catalyst is produced by NEJM Group, a division of the Massachusetts Medical Society.Downloaded from catalyst.nejm.org on November 14, 2020. For personal use only. No other uses without permission. Copyright © 2020 Massachusetts Medical Society. All rights reserved. NEJM CATALYST INNOVATIONS IN CARE DELIVERY 2We conducted face-to-face interviews with 20 people (six ICU physicians, five nurses, three nurse practitioners, and six IT specialists) at four hospitals across the U.S. who had recently implemented this IT system, and another three IT specialists at the vendor company. Interviews took place between October 2016 and July 2017.We explored the implementation process by asking about the following topics:• When did people find out about the new system andwhat information were they given?• How was the implementation process negotiated?• Who did they work most closely with during implementation?• Were there roles whose importance was not anticipated?• Were there specific potentially avoidable delays or challenges?• How have different teams responded to the system once live?• What, if anything, would people have done differently with hindsight?We then carefully analyzed transcriptions of each interview to identify common themes and developed storyboards that showcased the barriers. We contracted a cartoonist and worked closely with them to develop characters and cartoon strips to illustrate the storyboards. In parallel, we selected key quotes from the different roles to accompany each cartoon with real examples and summarized the learning in short “Top Tips” sections.We shared the first cartoon drafts with all interviewees for feedback. Feedback was very positive, and we incorporated suggestions into these final versions.NEJM Catalyst is produced by NEJM Group, a division of the Massachusetts Medical Society.Downloaded from catalyst.nejm.org on November 14, 2020. For personal use only. No other uses without permission. Copyright © 2020 Massachusetts Medical Society. All rights reserved. NEJM CATALYST INNOVATIONS IN CARE DELIVERY 3Common Pitfalls of IT Implementation and How to Avoid ThemSTOP and read this first!This short booklet brings together the IT experiences of doctors, nurses, and IT staff at different hospitals sharing the things they’d wished someone had told them.These tips are mainly for smaller, specialized IT systems instead of big centrally run implementations such as electronic medical records.There are four main themes: each theme has one page of common pitfalls and tips and one page of helpful quotes from interviewed hospital staff.We hope that you find these tips useful.NEJM Catalyst is produced by NEJM Group, a division of the Massachusetts Medical Society.Downloaded from catalyst.nejm.org on November 14, 2020. For personal use only. No other uses without permission. Copyright © 2020 Massachusetts Medical Society. All rights reserved. NEJM CATALYST INNOVATIONS IN CARE DELIVERY 4Getting to ink on contracts — you probably haven’t even met most of the people you need to yet!Be proactive! Delays are the default:• Who you know: Make a list of all the departments / leadership you think you need to involve.This will not be everyone you need.• Who they know: Talk to those peoplenow and ask them whothey think should be involved. Then askthose people . . . keep going until there are no new names.• Talk: Get people together to talk and understand processes. You will need to jump through hoops you never knew existed — held by people you have never met. Hospitals often require approvals from many different places.Be patient!NEJM Catalyst is produced by NEJM Group, a division of the Massachusetts Medical Society.Downloaded from catalyst.nejm.org on November 14, 2020. For personal use only. No other uses without permission. Copyright © 2020 Massachusetts Medical Society. All rights reserved. NEJM CATALYST INNOVATIONS IN CARE DELIVERY 5Technical installation — expect the unexpectedTop tips from your peers:NEJM Catalyst is produced by NEJM Group, a division of the Massachusetts Medical Society.Downloaded from catalyst.nejm.org on November 14, 2020. For personal use only. No other uses without permission. Copyright © 2020 Massachusetts Medical Society. All rights reserved. NEJM CATALYST INNOVATIONS IN CARE DELIVERY 6NEJM Catalyst is produced by NEJM Group, a division of the Massachusetts Medical Society.Downloaded from catalyst.nejm.org on November 14, 2020. For personal use only. No other uses without permission. Copyright © 2020 Massachusetts Medical Society. All rights reserved. NEJM CATALYST INNOVATIONS IN CARE DELIVERY 7NEJM Catalyst is produced by NEJM Group, a division of the Massachusetts Medical Society.Downloaded from catalyst.nejm.org on November 14, 2020. For personal use only. No other uses without permission. Copyright © 2020 Massachusetts Medical Society. All rights reserved. NEJM CATALYST INNOVATIONS IN CARE DELIVERY 8Nursing and other frontline staff — involve them from the start and then at every stageDon’t forget the front line:• Involve nursing and frontline staff from the start: If you’re buying a system that you want frontline staff to use, check that nursing leadership agrees that the new system will improve care. Then get them on board as nursing champions.• Involve nursing and frontline staff at every stage: Don’t make logistical decisions without front line involvement — a frontline system that is inconvenient to use won’t be used.• Involve nursing and frontline staff in designing use cases: Frontline staff won’t use a system if they can’t see how it helps their patient. Be clear on how the new system will improve care.NEJM Catalyst is produced by NEJM Group, a division of the Massachusetts Medical Society.Downloaded from catalyst.nejm.org on November 14, 2020. For personal use only. No other uses without permission. Copyright © 2020 Massachusetts Medical Society. All rights reserved. NEJM CATALYST INNOVATIONS IN CARE DELIVERY 9NEJM Catalyst is produced by NEJM Group, a division of the Massachusetts Medical Society.Downloaded from catalyst.nejm.org on November 14, 2020. For personal use only. No other uses without permission. Copyright © 2020 Massachusetts Medical Society. All rights reserved. NEJM CATALYST INNOVATIONS IN CARE DELIVERY 10Why, how, and when should people use it? Plan out the workflow!Plan and communicate:• Set goals: Be clear about what you are trying to accomplish with the system.• Why should busy front line staff care about it?How can you excite them about the new system?• How will the system achieve the goals you have set?Open the black box.NEJM Catalyst is produced by NEJM Group, a division of the Massachusetts Medical Society.Downloaded from catalyst.nejm.org on November 14, 2020. For personal use only. No other uses without permission. Copyright © 2020 Massachusetts Medical Society. All rights reserved. NEJM CATALYST INNOVATIONS IN CARE DELIVERY 11NEJM Catalyst is produced by NEJM Group, a division of the Massachusetts Medical Society.Downloaded from catalyst.nejm.org on November 14, 2020. For personal use only. No other uses without permission. Copyright © 2020 Massachusetts Medical Society. All rights reserved. NEJM CATALYST INNOVATIONS IN CARE DELIVERY 12FINALLY: Things that really worked, and other tips:Simple Checklist!• Have you identified all the departments you will need?e.g., Finance, Procurement, Contracts, Compliance, IT hardware, IT security, IT software, Logis-tics, Facilities, Administrators, Clinical teams that will use the systemNEJM Catalyst is produced by NEJM Group, a division of the Massachusetts Medical Society.Downloaded from catalyst.nejm.org on November 14, 2020. For personal use only. No other uses without permission. Copyright © 2020 Massachusetts Medical Society. All rights reserved. NEJM CATALYST INNOVATIONS IN CARE DELIVERY 13• Have you identified champions from senior clinicians, senior nurses, junior clinicians, and frontline nurses? Do you need to involve other bedside staff?• Is there a clear implementation timeline with clear roles and responsibilities outlined within the project team?• Have you included extra time for unforeseen delays?If not, you should!• Is there a clear plan of how the system will be used — and how it will improve care?• Have you considered piloting the system first to test plans and identify problems?• How are you and the project team going to advertise the new system and communicate the plan for its use?Development of This GuideThis booklet (included in the Appendix) was developed in 2017 by Christina Pagel with colleagues in academia, hospitals, and IT companies. Christina is a mathematician and health services researcher at University College London, UK. From 2016 – 2017, she spent a year in the USA on a Harkness Fellowship in Health Policy and Practice, funded by the Commonwealth Fund.During this year, she interviewed doctors, nurses, and IT staff at four US hospitals to learn about their experiences of implementation of a clinical IT system over the previous 2 years. She also observed how the IT system was currently being used on the wards.The cartoons in this guide illustrate themes and situations that arose directly from her analysis of the hospital visits. The quotes come directly from interviews with hospital staff. The guide was shared with interviewees and other experts and feedback incorporated into the final version.Christina Pagel, PhDProfessor, University College LondonDavid W. Bates, MD, MScProfessor of Medicine, Harvard Medical School Chief, Division of General Internal Medicine, Brigham and Women’s HospitalDonald Goldmann, MDChief Medical and Scientific Officer, Institute for Healthcare Improvement Professor, Department of Immunology and Infectious Diseases, Harvard. T.H. Chan School of Public Health Clinical Professor of Pediatrics, Harvard Medical SchoolFull booklet: Common Pitfalls of IT Implementation and How to Avoid Them.Disclosures: Christina Pagel, David Bates, and Don Goldmann have nothing to disclose.NEJM Catalyst is produced by NEJM Group, a division of the Massachusetts Medical Society.Downloaded from catalyst.nejm.org on November 14, 2020. For personal use only. No other uses without permission. Copyright © 2020 Massachusetts Medical Society. All rights reserved. NEJM CATALYST INNOVATIONS IN CARE DELIVERY 14References 1. Mishuris RG, Linder JA, Bates DW, Bitton A. 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Organizational factors that affect the implementation of information technology: perspectives of middle managers in Iran. Acta Inform Med. 2014;22(6):325-8 7. Djalali S, Ursprung N, Rosemann T, Senn O, Tandjung R. Undirected health IT implementation in ambulatory care favors paper-based workarounds and limits health data exchange. Int J Med Inf August 4, 2015. 8. Ammenwerth E, Iller C, Mahler C. IT-adoption and the interaction of task, technology and individuals: a fit framework and a case study. BMC Med Inform Decis Mak. 9. Beeler PE, Bates DW, Hug BL. Clinical decision support systems. Swiss Med Wkly. 10. Emani S, Ting DY, Healey M. Physician beliefs about the impact of meaningful use of the EHR: a cross-sectional study. Appl Clin Inform. 2014;5(6):789-801 11. Clarke A, Adamson J, Sheard L, Cairns P, Watt I, Wright J. Implementing electronic patient record systems (EPRs) into England’s acute, mental health and community care trusts: a mixed methods study. BMC Med Inform Decis Mak. 12. Mennemeyer ST, Menachemi N, Rahurkar S, Ford EW. Impact of the HITECH act on physicians’ adoption of electronic health records. J Am Med Inform Assoc. 13. Greenhalgh T, Swinglehurst D. Studying technology use as social practice: the untapped potential of ethnography. BMC Med. 14. Lucas B, Nacer H. The Habits of an Improver: Thinking About Learning for Improvement in Health Care. The Health Foundation. October 2015. http://www.health.org.uk/sites/default/files/TheHabitsOfAnImprover.pdf.NEJM Catalyst is produced by NEJM Group, a division of the Massachusetts Medical Society.Downloaded from catalyst.nejm.org on November 14, 2020. For personal use only. No other uses without permission. Copyright © 2020 Massachusetts Medical Society. All rights reserved. NEJM CATALYST INNOVATIONS IN CARE DELIVERY 15 15. Dixon-Woods M. Perspectives on Context: The Problem of Context in Quality Improvement. The Health Foundation. September 2015. http://www.health.org.uk/sites/default/files/PerspectivesOnContextDixonWoodsTheProblemOfContextInQualityImprovement.pdf. 16. Russ SJ, Sevdalis N, Moorthy K. A qualitative evaluation of the barriers and facilitators toward implementation of the WHO surgical safety checklist across hospitals in England: lessons from the “Surgical Checklist Implementation Project”. Ann Surg. 2015;261(6):81-91 17. Hayes CW, Batalden PB, Goldmann D. A ‘work smarter, not harder’ approach to improving healthcare quality. BMJ Qual Saf. 2015;24(6):100-2 18. Fulop N, Robert G. Context for Successful Quality Improvement. The Health Foundation. October 2015. http://www.health.org.uk/sites/default/files/ContextForSuccessfulQualityImprovement.pdf. 19. Marshall M, Pronovost P, Dixon-Woods M. Promotion of improvement as a science. Lancet. 2013;381(6):419-21 20. Cresswell KM, Lee L, Slee A, Coleman J, Bates DW, Sheikh A. Qualitative analysis of vendor discussions on the procurement of Computerised Physician Order Entry and Clinical Decision Support systems in hospitals. BMJ Open. 21. Nanji KC, Cina J, Patel N, Churchill W, Gandhi TK, Poon EG. Overcoming barriers to the implementation of a pharmacy bar code scanning system for medication dispensing: a case study. J Am Med Inform Assoc. 2009;16(6):645-50 22. Cresswell KM, Bates DW, Sheikh A. Ten key considerations for the successful optimization of large-scale health information technology. J Am Med Inform Assoc. 2017;24(6):182-7 23. Schnall R, Smith AB, Sikka M. Employing the FITT framework to explore HIV case managers’ perceptions of two electronic clinical data (ECD) summary systems. Int J Med Inform. 2012;81(6):e56-62NEJM Catalyst is produced by NEJM Group, a division of the Massachusetts Medical Society.Downloaded from catalyst.nejm.org on November 14, 2020. For personal use only. No other uses without permission. Copyright © 2020 Massachusetts Medical Society. All rights reserved. 

How to Avoid Common Pitfalls of Health IT Implementation

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How to Avoid Common Pitfalls of Health IT Implementation

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