Electronic health records (EHR) deployment projects
a three-year retrospective of the best and worst project management practices
This paper explores the unique challenges and opportunities that have surfaced in the healthcare field over the past three years in managing Electronic Health Record (EHR) systems projects since the passing of ARRA and the HITECH Act in 2009.
This paper provides answers to these questions: What are the 48 “best practices” in healthcare project management and how can we maximize or optimize their use on EHR systems projects? Is the “2011 List of Project Management Best Practices in a Healthcare Delivery Organization,” published by PMI's Healthcare Community of Practice a comprehensive and complete model for use by healthcare project managers? What are the 41 “worst practices” in healthcare project management and how can we minimize or eliminate their use on EHR systems projects?
The paper concludes with a set of recommendations for addressing the project management challenges of complying with this phased-in, healthcare legislation in the future.
An Overview of the American Recovery and Reinvestment Act of 2009 (“ARRA”)
The American Recovery and Reinvestment Act of 2009 (ARRA) was passed by Congress and signed into law by the then newly inaugurated President Barack Obama on 17 February 2009. A direct response to the economic crisis that existed at the time, ARRA had five purposes:
1. To preserve and create new jobs and promote economic recovery;
2. To assist those most impacted by the recession;
3. To provide investments needed to increase economic efficiency by spurring technological advances in science and health;
4. To invest in transportation, environmental protection, and other infrastructure that will provide long-term economic benefits; and,
5. To stabilize state and local government budgets, in order to minimize and avoid reductions in essential services and counterproductive state and local tax increases. (U.S. GPO, 2009, p. 1-2)
ARRA contains two Divisions: Division “A” for “Appropriation Provisions” and Division “B” for “Tax, Unemployment, Health, State Fiscal Relief, and Other Provisions.” Division “A” is, in turn, divided up into sixteen separate “Titles” one of which is “Title XIII – Health Information Technology.” (U.S. GPO, 2009. p. 112-165)
This paper focuses on those provisions that are contained in Title XIII (also known as the “Health Information Technology for Economic and Clinical Health Act” or simply “HITECH Act”) that have facilitated or caused the deployment of EHR systems projects and programs that have been driving the efforts to fulfill ARRA Purpose #3 over the past three years.
HITECH, Financial Incentives for Adopting an EHR System, and the Concept of “Meaningful Use”
The HITECH Act provided an EHR deployment financial incentive program through grants from the Centers for Medicare and Medicaid Services (CMS). This voluntary incentive program was designed to encourage widespread EHR deployment, promote innovation, and avoid imposing excessive financial burdens on healthcare providers. These incentive payments range from US$44,000 each over five years for the Medicare providers to US$63,750 each over six years for Medicaid providers (starting in 2011). CMS grants these incentive payments to Eligible Professionals (EPs) or Eligible Hospitals (EHs), who can demonstrate that they are engaging in efforts to adopt, implement, or upgrade certified EHR technology. While participation in the CMS EHR incentive program is totally voluntary, there is a disincentive for the lack of participation, too: for those EPs or EHs that fail to join in by 2015, there will be negative adjustments to their Medicare/Medicaid fees, starting at a 1% reduction and escalating to a 3% reduction by 2017 and beyond. (U.S. GPO, 2009, p. 353-398)
Yet, these up-front financial incentives come with a substantial obligation to demonstrate what the HITECH Act calls “meeting the test of meaningful use.” The concept of “meaningful use” is defined by the use of certified EHR technology in a “meaningful” manner (for example electronic prescribing); ensuring that the certified EHR technology is connected in a manner that provides for the electronic exchange of health information to improve patient safety and the quality of care; and that in using certified EHR technology the provider must submit to the Secretary of Health & Human Services (HHS) information on quality of care and other measures.
“Meaningful use” rests on the ‘five pillars’ of health outcomes policy priorities, namely: (1) Improving quality, safety, efficiency, and reducing health disparities; (2) Engaging patients and families in their health; (3) Improving care coordination; (4) Improving population and public health; and (5) Ensuring adequate privacy and security protection for personal health information through the use of certified EHR technology. In order to avoid imposing excessive administrative burden on healthcare providers all at once, the “meaningful use” concept was showcased as a phased approach divided into three stages: Stage I-2011 (data capture and sharing), Stage II-2013 (advanced clinical processes), and Stage III-2015 (improved outcomes). (CDC, 2011)
The Stage II guidelines for “meaningful use” were released in February 2012 and, as of August 2012 (when this paper was submitted for publication) they are still in the obligatory 6-month comment period. However, if they are approved, for the first time, they will focus on the patient rather than the provider and require that patients actually use the digital technology as a fulfillment of Pillar #2 (“Engaging patients and families in their health.”). These Stage II rules require healthcare providers to offer EHR access to more than half of their patients. Clinics and private practices must also prove at least 10% of their patients are actually accessing healthcare information on EHRs. That includes radiological imaging results, which can be accessed directly in an EHR or through a link in the EHR to the images. If approved, patient action will become a requirement for “meaningful use” in 2013. (Mearian, 2012a)
Finally, there is always the chance that Eligible Professionals (EPs) or Eligible Hospitals (EHs), who cannot demonstrate that they have been successful in meeting the test of “meaningful use could be forced to refund CMS a portion or all of the upfront incentive payments.
ARRA and HITECH: The Impact on Healthcare Providers (2009–2012)
The movement toward implementing electronic health record systems and digital medical records (and away from paper-driven ones) came with some big promises back in 2009. In an April 2010 article, “Can Technology Cure Health Care?” in WSJ Online, Jacob Goldstein identified three such “promises:” “They'll improve patient care, in part by eliminating many errors. They'll stem the soaring growth in costs. They'll make healthcare more efficient.” along with a “quasi-status report” embodied in the article's sub-title: “How hospitals can make sure digital records live up to their promise. Because, so far, they haven't.” (Goldstein, 2010)
Yet, in an era of partisan government, the ARRA/HITECH Act's funded programs seem to have enjoyed bipartisan support or, at least, bipartisan tolerance, thus far. While only three Republicans voted for this stimulus bill in 2009, few have spoken out against it over the past three years. The fact that the information technology industry is a big supporter — giants such as IBM, Microsoft, General Electric, Hewlett-Packard and a host of smaller healthcare specialty technology companies — hasn't hurt. As much as US$27 billion has flowed their way, and plenty of high-priced lobbyists are working hard to keep it flowing. (Mitchell, 2012)
According to a 19 June 2012 Computerworld (online) article: “Electronic health records (EHR) are now being used by 110,000 healthcare providers and more than 2,400 hospitals, according to a report released today. In all, there are about a half-million healthcare providers and just over 5,000 hospitals across the country that are eligible to receive reimbursements for EHR rollouts through the Medicare and Medicaid EHR Incentive Programs, according to the Office of the National Coordinator for Health Information Technology (ONC).
A recent report from the ONC and the Centers for Medicare and Medicaid Services (CMS) also showed that US$5.7 billion in reimbursements have been paid to healthcare providers through the incentive programs. CMS Acting Administrator, Marilyn Tavenner and National Coordinator for Health Information Technology, Farzad Mostashari set a goal three months ago of having 100,000 healthcare providers making so-called “meaningful use” of EHRs by the end of 2012. “Meeting this goal so early in the year is a testament to the commitment of everyone who has worked hard to meet the challenges of integrating EHRs and health information technology into clinical practice,” Tavenner said in a statement.
As of the end of (May), about 48% of all eligible hospitals in the United States had received an incentive payment for making meaningful use of EHRs, the ONC stated. And one in every five Medicare and Medicaid eligible healthcare professionals in the United States had received similar incentive payments. “The EHR Incentive Programs have really helped jump start the use of electronic health records by healthcare providers all across the country,” Mostashari said. (Mearian, 2012b)
The message for healthcare project, program, and portfolio managers implementing and deploying EHR systems in the United States is clear: this initiative has gained momentum and is moving forward rapidly nationwide. You need to have a set of goals based on a set of best practices in healthcare project management and the lessons learned from those EHR deployment projects that have already been completed. Fortunately, these are now available…
PMI Healthcare Community of Practice List of PMBPs: Goals and Supporting Points
In 2011, the PMI Healthcare Community of Practice created and published Version 1.0 of a “List of Project Management Best Practices in a Healthcare Delivery Organization.” This document defines this list of Project Management Best Practices as “a series of repeatable actions which produce the desired result on a consistent basis and help the team perfect the implementation of change caused by the need to improve business outcomes.” (Crilly et.al, 2011, p. 1)
It states that “Healthcare delivery organization project teams often request that eleven key goals be met (and that) these goals are viewed as critical to a project team's success.” These eleven key goals and their respective “supporting points” (1st level only) are displayed in Exhibit 1 below: (Crilly et.al, 2011, p. 1-5)
Exhibit 1 – PMI Healthcare CoP's List of Project Management Best Practices — Key Goals and Supporting Points
These eleven key goals will be referenced in the remaining sections of this paper to determine if the “list” is both comprehensive and complete, or if there are other key goals that need to be considered for inclusion on the next version of the list.
EHR System Deployment Projects: Lessons Learned
The author is a member of a LinkedIn online group for professionals and practitioners who are interested in discussing issues related to “Healthcare Information and Management Systems” for members of the Healthcare Information and Management Systems Society (HIMSS). Since late 2009, there have been two threaded discussions on this LinkedIn Group that have focused on the implementation of Electronic Health Record/Electronic Medical Record systems:
The first one was set up to exchange the “Top Ten” Reasons Why Your EHR/EMR Implementations are Failing, with the first posting on 21 November 2009. (Kashyap et.al, 2010-2012) The second one was set up to exchange the “Top 10 Reasons Why Your EMR/EHR Implementations are Succeeding,” with the first posting on 8 April 2010. (Ahmad et.al, 2009-2012) Let's look at the “Project Success Factors and Best Practices” first.
Project Success Factors and Best Practices
For the purposes of this paper, the operational definitions for “success” are as follows: (Litsikakis, 2009)
- “Project Success: “any project that has fulfilled all of the success criteria typically agreed upon by the stakeholders before the start of the project, upon completion of the project. However, these criteria may change, by stakeholder consensus agreement, over the project life cycle.”
- “Project Success Criterion: “any measurable performance indicator that is established and agreed upon by the stakeholders before the start of the project. There is typically more than one criterion which is typically focused on project performance commitments related to time, cost, and quality, plus the delivery of some type of “business value,” These criteria may change, by stakeholder consensus agreement, over the project life cycle.”
- “Project Success Factors: “those inputs to the management system or approach that led directly or indirectly to the success of the project, upon its completion.”
In Exhibit 2 below, there are forty-eight “project success factors” that were identified in the LinkedIn online discussion group that are matched with one of the eleven key goals identified by the PMI Healthcare Community of Practice's “List of Project Management Best Practices” in the previous section of this paper.
Exhibit 2 – PMI Healthcare CoP's PMBP Goals and LinkedIn Discussion Group “Success Factors” Matches.
Project Failure Factors and Worst Practices
As mentioned earlier, one of the fundamental challenges in this LinkedIn threaded discussion involved the lack of a common definition of “failure” (and “success”). Therefore, this paper will use the following operational definitions for “failure:” (derived from Litsikakis, 2009)
- “Project Failure: “any project that has not fulfilled all of the success criteria typically agreed upon by the stakeholders before the start of the project. While these criteria may change, by stakeholder consensus agreement, over the project life cycle, at least one of them was not fulfilled upon completion of the project.”
- “Project Failure Criterion: “any measurable performance indicator for success that is established and agreed upon by the stakeholders before the start of the project, which was not met upon completion of the project. There is typically more than one criterion, which is typically focused on project performance commitments related to time, cost, and quality, plus the delivery of some type of “business value.” Although these criteria may change, by stakeholder consensus agreement, over the project life cycle, at least one of them was not fulfilled upon completion of the project.”
- “Project Failure Factors: “those inputs to the management system or approach which led directly or indirectly to the failure of the project, upon its completion.” (Note: These may also include the lack of a project success factor.)
In Exhibit 3 below, there are forty-one “project failure factors” that were identified in the LinkedIn online discussion group that are matched with one of the eleven key goals identified by the PMI Healthcare Community of Practice's “List of Project Management Best Practices” in the previous section of this paper:
Exhibit 3 – PMI Healthcare CoP's PMBP Goals and LinkedIn Discussion Group “Failure Factors” Matches.
Recommendations for the Future
Based on the preceding forty-eight Project Success Factors, and forty-one Project Failure Factors, here are eight recommendations for updating the PMI Healthcare CoP's List of PMBPs and applying it toward executing successful EHR deployment projects in the future:
1. Best Practices vs Good Practices as a Standard for Healthcare: The PMI Healthcare CoP's calls its document the “List of Project Management Best Practices” and that “the best practice should be relevant to all healthcare delivery organization projects.” (Crilly et.al, 2011, p. 1) Yet, A Guide to the Project Management Body of Knowledge (PMBOK®_Guide) is PMI's premiere recognized global standard for the project management profession and it even states that “the knowledge contained in (it) evolved from the good practices of project management practitioners who contributed to (its) development” and that “Chapter 3 is the standard for project management…summariz(ing) the processes, inputs, and outputs that are considered good practices on most projects most of the time.” (PMI, 2008, p. 3) Hence, I believe the PMI Healthcare CoP's “List of Project Management Best Practices” should be changed to “Good Practices” and they should be applied on “most healthcare delivery organization projects most of the time,” not “all healthcare delivery organization projects.”
2. Patient Safety: One of the statements I tried to classify as a “Success Factor” was this: “While (an EHR system) is a huge initial investment, the ROI and potential for improved patient safety and reduced errors makes this worthwhile.” When I looked for the words “patient” or “safety,” nowhere did they appear in the current PMI Healthcare CoP's List of PMBPs. To reflect the current healthcare industry transformation, I recommend including these two items in a Version 2.0. This recognition of important industry terms will position this document as a “healthcare” reference, rather than an “information technology/software reference.” They form one of the primary “battle calls” of the current healthcare industry transformation. (Note: I ended up putting it in Goal #7 - “Risks are clearly understood.”)
3. EHR Vendor Selection: There is one vital process that all healthcare providers must undertake to make a sound EHR vendor selection decision: due diligence. With the substantial investment required and the long-term health IT forecast, providers both large and small need to be confident that their selected EHR vendor cannot only meet clinical needs, but can also be a viable partner in the future. Therefore, “Vendor Selection” needs to be added as a “Good Practice” and deserves to have its own “Key Goal” and “Supporting Points.”
4. The Role of Governance: The “lack of or inappropriate governance or a governance structure” was, by far, the most common “Failure Factor” identified in that LinkedIn threaded discussion. Although Version 1.0 of the PMI Healthcare CoP's “List of Project Management Best Practices” has a “Goal” entitled “Project Financial Governance,” there appears to be a missed opportunity to cover other aspects of project governance beyond the financial arena. Hence, I recommend that “Strategic Governance” be added as a separate “Good Practice” with its own “Key Goal” and “Supporting Points” in the next version.
5. Current and Future State Workflows: Workflows are included in Version 1.0 of the PMI Healthcare CoP's “List of Project Management Best Practices,” especially “Future State” workflows. However, I believe that since BOTH types of workflows – “Current-State” and “Future-State” – are mentioned so many times in these two LinkedIn threaded discussions, that “Workflows” deserve to be added as a separate “Good Practice” with its own “Key Goal” and “Supporting Points” in the next version.
6. The Evolution of “Meaningful Use”: Since the concept of ‘meaningful use’ is so central to the fulfillment of the project success criteria in an Electronic Health Record systems implementation project environment, and since its definition continues to evolve from Stage 1 to Stage 2 in 2013 and, in 2015, from Stage 2 to Stage 3, Healthcare professionals of all types – including Healthcare Project Managers – must remain ever-vigilant in the routine surveillance of announcements coming from the U.S. Department for Health and Human Services.
7. Make the Format and Wording of the Goals and Their Supporting Points Consistent and Compatible: The format and wording of the existing “Goals” don't match one another. For example, Goal #1 is stated as: “Clear understanding of the project objectives” but Goal #2 is stated as: “The project's deliverables are clearly defined” rather than “Clear definition of the project's deliverables” which would make it compatible or consistent with Goal #1. Conversely, Goal #1 could be revised to be: “The project objectives are clearly-understood” to be consistent with Goal #2. Whichever direction is taken is not as important as making each Goal statement consistent and compatible with one another. There are several other inconsistencies and incompatibilities amongst the other nine Goals, too.
8. The exclusion of references to “project manager” or his or her role in a Healthcare Delivery Organization is another missed opportunity in Version 1.0 of the PMI Healthcare CoP's “List of Project Management Best Practices.” I think its inclusion would be appropriate and very likely expected in a Version 2.0 document.
Ahmad, S.S. et.al (2010-2012) ‘Top Ten’ Reasons Why Your EHR/EMR Implementations are Succeeding, LinkedIn HIMSS Group Online Threaded Discussion, Retrieved on 1 August 2012 from http://www.linkedin.com/groups?gid=93115&trk=myg_ugrp_ovr (Members ONLY Group).
CDC (2011) Meaningful Use – An Introduction, Centers for Disease Control and Prevention, Atlanta, GA; Retrieved on 31 July 2012 from http://www.cdc.gov/ehrmeaningfuluse/introduction.html.
Crilly, J. et.al (2011) List of Project Management Best Practices in a Healthcare Delivery Organization, PMI Healthcare Community of Practice, Retrieved on 5 March 2012 from http://healthcare.vc.pmi.org/Share/Documents.aspx/List_of_Best_Practices_Final
Goldstein, J. (2010, April) Can Technology Cure Health Care? WSJ Online [Electronic Version], Retrieved on 6 June 2011 from http://online.wsj.com/article/SB10001424052748704259304575043572008622004.html.
Kashyap, R. et.al (2009-2012) ‘Top Ten’ Reasons Why Your EHR/EMR Implementations are Failing, LinkedIn HIMSS Group Online Threaded Discussion, Retrieved on 1 August 2012 from http://www.linkedin.com/groups?gid=93115&trk=myg_ugrp_ovr (Members ONLY Group).
Litsikakis, D. (2009) Analysis of Project Success Criteria and Success Factors, Retrieved on 1 August 2012 from http://litsikakis.wordpress.com/article/analysis-of-project-success-criteria-3ib8exvrc87n4-4
Mearian, L. (2012a, March) Latest Healthcare ‘Meaningful Use’ Rules Require Patient Involvement Computerworld [Electronic Version], Retrieved on 2 April 2012 from http://www.computerworld.com/s/article/9225599/Latest_healthcare_meaningful_use_rules_require_patient_involvement.
Mearian, L. (2012b, June) E-Health Records Adopted By More Than 100K Healthcare Providers Computerworld [Electronic Version], Retrieved on 15 August 2012 from http://www.computerworld.com/s/article/_9228235/E_health_records_adopted_by_more_than_100K_healthcare_providers.
Mitchell, R. (2012, March) Farzad Mostashari: Man On A Digital Mission Kaiser Health News [Electronic Version] produced in partnership with Fortune, Retrieved on 2 April 2012 from http://www.kaiserhealthnews.org/stories/2012/march/09/farzad-mostashari-health-information-technology.aspx.
PMI (2008) A Guide to the Project Management Body of Knowledge (PMBOK® Guide) (4th ed.). Newtown Square, PA: Project Management Institute
U.S. GPO (2009) The American Recovery and Reinvestment Act of 2009 (ARRA), HR 1, Government Publications Office, Washington, DC. Retrieved on 1 March 2009 from http://www.gpo.gov/fdsys/pkg/BILLS-111hr1enr/pdf/BILLS-111hr1enr.pdf.
© 2012, William S. Ruggles
Originally published as a part of the 2012 PMI Global Congress Proceedings – Vancouver, Canada