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Vendor Issues Management: A Problem List for IT
Presented by [Joe Wivoda] (67-minute Webinar) [00-00-2010]
Angie LaFlamme: Good morning, I’m Angie LaFlamme and I’m an Outreach Coordinator with REACH and I’d like to welcome you to today’s webinar.
I want to start the webinar by giving you a brief overview of our REACH Program. REACH is a non-profit FederalHITRegionalExtensionCenter, dedicated to helping providers and clinics, small hospitals and other settings in Minnesota and North Dakota implement and effectively use their EHRs. Our mission is to assure that each of our REACH clients achieve meaningful use.
REACH is a program of the Key Health Alliance, which is made up of a partnership of Stratis Health, the NationalWorldHealthResourceCenter and the College of St. Scholastica, which also collaborates with the North Dakota Healthcare Review and the University of North Dakota School of Medicine and HealthSciencesCenter for Rural Health.
With that I’d like to welcome today’s speaker. Today we have Joe Wivoda to present for us. Joe is an HIT Consultant with the RegionalExtensionAssistanceCenter for HIT (REACH). Joe’s been working in information technology since 1990 and with health information technology since 1993. He has been IT Mgr. Director of IT and CIO at several hospitals, clinics and other healthcare organizations. In addition to his healthcare experience, he has worked as a software developer and has worked in several other industries, including manufacturing, engineering, education and legal.
Joe’s expertise in IT leadership, strategy, service delivery and the process of innovation. He has led several selections and implementations of various HIT systems, including LIS, RIF and EHR. Joe received his BS and MS in physics from the University of Minnesota, Duluth and is currently pursuing a PhD in business administration from NorthCentralUniversity.
Thanks Joe for being with us today.
Joe Wivoda:Thanks Angie. I’m looking forward to talking about vendor issues management today. It means a lot of things to a lot of people and there are a lot of different perspectives on it. This talk will focus quite a bit on what the perspective from the vendor is compared to the perspective from a healthcare provider. So keeping that in mind, it’s about getting your issues resolved in a timely manner, that’s all vendor issues management is about.
Once again, we need to consider the perspective of the vendor that can help you get your issues resolved in a timely manner. We’re going to look at all those contrasted differences between the two perspectives, because they are different, and there will be quite a bit of discussion on some of the techniques to use to track issues, escalate them and also some things to look out for. It’s important to remember that the vendor is your partner.
This is not about beating up the vendor or trying to get everything, it’s about keeping in mind that the vendor is your partner and using these tools in conjunction with understanding what their perspective is, to get the issues that are most important to you escalated and resolved. So keep that in mind.
Starting off with looking at what the point of view of the vendor is, what I did here was to use a hierarchy of need for the vendor. We think of Maslow’s hierarchy of need and on the bottom we have that survival. They want to sustain the business and part of that is to avoid liability. They want to make sure they don’t have a product that endangers patients, that is unsafe, so that bottom is that they want to sustain the business.
Next up on the rung is that they want to have a profitable business. If they’re public and they’re traded, as many vendors are, than they want to have a dividend to their stockholders. They also want to keep the existing customers and acquire new. Keeping a customer is much less expensive than acquiring a new one. They want to keep existing customers happy.
On the top of the pyramid is engaging their employees and making a difference in the community. For many vendors making a difference means that they want to give back to their local community. Making a difference may also mean improving healthcare with their clients. Many of them do have an altruistic part of their model that says they want to make a difference in healthcare.
Some of the efforts they do to try and support these needs to sustain their business and avoid liability, they want to minimize liability actually and the contract will specify things that will limit their liability. Typically, it’s a limitation of liability clause. To keep customers and be profitable they charge support fees, that’s a big part of their income is that support fee. They need to manage their support efficiency through a multi-tiered help desk.
The way that they can also get new customers is to have a product development effort. All vendors have product development and they manage that, so for their employees they have workforce development. They have plans for people to move between development and support. They have plans for people to grow in their positions and part of the thing with these is there are barriers to these efforts that make it more difficult.
On support fees they have to make the product affordable. If they wanted to provide the top level of support that’s probably going to cost more, so they have to balance that with the affordability of the product. In support, one of the barriers is how to manage the priorities. Everybody’s problem is always considered number one and high priority, but that’s just not the case. They have to manage the priorities and some will be low and some will be high, which can be a barrier to support efficiency, making sure they effectively manage those priorities.
I’ll talk about how those priorities are managed from a vendor point of view and how you can escalate your issues to be a higher priority from their point of view.
They need to balance their product development and support. If you put too much money into development and you have a large development crew and you don’t put enough money into support, that will cause issues. You have to have a good balance between development and support and they have to be linked pretty closely.
The final barrier that I’ll talk about is the HIT workforce shortage that we’re going through at this time. There’s a significant shortage of healthcare IT staff. It’s true for providers as well as vendors. Go to your vendors website and I recommend this to people, go to their main site and look at what job openings they have. Be aware of how many people they’re looking for. Be aware of what areas they’re looking for staff in.
Many vendors have hundreds of job openings for implementation, development and support people. That’s a significant barrier right now. Vendors are all growing and there’s a lot of pressure on their existing employees that have a higher workload and they’re having a harder time finding newer employees. This is a barrier that’s important to keep in mind.
As you look at the point of view of the vendor, think about what drives them, what their business is and let’s look at the point of view of the healthcare provider.
You may disagree with some of this but I put in some of the hierarchy of needs for a provider too. This is a hospital or a clinic and their main priority is to keep the facility open, have financial security so that they can provide their mission and make sure the facility is safe and sound. Basically, I’ve worked in hospitals and clinics where the goal, particularly for hospitals is to be around forever, to be a resource for the community and that’s what that bottom part is talking about.
Moving up the ladder, patient safety is a critical piece as well as quality clinical care and making a difference in the community. Again, healthcare wants to engage their employees and physicians. They want to make sure that it’s a good place to work and they’re motivated. Some of the efforts they put in place, many of the facilities have ballot scorecards where they look at finance clinical and try to balance that. You can see the balance scorecard is one effort, while quality measures whether… most facilities are mandated to do certain quality measures and report them publicly.
They’re also doing quality measures that aren’t mandated just to make sure they’re delivering quality care. Facilities have safety programs where they make sure there’s a fall prevention program. To support patient safety many facilities are putting in electronic health records to improve quality and deliver that information out to the patients and make them more active participants in their care. The electronic healthcare record is a major effort right now.
All facilities have a workforce development program, whether that’s a physician engagement or staff development. There are paths for people to grow in their jobs and there’s awareness about how important it is to have engaged staff. Some of the barriers here, quality measures, how do you collect the data? Is the data put in the right place in the electronic health record if you have one? If you don’t have one in place then how are you doing your chart reviews? It’s a lot of work to go through to capture that data off paper and look at it.
The EHR support safety, do you have to put processes in place in facilities that actually make it less safe because of the EHR? That can happen and can be a significant barrier to safety. Does the EHR really support safety? How easy is the EHR to use? If it’s difficult to use you may not get physician engagement. You’ll have a harder time getting the staff to use it. That can be a barrier. Again, for workforce development, you’re dealing with an HIT workforce shortage as well and in rural areas in particular there aren’t many people, if any, available.
The HIT workforce shortage is causing a significant hardship for organizations to be able to implement and maintain electronic healthcare records. Workforce development there are other barriers too of availability of staff, physicians and other things I’m sure you’re aware of.
Contrast this a little with what the point of view of the vendor is. You can see that patient safety is an important thing for you and is also a fundamental thing for the vendor. So if something is a patient safety issue then you can bet that that will take a high priority for the vendor. If it’s how do you measure quality, that may not be as important to the vendor as it is to you.
So keep these points of view in mind. The vendor is coming from a little bit of a different angle.
Now I’ll talk a little about what issues are. It’s fundamental but I want to talk about what is an issue and what may or may not be an issue. Some things that are serious issues, a patient safety problem like orders that are lost, missed orders. If an order is placed in order entry or CPOE and is never delivered to the lab or pharmacy, that can be a significant patient safety issue.
Same thing with results coming back or mis-delivered results. Reliability can be a serious issue, so if there’s a software flaw that causes the system to be unreliable and you constantly have to put in paper processes or work around because of a software flaw then that’s a serious issue. If there’s a productivity waster, the screen changes are slow and you have to do some extra screens more than you think you should, those can be productivity wasters that probably aren’t considered a serious issue.
Those are usually considered a non-critical or minor issue. Look and feel things are never a serious issue. They can certainly help with engagement but they aren’t critical. Non-issues, at least for the vendor, are things like reliability due to your inaction. If the vendor has said you have a problem in your network because it’s outdated and some of the hardware is faulty or if the vendor tells you that your computers are so old that they aren’t going to work with our newer versions of the software very well. That’s a non-issue and they will shove that off.
If it’s due to a PC problem or something of your inaction then that’s a non-issue from the vendors point of view. It’s not their vault. If you take a poor workflow and overlay it onto the EHR and then say it’s not working because the way we overlaid our workflow onto the EHR isn’t helping. For example, if your workflow is to, you know, in the paper world to place lab orders on a piece of paper or order sheet and fax it to the lab, where somebody in the lab hears a fax machine go off, grab the order and enter it into the system. Then you implement CPOE and you want to mirror that.
You want to have CPOE put a fax down in the lab and have them react to that fact. It’s not designed to do that. They aren’t going to put special procedures into their system to support that kind of poor workflow. Workflow that’s not taking into account how the order should flow in the electronic healthcare record. Those are non-issues.
The next chart is intended to give you an idea of which items are appropriate for an issues list. One of the main tools for managing your issues is the issues list and I’ll go over what that should include. At this time I want to talk a little about categorizing your issues. I’m looking at something here that on the X axis going left and right is a measure of the risk versus convenience.
Something on the far left hand side is going to be something that’s closer to an inconvenience for the user and something on the right hand side is going to be a patient safety risk. The further you move to the right the riskier the problem is. On the Y axis I have the number of users that are affected. So going down it’s very few and going up it’s all users are affected.
The critical issues are going to be those that pose a significant risk and all or many users are affected. Some way you’ll manage through those is by putting in double checks, so if you’re losing orders, if low orders aren’t getting to the lab, the pharmacy or physical therapy and dietary than you may put in double checks where you’re having the order placed by nursing and then nursing makes a phone call to ensure the order is in.
You may put in backup procedures that are in place just to make sure that things are covered. In some cases, the system may need to be disabled. If the patient safety risk is high enough and it’s affecting all users, it may be wise to disable the system and go to a complete paper process, depending on the amount of risk.
Those are what I consider critical issues. These are issues where they take on a high importance. Going down to the yellow box, important issues are those that have a significant risk, but maybe don’t affect many users, maybe it’s one or two. You’d probably use checks and balances, maybe some double checks, but these are problems that usually require escalation and you should track those diligently.
Something that’s affecting all users and is an inconvenience further away from the risk scale, you may have a work around for it. It might decrease productivity, it’s called a non-critical issue, it’s something that’s non-critical. It’s not of high importance and it’s the sort of issue that should also be tracked. Keep an eye on these.
Something I would consider a non-issue or something that’s annoying. It doesn’t affect many users, it causes closer to the end of the inconvenience scale that you may have work arounds. You may be using the system improperly and this isn’t anything that’s worth fighting over with the vendor. It would be an enhancement request and the vendor might say it’s a great idea here’s how much it will cost if you want it put in place and you’ll have to figure out if that’s something that’s wise.
These two should be focused on the most. Those critical and important issues are the biggies.
Let’s look a little bit at what the vendors point of view is. On the X axis for the vendors point of view, when they’re looking at your issues and trying to prioritize them, they have a little bit of a different look. They still have a risk scale going from left to right on the X axis, which is low risk to high risk. Remember one of their fundamental needs is to minimize liability and make sure things are safe.
They’re also going to look at how many customers are affected. It’s probably a 3-dimensional graph, but for now let’s talk about risk and number of customers affected. On the Y axis we have the amount of effort. They need to balance their amount of resources that they have is limited so they need to balance what they work on, if it’s going to take a lot of effort versus a little effort.