CHAPTER 4 How to Avoid the Train Wreck hor Thorssen recalled that his assistant had put together some clippings on EHRs and placed them in his briefcase. Thor opened his briefcase— on the top of the pile was an ominous article entitled “Physician Ultimatum Forces Health System to Turn Off New Electronic Medical Record After Only Three Months.” The next article in the stack read “Down for the Count—Hospital’s Network Grinds to a Halt Under Weight of New Electronic Health Record.” After reading the stories, Thor was struck that if this could happen to highly regarded organizations, what would Dynamic need to do to avoid the same fate? Were there lessons learned from these organizations’ experiences that Dynamic could apply? Was Dynamic ready to move forward with an EHR project? Thor made a note to ask his CIO if there were objective means to assess Dynamic’s state of readiness prior to making a decision to move forward with implementation. T HOW TO AVOID THE TRAIN WRECK | 53 Success has a thousand fathers, but failure is a motherless child. — Ancient Proverb Healthcare in the United States now consumes more than 15 percent of gross domestic product, yet we generally do not live longer nor are we healthier than other developed nations that spend less than half that amount on healthcare (Goldman and McGlynn 2005). The reality of these statistics, along with the IOM’s report on preventable deaths in this country, has energized the federal and state governments in ways that will continue to put pressure on healthcare organizations (Kohn, Corrigan, and Donaldson 1999). Plans for reduced reimbursement rates will put a crimp on the bottom line, increasing pressures to ensure that any investments in capital have envisioned returns. Clearly, just by their sheer size, seven-, eight-, or even nine-figure EHR projects (depending on the size of the organization) should create an automatic heightened need for due diligence among healthcare executives. Nothing can get an executive fired faster than spending $50 million with nothing to show for it. 54 In their 2006 American College of Healthcare Executives (ACHE) Congress on Healthcare Leadership presentation, “IT Disasters: The Worst IT Debacles and the Lessons Learned from Them,” Ciotti and Hunter (2006) provided ample evidence of clear risks associated with large-scale IT projects if not properly executed. But as noted in Chapter 1, the opportunity costs of doing nothing are clearly mounting. So, given that EHR projects are not a walk in the park, we present a number of critical success factors that healthcare executives can use to increase the chances for a successful EHR implementation and avoid “the train wreck.” TECHNICAL AND ORGANIZATIONAL CAUSES OF IT FAILURE IT projects fail for both technical and organizational reasons. Technical factors are those connected with the actual information systems and supporting technical infrastructure. Organizational factors include issues connected with the work setting and the individuals within it. | THE EXECUTIVE’S GUIDE TO ELECTRONIC HEALTH RECORDS Some Technical Causes of Train Wrecks software that you can go see in stable operation at a peer organization. BUYING THE FUTURE. One of the technical reasons for failure is that all EHR systems still lack many desired functionalities. Likely, the most common train wreck of the past decade has involved buying the proverbial “vaporware”—software that you can see in demonstrations at trade shows and in slick sales presentations but cannot find being successfully used at any healthcare organization similar to your own anywhere in the country. The scenario for such a train wreck typically plays out like this—key executives of the healthcare organization are wined and dined and sold on the product, but actual users are kept as far away as possible from “kicking the tires.” Typically, the vendor offers significant discounts for the healthcare organization to be a “beta site,” or an early adopter. A contract without any delivery penalties is signed, and then the organization waits…and waits…and waits…pouring people’s time and the organization’s money at the continuing development efforts that never seem to materialize. The lesson learned from this generic case is that if you want to minimize risk, only purchase tried and proven EHR BUILDING A HOUSE ON A FOUNDATION OF SAND. While clearly not a sexy topic, the IT network infrastructure is the cause of the next most common train wreck. If your organization is like most, the IT network grew organically and eclectically. Recently, some fairly well-established integrated delivery systems had some well-publicized failures when bringing up new EHR functionality. These failures turned out to be caused by a network infrastructure that no longer could bear the weight of the additional transactions that the new EHR was trying to push through its aging pipe works. To be sure, network upgrades are not cheap endeavors. They easily can reach into the seven-figure range for even medium-sized healthcare organizations. However, rather than consider needed IT network infrastructure upgrades as part of the EHR project, these organizations either assumed the current network could bear the additional application or were not willing or able to shell out the additional funds for both a network upgrade and an EHR. These organizations learned the lesson the hard way, with days and HOW TO AVOID THE TRAIN WRECK | 55 even weeks of downtime and millions of dollars of revenue lost. Not only is the loss of revenue a major issue, but the loss of clinician confidence in the system can lead to future resistance to a new system even after the network problems get fixed. The lesson here is to have your IT department fully assess the impact of an EHR on the network infrastructure and, if needed, build network upgrades into the ten-year total cost of ownership of the project (see Chapter 1). WORKING WITH INCOMPATIBLE “LEGACY” SYSTEMS. In Chapter 2, we discussed some of the back-end systems that are needed to gain full advantage from the EHR. Often, a new clinical system is purchased without sufficient thought as to how it will integrate with the existing systems. Failure to achieve full integration can lead to the exclusion of key functionalities. For instance, if one wants to use clinical decision support systems to avoid duplicate laboratory test ordering, obviously the lab and the order entry systems must be integrated. Planning for this integration should be done up front, and, if extensive work is needed to achieve the integration, it should be factored into the cost of the project. 56 | EXECUTIVE TAKEAWAYS: TECHNICAL CONSIDERATIONS ■ ■ ■ To minimize risk, only acquire tried and proven EHR software that you can go see in operation at a peer organization. Shifting your core business processes from paper to electronic requires much higher levels of up time from the network infrastructure. Accomplish an infrastructure assessment when implementing an EHR, and be prepared to make infrastructure upgrades/enhancements a part of your EHR total cost of ownership. People and Organizational Factors The support of top leadership is a must-have for clinical IT project success. While the CEO will usually delegate to and rely on the IT department for review of the technical issues, the CEO’s involvement is crucial to avoid the organizational problems that are as, or even more, significant than the technical issues in leading to IT implementation failures. Below we review some common issues. LACK OF PHYSICIAN LEADERSHIP AND PARTICIPATION. EHRs with the key essential components of CPOE and CDSS absolutely require physician leadership and participation. Implementation of an EHR almost THE EXECUTIVE’S GUIDE TO ELECTRONIC HEALTH RECORDS always requires significant workflow analysis and often requires a major redesign of the processes. In addition, the design of appropriate CDS tools requires the input of the clinicians whose work is being supported. The IT department should not lead but rather serve as facilitators for physician leadership in the design of order workflows or alert and reminder settings. Weak physician leadership or weak participation by a physician design oversight team can lead to poor decision making with regard to system configuration settings. Fully understanding the current “as is” physician order work flow process and ensuring that a representative group of physicians is involved is critical as the process is automated into an EHR with CPOE and CDSS (see Chapter 2 for more detail on CPOE and CDSS). For instance, in one organization, the alerts were set at such a low threshold that physicians quickly became frustrated with the system’s constant alerts and reminders, most of which were for items that did not have a bearing on treating the patient at hand. In that organization, physicians threatened to walk out if they had to continue using the system. This might have been avoided had physicians been involved when decisions about alerts and reminders were being built into the system configuration. While the organization could have gone back and set the thresholds to alert only for specific and germane patient safety items, credibility and faith had already been lost with the physicians. Organizations would do well to select key influence leader physicians to serve on the oversight team for the EHR design/implementation team and also to obtain participation from a number of varied specialties. In fact, most organizations set aside some resources to compensate physicians for their time in working on the order and decision support design phase of the EHR. The physician leader or champion should not be what Dave Garets of HIMSS Analytics calls a “techno doc,” who never met a gadget he didn’t want to have, but rather should be a clinician who already holds a position of influence within the medical staff and who believes in the rationale for the EHR. INADEQUATE TRAINING AND SUPPORT. Institutions that rely primarily on residents to use the EHR may have an easier time of training, because residents are not only younger (and more familiar with and therefore receptive to new technology) but can also be required to undergo training. HOW TO AVOID THE TRAIN WRECK | 57 In most other settings, especially nonacademic hospitals or academic hospitals with a large contingent of community physicians, training may have to be customized and the physicians cajoled to get them to learn the system. Failure to provide adequate training, or failure to provide adequate high-touch support during the initial “go live” period, can lead to lack of use of the system, inadequate feedback for modifications, and ultimate failure. Both the timing and the mode of training are important. Training should be done on a just-intime basis—with enough time for key users to learn and practice before implementation, but not so long in advance that they will forget what they have learned. Also, physicians and nurses often have different learning styles, and the same mode of training may not work equally well for both groups. Physicians are often uncomfortable with group training sessions and one-on-one training may be needed. Support should be available 24/7 during the initial implementation period, even for users who supposedly were trained in advance. One famous early IT failure in the news mandated minimal training and certification on the new system. Although training was mandated, physicians were offered the 58 | opportunity to practice with the system, but they were not required to do so. The community physicians did not take the time to become familiar with using the system during the lead up to implementation and then complained that the system led to unsafe care. Their resistance succeeded in getting the system dismantled four months after it was rolled out. FAILURE TO UNDERSTAND REASONS FOR RESISTANCE. While any change in process may meet resistance, if your clinicians are anxious about using computers, they will have specific resistance to a new IT system. Don’t underestimate something as simple as typing or mouse skills. For an individual who cannot type well, the use of an EHR may be too burdensome. This factor will likely decrease if you use a combination of other input strategies, such as voice recognition, and as more clinicians become comfortable using the keyboard. Another factor is what could be called clinician role issues. This is resistance based on considering direct interaction with computers as outside the role of the clinician. Many clinicians see using a computer as a technician’s or clerk’s job, not that of THE EXECUTIVE’S GUIDE TO ELECTRONIC HEALTH RECORDS EXECUTIVE TAKEAWAYS: ORGANIZATIONAL CONSIDERATIONS ■ ■ ■ ■ Select a senior, respected physician leader to oversee the clinical configuration aspects of the EHR. Enlist and compensate a core group of representative physicians to work with the senior physician leader to make decisions regarding the clinical configuration of the EHR and thereby increase adoption. Set realistic expectations, and anticipate and reduce sources of resistance. Arrange for customized just-in-time training for all users of the system. a professional. While that perception may change in the future, for now these issues—even if not stated directly—can underlie resistance to EHR implementation. If these concerns are recognized, they can be addressed through more individualized training; but if they are not recognized, they can create an atmosphere that will exacerbate the inevitable tensions. ROSE-COLORED GLASSES. Because computers can do many things more quickly than people can, there may be an expectation that the computer will save the clinicians time when used to record orders or documentation. In fact, that particular part of the process may actually take longer than the manual process, which can lead to disappointment. What should be considered is the time taken for the entire episode of care—from that initial order being entered to the order being implemented with the patient. What the individual physician may not recognize is, for example, how much time he spends responding to questions about the order from other personnel or how long it takes for the order to actually be implemented with the patient. The entire care process is often more efficient using an EHR, but to an individual clinician it may not seem so. POOR EXECUTION. The single greatest cause of EHR project failures, and all IT project failures for that matter, is poor execution. We have all seen headlines in the popular press about IT systems causing rather than reducing medical errors. Reading the original articles on which the lay press reports were based shows obvious design and implementation problems (Koppel et al. 2005; Han et al. 2006). A recent Standish Group study found that only 29 percent of IT projects achieved the envisioned benefits (Hayes 2004). Organizations that fall into the category of the 71 HOW TO AVOID THE TRAIN WRECK | 59 percent who fail to achieve benefits often rely on the collected experience of the individuals who have previously implemented IT at the organization but typically do not employ disciplined project management methodologies, such as those suggested by the Project Management Institute (www.pmi.org). An EHR is an incredibly complex application that touches virtually every workflow process within a healthcare service delivery organization. Organizations that fall into the 71 percent typically go live and only then find out that large stakeholder groups or key workflows have been left out. These organizations wind up scrambling after the fact to reengineer processes that easily could have been proactively addressed had the organization followed disciplined project management methodologies, as described below. STEPS YOU CAN TAKE TO PREVENT TRAIN WRECKS Assess Organizational Readiness for an EHR Just like our fictitious CEO, Thor Thorssen, more than a few CEOs, COOs, and CFOs have ample cause to 60 | worry about large-scale IT projects such as enterprise-wide EHR projects. What these executives will find comforting is that an EHR implementation can be similar to the large-scale building projects with which they tend to be more comfortable. Very similar methodologies and questions can be asked to assess an organization’s readiness for investing in and implementing an EHR project. A highlevel EHR organizational readiness assessment checklist follows: ■ ■ Do all three ancillary departments (laboratory, radiology, pharmacy) already have stable ancillary information systems in place? Does the organization have a demonstrated successful capability within its IT department for interfacing the various information systems that are already in place? Some day in the future, vendors will begin to produce “out-of-the-box” interoperability, but because many of your pre-existing systems are built on old technology, you will still need the ability to interface the new EHR with these other THE EXECUTIVE’S GUIDE TO ELECTRONIC HEALTH RECORDS ■ ■ ■ ■ pre-existing systems (such as radiology, laboratory, pharmacy, billing). Is there enterprise IT governance of some sort that is representative of all of the stakeholders of the organization (we go into governance in more detail later in this chapter)? Does the organization have at least one, if not more, senior ranking physicians who are strong supporters of IT and can act as dedicated champions and influence leaders for an EHR project? Does the organization have a pre-existing investment in a stable and active enterprisewide continuous process improvement methodology/ function with demonstrated success in cross departmental workflow redesign (remember, an EHR initiative is actually just a large-scale organizational and cultural transformation project)? Does the organization understand the TCO of an EHR (see Chapter 1), and is it financially prepared to invest in an EHR? Cutting corners in an EHR project is not suggested. Analyzing the total long-term capital and operating costs and ■ ■ building a financial long-term plan and commitment to support the EHR project is vital. Do you have access to or are you willing to invest in short-term legal expertise accustomed to crafting and negotiating large-scale IT projects and preferably EHR contracts (see Chapter 3 for best practices in EHR contracting)? Many different contracting models for EHRs exist, so having experts with experience in such contracts can save you millions of dollars and significantly minimize your contracting risk. Has your team, prior to signing a contract, performed a workflow analysis of each of the major service lines (primary care, your main specialties, etc.) and identified opportunities for reengineering? Employ Disciplined Project Management Methodologies Many organizations are adopting formal project management methodologies to decrease execution risk and assure themselves prior to going live that they have done everything in their power to cover the bases. Figure 4.1 provides some high-level HOW TO AVOID THE TRAIN WRECK | 61 Figure 4.1—Project Management Processes Project Management Processes Initiation and integration • • • • • • • Develop project charter Develop scope statement Develop project plan Direct and manage execution Monitor and control project work Integrate change control Close project Scope management • • • • • Scope planning Scope definition Create work breakdown structure Scope verification Scope control Time management • • • • • • • • • Activity definition Activity sequencing Activity resource estimating Activity duration estimating Schedule development Schedule control Cost estimating Cost budgeting Cost control Quality management • • • Quality planning Quality assurance Quality control HR management • • • • HR planning Acquire project team Develop project team Manage project team Communications management • • • • Communications planning Information distribution Performance reporting Manage stakeholders Cost management 62 | THE EXECUTIVE’S GUIDE TO ELECTRONIC HEALTH RECORDS Figure 4.1 Project Management Processes (cont.) Risk management • • • • • • Risk management planning Risk identification Qualitative risk analysis Quantitative risk analysis Risk response planning Risk monitoring and control Procurement management • • • • • • Plan purchase/acquisition Plan contracting Request seller response (RFP) Select seller Contract administration Contract closure Source: Project Management Institute (2004). guidance regarding the formal processes that should be built into any IT project and particularly an EHR project. While the items in the table are not intended to be overly granular, insisting that your organization run the EHR implementation while employing disciplined processes will ensure that key aspects that have been shown to be major causes of EHR and IT project failures in general (e.g., stakeholder management and involvement, contract administration, scope creep) are explicitly addressed via the methodology. Establish Champions, Leadership, and Governance Effective leadership and oversight is often a top-of-mind reference in any coverage of success in any topic area, and EHR implementation projects are no exception. As mentioned earlier, physician leadership and participation is vitally important in an EHR implementation. We’d like to elaborate on that topic and add the element of effective governance of an EHR project. Some organizations tend to pick the techno doc physician to oversee an EHR project—unless that physician is a highly respected, HOW TO AVOID THE TRAIN WRECK | 63 influential leader as a clinician, the project is already at undue risk. Remember an assertion that we make over and over in this text—an EHR is, in reality, a large-scale organizational transformation project first and foremost. An EHR project will ask your organization to redesign longstanding clinical workflows. Change on that order of magnitude absolutely requires a respected physician leader who can influence changes in behavior not only among the physician population but also among the entire cast of characters involved in the patient care process. Typically, the medical director or chief medical officer is ideally suited to act as the champion leader of an EHR project. Many hospitals, in fact, are developing the position of chief medical information officer (CMIO), or some similar title, for that purpose and as an ongoing liaison with the physician community in regard to IT projects. If you do hire for such a position, you need to make sure that the individual has the ability to address and manage the issues discussed in this chapter and is not just a physician who loves technology. Given that you are able to enlist a respected physician leader, you need to establish a governance structure to leverage that physician leader. 64 | Typically, an EHR steering team is chartered by the executive committee of the healthcare organization and seeded with representatives from throughout the healthcare organization and physician group. Figure 4.2 depicts a sample EHR governance structure along with representation from a number of areas of the healthcare organization. Note that in this structure, the EHR steering committee is made up of senior influence leaders who will make key decisions regarding the EHR implementation, including but not limited to timing of events, major workflow redesign decisions, attempts at scope creep, and differences of opinion with respect to design and configuration. On the other hand, the EHR implementation team is ideally made up of individuals who are highly respected within the organization but who also will be the hands-on users of the system. Typically, the implementation team also should be led by a physician champion. The EHR implementation team is charged with overseeing the disciplined project management processes outlined previously—in essence, they do the yeoman’s work in designing the system, developing business rules for the order sets and alerts and reminders, and generally THE EXECUTIVE’S GUIDE TO ELECTRONIC HEALTH RECORDS Figure 4.2—Example of EHR Governance Structure Hospital or IDS Executive Committee EHR Steering Committee – Medical director (chair) – Group practice leader – Primary care physician – Surgeon – Key specialty physicians (2–4) – CIO – Key senior IT subject matter experts (1–3) – Purchasing/contracting officer – Revenue cycle leader – Legal counsel – Privacy officer – Director, records department – Professional project manager EHR Implementation Team moving the project through its paces. Additionally, the EHR implementation team is charged with periodic performance monitoring and reporting to the EHR steering committee. Develop Strategies to Reduce Resistance The inevitable resistance to change for projects of this magnitude can be reduced. In addition to training and post-implementation support, showing the benefits of the system to the user and aligning incentives will help achieve clinician commitment. IDENTIFY THE BENEFITS FOR USERS. Some of the benefits mentioned earlier, such as improved access and efficiency, may impress some users, but if a user is content with the present system and finds it efficient enough, efficiencies may not be a sufficient motivation to change. The added capabilities that using the system can provide for the individual user may be more persuasive. For HOW TO AVOID THE TRAIN WRECK | 65 instance, in addition to the potential for decision support and although the order entry process may take a little longer, a variety of types of reports can also be generated as soon as the data are entered. And, of course, the data are likely to be more accurate. Another benefit is customizing the view that is presented to the user. Several users can work with the same underlying database, but to save time and to adapt to individual physician needs, systems can often be set up to customize the way the information is displayed, the order sets, the preferred medications, and so forth. This is where the investment in high-touch support staff that can individually work with physicians to set up their own customized views will pay off in much higher adoption rates. We have said before that one way to decrease resistance is to encourage user involvement. To accomplish this, the implementation team should not only seek the input of the clinicians but may also want to observe the actual process of care. In many cases, the physicians may not be aware of all that goes on between their placing an order and having it implemented. Observation by an outsider can identify ways the process itself can be improved 66 | because you certainly don’t want to automate a process that is inefficient to begin with. As an example, a research study (Murray et al. 1998) showed that pharmacists had to correct more errors with physician order entry. The reason was discovered to be that they allowed free text entry of orders but had not built an automated correction mechanism into the system. Previously, the errors related to medication dosages may have been corrected by the personnel who had entered the orders into the system; this issue might have been detected before implementation of CPOE with careful observation of the whole process of order entry. A study that did such observations with a paperbased system found that physicians frequently did not provide complete information on the orders, leaving the nurses to fill in the details (Beuscart-Zéphir et al. 2004). Obviously, in some cases, the process itself needs to be modified or the information system needs to be designed to fit the actual, not the theoretical, processes. In the examples described, for instance, free text might not be optimal for order entry, or some other mechanism for correction might need to be incorporated. THE EXECUTIVE’S GUIDE TO ELECTRONIC HEALTH RECORDS EXECUTIVE TAKEAWAYS: STEPS FOR SUCCESSFUL IMPLEMENTATION ■ ■ ■ ■ ■ Assess the readiness of your organization as part of the planning for the EHR project. Overcome failures of execution by employing professional project management methodologies. Make sure EHR project steering committees and implementation teams have adequate and engaged physician leadership and representation. Put in place an effective EHR governance structure to leverage your physician leader and provide him or her with the support structure for success. Reduce resistance and encourage adoption of the EHR by demonstrating benefits and aligning incentives. ALIGN INCENTIVES AND REWARD ADOPTION. Another key factor in reducing risk to your EHR project is to fully understand where benefits accrue and, therefore, where you need to focus incentives to reward adoption. As we noted in Chapter 1, most of the benefits of an EHR accrue to the hospital and to managed care organizations, insurers, and employers. Downstream benefits do accrue to physicians in the form of actually having the information they need to practice more informed medicine and gaining accounts receivable via cleaner, information-supported billing. However, some physicians are burdened by the electronic entry required by CPOE and therefore continue to shun adoption. Additionally, prior to the new safe-harbor Stark provision, many physicians found investment in EHRs too high for their practices. In its review of financial, legal, and organizational approaches to achieving electronic connectivity in healthcare, the Markle Foundation suggests that “financial incentives, regardless of the way in which they are derived (e.g., pay for performance or another incentive structure) for small and mediumsized practices will need to cover most of the initial costs of the EHR. Incentives in the range of $12,000 to $24,000 per full-time physician per year should achieve broad adoption of EHR on an accelerated timetable” (Markle Foundation 2004). With respect to opportunity costs discussed in Chapter 1, organizations that have EHRs in place when the Stark safe-harbor law is enacted will be poised to attract community physicians that may not want to invest in an EHR for their office setting but would be willing to adopt the EHR of their preferred referral hospital. Even before the safe-harbor provision is put in place, organizations like the Cleveland HOW TO AVOID THE TRAIN WRECK | 67 Clinic are providing incentives for unaffiliated community referring physicians to use their EHR for the market rate of $7,200 per physician per annum (Harris 2006). While the Cleveland Clinic boasts modest adoption among these physicians, the new safe-harbor provision will allow them—and all healthcare organizations—to offer the EHR at greatly reduced rates, thereby better aligning incentives for adoption and rewarding the physicians for using an EHR that will greatly benefit all of the actors and stakeholders in the care delivery process. SUMMARY ■ ■ ■ The causes of an EHR project train wreck are not that dissimilar from other IT project failures. If risk mitigation is an important consideration, then healthcare executives are cautioned to absorb lessons learned about the success and failure of EHR projects described in this chapter. These include the following: ■ ■ Beware of “buying the future.” To minimize risk, seek out proven vendor products that are in productive use at other 68 | healthcare organizations that are similar to your own organization. Do not build your house upon a foundation of sand. Recognize the need to assess your organization’s IT infrastructure for necessary upgrades to sustain the new EHR transactions. Recognize the need to interface the new EHR with some of your pre-existing, legacy applications. Ensure that your IT department has assessed the interface needs and is comfortable that the vendors’ products can be successfully interfaced. Recognize the need for strong influential physician leadership (not a techno doc) for the EHR project. Remember that EHRs are large-scale cultural and clinical workflow transformation projects and need influential leaders to gain the needed changes in workflow design and caregiver behavior. Do not skimp on training and high-touch implementation support. Physicians in particular need one-on-one training and high-touch THE EXECUTIVE’S GUIDE TO ELECTRONIC HEALTH RECORDS ■ ■ ■ implementation support to increase adoption. Plan to proactively address the likely resistance to change you will encounter in an EHR project. Minimize EHR project failure risk by instituting professional project management methodologies as prescribed by the Project Management Institute. Create a strong EHR project governance to oversee all aspects of the EHR project; the EHR steering committee should be led by a strong, influential physician ■ and be seeded with equally strong representatives from throughout the organization. Be sure to align rewards and incentives in a way that increases the likelihood of adoption of the EHR. While no prescriptions for complex IT projects are fail-safe, employing these measures will significantly reduce your organization’s risk exposure and increase the likelihood of a successful EHR implementation. REFERENCES Beuscart-Zéphir M. C., S. Pelayo, P. Degoulet, F. Anceaux, S. Guerlinger, and J. Meaux. 2004. “A Usability Study of CPOE’s Medication Administration Functions: Impact on Physician-Nurse Cooperation.” In Medinfo 2004, edited by M. Fieschi, E. Coiera, and Y.-C. J. Li, 1018–22. Amsterdam: IOS Press. Ciotti, V., and D. P. Hunter. 2006. “IT Disasters: The Worst IT Debacles and the Lessons Learned From Them.” Presentation at the American College of Healthcare Executives Congress on Healthcare Leadership. Chicago, March 28, 29. Goldman, D., and E. McGlynn. 2005. U.S. Health Care: Facts about Cost, Access and Quality. Santa Monica, CA: RAND. Han, Y. Y., J. A. Carcillo, S. T. Venkataraman, R. S. B. Clark, R. S. Watson, T. C. Nguyen, H. Bayir, and R. R. Orr. 2005. “Unexpected Increased Mortality After Implementation of a Commercially Sold Computerized Physician Order Entry System.” Pediatrics 116 (6): 1506–12. Harris, M. 2006. “The eVolution of the Practice of Medicine: Electronic Medical Record Technology in Practice” Responses to Questions. The Healthcare Technology Summit, La Quinta, CA, May 8. Hayes, F., 2004. “Chaos is Back.” Computerworld, November 8. HOW TO AVOID THE TRAIN WRECK | 69 Kohn, L., J. Corrigan, and M. Donaldson (eds.). 1999. To Err Is Human: Building a Safer Health System. Washington, DC: National Academies Press. Koppel, R., J. P. Metlay, A. Cohen, B. Abaluck, A. R. Localio, S. E. Kimmel, and B. Strom. 2005. “Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors.” Journal of the American Medical Association 293 (10): 1197–203. Markle Foundation. 2004. “Financial, Legal and Organizational Approaches to Achieving Electronic Connectivity in Healthcare: The Working Group on Financial, Organizational and Legal Sustainability of Health Information Exchange.” Connecting for Health [Online white paper; retrieved 10/31/06.] http://www.connectingforhealth.org/resources/generalresources.html. Murray M. D., B. Loos, T. Wanzhu, G. J. Eckert, X. Zhou, and W. M. Tierney. 1998. “Effects of Computer-Based Prescribing on Pharmacist Work Patterns.” Journal of the American Medical Informatics Association 5 (6): 546–53. Project Management Institute. 2005. A Guide to the Project Management Body of Knowledge (PMBOK Guide), Third Edition. Newtown Square, PA: Project Management Institutue. 70 | THE EXECUTIVE’S GUIDE TO ELECTRONIC HEALTH RECORDS
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