Implementing a Total Healthcare Enterprise Resource Planning System Omar Adwan 1, Azzam Sleit 1*, Mohammed Qatawneh 1, Ammar Huneiti 1, Tawfiq Khalil 2, Abdel Latif Abu Dalhoum 1* 1 Department of Computer Science, King Abdulla II School for Information Technology, University of Jordan, P.O. Box 13898, Amman 11942, Jordan {Adwanoy, azzam.sleit, Mohd.qat, a.huneiti a.latif}@ju.edu.jo 2 Department of Computer Science, Oakland University, Michigan, USA ttkhalil@oakland.edu * On Sabbatical leave from the University of Jordan Abstract Efficient patient care delivery by physicians and clinicians is a necessity for healthcare organizations. Physicians need timely access to patient data and information stored in the hospital and clinical information systems. The integration of information systems must be seamless to the user. Physicians may need to use multiple systems and workstations throughout the hospital when assessing and diagnosing patients. We propose a Total Healthcare Enterprise Resource Planning (THERP) system for healthcare organizations with a single point of access and synchronized view of all applications, regardless of the location of access. The THERP system may improve outcomes, reduce errors, prevents mistakes, speeds information access, and automates charge capture by capturing charges versus cost in real-time. The aim of this paper is to provide an overview of guiding principles and benefits of a THERP system. A six phase implementation methodology is presented with timelines. A THERP system views technology as an integral part of an organization s overall business strategy. Keywords: THERP, ERP, Health Information Management System, Computer Aided Software Engineering, Business Process Re-engineering 1. Introduction A revolution is taking place in the healthcare field with information technology (IT) playing an increasingly important role in its delivery. The United States spends an estimated $2 trillion annually on healthcare expenses which represents more than 17 percent of its GDP in 2009 [1]. Further exponential growth is expected as the healthcare industry implements electronic medical records upgrading Health Information Management Systems (HIMS) into a Total Healthcare Enterprise Resource Planning System (THERP) and setting up intranets for sharing information and providing remote diagnostics via telemedicine. Studies demonstrated that the use of computers by physicians resulted in charges and hospital costs that were 13% lower per admission than those generated by physicians in a control group [5]. Also, 44% of the physicians who participated in the study felt that using the system for direct order entry helped them to perform their clinical work faster and 52% felt that the system made their work easier [2]. Total Healthcare Enterprise Resource Planning (THERP) is a classification of the ERP category, which is designed to operate the entire healthcare functionalities and all related activities including finance, materials management, human resources, and decision support. ERP (i.e. Enterprise Resource Planning) is a derivative of "Manufacturing Resource Planning", which has become an old term because industry professionals were not being successful with it due to the limitations of the software tools which existed at that time. This was known as MRP II to differentiate it from an earlier term "Material Requirements Planning", which meant more or less the same thing. The substitution of the word "Enterprise" for "Manufacturing" was actually quite convenient because it allowed people to extend the concept to organizations that do not manufacture anything. There are three basic themes of an ERP system [2][3]. Firstly, the unification by means of a common database of the basic record keeping needs of the enterprise. For a normal enterprise this would involve the activity of Logistics, Services, Production, Finance, Human Resources, Materials Management, etc. The records would include orders, suppliers, purchases, assets, bills or materials, inventories etc. Secondly, the ERP implements the notion of an integrated financial control where all activities in the
enterprise generate the appropriate entry in the book keeping systems. Thirdly, the ERP focuses on the management of resources of the enterprise by dealing with the fundamental issues of priorities and capacity. Before implementing a THERP system, the healthcare organization must agree on guiding principles to assist in defining and achieving the vision of a state-of-the-art digital hospital. These guiding principles will act as a starting point for the THERP system but will need to be revised as the overall vision of the organization becomes clearer and increasingly granular. The following are typical guiding principles: The selection of health care and clinical information systems and vendors will support a wireless, paperless, and filmless environment. Policies and procedures, process workflow design, and supporting administrative and clinical information functionality will support the ability to focus service at the point of care. Automating supporting functions including finance, purchasing, stocks, and human resources in order to ensure integration with the core health information system. Enhancing capacity planning by providing online access for dynamic reports and real-time data across the enterprise. Dynamic reporting tools provide ad hoc reporting capabilities which can be built online and run on as needed basis without the need to go back to the programmers. True data and workflow integration between all functional areas will exist and redundant processes will not be tolerated or deemed acceptable. All information technology decisions made will complement the hospital s goal in being as digital as possible. The healthcare organization should view the THERP system as an integral and fundamental part of its overall business strategy. It is recommend that technology is applied to every facet of clinical and business operations, integrating people, process, technology, and cultural elements [5]. The healthcare organization should not implement only core healthcare information and ancillary systems, but expand its implementation to include: the comprehensive medical device spectrum, from patient beds and surgical equipment to lighting systems and pagers. The organization should leverage industry standards and legislation to enhance connectivity with stakeholders and business partners outside the hospital [6, 7]. It will be imperative to plan for the next generation of product and industry evolution to ensure current efforts are scalable as the industry and standards evolve in the future. Clinical and business operations, patient safety, and operational performance will be optimized by building a state-of-the-art, world-class digital hospital complete with leading-edge technology [8, 9]. Figure 1 demonstrates the comprehensive elements necessary to build a world-class THERP system. In order to maximize the overall value of the technology investment, there will need to be a focus on assuring integration among the individual elements. Finance Data warehouse DSS Quality Management Human Resources THERP Materials Management Healthcare core Healthcare none-core Figure 1. A Total Healthcare Enterprise Resource Planning System Applications and Technologies
2. Benefits of a THERP System Key technology applications require a clinical data repository that contains longitudinal medical records of every individual served by the healthcare delivery system. Clinical decision support applications that mine the clinical data repository provide evidence based practice information in real time to facilitate safe and effective patient care. These applications are accessed through an electronic medical record application that includes 1) a longitudinal collection of health information about the medical history, current health status, and professional healthcare services provided to an individual, 2) immediate access to health information by the individual, health care providers, and researchers, 3) decision support that enhances quality, safety and efficiency of patient care, and 4) support of efficient cost-effective processes for health care delivery. Due to the electronic nature of the technology and connectivity access, healthcare professionals are able discuss patient needs in real time, viewing the same data from anywhere in the world. Consultation with a specialist or research expert can be done any day, any time based on the needs of the patient or health care provider. Libraries no longer have geographic limitations. The public and professionals can search for specific health care information online as needed [3]. Inpatient length of stay may drop substantially due the utilization of a THERP system. The efficiency of invasive technology has reduced open surgery to camera and robot assisted surgery decreasing complications and speeding recovery time. Outpatient care is growing at more than twice the rate of inpatient care due to advanced technologies that facilitate minimally invasive surgery and home monitoring technology. Terminal tumors are being treated by laser intervention requiring only an outpatient stay. Endoscopic diagnostic work-ups are done at home with a video capsule [4]. These incredible advances in healthcare delivery efficacy are a compelling argument to move forward with a comprehensive THERP system despite the barriers of cost and resistance to change. The need for a longitudinal medical record with legitimate data mining to continually update evidence based clinical decision applications provide a societal benefit that is undeniable. Technology is propelling the world-wide advancement of health care offering the greatest opportunity to implement best practices, utilize evidence-based medicine, reduce human error, improve efficiency, compile comprehensive health data sources, and provide minimally invasive care tools. Technology is removing access to expertise barriers through telehealth and telemedicine. THERP systems can rapidly convert from analog to digital distribution of information. In the future, all information and communication will convert to digital format in which the Internet will link millions of providers, services, and settings link seamless web of care [12]. Healthcare organizations will have the ability to transform how care is delivered. Healthcare in the future will become a global industry where patients will seek out the best-of-the-best medical practitioners and facilities in the world. With the transformation into a THERP system, a healthcare organization has the opportunity to: Attract world-class physicians, clinicians, and researchers by providing a very effective and efficient environment. Dramatically improve the quality of care for patients. Become a recognized Center of Excellence and healthcare destination of choice. Transform how medical care is delivered. Streamline care delivery, eliminating duplicate and manual processes. Proactively increase patient safety through the use of efficient and effective information systems. 3. Implementation Methodology and Timelines Computer software implementation methodologies have been around for close to 40 years. Beginning in the 1960s, common standards were developed to make development and maintenance of software easier. The 1970s brought a systems approach. During this time, hardware cost began to fall rapidly, and programming became less of an art and more like a manufacturing process [3]. The 1980s saw the advent of structured systems approaches, where business needs and not just information technology (IT) needs, began to be considered. CASE tools were developed to automate the process of turning a business requirement into programs. Some argue that today s enterprise resource planning solutions are nothing but Computer Aided Software Engineering (CASE) tools. In the 1990s, the coincident emergence of business process re-engineering (BPR) led to the attempt to user enterprise resource
planning information technology as an enabler for process enhancement. Today, enterprise-engineering solutions allow organizations to forget about developing software and instead concentrate on developing business solutions using packaged software. When implementing ERP s, it is necessary to follow a clear and well-defined structured approach for accomplishing the massive work effort. A THERP implementation is often the largest business change activity a healthcare organization may ever undertake. An implementation methodology serves to break down the entire work effort into a series of steps that must take place over time, in the proper sequence or in small groups of parallel steps. The implementation of a THERP system must go through the following six phases: Operations and Procedure phase: This phase is responsible for revising and documenting all processes of the healthcare organization taking into consideration best practices. Software selection phase: Based on the strategic goals of the healthcare organization and the documented operations and procedures, a software package that best meets the organization s requirements and budget is selected. It is essential to ensure that the selected software follows standards such as the Health Level Seven International (HL7) and Digital Imaging [10, 11] and Communications in Medicine (DICOM). Customization requirements phase: During this phase a comprehensive gap analysis is conducted between the requirements of the organization and the specific functionalities of the software. The Operations and Procedures phase may have to be revisited to make sure that best practices offered by the software package are preserved. Keeping in mind minimal customization requirements will help expedite the implementation of the system as well as future upgrades. System implementation phase: The document generated as an outcome of the Customization requirements phase is used to customize and set the parameters of the software. Additional functionalities may have to be added or altered depending on the requirements. Data migration, training and testing phase: This phase is responsible for data cleansing and movement from legacy systems into the THERP system. User training will be conducted on restricted data views. Systems testing by technical staff as well as user-acceptance testing are conducted before the end of this phase. Offline/Online Live phase: This phase starts with Offline operations where THERP is run in parallel with existing systems in order to further validate the new system and fine tune the databases to ensure acceptable response time for various functionalities. The Offline Live step is followed by Online Live where the organization becomes mainly operational using THERP. Figure 2 provides a detailed proposed THERP implementation methodology based on the six abovementioned phases.
Discussions Of Operations & Procedures Familiarization on Training Discussions of Proposed operations & Procedures report Revision Of Proposed Operations & Procedures Report Final Operations & Procedures Document Gap Analysis Documentation of Customization Specifications Discussions of Customizations Specifications Final Customization Specifications Documents Design Development Design & Order Initial Data Setup Data Conversion Design User Role Definition Testing Quality Control of Forms/Cards and -Documentation Specifications & Documentation Preprinted Stationary -Discussions Definition Initial Data Setup Entry into the Control Files Development of Data Conversion Software Validation & Acceptance Documentation Testing of Data Conversion Software Developing test cases Delivery & Installation of THERP System Software System Testing Training Data Migration Forms Availability Environment Creation (Database, Procedures, Data Setup Entry into the Control Files Offline Live Online live Figure 2. A proposed THERP implementation methodology
Figure 3 provides a high-level THERP implementation timelines plan that spans four years. The plan was developed for the implementation of a THERP system for a healthcare organization which consisted of five hospitals and twenty-five primary-care centers. The five hospitals had a total of 2,500 beds in addition to outpatient clinics. The proposed timelines may differ depending on the customization requirements. The cost of implementing a THERP system may substantially vary depending on the expenses of human resources in the county, volume of customization requirements, selected software and the readiness of the healthcare organization to undertake such a strategic project. Stages Years 1 2 3 4 5 - Detailed Planning and Project Operations Planning & Procedures Phases 26 months Strategic Software Selection Partner/Vendor & Customization Selection requirements phases 98 months Detailed System implementation Implementation & Planning Data migration phases 4 months 24 months Implementation Training 4 months Go-Live Offline live 6 months Ongoing Online live & Support ongoing support Ongoing Figure 3. Proposed timelines for implementing a THERP system. 4. Conclusion Healthcare organizations of the future will be differentiated by a top-down strategic investment in implementing a THERP system to optimize clinical, financial, and administrative processes. The hospital of the future is more than an electronic patient record as it involves integrating the full spectrum of technology in a hospital linking clinical systems with various medical devices, smart equipment, telecommunication technologies, and bioinformatics applications to form the basis of the intelligent hospital. Medical devices and clinical information systems must be integrated to have a truly digital health environment. A THERP system views technology as an integral part of the overall business strategy. Technology is applied to every facet of clinical and business operations; integrating people, processes, and technology. This includes integrating medical devices, patient beds, surgery rooms, hospital lighting systems, HVAC systems, mobile phones, PDAs, pagers, and other devices that act as both input and output instruments. Under this framework, clinical and business operations are optimized which may lead to a dramatic improvement in patient safety, financials, and operation metrics. Technology planning for a THERP system should be embedded in the overall strategic planning process of the healthcare organization.
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