Research Publication Date: 27 September 2011 ID Number: G00219503 Case Study: Dartmouth-Hitchcock Medical Center Establishes Effective IT Support Triage Jarod Greene, Ben Flam To appropriately support the rollout of an electronic health record (EHR) system, the Dartmouth-Hitchcock Medical Center (DHMC) undertook a just-in-time support approach from people, process and technology perspectives. Healthcare delivery organizations (HDOs) and organizations outside of healthcare with comprehensive application deployments should first understand the support components and requirements to better position themselves for a support strategy throughout the implementation life cycle. Key Findings DHMC's EHR implementation success is credited to careful planning, departmental collaboration, strong executive leadership, proactive stakeholder communication and end-user engagement throughout the implementation life cycle. Careful planning of postimplementation support enabled DHMC to determine the appropriate support roles and responsibilities for the rollout. The recognition of roles and responsibilities provided effective triage support that focused on resource optimization. Recommendations Engage executive leadership and stakeholders at the outset of projects to better understand support requirements. Identify support staff by anticipating demand. Account for current capabilities when determining specific roles and responsibilities to optimize resources. Request resources within the business for support that can be leveraged as ongoing subject matter experts (SMEs) after the initial support rollout. Enable mechanisms to provide reporting and dashboard capabilities throughout all project phases. Establish audience-appropriate reports and dashboards by distinguishing between executive leadership, operational, tactical and end-user metrics. 2011 Gartner, Inc. and/or its affiliates. All rights reserved. Gartner is a registered trademark of Gartner, Inc. or its affiliates. This publication may not be reproduced or distributed in any form without Gartner's prior written permission. The information contained in this publication has been obtained from sources believed to be reliable. Gartner disclaims all warranties as to the accuracy, completeness or adequacy of such information and shall have no liability for errors, omissions or inadequacies in such information. This publication consists of the opinions of Gartner's research organization and should not be construed as statements of fact. The opinions expressed herein are subject to change without notice. Although Gartner research may include a discussion of related legal issues, Gartner does not provide legal advice or services and its research should not be construed or used as such. Gartner is a public company, and its shareholders may include firms and funds that have financial interests in entities covered in Gartner research. Gartner's Board of Directors may include senior managers of these firms or funds. Gartner research is produced independently by its research organization without input or influence from these firms, funds or their managers. For further information on the independence and integrity of Gartner research, see "Guiding Principles on Independence and Objectivity" on its website, http://www.gartner.com/technology/about/ombudsman/omb_guide2.jsp
WHAT YOU NEED TO KNOW Dartmouth-Hitchcock Health (DHH) is an integrated delivery network (IDN) located throughout New England consisting of physicians, specialists and other healthcare providers working to meet patient healthcare needs. DHMC is one of several facilities that comprise the DHH IDN. Others included the Dartmouth Medical School (in Hanover, New Hampshire) and White River Junction VA Medical Center (in White River Junction, Vermont). DHMC has 335 licensed beds currently in operation, and 2010 revenue of slightly more than $1.2 billion. To improve the quality of clinical care, DHMC sought to acquire a comprehensive EHR system. EHR systems are integrated point-of-care systems used by clinicians of acute care HDOs to facilitate the delivery of care across the continuum and that, at a minimum, provide functionality for outpatient/ambulatory and inpatient/acute care settings (see "Clinical IT Terms: Globally Aligning the Use of EHR, HIE, PHR and Others"). Typically, successful implementations are credited to careful planning, departmental collaboration, strong executive leadership, proactive stakeholder communication, and end-user engagement throughout the implementation life cycle. The HDO must also consider how the EHR implementation will be supported and understand the roles and responsibilities of the primary constituents using the EHR: clinicians. Clinician-generated service requests offer unique challenges, because their issues can affect patient care, requiring the service desk to quickly respond and resolve the problem. CASE STUDY Introduction DHMC chose Epic Systems' (Epic) EpicCare suite, which included 14 modules (see Note 1). This was an $80 million initiative, requiring considerable time and resources for implementation, and was set for roll out on 1 April 2011. To support EHR services, DHMC first considered using a SharePoint-based solution for EHR incident, tracking and reporting purposes. However, through testing, it was determined that SharePoint would not meet requirements related to issue workflow, reporting capabilities and collaboration extensibility. In a separate IT project, DHMC had recently replaced its homegrown IT incident management solution with an off-the-shelf IT service management (ITSM) solution (Cherwell Software). Having completed that deployment in October 2010, considerations were made shortly after to leverage Cherwell for support of EpicCare. DHMC needed to test Cherwell's extensibility quickly. A clinical transformation team of 65 members was already in place to facilitate the EpicCare rollout (branded as ed-h), and Cherwell was piloted for support of Epic Willow, an in-patient pharmacy module that was set for deployment prior to ed-h. By 22 January 2011, all Willow-related data was entered into Cherwell, and the module was effectively supported. Due to the success of supporting Willow, DHMC executive leadership decided that Cherwell would fully support the ed-h go-live. By December 2010, Cherwell (branded as Dartmouth-Hitchcock Service Management) was implemented into production. The Challenge With the solution in place, DHMC was faced with determining the appropriate postimplementation support structure to triage issues in an effective and efficient manner. Two IT service support administrators were given to the clinical transition team. These individuals gathered requirements and requested the appropriate reconfigurations for Cherwell. This required careful planning and departmental collaboration among executive leadership, clinicians and the IT organization. After identifying the support requirements, the roles and responsibilities for each support level were defined, enabling IT support to optimize skilled resources appropriately. Publication Date: 27 September 2011/ID Number: G00219503 Page 2 of 9
DHMC originally considered leveraging SMEs as an initial point of contact to support each EpicCare module. Doing so would enable users to take advantage of point expertise in a consistent manner. However, DHMC realized that SMEs would not enable the service desk to effectively handle the anticipated volume appropriately, nor would this model enable the cultivation of knowledge across all support levels. Approach A four-tier, single-point-of-contact model was developed to optimize support resources and allow issues to be triaged appropriately: Level 0 Local support of 600 power users, whose sole job for the go-live period was to support ed-h, and trained to direct self-service for incident/request management submission of issues. Level 1 A call center of 50 agents (over three shifts), composed of the normal help desk, and individuals from the enterprise and term-limited new hires with no prior IT help desk experience. These agents were not contractors, and only four term-limited staff were hired for the implementation. This tier received one day of just-in-time training, a single business day prior to the rollout. Level 2 A 24/7 technical command center, composed of several hundred ed-h configuration staff, technical staff and Epic consultants, each with his or her own phone and laptop. This included 200 Epic consultants, 60 application configuration analysts, 60 internal IT team members and 30 clinicians. Level 3 An incident command center, composed of two rotating senior directors of clinical systems who required reporting on high-impact and priority incidents. The CIO, chief medical informatics officer (CMIO), chief nursing informatics officer (CNIO) and Epic project director were also at the "commanders table" for technical command center (TCS) leadership. Operations incident commanders also rotated between the chief nursing officer, vice president of operations, and vice president of facilities. This group was created to ensure that IT resources were being applied to the areas with the mostcritical requirements (see Figure 1). Publication Date: 27 September 2011/ID Number: G00219503 Page 3 of 9
Figure 1. ed-h Incident Command Structure Source: Dartmouth-Hitchcock Medical Center Publication Date: 27 September 2011/ID Number: G00219503 Page 4 of 9
Results On 4 April 2011, the ed-h went live. The initial emphasis was placed on training the call center staff to provide initial incident triage. By managing incidents by support level, all calls were ticketed in the service management system. Urgent calls from clinicians that stated they were unable to provide care were quickly transferred to a command center specialist. Call tree documentation was provided for triage so that local support unfamiliar with standard support scripts could leverage them to route issues to the appropriate specialists. As many as four call center experts circulated to assist any agent handling a difficult request. Procedural escalation enabled optimization at Level 1 by ensuring that instances where they did not have the skills to resolve an issue were escalated to an SME who did. As the projected incident volume exceeded the projected call center capacity, IT self-service became an essential component of success. Of the 2,000 incidents entered daily for the peak golive period, more than half were entered via the IT self-service portal. Self-service eased triage of phone support and reduced the impact of the call center, enabling them to achieve sub-14- second average answer time. In the first three weeks of the go-live, self-service utilization spiked as high as 1200 issues self-ticketed in a single day, but eventually quelled by week four. Because they handled the initial rush of activity so well, the call center was able to step down to an augmented version of the help desk after 14 days. Upon transition, the call center shared FAQs, tips and tricks, and guidance with the traditional service desk's analysts (see Figure 2). Publication Date: 27 September 2011/ID Number: G00219503 Page 5 of 9
Figure 2. Number of Incidents Entered Daily Source: Dartmouth-Hitchcock Medical Center Throughout the go-live, the incident command structure and executive leadership teams had realtime access to performance dashboards. The ed-h dashboard provided feedback on the impact of incidents on their business units and enabled prioritization of assistance to the technical command center. There were 237 different reports preconfigured for ed-h. These reports could be run by any member of leadership or management. A feature of the service management platform provided access to system data from any machine with Internet access, when customer service management (CSM) was not installed on the local client incident command center. and executive leadership reported that the dashboard viewer and reporting engine were very easy to use, and the access method did not require the purchase of additional licenses. Critical Success Factors Departmental collaboration among executive leadership, clinicians and the IT organizational collectively anticipated the demand and organized support to meet it. By Publication Date: 27 September 2011/ID Number: G00219503 Page 6 of 9
making support of the business objective an early consideration, IT was better positioned and informed to support ed-h more efficiently. Careful planning of postimplementation support considerations enabled DHMC to understand and determine appropriate support roles and responsibilities, as well as the scope of services provided to organize support in a manner that optimized resources appropriately. Easy, accurate reporting and using dashboards for all support levels unified local incident commands with the technical command center and enterprise incident command center. IT self-service eased call center phone support. By placing an emphasis on IT selfservice for entering tickets, call center agents were more readily available to field highpriority support calls. Lessons Learned Organizational change management was paramount in providing the appropriate amount of support for the launch. Executive leadership's ability to gain buy-in from all members of the organization was essential in mobilizing resources to provide support for a rollout critical to the business. The recognition of roles and responsibilities provided effective triage support that focused on resource optimization. By understanding the importance of a single point of contact from an enterprise perspective, users receive service support from the appropriate resource as quickly as possible. Real-time reporting and use of dashboards allowed leadership to view ed-h open problems, incidents waiting for triage and incidents by urgency. Views were fully customizable, without burdening IT to generate reports in an ad hoc fashion. It also provided insight into recurring issues requiring immediate attention. Self-service's ability to enter tickets, instead of phone triage for support, reduced call volume, and provided visibility into frequently trending issues. It also served as the platform to centralize and document knowledge, seen in the user feedback for FAQs and tips and tricks. RECOMMENDED READING Some documents may not be available as part of your current Gartner subscription. "IT Service Desk Organizational Principles for Resource Optimization" "Addressing IT Self-Service Myths and Realities for Successful Implementations" "Clinical IT Terms: Globally Aligning the Use of EHR, HIE, PHR and Others" "Healthcare Delivery Organizations Must Address the Growing IT Support Crisis" Note 1 EHR Modules Implemented by DHMC EpicCare EMR In-patient clinical documentation Publication Date: 27 September 2011/ID Number: G00219503 Page 7 of 9
In-patient order entry ASAP Emergency Department Information System Beacon Oncology Information System Kaleidoscope General Ophthalmology Cardiant Cardiovascular Information System Stork Obstetrics/L&D Information System MyChart EpicCare Link Health Information Management OpTime Epic Clarity Identity Enterprise Master Patient Index (EMPI) Publication Date: 27 September 2011/ID Number: G00219503 Page 8 of 9
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