Clinical Information System Implementations: A "Three-Way" Street

The centerpiece of many current Healthcare Information Technology (HIT) outsourcing initiatives is the buyer's (Buyer's) decision to implement a new Clinical Information System (CIS) as a principal part of the HIT outsourcing. Unfortunately, Buyers have traditionally gone down one of two roads with their IT outsourcing supplier (Supplier) in accomplishing their CIS objectives - neither path being the best route to a successful CIS implementation.

Proceeding on Either of the Commonly Taken One-Way Streets. On the first road, the Buyer decides that it will "take the lead" on CIS implementation (because, ostensibly, only the Buyer can decide what's best for the Buyer), and then "hand over" the CIS to the Supplier upon the implementation. The Buyer selects the CIS software provider (Vendor), makes the determinations regarding necessary hardware, negotiates all of the prices, contracts and licenses with the Vendor and third-parties, and pays all of the bills. This ignores several important details, however. First, that when it comes to HIT or CIS, the Buyer probably doesn't know what's best. Second, the Buyer probably has far more limited expertise, experience and possible buying leverage with Vendors than its Supplier. Third, the implemented CIS must be managed, operated and maintained within the existing and changing IT environment - an environment that is being managed, operated and maintained by the Supplier. At best, a CIS implementation done "outside" of the HIT outsourcing will require significant Supplier contract changes - i.e., price increases; at worst, it may create significant interoperability problems and system performance issues.

On the second road, the Buyer decides that it will put its Supplier in the driver's seat, and make the Supplier responsible for all contractual, operational and financial obligations for the CIS implementation as part of the HIT outsourcing - i.e., the proverbial "one throat to choke" model. However, this also ignores several important details. First, this results in the Buyer having no (or very little) interface, working relationship or contractual privity with the Vendor, never a good idea for an HIT component with which so many of the Buyer's own staff will use on a daily basis. Second, it assumes that the Buyer's and Supplier's interests with respect to the CIS implementation are aligned - depending on how the Supplier's HIT outsourcing contract is structured, there could very well be many cross-purposes and disincentives regarding performance and cost of a Supplier-driven CIS implementation. Third, it may seriously complicate unwinding your HIT outsourcing contract upon expiration and non-renewal or earlier termination for whatever reason.

CIS Implementations Should Follow the "Three-Way" Street. The Supplier and Buyer, in consultation and "partnership" with one another, should share the contractual, operational and financial responsibilities for and control of the CIS implementation. This includes negotiating and contracting with the selected Vendor, communicating with end users, identifying issues and obstacles, completing the CIS implementation on time and within budget, and satisfying functional requirements. This should be described in a "Preliminary CIS Implementation Plan" made a part of the HIT outsourcing contract. On the three-way street with the CIS Vendor, the Supplier and the Buyer should have the following respective responsibilities regarding the CIS implementation:

Project Initiation

Supplier and Buyer CIS implementation project leaders will work together to define the project team, define decision-making bodies, develop the project charter and conduct the project kick-off meeting.

Supplier and Buyer will establish the "Final CIS Implementation Plan."

Buyer will identify sponsors appropriate to champion and participate in strategic decisions relative to the CIS implementation and to assist in resolving internal roadblocks.

Buyer will identify the CIS Vendor contract negotiation team, including legal counsel, to participate in contract negotiations.

Buyer will identify departmental subject matter experts and super users.

Project Management

Supplier will assume project management responsibility to include:

- Management and control of process definition;

- Definition of key team member responsibilities;

- Coordination of project team meetings;

- Risk mitigation (e.g., change control and tracking mechanisms);

- Facilitation of design decisions;

- Monitoring and communication of project progress;

- Management of Vendor provided services;

- Identification and resolution of day-to-day projected related issues;

- Budget tracking;

- Development of Buyer staffing requirements.

Buyer will assume responsibility for:

- Providing appropriate sponsorship to ensure the internal non IT resources (e.g., department managers, subject matter experts, and departmental super users) are available throughout the project;

- Identifying "super users";

- Reviewing and (if acceptable) signing off on design documents.

Vendor Contract Negotiations

Supplier will review the CIS Vendor contract presented to Buyer, from a business and technical perspective, and identify areas of concern or issues that require review and response. Supplier will not provide legal advice regarding contract terms and conditions. Buyer will use legal counsel as it deems prudent throughout the contracting process.

Buyer will review the CIS vendor contract and identify areas of concern or issues that require review and response. The review will include financial arrangements, contract terms and conditions.

Buyer's legal counsel will review the CIS vendor contract and identify areas of concern or issues that require review and response.

Pre-Implementation Planning

Supplier will assume responsibility for:

- Evaluation and recommendation of opportunities to improve patient outcomes, financial performance and employee productivity through process redesign;

- Examination of current operating organization structure;

- Gap analysis and impact analysis for organization process and technology changes.

Buyer's appropriate sponsor will ensure participation of the department managers and super users in the analysis to be conducted by Supplier.

Buyer's CIS "steering committee" will participate in reviewing the evaluations and recommendations provided by the Supplier.

Buyer's appropriate sponsor will assist in implementing organizational process changes.

Clinical Transformation

Supplier will merge its technical system competency with operational and process improvement expertise to lead the organizational change management.

Buyer will provide appropriate sponsorship and assist in encouraging adoption of Supplier's recommendations.


Application design

- Supplier will assume responsibility for screen, table, and work list definition; identification of required reports; and review and development of the training strategy.

- Supplier and Buyer (steering committee, department managers, department subject matter experts, and super users) will work together to identify staff to be trained.

Application building

- Supplier will assume responsibility for building master files, tables, order sets, and worklists.

- Supplier and Buyer (department managers, super users, and training department) will work together to develop training agendas, curriculum material, certification tests and job aids.

Integration testing

- Supplier will lead the integration testing by defining and coordinating required interfaces and conversions, providing integration test plan(s), providing application and operational testing reports, and conducting operation testing.

- Supplier and Buyer (department subject matter experts and super users) will work together to conduct and document integrated testing.


- Supplier will lead the development of training materials, development of the training plan, and execution of the training program.

- Buyer's training department will assist the Supplier in developing and executing the program and the executive sponsor will ensure end user participation in the training sessions.

Operational Readiness

- Supplier will provide the final "cut" of the database build and system design, and confirm technical operational readiness.

- Buyer (department subject matter experts and super users) and Supplier will work together to conduct final system validation.

Coordination of user acceptance testing (production testing)

- Supplier will provide testing plans, coordinate testing activities, implement change control processes, perform and test the historical upload, and conduct volume and performance testing.

- Buyer will review and (if acceptable) sign off on user acceptance testing; department subject matter experts and super Users will assist with execution of acceptance tests.

Conversion (Go-live readiness)

- Supplier will conduct conversion, technical, and application readiness assessments; prepare and execute operations test plans; conduct, and develop and validate conversion plan.

- Buyer will review and (if acceptable) approve conversion acceptance criteria.

Conversion (Go-live)

- Supplier will finalize go-live plans and timeframes; prepare the production environment; confirm that system, peripheral devices, and interfaces are prepared to support the conversion; lead execution of go-live activities; develop command center plan; finalize support team requirements for go-live; and resolve go-live issues.

- Buyer will review and (if acceptable) approve go-live plans and assist with staffing the command center (departmental super users).

Lessons From The Outsourcing Journal

Of course, no one strategy is the right one for all scenarios. From time to time, there may be situations where it is appropriate for a Buyer to take on a CIS implementation "solo." And there may be situations where the Supplier should be solely "on the hook" to deliver the CIS as part of a comprehensive HIT outsourcing. It's my experience, though, that the right road to take is the three-way street: one on which Buyer, Supplier and CIS Vendor are inextricably connected. With that in mind:

A principal focus and centerpiece of the HIT outsourcing contract must be a well-thought-out and comprehensive CIS Implementation Plan;

The Buyer and the Supplier must work together in a "partnership" like no other partnership between a customer and a vendor of services regarding CIS;

Although normally difficult to do in a traditional customer-vendor relationship, the interests of the Buyer and the Supplier must be absolutely aligned on a CIS implementation if it is to be successful;

Finally, success does not occur upon merely the technically acceptable implementation of the Clinical Information System - success occurs upon the measurable "Adoption" of the CIS by the Buyer's users. More on that in another article ...

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