Section 5.1 Maintain
Ongoing System Maintenance,
Administration, and Data Quality
Management
Use this tool for guidance on the importance of ongoing system maintenance, tools to evaluate
system administration, and tips to ensure data quality management.
Time needed: 6 - 8 hours
Suggested other tools: Section 1.4 EHR Technology Readiness Inventory, Section 1.5 HIE
Technology Readiness Inventory Section 4.8 Change Control
How to Use
1. Use the information on ongoing system maintenance to ensure that your information systems
are well-maintained and you have contingency plans in the event of any service disruption.
2. Evaluate the need for and management of system administration.
3. Implement a process to ensure data quality.
Ongoing System Maintenance
1. Corrective maintenance refers to any remedial steps needed to correct problems with the
network, hardware, software, or utilization of information systems. These often reach the
attention of IT staff through an informal process that, if not well managed can become
burdensome for your staff. If you are using an application service provider (ASP) or software
as a service (SaaS) vendor as your primary support, your informal process could cause you to
exceed your “routine maintenance” budget and you could be charged extra for service calls.
Whether you use internal staff or a third party for IT support, one person within the
organization (with appropriate backup) should track all corrective maintenance requests and
be responsible for their documentation and resolution. Essentially, corrective maintenance is
an extension of the issues management process (see Section 4.3 Issues Management)set up
during planning for implementation. Corrective maintenance includes additional training or
support that enables users to appropriately and fully utilize the information systems. Users
may seek help directly, or training needs may be identified through system audits. These
should be documented.
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Many organizations refer to corrective maintenance and ongoing issues management
as help desk functions. You may not have a formal help desk, but someone in the
facility should support this function. If your vendor has a help desk and you have
contracted for ongoing maintenance and support, be aware that some vendors charge
more for help when the information is already available to you through their system
documentation. This is another good reason to have someone in your organization
designated to receive these requests and to review the documentation to determine
whether the problem can be fixed internally or needs to be referred to the vendor.
2. Customized maintenance refers to modifying features already in existence in information
systems that need to be updated or modified for user needs. Customized maintenance is
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essential in clinical information systems, as health care is constantly changing with new
drugs, new treatment guidance, etc. Customized maintenance may be a part of help desk
functionality. In addition to issues management, change control is an important element of
customized maintenance. As introduced in the planning for sections of this toolkit, changes to
clinical information systems can have a ripple effect, which is not always desirable. IT staff
should never act upon a clinical customization project without the approvals required by the
change control procedure.
3. Enhancement maintenance refers to improving the performance of the network, hardware,
application, or even the role of people in their development and use of these tools. IT staff
and/or end users may be further trained as super users and be offered advanced skills in
systems use and/or development (e.g., a super user may learn more advanced reporting skills,
or an IT staff member may take an online relational database design course). Most of the
enhancement maintenance is directed to the network, hardware, and software. Unfortunately,
such enhancements are often made in reaction to a problem rather than proactively. For
example, an electronic document management system (EDMS) application may necessitate
network enhancement, or the fact that the vendor no longer supports an application may
trigger a search for a new product. All enhancements should be made within the context of
appropriate issues management and change control procedures. For many such projects, a
formal project plan (see 4.2 Project Plan), including business case and budget approval
process (see 2.11 Business Case: Total Cost of Ownership and Return on Investment for
EHR and HIE, and even acquisition process (see Section 3.3 EHR and HIE Vendor Selection
and Understanding the Marketplace) may be needed.
4. Preventive maintenance involves taking steps in advance to reduce the risk of a serious
problem. It may include everything from resetting a person’s password, performing a backup,
or recharging batteries to applying operating system patches, running a network scan, or
replacing devices when they become obsolete. Some of these are routine system
administration steps, while others may be major projects. Maintaining system documentation
and managing all aspects of security, including contingency planning also fall within the
category of preventive maintenance. Many health care delivery organizations have been
somewhat lax about preventive maintenance, especially relating to contingency planning.
However, as electronic health records (EHR) and other health information technology (HIT)
are adopted—becoming mission critical to the organization—preventive maintenance must
be planned for as thoroughly as the original applications. Some key preventive maintenance
steps include:
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Install all patches and updates for the operating system, application (including
interfaces), and security software.R eview information system activity, including
system utilization, capacity, and response time.
Replace servers, client devices, and network devices on a routine schedule.
Provide for system administration services 24/7.
Maintain network schematics, application inventories, and network inventories,
potentially using automated tools to detect rogue devices or applications.
Ensure network, server, and device redundancy with failure and fault tolerance
capability.
Maintain and test contingency plans for routine backup and restoration, business
continuity, and disaster recovery—including manual contingency plans to be
performed by end users if necessary.
Utilize Internet and email usage/monitoring tools, firewalls, intrusion detection, and
anti-malware tools.
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Secure all servers and network devices in an appropriate data center environment.
Ensure system administration passwords are especially strong and protected. Separate
system administration duties from authorization responsibilities.
System Administration
System administration is the process of maintaining and operating computer systems and networks.
This may be a relatively small job for IT in an ASP or SaaS environment. For an organization
maintaining its own servers and network components, the systems administrator has wide-ranging
duties. Whatever the scope of your needs, there must be at least one person tasked to perform or
oversee these functions. Even when an outside company supplies system administration functions,
including remote hosting, someone needs to manage that account and someone must be able to
perform basic system administration duties relating to hardware and documentation of needed
changes.
As the role of EHR, health information exchange (HIE), and HIT grow in your agency, you may
need to find a staff member who can take on more system administration tasks, or even hire or
contract for a system administrator. The following are general system administrator responsibilities:
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Perform routine audits of systems and software.
Perform backups.
Apply operating system updates, patches, and configuration changes.
Install and configure new hardware and software, including supporting and maintaining
severs and other computers.
Add, remove, or update user account information, reset passwords, etc.
Answer technical queries.
Perform security functions, including responding to service outages.
Participate in system build and document the configuration of the system.
Troubleshoot any reported problems.
Fine-tune system performance.
Insure that the network infrastructure is up and running.
Handle basic programming.
Conduct basic end user training.
Manage projects.
Participate in systems selection.
Provide periodic reports to management.
Data Quality Management
As EHRs, HIE, and other HIT are installed, they become important clinical tools; the quality of the
data captured by these systems needs to be assured. All clinical tools require professional judgment
for use and need to be calibrated regularly to ensure they perform optimally. Think of EHR as having
these five rights:
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Right clinical data – to be captured and quality assured
Right presentation – to be able to capture and retrieve the right data and be alerted properly
Right decision – to have the right clinical decision support, based on the right data, presented
in the right manner
 Right work processes – to support the capture and use of data
 Right outcomes – to result in the best possible outcomes for patient safety and quality of care
See Section 4.6 Data Management in EHR and Data Stewardship in HIE for a comprehensive
discussion of ensuring the quality of data as it is captured in new ways.
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To evaluate data quality and ensure it supports optimal use of systems at the point of care—as well as
for quality improvement, data analytics for achieving health care value, public reporting, and other
expanded functions—various steps can be performed:
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Health care professionals conduct audits of EHRs and resultant reports, looking for potential
inconsistencies. For example, a list of clients and their lab results may reveal that some of the
clients are no longer active in your agency.
Monitor complaint logs by end users to determine whether if data fields allow for precise
entries and whether edit checks occur correctly.
Test data entry to determine that alerts and reminders fire correctly and can be performed,
and review clinical decision alert overrides to see if they point to data quality issues (see 6.4
Optimization Strategies for Clinical Decision Support)
Review the contents of comments or narrative fields to determine:
 Where structured data templating is not occurring
 Where there are inconsistencies and/or repetition between data templating and
narrative fields
Run various reports to perform reasonableness tests (e.g., how many clients are likely to have
certain data elements included or excluded).
As data quality issues are identified, remediation activities are needed, such as retraining, application
modification, or policy modifications. Ensure that any changes made are documented in your Change
Control log.
Copyright © 2013
Updated 11-20-13
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