Section 2.5 Plan
HIT Vision and Strategic Planning
This document describes a vision for health information technology (HIT) in nursing homes,
including the purpose of implementing an electronic health record (EHR), along with a conceptual
model of an EHR and suggestions for strategic planning.
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How to Use
HIT refers to the broad class of information technology that aids health care organizations in
achieving efficient and effective care delivery. EHR refers to the specific application of HIT to
capture data at the point of care, use the data in making clinical decisions, and share data as
authorized across the continuum of care and with individual residents and/or family members in a
secure manner. All HIT encompasses software applications and hardware, as well as requisite people,
policies, and processes. It is unlikely that any nursing home will acquire all components of its vision
for HIT at once, but having a vision and a plan to achieve the vision helps build momentum and
reduces reactive buying that may result in costly mistakes.
Software Applications
Within HIT are many types of information system applications. In general, these include:
1. Financial and administrative systems that include, at a minimum, resident registration-admission,
discharge, transfer (R-ADT) and billing systems. R-ADT includes the ability to: maintain an
index of all residents you have treated; document their demographic, contact, and insurance
information; manage the census of current residents; and other associated functions. Billing
systems will support charge capture, accounts receivable, collections, trust accounts, general
ledger, accounts payable, etc.
2. Departmental or ancillary systems that support the operations of various departments or types of
staff. For a skilled nursing facility, these may include a clinical laboratory information system
(LIS), radiology information system (RIS), nutrition and food services (N&FS), therapy
department systems (e.g., rehabilitation, physical therapy, occupational therapy, speech and
language therapy, respiratory therapy and others), human resources, time and attendance,
staffing, materials management/ procurement and executive decision support. The minimum data
set (MDS), if it is a standalone software system, may be treated as an ancillary system. Some
nursing homes may also have health information management (HIM) functions that are
automated, such as a master person index if not included in the R-ADT module,
dictation/transcription and electronic signature, encoder, chart tracking, and deficiency analysis.
3. Clinical information systems that support health care professionals in direct care delivery. When
these clinical systems work together, they are often described as an electronic health record
(EHR) system. Clinical information systems in skilled nursing facilities may be all inclusive in a
single suite of functions, or may be several distinct modules (which may not necessarily be
implemented in a specific sequence). A suite of applications for nursing documentation may
include nurse assessments, interdisciplinary care plans, clinical pathways, vital signs
documentation and workflow support. More sophisticated clinical systems require significant
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connectivity with the departmental systems. These typically include electronic/barcode
medication administration records (EMAR/BC-MAR) in skilled nursing facilities. Another more
sophisticated clinical system not always found in a nursing home is computerized provider order
entry (CPOE). Physicians who are ordering medications may use an e-prescribing system to do
so. Although clinical decision support (CDS) is generally included in EMAR/BC-MAR and
CPOE/e-prescribing applications related to medication management, more sophisticated CDS
and point-of-care (POC) charting for providers applications frequently are implemented after
most others. (Note that a more comprehensive discussion of clinical information system
applications is provided in separate tools within this toolkit.)
4. Clinical data repository (CDR) is the means by which data from the various applications come
together for various forms of processing. A CDR is essentially a database that is optimized to
manage all transactions for each resident. Some examples include:
a.
A CDR may enable the development of a graph showing a resident’s vital signs in
comparison to medication administration. Clinical decision support is greatly enabled
by a CDR.
b.
When a drug to be administered for a given patient appears on the EMAR/BC-MAR,
the drug can be compared with drug knowledge information and perhaps also to the
resident’s lab results if all this data is present in a CDR. If the resident is allergic to
the drug to be administered, or if it is contraindicated for that resident for some other
reason, an alert will display stating the potential contraindication. This also occurs in
CPOE and e-prescribing systems so that the ordering provider is alerted. The system
may also suggest a lower dose, alternative drug or closer monitoring, as applicable to
the situation. The ordering provider may accept the recommendation and the finalized
prescription is then transmitted to a pharmacy. The recommendation may also be
rejected, in which case the original prescription is transmitted to a pharmacy. The
ordering provider may be asked by the CPOE or e-prescribing application to identify
the reason for the rejection, which then is held in the CDR as part of the resident’s
EHR.
Some EHR vendors fully integrate their clinical components with a CDR. This is generally true
for some nursing home EHR vendors, though not necessarily all do this. If you buy different
applications separately from the same vendor, you might inquire if there is a CDR that integrates
the data from the applications—as this helps improve both clinical decision support and reporting
functions. If you have to buy different applications from different vendors, you may be faced
with buying a CDR from a third party or managing multiple interfaces between the applications.
Although a CDR is primarily designed to integrate structured data, some repositories also include
pointers to documents and images.
5. Electronic document management system (EDMS) is often used where a bridging strategy is
needed to achieve a paperless environment during the time clinical systems are being
implemented. EDMS allows document scanning and indexing to archive documents until all data
collection aspects of the health record are automated. Later, EDMS supplements the EHR when
external documents are received in paper or digital form (e.g., email, e-fax, or digital dictation).
6. Portals are another important application that are used to connect different providers to one
another, such as physicians to your facility or your facility to a hospital or multiple hospitals.
Patient portals allow a resident or family member to complete intake forms, retrieve copies of
their health record or summaries of their care, and perform other functions directly from your
facility’s applications. In general, a portal is a Web interface that serves as a secure door to
related sets of data and services. For example, a physician from a home or office may gain access
to the nursing home’s EHR, obtain a resident’s vital signs, and enter orders.
Section 2 Plan—HIT Vision and Strategic Planning - 2
7.
Data warehouse is a database that has been optimized to collect and manage data on which
complex queries and analysis, such as data mining, can be performed. Such databases may also
be called translational or analytical databases. While you can do some analysis and reporting
from any database, including the databases in individual applications or the CDR, very complex
analyses on large quantities of data will significantly slow down the system. Most skilled nursing
facilities contribute data to external data warehouses, such those as held by the Centers for
Medicare & Medicaid Services (CMS), their corporation, or various other payers, quality
registries, etc.
8. Telehealth, personal health records (PHR), and health information exchange (HIE) services are
yet other forms of HIT which are rapidly evolving and being adopted by large and small health
care delivery organizations. Many small and rural communities have extensive telehealth
implementations, connecting to their closest tertiary care facility or reaching out to very remote
areas for patient monitoring and to supplement care delivery. Skilled nursing facilitieswill
certainly find using a referral management system that reaches out to a variety of other
organizations to be advantageous. PHRs are just starting to be recognized as important adjuncts
to health care delivery. Several health plans (including a number of Blue Cross Blue Shield
plans) are promoting use of PHRs. The U.S. Department of Veterans Affairs has created
myHealtheVet, a PHR systems for veterans. Some vendors are supplying various forms of PHRs.
Some of these are in form of patient-friendly summaries of care; others provide access to lab
results and even self-administered medical history systems that reduce the documentation burden
for providers. Many families of chronically ill patients or elderly residents in nursing homes find
that PHR is the only way they can keep track of all the medications, physician visits, etc.
9. Middleware is another type of software that is important to include in HIT. While often not a
concern to end users, various report writing applications, presentation layer utilities, interfaces,
database management systems, and other software is required to make all of the end-user
applications work.
Hardware
Hardware includes the various processing devices and servers to run the applications.
1. Data entry requires various input devices (e.g., desktop computers, tablets, personal data
assistants [PDAs], speech microphones, etc.) and output devices (monitors, display screens,
printers, fax machines, speakers, etc.).
2. Data also must be archived, so storage functionality is needed. This may be provided byvarious
storage devices, each with its associated media (magnetic disks, optical disks, flash drives, etc.).
A variety of storage area networks and storage management systems are used to manage large
volumes of archived data. As the HIT becomes more mission critical, backup storage and
redundant processing devices are necessary, often with middleware applications to provide
automatic failover.
3. Hardware devices and servers must connect to one another in a network.
a. Within a given facility, a local area network (LAN)—which may be wired, wireless, or a
combination of the two—requires various network devices and their associated media
(including various forms of cable for wired networks and wireless network capability).
b. If you are connecting across disparate organizations (such as with your vendor, a hospital,
physicians, pharmacy, etc.) you will also need a wide area network (WAN) and WAN
services. Trunk lines may be purchased through a telephone company for a point-to-point
connection over a virtual private network, or you may use an Internet Service Provider for an
Internet connection.
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Conceptual Model of EHR
This diagram illustrates the many HIT components described above. While this diagram may seem
overwhelming, it is designed to show that as clinical computing requirements are addressed, the
complexity of applications, technology, and operational elements to support them increases, as does
the skilled nursing facility’s ability to use the resulting information and knowledge.
Copyright © 2014, Margret\A Consulting, LLC. Used with permission of author
Strategic Planning
Planning the sequencing and nature of acquiring the various HIT components is very important.
Rarely does any health care delivery organization acquire everything at once. Two key elements
should be considered in planning. First is the sequence of components to be acquired and second is
the manner in which the components will be acquired.
Migration Path
A migration path is a strategic plan for the HIT components that an organization plans to acquire
over time. A migration path identifies:
□ All current applications and applications proposed to be acquired over time. Plotting the
applications to be acquired over time helps identify the various dependencies and
interrelationships among applications. For example, many organizations begin with RADT/Census and Billing applications. For some organizations, the next move they might
consider would be EMAR in order to address patient safety concerns. However, it is possible that
an order entry or e-prescribing system may be needed prior to the EMAR in order populate the
drug data in the EMAR application—otherwise nurses will have to manually enter drugs into the
EMAR. Plotting application implementations over time also can help you identify gaps in
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applications or whether too many applications are planned to be implemented at one time. For
example, in addressing the full range of EHR capabilities, a nursing home may be tempted to
implement both an EHR and portal at the same time. This may overwhelm both IT and the end
users—the staff who have to learn how to use the systems. Plotting out the prerequisites for the
systems’ success also may identify critical, but missing, applications.
□ Current technical infrastructure and all new technology needed to support the new applications.
As your organization implements various new applications, it will clearly see that some new
technology is required. For example, implementing e-prescribing may require more input devices
at the nursing unit or at the point of care. Alternatively, if most physicians prescribe remotely,
you may not need more devices but more connectivity capability. As you move toward point of
care documentation and EMAR, you will need to determine the type of input devices and
whether they will be wireless or hard-wired. Many small organizations find that they do not
initially acquire the technology to optimally run their new applications. In many cases, the
application vendor either has not known or not informed them about the technology needed,
perhaps to avoid the sticker shock or because the vendor does not support the new technology.
□ All operational elements—the people, policies, and processes that must be put into place for the
applications and technology—are often considered the most important element of both strategic
planning and successful implementation of an EHR. Some go so far as to suggest that the 80/20
rule applies, meaning 80 percent of the focus should be on operational elements and just 20
percent on applications and technology. Without appropriate change management, workflow
redesign, training, and many other operational considerations, even the best software and
hardware will fail.
A migration path template for plotting your HIT strategy is provided.
1. List all current applications, technology, and people-policy-process elements that you have in
place to support the current HIT strategy.
2. Identify and record your high-level HIT objectives. In general, organizations have some sense of
phasing for these objectives. Often, starting simple with e-mail applications or a portal to a
hospital can be effective.
3. Identify and record the time period in which you believe each high-level HIT objective can be
accomplished. Generally, this may be in one to two years, or more, per objective.
4. List all applications, technology and operational elements you believe are necessary to support
each phase and high-level HIT objective.
5. Review and critique the migration path. Once you have plotted all of the elements on the
migration path, step back and review the process with an eye toward determining if it is logical
and feasible. Adjustments may need to be made, especially when there are dependencies between
applications. Once you have identified the applications and technology, determine whether you
need to expand the operational elements plotted on the IT plan.
6. In addition to making necessary modifications to the migration path, many organizations add
other, more-detailed documentation to the migration path. You may want job descriptions for
staff you need to add. You might want to add an information model to the migration path where
you need to illustrate the need for an interface. Many other potential documents support the
migration path.
7. Maintain the migration path. While the migration path is a high-level HIT strategic plan which
should not be changed on a whim, changes will be needed over time. New regulations may
require an adjustment in sequencing. The EHR meaningful use incentive program for hospitals
and physicians significantly changed many organizations’ plans, which generally included
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adoption of EMAR before CPOE; however, the incentive program required that CPOE be
implemented before EMAR. Vendor changes, products that are sunsetted, new applications, and
new technology may require a review of the migration path. Internal factors such as a merger or
acquisition also may require another look at the migration path. Changes in the migration path
should be made with the consensus of all stakeholders and only for important reasons.
Migration Path Template
Timeline
Current
Phase I
Phase II
Phase N
High Level HIT Objectives
Applications
 Financial/ administrative
 Operational/departmental
 Clinical
Technology
 Database
 Network
 Business Continuity/redundancy
 Security
 Disaster recovery
 Interfaces
Operations
 People
– Leadership
– Clinical
– IT
– Governance
– Computer skills
– Training
 Policy
– Transformational culture
– Adoption strategy
– Benefits realization
 Process
– Communication/ celebration
– Goal setting
– Change management
– Workflow/process redesign
– Data quality and information
management
Copyright © 2014, Margret\A Consulting, LLC. Used with permission of author
HIT Acquisition Strategy
How you plan to acquire your HIT is also an important early consideration. There are two key
considerations: single vs. multiple vendors and in-house vs. hosted.
Single vs. Multiple Vendors
Whether you will acquire most or all of the applications from a single vendor or from many vendors
may be determined by how many applications you have already and the nature of the applications
you need.
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1. A best-of-fit strategy is one in which all or almost all of the applications are acquired from a
single vendor and generally work together—either because the vendor has built them from the
same platform (and there is a CDR), or the vendor has developed “hard-wired” interfaces
between the applications.
2. A best-of-breed strategy is where an organization acquires products from a variety of vendors.
This may be done intentionally to get the “best” product of that type or because no one vendor
has all the desired products. It may also occur as a result of acquiring products over a fairly long
period of time without a formal strategic plan or migration path. Many organizations add
products from different vendors because existing products from other vendors are “tried and true”
but these vendors do not have the newer applications desired. The organization has invested a lot
of money and time in the older applications and they work. It is often believed that buying all
new applications from one vendor (sometimes referred to as “rip-and-replace” will cost more and
be a significant hassle. However, this strategy can be a mistake because older products will not
have many of the newer functions that save time and money in the long run. They often do not
interface well with newer applications and the incremental cost of acquiring a new application is
not as great as most believe. The biggest problem with the best-of-breed approach, however, is in
maintaining the systems. In order to get the systems to share data, interfaces have to be built.
They also must be maintained; when one application has an upgrade, all interfaces to other
applications with which the upgraded application shares data must be upgraded as well.
3. Dual core is a third strategy in which (often older) administrative/financial applications are from
one vendor and (newer) clinical applications are acquired from a second vendor. This strategy is
somewhat better than best-of-breed. However, as integration of financial and clinical data
increases, this strategy may not work well in the future.
4. Replacement is a final consideration with respect to how many and which vendors to use in
acquiring HIT. This is less a strategy and more of an incident where applications have already
been acquired but must be replaced for one reason or another. Understandably, this may occur in
a merger situation where the acquiring organization wants everyone to be on the same vendor
platform. Other circumstances include the incumbent vendor going out of business or, for a
myriad of reasons, the incumbent vendor is just not working for the organization. While some
vendor markets are quite stable, others are not. For instance, prior to the meaningful use incentive
program, there were a few hundred vendors servicing the physician market. Before Stage 2 of
the program started, the number of vendors had grown to more than 1,000—not a sustainable
situation and hence a lot of replacement of vendors. During this same period the hospital market
also grew, but not to the same extent. The nursing home market has fewer vendors than either of
these, but that could change if something like meaningful use is adopted for this market.
Perhaps as a consequence of many new and untested vendors, but also because of the haste with
which many initial purchases were made in order to take advantage of the meaningful use
incentive program, the vast majority of vendor replacements are occurring because the product is
deemed not to meet the needs of the organization. However, given the importance of the “people,
policy, and process” elements in selecting, implementing, and optimizing HIT, it is conceivable
that many of the replacements are occurring not because of the specific vendor’s performance but
because change management, workflow and process improvements, training, end-user
engagement, and other key operational elements were not given the attention deserved. A lesson
learned, then, is to avoid the rush to market, plan carefully, and truly appreciate the scope of
change that HIT requires.
In-house vs. Hosted
A final consideration is whether the organization will acquire and manage all elements of HIT or will
seek a hosted solution. There is actually a continuum from in-house to partially hosted (or contract
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services), remote hosted/application service provider and fully-hosted/cloud computing/Software as a
Service.
1. In-house refers to the fact that most HIT is acquired under a license arrangement where the
software is stored on servers within the organization. It is the organization’s responsibility to
maintain the software and the hardware, including the servers and end-user devices referred to as
clients. This form of acquisition is often referred to as “licensure of client/server products.”
2. Partially hosted/contract services strategy refers to use of a separate company to host the
applications on its servers, and/or to utilize a contractor to provide IT services in-house or at a
hosted site. This strategy reduces hardware costs and internal IT staff needs. Using hosted or
contracted services, however, still means that the software is licensed by the organization. This
enables the organization to make modifications to the software within the boundaries of the
licensing agreement. Licensed products are highly customizable.
3. Remote hosted/application service provider (ASP) is another option for acquiring HIT. ASP takes
advantage of the power of the Internet to deliver software housed on the vendor’s servers to users
over the Internet. This further reduces cost because the vendor is able to take advantage of
economies of scale. However, in order to also lower the cost of the software, these vendors
curtail the customer’s ability to customize the software. The basic underlying structure of the
software, however, is still “client/server,” just delivered over the Internet. Some ASPs now refer
to themselves as “Web-based” service providers. Web-based, however, refers to the architecture
of the software itself and not that it is delivered via the Web.
4. Fully hosted/cloud computing, also known as Software as a Service (SaaS), has become popular
fairly recently. Cloud computing originally was considered “on demand.” Theoretically, such a
product offering provides a subscription service to use and pay for software as it is used. An
example of on-demand use is an organization that needs to run monthly accounting reports and
uses special software only once a month to do so. Cloud computing, however, has now grown
into a lower-priced option for continual use. Much like the ASP model, the lower price is
achieved through even larger economies of scale that are achievable because of the ability to
virtualize servers. This means that vendors are now able to “borrow” server time from many
different places—potentially all over the world, and often changing as lower-cost server time
becomes available. In addition, these vendors are using more Web-based programming
techniques, capitalizing on XML structures and browser-based technology that are easier (and
cheaper) to maintain. The result is an entirely different look and feel to the software than the
traditional client/server offerings.
As a result, when an EHR is offered through cloud computing/SaaS, there is very little
customization capability. The acquiring health care organization does not usually know where
data resides at any given point in time. (Health care organizations are therefore cautioned to
stipulate whether they will permit their data to be housed in offshore servers.) What the user sees
in these new EHRs (referred to as the user interface) is a significantly more modern “look and
feel,” and the product costs significantly less. It should be noted that the newer hosted, ASP, or
cloud computing options require fully redundant connectivity so that access to the software is
available 24x7x365. It should also be noted that health care organizations still have to acquire
and maintain their own input/output devices and address all the change management, training,
and other operational elements. In making a decision about how to acquire an EHR,
organizations should balance the costs against their customization needs.
HIE Partner Identification
The participation agreement you sign to participate in an HIE organizations (HIO) should include
information on identification of partners—most likely a link to a partner directory. However, if you
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are relying on a portal to access information from another provider or to provide access to
information in your EHR, or if you are only using the Direct protocol for email exchange, you may
need to maintain your own list of such partners. These may seem obvious, but you may have more
connections than you realize—and if they are consolidated through an HIO, your work to maintain
all the different connection points could decrease.
Additional Resources
The Center for Aging Services Technologies (CAST) has a Technology toolkit that includes several
tools for visioning, strategic planning, Tools listed below relating to Vision and Strategic Planning
are available at: http://www.leadingage.org/toolkits.aspx

Technology Assessment Tool for Providers: “Imagine: the Future of Aging – Practical Action
Steps” provides ideas on making the business case for information technology adoption.

Seven Steps to Developing an Effective IT Strategic Plan helps align goals with technology
projects.
Copyright © 2014
Section 2 Plan—HIT Vision and Strategic Planning - 9
Updated 03-19-2014