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HIT or Miss
Lessons Learned from Health Information
Technology Projects

Third Edition
 HIMSS Book Series
Participatory Healthcare: A Person-Centered Approach to
Healthcare Transformation
Jan Oldenburg
The Journey Never Ends: Technology’s Role in Helping Perfect
Health Care Outcomes
David Garets and Claire McCarthy Garets
Glaser on Health Care IT: Perspectives from the Decade that
Defined Health Care Information Technology
John P. Glaser
Leveraging Data in Healthcare: Best Practices for Controlling,
Analyzing, and Using Data
Rebecca Mendoza Saltiel Busch
HIT or Miss
Lessons Learned from Health Information
Technology Projects

Third Edition

Edited by Jonathan Leviss

CRC Press
Taylor & Francis Group
6000 Broken Sound Parkway NW, Suite 300
Boca Raton, FL 33487-2742

© 2019 by Taylor & Francis Group, LLC

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Library of Congress Cataloging-in-Publication Data

Names: Leviss, Jonathan, author.

Title: HIT or miss : lessons learned from health information technology
projects / Jonathan Leviss.
Description: 3rd edition. | Boca Raton : Taylor & Francis, 2019. | “A CRC
title, part of the Taylor & Francis imprint, a member of the Taylor &
Francis Group, the academic division of T&F Informa plc.” | Includes
bibliographical references and index.
Identifiers: LCCN 2019004821 (print) | LCCN 2019006832 (ebook) |
ISBN 9780429031403 (e-Book) | ISBN 9780367143466 (hardback : alk. paper)
Subjects: LCSH: Health services administration—Information technology. |
Information storage and retrieval systems—Medical care. | Medical
records—Data processing.
Classification: LCC R858 (ebook) | LCC R858 .H25 2019 (print) |
DDC 362.10285—dc23
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 To Emmy and Becca—keep doing good stuff … keep learning
from your stumbles … and keep making it fun!
To Perri—my best friend, wife, and most important source of support.
Thanks for everything, especially for your love. Much aloha.
Contents

Foreword.....................................................................................................................................xi
Acknowledgments.....................................................................................................................xv
Introduction and Methodology.............................................................................................xvii
Editor........................................................................................................................................xxi
Associate Editors....................................................................................................................xxiii
Contributing Experts, Authors, and Author Teams..............................................................xxv

Section I HOSPITAL CARE FOCUS

1 Build It with Them, Make It Mandatory, and They Will Come:
Implementing CPOE����������������������������������������������������������������������������������������������������3
EDITOR: BONNIE KAPLAN

2 One Size Does Not Fit All: Multihospital EHR Implementation..................................7

EDITOR: PAM CHARNEY

3 Putting the Cart before the Horse: IDN Integration..................................................11

EDITOR: CHRISTINA STEPHAN

4 Hospital Objectives versus Project Timelines: An Electronic Medication

Administration Record................................................................................................15
EDITOR: BRIAN GUGERTY

5 Clinical Quality Improvement or Administrative Oversight: Clinical Decision

Support Systems..........................................................................................................19
EDITOR: JONATHAN LEVISS

6 A Legacy Shortfall Reinforces a New Endeavor: Business Intelligence.......................23

EDITOR: JONATHAN LEVISS

7 When Value Endures: Legacy Data Viewer.................................................................27

EDITOR: MELISSA BAYSARI

8 Usability Reigns Supreme: Medication Alerts.............................................................31

EDITOR: CHRISTINA STEPHAN

9 A Mobile App That Didn’t: Antibiotic Approvals........................................................35

EDITOR: DAVID LEANDER

vii
viii ◾ Contents

10 Disruptive Workflow Disrupts the Rollout: Electronic Medication

Reconciliation........................................................................................................ 39
EDITOR: GAIL KEENAN

11 Anatomy of a Preventable Mistake: Unrecognized Workflow Change in

Medication Management.............................................................................................43
EDITOR: JONATHAN LEVISS

12 Failure to Plan, Failure to Rollout: Bar Code Medication Verification Failure..........47

EDITOR: PAM CHARNEY

13 Fitting a Square Peg into a Round Hole: Enterprise EHR for Obstetrics....................51
EDITOR: CHRISTOPHER CORBIT

14 Basic Math: HL7 Interfaces from CPOE to Pharmacy to eMAR................................55

EDITORS: LARRY OZERAN AND JONATHAN LEVISS

15 In with the New Does Not Mean Out with the Old: Mobile Devices..........................59
EDITOR: RICHARD SCHREIBER

16 First-Time Failures Ensured Later Success: Pharmacy System Upgrade.....................63

EDITOR: ERIC ROSE

17 Device Selection: No Other Phase Is More Important: Mobile Nursing Devices.......69

EDITOR: GAIL KEENAN

18 How Many Is Too Many: ICU Data Capture..............................................................73

EDITOR: KAI ZHENG

19 Simultaneous Systems Migration: Fetal Monitoring...................................................77

EDITOR: CHRISTINA STEPHAN

20 Notification Failure: Critical Laboratory Result.........................................................81

EDITOR: KARL POTERACK

21 Collaboration Is Essential: Care Planning and Documentation.................................85

EDITOR: JONATHAN LEVISS

22 Lessons Beyond Bar Coding: Laboratory Automation and Custom Development.....89

EDITOR: EDWARD WU

23 A Single Point of Failure: Protecting the Data Center................................................95

EDITOR: BONNIE KAPLAN

24 Vendor and Customer: Single Sign-On.......................................................................99

EDITOR: JUSTIN GRAHAM

25 The Phone’s On, but Nobody’s Home: Communications Upgrade...........................103

EDITOR: MELISSA BAYSARI

26 Ready for the Upgrade: Upgrading a Hospital EHR for Meaningful Use.................107
EDITOR: EDWARD WU
 Contents ◾ ix

27 Effective Leadership Includes the Right People: Informatics Expertise.................... 111

EDITOR: GAIL KEENAN

28 Culture Eats Implementation for Lunch: Chronic Care Model................................115

EDITOR: MELISSA BAYSARI

29 Shortsighted Vision: CPOE after Go-Live................................................................. 119

EDITOR: CHRISTOPHER CORBIT

30 Committing Leadership Resources: A CMIO and CPOE Governance.....................123

EDITOR: GAIL KEENAN

31 When to Throw in the Towel…ED Downtime..........................................................127

EDITOR: RICHARD SCHREIBER

32 When Life Throws You Lemons, Make Lemonade: Voice Recognition.....................131

EDITOR: CHRISTOPHER CORBIT

Section II AMBULATORY CARE FOCUS

33 All Automation Isn’t Good: CPOE and Order Sets...................................................137
EDITOR: PAMELA CHARNEY

34 Start Simple…Maybe: Multispecialty EHR Rollout.................................................143

EDITOR: ERIC POON

35 It’s in the EHR…but Where?: Patient Records..........................................................147

EDITOR: DAVID LEANDER

36 All Systems Down…What Now?: Ambulatory EHR.................................................151

EDITOR: CHRISTOPHER CORBIT

37 Weekends Are Not Just for Relaxing: Reconciliation after EHR Downtime............157
EDITORS: JUSTIN GRAHAM AND ERIC ROSE

38 104 Synergistic Problems: An Enterprise EHR......................................................... 161

EDITOR: ERIC ROSE

39 What Defines “Failure”: Small Practice EHR...........................................................165

EDITORS: LARRY OZERAN AND JONATHAN LEVISS

40 Digital Surveys Don’t Always Mean Easier…Patient Surveys...................................169

EDITOR: RICHARD SCHREIBER

Section III COMMUNITY FOCUS

41 Push vs. Pull: Sharing Information across a Physician Referral Network................175
EDITOR: JONATHAN LEVISS

42 Disconnecting Primary Care Providers: HIE Alerts.................................................181

EDITOR: RICHARD SCHREIBER
x ◾ Contents

43 Loss Aversion: Adolescent Confidentiality and Pediatric PHR Access......................185

EDITOR: ERIC POON

44 Improved Population Management Requires Management: Care Coordination........ 189

EDITOR: CATHERINE CRAVEN

Section IV POINTS OF VIEW

45 Theoretical Perspective: A Review of HIT Failure.....................................................195
AUTHORS: BONNIE KAPLAN, SCOT SILVERSTEIN, JONATHAN LEVISS, AND
LARRY OZERAN

46 EHR Transitions: deja vous.......................................................................................199

AUTHOR: RICHARD SCHREIBER

47 User Interface: Poor Designs Hinder Adoption........................................................203

AUTHOR: KAI ZHENG

48 Exploring HIT Contract Cadavers to Avoid HIT Managerial Malpractice..............209

AUTHOR: HENRY W. JONES III

Section V APPENDICES
Appendix A: HIT Project Categories.................................................................................225
Appendix B: Lessons Learned Categories..........................................................................229
Appendix C: Case Study References and Bibliography of Additional Resources...............235
Index..................................................................................................................................241
Foreword

Ross Koppel, PhD, FACMI,

University of Pennsylvania and SUNY @ Buffalo

Once again, the editors and authors of HIT or Miss endow us with lessons on actual implementa-
tions and uses of health information technology (HIT)—electronic health records (EHRs) and
other digital efforts designed to make healthcare more efficient, safe, and less costly. Although
there are some wonderful exceptions, these stories illustrate how many (most?) careful plans are
often shattered by the complexity of healthcare delivery. Every vignette should be required read-
ing by every medical information technology (IT) person, every EHR vendor, every medical and
IT leader (Chief Medical Information Officer/CMIO, Chief Information Officer/CIO, Chief
Technology Officer/CTO, and Chief Executive Officer/CEO,), and anyone with the authority to
buy or install digital technology in a medical setting. Every EHR contract and every consultant
agreement with healthcare providers should include this book in the document, and be required
reading.
The few hours it would take these leaders to read this volume would be the best return on
investment (ROI) they will ever achieve. These lessons will result in reductions of frustration,
patient harm, clinician rage, organizational disharmony, and burnout. They would also save
money and time. This book will not eliminate HIT’s unintended consequences, but it will help
readers more quickly identify them, prepare for them, reduce them, and find solutions for them.
Some of the recent offerings in this third edition highlight the difficulties of integrating HIT
into medical workflows or into some of the stakeholders’ workflows. Many of the vignettes illus-
trate the unfortunate results of communication failure—among teams, among professions, among
consultants, among users and intended users, among consultants, and among IT sellers with
everyone else. Moreover, even when the groups communicate and are all involved with the HIT’s
implementation and design, there are usually what are perceived as winners and losers—where the
outcomes favor one profession or service more than others; where one group adopts the resulting
products, while others ignore them; and where some functions work as desired and others do not
integrate into workflows, or fail completely.
There are also new stories about old problems, for example, ongoing dissatisfaction with com-
puterized decision support (CDS) alerts; finding them irrelevant, annoying, or downright danger-
ous because they interfere with thought-flow and workflow, because the pop-ups hide essential
information, and because they are so often wrong. Excessive and inappropriate alerts result in
override rates that remain stunningly high, often in the 95%–99% range, which exacerbates
dissatisfaction.
There are new and thoughtful pieces on problems created when leaders seek to change the
scope or scale of a planned project. Many of the contemplated changes initially seem wise. But

xi
xii ◾ Foreword

these stories tell of results that are anything but wise. The changes in plans wreak havoc not only
on the new or planned added efforts, but also on even the existing systems. Alas, this lesson about
late modifications is a difficult one because we know that it’s often impossible to predict what will
emerge when envisioning or effecting HIT changes. We want to encourage—not discourage—
flexible and responsive adjustments and improvements to HIT projects. The complications point
to the complex and interrelatedness of HIT. EHRs are made up of thousands (hundreds of thou-
sands) of moving parts, algorithms, expected inputs (e.g., patient weights, pharmacy data, labora-
tory reports), pieces of vestigial software embedded into the larger whole. When we add the myriad
other interacting elements from outside laboratories, inventory systems, pharmaceutical company
changes, and from the thousands of devices (e.g., smart pumps, monitors), we confront the reality
that EHRs and medicine’s digital landscape are moving entities, not static “things.” Previously,
I’ve suggested that an EHR is always changing—with new algorithms, new drugs, new processes,
and new rules. EHRs are a river, not a lake. I’ll extend that metaphor to the entirety of healthcare
facilities and their network of providers: everything is always flowing. Also, as Heraclitus reminds
us, it’s never even the same river.
This third edition builds on the previous two editions of HIT or Miss, which were enclaves
of honesty amid the incessant advertising by the HIT industry, its supporters in government,
and the enthusiasts who were so enamored of HIT’s promise that they regarded any criticism as
heresy. The first two editions of HIT or Miss contained what few uttered but what we all knew to
be essential, basic, and true: implementing HIT is difficult, often precarious, and always involves
uncertain outcomes. Nevertheless, most of us felt and still feel the promise of HIT is so great that
it was and is worth the effort. The earlier editions of HIT or Miss did not say the emperor was
naked, but they exposed the threadbare reality faced by medical offices and hospitals implement-
ing and using HIT. This third edition is even stronger. It reminds us that HIT is a magnificent
idea, but its execution is generally a serious struggle—most often a struggle each hospital or office
negotiates without the needed information from sharing honest stories like these. As the saying
goes: “You’ve seen one EHR implementation, you’ve seen one EHR implementation.” To make the
systems work always requires a lot more work than imagined.
We’ve known for years that “IT Projects Have a 70% Failure Rate…” (Novak, 2012). HIMSS
offered project management training as a solution. Ordinarily, an admission of that high a failure
rate would generate condemnation from HIMSS and the Office of the National Coordinator
for Health Information Technology (ONC), accusing those voicing such data of technophobia,
Luddite tendencies, and worse. But the costs of digital systems in money and time are so great,
and the benefits are so desired, few can admit failure. Instead, we invest millions more and usually
get something to function after months or years of additional toil. What the industry promoters
still fail to understand is that we often learn far more from examining our mistakes than from
touting our successes—especially when those successes may obscure myriad problems that were
later surmounted at great cost.
One of the joys of this third edition of HIT or Miss is that it continues to move us up on the
learning curve from the dominant presentation of HIT as unalloyed joy and progress to the reality
of what must be done to get HIT to work in situ. It shows us the absurdity of the continued refusal
of industry and government to demand data standards and to delay or sidestep interoperability
needs. It again illustrates the need for usability as a cause of patient-safety dangers and clinical
inefficiencies. It reminds us of the need for constant vigilance and evaluation by clinical and IT
personnel, along with cooperation from vendors and regulators. That is also why this book is so
valuable. Achieving usable HIT requires that we learn from these clear and thoughtful examples.
Each chapter offers invaluable lessons on HIT’s implementation and use. Some focus on order
 Foreword ◾ xiii

entry; some on bar coding; some on EHRs; some on medication reconciliation; most on workflow;
almost all on the need for planning and how planning is never enough.
Collectively, these vignettes often delineate the ongoing, Hobbesian struggles of machine vs.
man vs. local organization vs. enterprise headquarters vs. professional allegiance (e.g., nurses vs.
doctors vs. pharmacists) vs. vendor sales departments vs. consultants vs. IT staff vs. HIT design-
ers vs. cybersecurity protectors vs. finance departments vs. everyone’s desire to help patients and
avoid errors. Happily, the providers are usually well-intentioned, good people who deliver good
care. Sometimes, the struggles are overwhelming, and the care is not good. Patient safety requires
resilience and the seemingly paradoxical task of seeing what falls through the cracks. Making
HIT work requires similar observational skills. It requires that we recognize when the extra clicks,
confusing data displays, and lousy navigation that we have learned and to which we are now accus-
tomed are dangerous and lead to errors. Errors we sometimes don’t see.
Almost all of chapters speak of the vision and synoptic understanding required for HIT to
work. We learn that we are never done:

◾◾ Upgrades and patches are constant.

◾◾ Connections with the many other systems are vulnerabilities as well as opportunities.
◾◾ Our clinicians need ongoing training on changes.
◾◾ If we are a teaching hospital, we face additional challenges of HIT training while teaching
patient care.
◾◾ All facilities face new users of varying skill levels.
◾◾ Almost all facilities confront users with experiences of other systems or implementations
(ongoing or past) with very different interfaces and ways of finding essential data.

Many of these chapters discuss efforts to achieve regulatory compliance. While the ONC and
Centers for Medicare and Medicaid Services (CMS) are currently seeking greater flexibility, we are
still burdened with their original sin of requiring providers to purchase HIT rather than with first
demanding HIT with the data fluidity and usability that would make users want to buy it. Many,
also, are incensed at the ONC’s continuing refusal to press vendors seriously to adopt data and
usability standards, and to allow open discussion and presentation of faults (e.g., screenshots of
dangerous data displays). Without data standards, HIT remains the “Tower of HIT Babel” these
authors so well describe. Providers need to have a way not only to get one system to work, but also
to get many IT systems to work together … while each is undergoing change from vendors, users,
and the interplay with others’ systems.
Before even the first edition of HIT or Miss existed, there were, of course, efforts to tell the
real tales of HIT implementations. But unhappy reports were spurned as the ravings of mal-
contents and technophobes. HIT or Miss’s first edition was a needed guide for those seeking to
implement HIT, which was of course best accomplished with the knowledge only learned from
real experiences in the trenches. The first two editions provided some of that. With this third
edition, we have more guidance from more examples and greater insights. The editorial com-
ments, and the analyses accompanying each vignette, continue to be models of brevity and clear
thinking.
The argument about whether or not HIT is better than paper is silly. HIT is better than
paper. It is also better than wet clay slabs with cuneiform styluses, pigeons, or smoke signals. The
task we face is to implement HIT in ways that work reasonably well, and then use HIT to better
serve patients and clinicians. HIT or Miss, Third Edition is just what the doctor needs, and should
order stat.
Acknowledgments

The HIT or Miss books have always been a team effort. Thanks to American Medical Informatics
Association (AMIA) for providing us with the forum to create the idea and the support for this
third edition; the AMIA Clinical Information Systems Working Group (CIS-WG) and the Ethics,
Legal and Social Issues Working Group for promoting the concept and helping to lead the pro-
cess; the Health Information and Management Systems Society (HIMSS) and CRC Press for
helping to prepare the manuscript and marketing our product; our colleagues for sharing many
failed—and successful—health information technology (HIT) initiatives; and the editorial team
for their support, ideas, and terrific writing, recruiting, and editing.

xv
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