The big-bang theory as a healthcare information technology implementation strategy famously fizzled during the 2002 rollout of a computerized physician order-entry system at Cedars Sinai Medical Center, Los Angeles.
But big bang has made a comeback recently, with several notable instances at Calgary Health Region, one of nine government-funded care networks in the Canadian province of Alberta. Calgary Health Region serves 1.2 million of the 3.2 million people in the province. The region was a winner last week of an award for excellence in applied medical informatics given by the Association of Medical Directors of Information Systems.
Belinda Boleantu and Tom Rosenal were part of a team at Calgary Health Region that implemented a full replacement and upgrade of its clinical information system at three of the four large urban hospitals in the 12-hospital system. The installations were completed over a 21-week span; the most recent was at the region's flagship Foothills Medical Centre in Calgary, which went live with all users on Jan. 26.
"We activated them in 10½ hours," said Boleantu—who is part of Calgary Health’s Patient Care Information Systems team—of Foothills, which has more than 900 beds. "We started the conversion on the back end, so there was a lot of time before that, but the users working on the new system, where the front-line clinicians were involved, that took us 10½ hours."
"I think we're both advocates of the big-bang approach," said Rosenal, the former medical director of clinical informatics at Calgary Health.
Conversion of paper-based, 135-bed Alberta Children's Hospital, the smallest of the four urban hospitals, is next on the list.
Boleantu and Rosenal agree that Calgary had a couple of uniquely Canadian advantages over their U.S. counterparts going into the approximately $75 million (U.S.) project, which began its planning stages four years ago. Having a single payer for acute care in the district and an integrated delivery system made planning and organizing much easier, they said.
The Calgary Health Region is an organization responsible for hospital care, outpatient mental health, public health, including restaurant inspection, but not private, outpatient care, Rosenal said. Most nurses are employed by the region, though some are indirectly employed by home-care organizations that have a contract with the region, he said.
"The vast majority of clinical physicians are in private practice, but some of them are paid by the region for doing work in the region as a department head," Rosenal said. For example, Rosenal says he receives money from the provincial government for his critical-care patients, a salary from the regional authority for being the head of the critical-care unit and a salary from the University of Calgary for being a teacher.
But, in addition, "One of the advantages we've had in the region is a lot of experience in information systems," Boleantu said. "We've had information systems in the region for a very long time, 20 years. We've had a very sophisticated critical-care charting system for over 10 years. We have had a system for anesthesia and home care for quite a long time. But up until the last four years, they have been siloed and what we've tried to do is have a patient-centric view so we have a holistic view of patient care across the continuum of care."
Broad participation, systematic and continuous training and clear and open lines of responsibility were keys to success for the big-bang implementations, all of the preparations are replicable in a U.S. healthcare environment, according to Boleantu and Rosenal.
Rosenal led a clinician-centric vendor selection team largely chosen by physician leaders.
"The important thing about the teams was they were clinical," Rosenal said. "They were selected by the president of the medical staff and half by the chief medical officer. For nurses, they were people considered to be respected senior nurses. Put all of those people together, we would have about 20, and we did three or four site visits both in Canada and the U.S."
"We were constrained for money at that time and we also recognized both from the literature and what other people had said that the traditional vendor selection through an RFP (request for proposal) was not useful," Rosenal said. "So we took a nontraditional approach. For the acute-care replacement system, we were looking at something where there were only about three vendors available that would be large enough to meet our needs. We took a very rapid non-RFP process to look at the vendors," he said, coming up with a short list of three.
From the start of the planning process, Rosenal said the team knew it would have a hybrid system from multiple vendors.
"We were very interested in having a core enterprise system," Rosenal said. "We knew safety would come out of CPOE and EMAR (electronic medication administration record). We also recognized that an enterprise system would be highly unlikely to provide us with a radiology systems, an OR system."
The mix includes Sunrise Clinical Manager from Eclipsys Corp. at the core; Cerner Corp. for labs and diagnostic imaging; Centricity from GE Healthcare for pharmacy; and Clinibase by Logibec for admission, discharge and transfer. All clinical information is housed in two third-party data centers run by IBM and Telus, a Canadian telecommunications company. At the same time, the region converted 2.5 million patient records to the system, running them through a patient-identification system by Initiate Systems, and tagging each with a unique regional patient identifier. Tying the disparate systems together is what Boleantu called “a strong interface engine” that was largely built in-house.
"We had to be technically flawless on our software implementation," Boleantu said. "So the issues become very focused on how do you do this."
"We tested the hell out of this," Rosenal added. "We spent a lot of time with our clinicians reducing the number of alerts dramatically with the idea we'd increase them over time. We just didn't want to lose them. There was a lot of careful planning for unexpected downtime."
But a successful big-bang implementation, and the long-term success of the entire system, requires more than smooth-running software; it needs capable users, and that means training and a system of training management, both said.
Responsibility for training was pushed down to the unit level, where each unit had at least three superusers whose training was funded by the region and who facilitated Web-based training for everyone on the unit. Each unit had counsel whose job it was "to convene and look at learning and training and workflow, how life is going to change on their unit," Boleantu said.
"We had a blended learning approach," Boleantu said. "It included training, it included workflow and practice. We had a fairly regimented process of how to go through those discussions and had feedback in an iterative process. Physicians need context for their discussions about their workflow. Access to the Web-based training program was available on every work station in the unit."
"For some," Rosenal said, "it was possible to dial in from the outside. One clinician near retirement dialed in from his cottage on the lake."
Unit counsel "had to actually declare that their people were ready, and if not, what needed to be done, and if not, the person that you were to report to knew you were in trouble," Boleantu said.
In addition, in each hospital preparing for a system rollout Calgary Health created the solution center, a telephone hot line staffed by people trained in the use of the application, but who also could dispatch a superuser to the affected unit.
"It was a very convenient way to dispatch people who needed help and knew right away if we had an area of weakness about this particular piece of technology," Boleantu said. "We really had a neural network of ways of getting information out and getting it back. As we moved from one site to the next, the center physically moved."
Training and assessment continued up until the moment the rollout began, but it can't stop there, considering turnover and system change and improvement, Boleantu said.
"If you think about a 10% new hire rate per year, with a 14,000-person implementation, we will continue on with this process of discussion and training and workflow. That's how we've been able to do this, scale has been our friend. The (Foothills) site was our biggest site. We secured help from the previous two sites, and that was the best site yet."
Rosenal said the hardest challenge was getting people throughout the region to get their heads around what was being attempted.
"The big transformation we were trying to achieve was getting the organization, from the leadership down to the bedside clinical folks, to get them to understand what we were doing wasn’t an IT project, but that it was a system to support care," Rosenal said. "There was a huge difference in understanding. I think our CFO thought we were spending a lot of money. At the bedside, there were some people who would say, 'You're making my life hell.' And others would say, 'God bless you, because we get out of bed every morning wanting to improve care, and you're making it easier to achieve (that) goal.' "
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