Chapter Two

SDLC

Systems development life cycle Primary resource for managing complex information system projects Primary purpose = ensure that a project is developed correctly and within time and budget constraints Applied in new software development projects, information system vendor selection, workflow and process redesigns, etc.

Interoperability

The ability of different information technology systems and software to communicate, exchange data, and use the information that has been exchanged Previously, many providers lacked this interoperability

Implement

The new system is developed The new components and programs are obtained and installed Users are trained in its use, and all aspects of performance are tested Adjustments are made at this stage if necessary

System outputs

The outcomes of inputs into a system Come in many forms and formats Ex. Lab test results, a visit summary, etc.

Open system

The parts are affected by the environment Information services vendors that apply an open system philosophy = adheres to open or readily available standards that enable software to interconnect with other open source software

Attributes

The properties of those objects that describe what they do and how they work

Test

The system is put into use This can be done in various ways The new system can be phased in, according to application or location, and the old system gradually replaced It may be more cost-effective to shut down the old system and implement the new system at the same time

Goal of system

The ultimate destination of information flow Must be value to the information processing

Structured data

The values or attributes of variables that can be processed by the computer Discrete facts and figures that can be encoded and processed by a computer Examples = data entered into templates, coded data (whether coded by a person or encoded by the computer), bar codes, radio frequency identification (RFID)

To achieve the goals of any information system

There must be a receiver Paper health record =the receiver is documentation, the direct output of the process EHR = the receiver has enhanced utility beyond documentation

Manual systems

Those that entail humans performing certain processes A filing system where paper charts are pulled and filed in accordance with specific policies and procedures = manual system designed to enable easy retrieval of charts

Maintain

When the new system is up and running for a while, it should be exhaustively evaluated maintenance must be kept up rigorously at all times System users should be kept up to date about the latest modifications and procedures

Relationships between objects and attributes

Help an information system achieve its purpose

Theory

A comprehensive explanation of an important feature of nature that is supported by many facts gathered over time Allow scientists to make predictions about as yet unobserved phenomena

Systems developments life cycle

A model that represents the ongoing process of developing (or purchasing) information systems The embodiment of information systems theory

Information system

A set of components that work together to achieve a common purpose Various types of information systems (ie. laboratory information systems, pharmacy information systems, disease registry systems) Although these information systems have inputs, processes, and outputs = their purpose is limited to scope of department's operations or their primary function

Process

A systematic series of actions taken to create a product or perform a service Used to generate information from inputs Data processing may also potentially generate new knowledge when experience is included in the data contributed to the system

Closed systems

A systems where all parts operate together without external influences In general systems theory = a closed system may be expected to eventually stop functioning as a system because it does not have the feedback necessary to adjust to changes in the environment In health IT = describes health IT that is proprietary and not freely shared with others

Cybernetics

A theory of control system based on communication (transfer of information) between components of systems with respect to their environment Special case in which information systems incorporate self regulation Control process in cybernetics creates a feedback loop that ensures integrity among the basic elements that have relationships comprising an information system

Best practices

AKA = clinical practice guidelines Statements that include recommendations, intended to optimize patient care, that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options Clinical decision support afforded through EHRs and other health IT systems should reflect best practices Can and should change over time, as new information and new knowledge are generated

Feasibility

AKA = planning step The existing (manual) system is evaluated and deficiencies are identified to determine whether it makes sense to proceed with the project

Sunset step

AKA = retirement step Optional 7th step Relevant when SDLC is being used in development of commercial software where the version or release is being retired

Closed proprietary systems

Adhere to standards but do so loosely, which makes it difficult for other software to work with them Closed health IT systems are influenced by government mandates but do no necessarily respond to customer demands without such a government mandate

Stage 2

Adoption = where intended users manage the majority of their basic information needs

Electronic systems

Aided by computing devices Electronic health information system = an information system where humans enter data into a computer to be stored and later retrieved to support patient care

Other aspects of maintenance

Also includes the orderly disposal of surplus or obsolete hardware, software, and data May involve a change in vendor control or software obsolescence Many providers look to replace EHRs because the vendor is retiring them, out of business, or because the system is not current with MU incentive program stage requirements

General systems theory

An interdisciplinary field of study that analyzes and describes how any group of objects work together to produce a result Generally grew out of biology and the notion that systems are open to and can interact with their environments, and they can acquire qualitatively new properties through emergence, resulting in evolution

Human-machine systems

Any form of supportive operations that assist humans in the performance of their work

Data flow

Basic information theory describes flow of data from a source to their ultimate destination Data are input into a system for the purpose of being processed and then output as useful information Ensures that data needed to create useful information are supplied and generate desired information

SDLC methodology

Called a waterfall methodology Describes a linear set of phases Does not emphasize a feedback mechanism Feedback is especially important for complex systems projects = therefore modern SDLC is modified to include a feedback mechanism

Unstructured data

Can be stored in and viewed from a computer but they cannot be processed by a computer Textual objects and images stored in a computer but not processed by a computer Examples = narrative notes, print files, video and voice files, scanned images of documents, pictures

Unity of purpose

Causes the collective parts of an information system to have integrity System must have an identity and describable boundaries EHR system must be designed around well established policies that set the boundaries for where the system starts and ends, and the adoption and realization of benefits

Social factors

Characteristics of individuals and groups of people involved in use of the information system May dictate how a system is designed, what input devices are used, and how users are trained to use the system Important determinants of EHR adoptions, requiring significant human factor engineering of the information system as well as change management for the intended users

Political factors

Competing demands that influence both the social and economic factors May promote incentive for use of an information system over disincentive, or they may discourage use

Objects

Component parts of a system

Knowledge

Considered a refinement of information, where experiential data are added to information, forming patterns over time Some of this knowledge can be supplied in an information system = this information can then be processed with other data entered Although the creation of knowledge is valuable = adding computer generated knowledge may not be cost effective in cases where human knowledge may be applied more readily

Structured and unstructured data

Data = generic term to mean any facts and figures However, to be processed into information by a computer system = data must be in discrete (structured) format Unstructured data are also incorporated into an EHR

Inputs

Data entered into the information system Includes data from source systems as well as those directly entered by a human

DIKW continuum

Data-information-knowledge-wisdom continuum Data are raw facts, symbols, and senses and are generated through research, creation, gathering, and discovery Data may be structured or unstructured Information is the result of processing data = processing forms relationships among data = gives data context and makes them useful

Boundaries

Describe the scope of a system EX. Boundaries of EHR system might be defined that only the core clinical system components are included

Mechanical systems

Developed by humans but can operate without human intervention Ex. heating and cooling systems

Policy

Directives or principles on which people perform their work or other activities May center on their business practices, social interactions, use of drugs, etc. Since EHR is a new construct, there are often few formal written policies May have huge economic and safety consequences for a healthcare organization since = multiple and parallel process always add operation costs and are prone to error

Open-source software

Does not mean free Means that the vendor that created an open system is willing to sell the software to others that , because the software is standards-based, may modify it to work with other systems Tends to be relatively inexpensive = makes it attractive to small practices but can't provide adequate support or customization Generally not feasible for hospitals because EHRs must connect with a large number of proprietary source systems

EHR

Electronic health record Also an information system that has inputs, processes, and outputs Typically much broader in scope than an application designed for a single department or function EHR depends on many other systems for its input, , performs many different types of processes, and generates a wide array of outputs

Steps for implementation (pt. 1)

Establishing an issues management Scheduling project tasks, milestones, and resources Developing a turnover strategy Planning for training Planning for testing Installing hardware and software Reconfiguring communications and network components Configuring the system Implementing security controls Unit and system testing

Specification of requirements includes

Executing a project overview for all stakeholders Delineating staff roles and responsibilities Performing process mapping and specifying functional requirements Specifying technical requirements Identifying project and risk management methodologies Defining deliverables Identifying control requirements and standards Charting a conversion strategy Documenting the planning for everything Performing staff development

Information systems theory

Explains how information, and ultimately knowledge and wisdom, are generated by data processed in predictable ways to contribute value Information system requires data and instructions for processing to produce results Information systems are often designed for specific purposes that can stand alone

Traditional SDLC methodology

Feasibility Analysis Design Implement Test Maintain Some include either a 7th step or replace the 6th step with a disposition or disposal step

System theory

Focuses on the arrangement of and relations between the parts that connect them into a whole The same concepts and principle of theory organization underlie different discipline System concepts include system-environment boundary, inputs, processes, outputs, and goal-directedness

Basic tenets of SDLC

Frequently adapted for project management of any type of project

Characteristics of information systems

Fundamental elements of information system = inputs, processes, and outputs Fundamental elements are accomplished through = adoption of hardware (equipment) and software (computing instructions) Need to consider hardware and software, but also people, policy, and process

Information theory

Help further the pursuit of health IT in an interoperable environment = use of EHRs will generate more that improved access to information traditionally recorded in paper documents Health IT will increase availability of records, supply data that support clinical decision making at the point of care, and provide foundation for real time public health surveillance

When the SDLC is applied to project management where software is being acquired, the following phases are included:

Identification of need, specification of requirements, acquisition, implementation, maintenance, and monitoring of results

Stage 1

Implementation = where basic functionality is put into place and users use the minimum functions of the EHR to earn incentives

Implementation

Implementation of acquired health IT includes = product installation, customization of the system to meet the organization's requirements, and turning the system over to users More than just installation Common misconception = software can be installed and used directly thereafter Even simple EHR requires system configuration, training, and testing

Feedback mechanisms

Provide information about environmental factors that interact with the functioning of the system EHR system can transform clinical practice = this chance can't be created or maintained without a constant feedback mechanism that celebrates success and identifies where correction is needed Includes a number of social, economic, and political factors

Data uses

Information theory recognizes not only the flow of data but also how data are used, how they may be converted to information, how experience may be applied to the information to support the creation of knowledge, and how multiple iterations of knowledge creation generates best practice DIKW continuum is part of information theory

Data sources

Input requires a source of data Source in health data = generally an observation about a patient or patient response Must be a transmitter = often a clinician Data may be objective or subjective Processing raw data into useful information is performed by a channel = ie. paper, process of forms that guide capture of data

Healthcare delivery system

Its boundaries are healthcare services for humans defined by reimbursement practices Its inputs are individuals seeking healthcare services Healthcare delivery system's processes are the services performed by providers, payers, oversight agencies Its outputs are the health outcomes in the human inputs

People

Key reason why information systems exist and determine how information systems exist Information systems are characterized as human-machine systems because people design and then use them

Wisdom

Knowledge gained from the iterative collection of data and informed by context and experience Provides best practices (principles upon which decisions can be made to direct work)

Monitoring of results

Provides the feedback mechanism needed to assess whether the intended goals and benefits of a project are being met and what changes need to be made to either the components of the project or the goals and expected benefits

Acquisition

Most healthcare organization will acquire an EHR, rather than develop it themselves

Analysis

New (automated) system requirements are defined Deficiencies in the existing system are addressed with specific proposal for improvement

Identification of need

Often addresses both the feasibility and analysis aspects of the traditional SDLC Feasibility may be viewed as "readiness assessment" and be associated with each new component or step in adoption process

Stage 3

Optimization = where value is realized from mastery of the EHR for all aspects of knowledge management

Maintenance

Relates to the ongoing support needed to keep the system current and accurate All software requires ongoing support, to ensure that errors in development are correct and patches to continually enhance security protection are applied Most health IT systems must be kept current with new information, refined best practices, updated drug data, reimbursement codes, etc.

Data quality

Relating to the accuracy, completeness, timeliness, precision, currency, granularity, relevancy, definition, accessibility, and consistency of the input

Human systems

Organized relationships among people Ex. healthcare delivery system

Monitoring involves

Performance measurement Benefits realization

Steps in acquisition

Performing market research Submitting a request for proposal development Submitting a request for proposal distribution, receipt, and analysis Performing due diligence to verify proposal content Negotiating the contract Obtaining approval to acquire the product Financing the acquisition

Design

Plans to address the physical construction, hardware, operating systems, programming, communications, and security issues of the proposed system are laid out

Specification of requirements

Potentially most important phase Often shortchanged

General information systems theory features

Set of elements = Hardware, Software, Human (People, Policy, Process) Working together = Interfaced, Integrated, Standards, Connectivity To achieve a common purpose = Quality of care, Patient safety, Access to care, Cost of care, Efficiency of care, Experience of care, and Health (in general)

Component of identification of need include

Setting strategic business goals Defining expected benefits Anticipating potential organizational changes Identifying budgeting, scheduling, personal constraints Assessing attitudes and beliefs Assessing computer skills Performing communication planning Performing change management to address human factor elements Doing a cost-benefit analysis

Maintenance includes the following

Software maintenance Hardware upgrades and maintenance Hardware and software inventories and license agreement maintenance User preference changes Disposal of out of date system components

Meaningful use incentives and SDLC

Stages of federal MU incentive program for EHRs were built around a SDLC perspective 3 stages

Health information technology

The broadest focus of health information systems It incorporates all source systems and core clinical systems used within a healthcare delivery organization, as well as information systems that are external to any given delivery organization and may span multiple health information systems Examples = systems that individuals use to monitor their health, systems that support population health, etc.

Process

The manner in which a task is performed Ex. process a provider uses to write an order for medication Process change is one of the most significant factors in the success or failure of EHR adoption Need to be well designed, accurate, kept up to date, and as intuitive as possible to use When considering changes, current processes must be understood so that both control points can be retained and workarounds and bottlenecks can be eliminated

Relationships

Tie the component parts together in accordance with their characteristics Goal = achieve a purpose o function equal to or better than what any individual object could achieve alone May be planned or unplanned, formal or informal BUT must exist if the collection of components is to constitute a system Key for designing EHR system = many disparate systems and their respectively disparate stakeholders must come together to form new relationships

Systems

To have value, all elements should be directed toward accomplishing something Systems may have one goal or many (ie. improve documentation, communication, etc. Many types if familiar systems Characterized as opened or closed

Steps for implementation (pt. 2)

Training "super" users who assist other end users Developing an interface and testing integration Converting data Performing stress testing Performing end-user training Providing documentation Providing go-live management and support Performing acceptance testing

Templates

Used to overcome errors Designed for data entry Often have predefined parameter that are checked as data are entered Such edits can address only the most evident logical errors, and too many such checks can be distracting for users

Information system does the following

Uses devices to capture data in multiple formats that are converted to a machine-processable state Applies instructions, also converted into a machine-processable state, to index, store, calculate, compare, and perform other functions on the data Use devices to display the original data at another time or place and present the results of calculations, comparisons, and other functions to users in various formats

Information systems theory

Uses facts about information systems to make predictions about how such systems will work Every information system is described, at minimum, by its inputs, processes, and outputs When planning information systems = necessary to anticipate the impact of these system component on the desired outcome of the system

Economic factors

Well known determinants of whether and what information systems are acquired Often directly in conflict with social factors = highly sophisticated, intuitive systems are easier to use than basic options but are much more expensive