Installation and Maintenance of Health IT Systems Troubleshooting; Maintenance and Upgrades; Interaction with Vendors, Developers and Users Welcome to Installation and Maintenance of Health IT Systems, Troubleshooting; Maintenance and Upgrades; Interaction with Vendors, Developers, and Users, This is lecture a. This component, Installation and Maintenance of Health IT Systems, covers fundamentals of selection, installation, and maintenance of typical Electronic Health Records (EHR) systems. This unit, Troubleshooting; Maintenance and Upgrades; Interaction with Vendors, Developers, and Users, will discuss ways you can implement an infrastructure for troubleshooting, and maintaining EHRs and their existing infrastructure. Lecture a This material (Comp 8 Unit 8) was developed by Duke University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000024. This material was updated in 2016 by The University of Texas Health Science Center at Houston under Award Number 90WT0006. This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/. Health IT Workforce Curriculum Version 4.0

Troubleshooting; Maintenance and Upgrades; Interaction with Vendors, Developers, and Users Learning Objectives Identify and implement an effective troubleshooting procedure for reporting, evaluating, fixing, deploying, and follow-up of errors, problems, or limitations for the system (lectures a & b) Integrate downtime schedule for OS, network, database, and client application maintenance and updates (lecture b) Objectives for this unit, Troubleshooting; Maintenance and Upgrades; Interaction with Vendors, Developers, and Users are to: Identify and implement an effective troubleshooting procedure for reporting, evaluating, fixing, deploying, and follow-up of errors, problems, or limitations for the system Integrate downtime schedule for OS, network, database, and client application maintenance and updates Creating an infrastructure that will be able to troubleshoot technical performance issues adequately and quickly is imperative to ensure successful workplace integration, maximum reliability and to minimize downtime. Nowhere is this need more apparent than in the healthcare setting whose dependence on its computer systems in recent years has increased exponentially, and where computer delays can jeopardize the health of patients. As an institution's size grows, this task becomes daunting as user issues, upgrade projects, and routine system maintenance all vie for the IT staff’s time. This section is designed to offer some suggestions for effectively managing these issues and to offer some proven diagnosis and management strategies. Today we will discuss creating a help desk, triaging and prioritizing trouble calls, and creating a tiered support strategy, especially for larger environments. Health IT Workforce Curriculum Version 4.0

Troubleshooting; Maintenance and Upgrades; Interaction with Vendors, Developers, and Users Learning Objectives (cont’d) Develop a process for communicating requirements and supplying updates between vendors/developer and users (lecture b) Create a baseline for system performance measurement and comparison for troubleshooting (lecture b) Additional objectives for this unit, Troubleshooting; Maintenance and Upgrades; Interaction with Vendors, Developers, and Users are to: Develop a process for communicating requirements and supplying updates between vendors/developers and users Create a baseline for system performance measurement and comparison for troubleshooting In the second part of our lecture, we will shift gears a bit to discuss troubleshooting, maintenance & upgrade strategies. We will discuss the importance of creating a baseline for measuring system performance. What is a baseline? What to measure? Finally, we will talk about interactions between vendors, developers, and users, and the importance of developing a process for communicating requirements and supplying updates. We will briefly discuss the importance of client-vendor relationships and offer some suggestions for ensuring a healthy and long life together. Health IT Workforce Curriculum Version 4.0

Troubleshooting: Support Staff Dedicated staff for maintenance, upgrades, & troubleshooting of IT systems, e.g. EHRs. May be in-house or contracted In-house personnel may be organized in different ways/ departments based on support responsibilities Even if your clinic or institution has their EHR system installation well underway and you’ve experienced no real issues, you must accept the fact that problems will eventually arise, often during implementation or even after the implementation process has been completed. Users will look to their HIT consultant to help them develop procedures for reporting problems and methods of monitoring the system's performance. You will need to decide how IT related issues can best be resolved based on the size and purpose of the organization, budgetary constraints and staffing resources you have available. EHR and IT support staff (in concert with your EHR vendor) are typically responsible for resolving these issues as they arise. Your IT support may be hired and developed in house or you may choose to contract or outsource with a third party to provide support on an as needed basis. If you choose to develop an in-house staff to provide partial or full technical support for your EHR system, there are a number of different organizational staffing models to choose from depending upon your particular institutional needs and support responsibilities. Health IT Workforce Curriculum Version 4.0

Troubleshooting: Support Staff (cont’d) Larger environments More cost-effective to provide on-site staffing for most maintenance & troubleshooting of EHR. Dedicated production support team to focus on customer support issues. Avoid temptation to share support responsibilities with development team. (Boyer, 2005) For larger institutions, the chore of maintaining a large EHR infrastructure, combined with the need to interface with (perhaps) hundreds of users on a daily basis, becomes a more daunting and costly task, typically requiring an additional in-house IT staffing component, often referred to as the development team, to maintain and further develop the system. The temptation is always there to share the production support responsibilities with the development team. This is particularly prevalent in mid-sized organizations where IT teams are in-house but may be smaller, forcing them to share the workload. This practice however often leads to productivity loss and long-term team dissatisfaction as project goals fall further and further behind schedule, necessitating the creation of a dedicated production support team to manage customer support issues. Health IT Workforce Curriculum Version 4.0

Troubleshooting: Support Staff (cont’d – 2) The Production Support Team should focus on: Being highly available and usable. Providing rapid response to service issues. Handling customer problems. Managing user access requests to the EHR. Reviewing daily interface error logs. Doing other day-to-day duties as needed. (Boyer, 2005) The production support team should provide highly available, highly usable and expedient support to address user service issues as they arise. In today’s healthcare environments, EHR downtime can potentially have a negative effect on patient outcomes. This means ensuring access to skilled IT support during all operational hours and devising an efficient method of ensuring user requests are processed and resolved in a timely manner to minimize productivity loss and any patient safety issues. Responsibilities of the support team could include managing user access to the EHR system, and monitoring the daily interface errors and discrepancies such as invalid interface filing types, patient mismatches, and duplicate orders. Health IT Workforce Curriculum Version 4.0

Troubleshooting: Support Staff (cont’d – 3) Production support team Customer-focused, excellent “soft skills” Versatile, with specialists in help desk, application, hardware, & network support. Thorough understanding of application & business processes (Boyer, 2005) The production support team should also be highly customer focused. This is especially true in healthcare environments where medical professionals are often working under stressful conditions and may be sensitive about being placed in subordinate roles. Your front-line support team should be able to use their soft skills to better understand and build good working relationships with their users while effectively addressing their technical needs. Your support team should be versatile, encompassing specialists in help desk, application-level, hardware, and network support; and have a thorough understanding of application and business processes. As your organization grows, it’s more common to compartmentalize depending on each skillset required to address a particular issue. Let’s take a closer look at one such method we could use. Health IT Workforce Curriculum Version 4.0

EHR Troubleshooting Workflow This diagram depicts a typical troubleshooting request workflow. As requests enter the system, they are evaluated by the helpdesk. If the helpdesk cannot resolve the issue immediately, the request is triaged, assigned a priority, and directed to the appropriate workgroup for resolution. This system provides the support team with an efficient workflow strategy designed to adequately address user needs. In this instance, the IT team is divided into five support categories: The help desk, who would triage incoming requests and process basic diagnosis and administrative requests; The applications team, who respond to issues surrounding the use of various supported software applications, including EHR software issues, and including trouble diagnosis and software upgrading; The networking team, who diagnose and resolve issues regarding connectivity and data exchange; general administrative, security, and account issues, and perhaps some server administration and hardware support issues; The Citrix Team, who would resolve issues arising from the use of supported virtual environments; and The workstation support team, who would respond to inquiries regarding workstation usage, including potential hardware malfunctions or local application support installation and troubleshooting. It’s important to note that this is just one variation of a support organization. Each IT department must find the balance between workload and available resources that best suits their organizational needs. Image by Scott Neal Health IT Workforce Curriculum Version 4.0

Troubleshooting: Tiered Approach Super users, help desk Workstation & network specialists, technical analysts Application support specialists, support consultants; often centrally located (Boyer, 2005) In larger organizations which often need to support multiple clinic sites, a tiered troubleshooting support approach is recommended to maximize IT support productivity while maintaining a high degree of customer service response. In these instances, a three-tiered approach is often most effective: The first tier, consisting of super users and or help desk staff; The second tier is staffed with workstation and networking specialists, and technical analysts are deployed to troubleshoot issues not resolved by the first tier’s efforts. The third tier is usually made up of application support specialists and support consultants. They are usually centrally located, which facilitates the face-to-face communication often needed to root out complex performance issues. Now, let’s talk about the different tiers in more detail. Health IT Workforce Curriculum Version 4.0

Troubleshooting: Tiered Approach (cont’d) “Super users” (tier 1) Usually clinical staff, well trained in EHR usage & workflow strategies Located on-site for front-line support Promote proper security & confidentiality Teaching & communication skills Liaison between EHR support team & clinic (Boyer, 2005) So-called “Super Users” are usually members of clinical teams who are well-versed in EHR usage and have received additional training in workflow strategies. They are strategically located at practice sites or departments to provide front line user support to commonly asked questions and to promote proper security and confidentiality practices. Super Users should be excellent teachers who enjoy the person-to-person interaction required to answer many user inquiries and often times serve as liaisons between the EHR support team and the clinic. Super users are also good at identifying problematic EHR and workflow issues and recommending potential improvements to the development team for consideration. Health IT Workforce Curriculum Version 4.0

Troubleshooting: Tiered Approach (cont’d – 2) Help desk analysts (tier 1) Provides first point of contact – Usually through phone & email support Workstation & application troubleshooting Documentation of issues & their resolution, for further analysis, in ticketing system Customer relation skills (Boyer, 2005) The Help Desk: Regardless of the size of your organization, it’s important that all incoming requests be handled efficiently and are properly prioritized (which we’ll discuss momentarily), the help desk should become the centralized, first point of contact for most user inquiries. The help desk is responsible for troubleshooting and resolving most common issues and assisting users with typical EHR usage inquiries often through phone and email support. When a problem arises that is beyond the scope of the helpdesk to resolve, they will prioritize the issue, triage it, and assign it to the appropriate group for resolution. Help desk staff also have the responsibility of documenting their work cases. Each call or support request should be tracked using a ticketing system, such as Remedy, Cerberus, or LANDesk to ensure proper documentation and timely service. Since an overwhelming majority of work requests will be funneled through the helpdesk at some point, thorough documentation of these work cases can, when analyzed, provide additional insight into trends and performance issues affecting the EHR system. Help desk staff should have excellent customer relations skills and be effective at triaging and assigning requests. They should have intermediate level workstation and peripheral troubleshooting skills and be proficient at supporting the various workplace applications. Health IT Workforce Curriculum Version 4.0

Troubleshooting: Tiered Approach (cont’d – 3) Network specialists & workstation analysts (tier 2) Dispersed throughout system Troubleshoot intermediate-advanced network & application issues Interface with various team members to expedite requests (Boyer, 2005) Network Specialists and Workstation Analysts have general network knowledge and proficiency with all supported utility applications. They typically are dispersed throughout the system to provide level two support and know who to contact when problems arise to expedite repairs. They are often times assigned to a particular workgroup and are dispatched by the helpdesk to meet with an end user to provide in-depth training or further triage an issue and attempt a resolution. Health IT Workforce Curriculum Version 4.0

Troubleshooting: Tiered Approach (cont’d – 4) Application support specialists (tier 3) Experts in EHR applications Troubleshoot difficult issues Research specific problems with vendor Production support consultants (tier 3) Similar to application support specialists Work effectively with clinicians & stakeholders Recommend & implement EHR upgrades (Boyer, 2005) Application support analysts and production support consultants represent the third tier in troubleshooting. In organizations with smaller budgets, these may also be part of the development team. Application support specialists provide expert support for EHR applications, including troubleshooting unique problems and interfacing with the vendor to find resolutions. Production support consultants are lead systems analysts. In addition to performing roles similar to application support specialists, they are responsible for training other analysts, as well as researching, recommending, and implementing EHR system upgrades. Health IT Workforce Curriculum Version 4.0

Troubleshooting: Tiered Approach (cont’d – 5) Communication is key. Especially with separate IT teams for projects & support; critical need for written documentation. Lines of communication between all facets of support infrastructure. Periodic training for communicating enhancements & known issues, soliciting feedback. Listening & communication skills; glean enhancement ideas from users. (Boyer, 2005) When separate teams are responsible for projects and production support, it becomes even more critical to produce vital written documentation and build other, more efficient means of communicating change across the IT teams. Periodic training sessions are also helpful for distributing latest enhancements or known issues to other team members. The ability to become a skilled listener and be able to accurately define the problem are important communication skills when interfacing with users. Often, the user is simply describing an EHR enhancement request rather than an actual problem with the system. This makes the support team a valuable asset for gleaning enhancement ideas. Health IT Workforce Curriculum Version 4.0

Troubleshooting: Prioritizing Requests Routine (Low) Intermittent; needs to be addressed but no impact on workflow or patient care. Important (Medium) Device nonfunctional but not impacting patient care. (Boyer, 2005) As we touched on earlier, prioritizing requests properly is key to maximizing user productivity and minimizing adverse patient outcomes and is initially done when a request comes into the helpdesk. Requests should always be prioritized based upon the level of impact. Here is a suggested 4-level prioritization scheme. A routine, or low, priority request is limited to an intermittent problem that needs addressing but is having no impact on workflow or patient care. An important, or medium, priority request indicates that a device is nonfunctional but not impacting patient care. Health IT Workforce Curriculum Version 4.0

Troubleshooting: Prioritizing Requests (cont’d) Urgent (High) Severely impacting individual or department workflow. Critical Critical device affected, with no other alternative for user; or directly affecting patient care. (Boyer, 2005) An urgent, or high, priority request is an issue that is severely impacting an individual’s or department’s workflow. Critical status is reserved for issues where a critical device is affected, with no other alternative for the user, or the issue is directly affecting a patient’s care. Health IT Workforce Curriculum Version 4.0

Troubleshooting: Concerns for Small Practices Lack of financing, technical staffing resources, and knowledge of best practices hinder small practice adoption rates. May need to contract with an IT consultant, an affiliated institution or IPA. Need go-to person assigned both to administer the system and to interface directly with IT consultants and vendor. (Felt-Lisk, 2005; Lake, 2011; Pereira, 2010) Despite the fact that almost 50% of the practicing physicians in the U.S. work in healthcare settings staffed with 5 or fewer physicians and the recently imposed governmental incentives for EHR usage, these smaller clinics continue to lag behind in EHR system adoption. Stakeholders in these settings often cite lack of sufficient financing, technical staffing resources and knowledge of best practices as reasons for delaying adoption. Their concerns are justified since the high cost of starting an EHR is typically only partially offset even with current incentives in place. Additionally, it’s said that the annual cost of maintaining an enterprise EHR system once in place can be up to four times the initial cost of the original purchase. For smaller environments this may mean outsourcing with an IT consultant or team and appointing an in-house “go-to” person with at least some technical proficiency who can perform administrative functions on the system and to interface with the consultant and the vendor when problems beyond the typical scope arise or when updates are ready for deployment. Health IT Workforce Curriculum Version 4.0

Troubleshooting: Concerns for Small Practices Purchase an EHR from a Vendor equipped to provide ongoing EHR support for your organization’s technical needs Consider partnering with your affiliate hospital or IPA for EHR and IT Support Services or a hosted solution Consider hiring a Health Information Management (HIM) Professional Take advantage of EHR system training (Felt-Lisk, 2009; Lake, 2011; Heubusch, 2008; Pereira, 2010) Many vendors offer support packages to accommodate these smaller healthcare settings. It’s important that you understand the amount of support your potential EHR vendor is willing to provide and how much on an annual basis you can expect to pay. Some clinics affiliated with larger hospitals or IPAs have the option of receiving technical support from these entities in order to offset in-house technical support or letting them host the EHR system altogether. Thanks to cloud computing, hosted solutions offer a big advantage where maintenance cost is a significant issue since much of the burden of maintenance and repair falls to the EHR vendor who, in many cases, provides 24 hour support for their system. Some smaller practices are beginning to bring Health Information Management Professionals on staff to assist with documenting and assessing workflow, EHR integration, and assisting with coding and data management. Lastly, whether you plan to work in a large or small environment, be sure to take full advantage of training opportunities as they come along for your particular EHR system. Most vendors offer extensive EHR software training (usually for a fee) at their corporate sites or through an online training package. Health IT Workforce Curriculum Version 4.0

Forward requests to appropriate specialist. Troubleshooting; Maintenance and Upgrades; Interaction with Vendors, Developers, and Users Summary Support staff Smaller healthcare settings might contract out IT services; larger institutions require in-house IT staff. Requests for support Triage & prioritize upon receipt to avoid urgent issues being overlooked. Forward requests to appropriate specialist. This concludes lecture a of, Troubleshooting; Maintenance and Upgrades; Interaction with Vendors, Developers, and Users. Well, that’s a good start for this unit. Let’s take a minute to summarize what we’ve learned so far. Smaller healthcare settings may get by contracting with a third party IT contractor or through their EHR vendor for a majority of their technology and EHR needs, while larger institutions will most likely require a dedicated in-house IT staff to provide efficient response to resolve system issues and user requests. Being able to triage and prioritize requests as they are received helps to ensure urgent issues are not overlooked. Also ensure that requests are forwarded to the appropriate specialist for resolution. Health IT Workforce Curriculum Version 4.0

Specialists with wide variety of skills Troubleshooting; Maintenance and Upgrades; Interaction with Vendors, Developers, and Users Summary (cont’d) Tiered structure can help manage workloads & user requests in larger institutions. Specialists with wide variety of skills Application support & development Networking infrastructure & security Hardware support There are a variety of ways an IT department can structure itself to best meet the needs of its users. For larger institutions however, a tiered approach can be quite effective at managing workloads and mitigating issues when they arise. Lastly, effective IT departments employ specialists with a wide variety of skillsets, including: application support and development networking infrastructure and security; and hardware support to better serve their customers without frequently depending on third-party resources. In lecture b we will begin to discuss specific strategies for troubleshooting, as well as upgrading and maintenance. We’ll also discuss the importance of the client vendor relationship when it comes to technology issues as well as strategies for interfacing with users. Health IT Workforce Curriculum Version 4.0

Troubleshooting; Maintenance and Upgrades; Interaction with Vendors, Developers, and Users References – Lecture a References Boyer, E. and Soback , M. (2005). Production Support. Implementing an Electronic Health Record System. J. M. Walker, E. J. Bieber and F. Richards, Springer London: 95-100. http://www.springerlink.com/content/n520ghg078416463/ Felt-Lisk, S; Johnson, L; Fleming, C; Shapiro, R; Natzke, B. 2009 September 22 [Internet]. . Toward understanding EHR use in small physician practices. Available from: http://www.thefreelibrary.com/Toward+understanding+EHR+use+in+small+physician+practices.-a0216632134 Heubusch, K. "Physician Practices and Information Management: HIM Professionals Offer Value in Changing Practices." Journal of AHIMA 79, no.8 (August 2008): 18-22. Lake,T, Collins, T, and Ginsburg, P (2011). “Fostering Health Information Technology in Small Physician Practices: Lessons from Independent Practice Associations”. National Institute for Health Care Reform. [Internet]. http://nihcr.org/analysis/news-hit-and-ipas/ Pereira, P (2010). “After EHR system implementation, maintenance, service questions remain “, SearchHealthIT. [Internet]. http://searchhealthit.techtarget.com/news/2240020962/After-EHR-system-implementation-maintenance-service-questions-remain No Audio. Ten seconds of silence. Images Slide 8: “EHR Troubleshooting Workflow” by Scott Neal. Used with Permission Health IT Workforce Curriculum Version 4.0

Installation and Maintenance of Health IT Systems Troubleshooting; Maintenance and Upgrades; Interaction with Vendors, Developers, and Users Lecture a This material was developed by Duke University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000024. This material was updated in 2016 by The University of Texas Health Science Center at Houston under Award Number 90WT0006. No Audio. Health IT Workforce Curriculum Version 4.0