Joseph M. DeLuca, FACHE, is a healthcare information technology futurist and chief executive officer of Information Technology Optimizers in Alameda, Calif. His cross-functional perspective has evolved out of 20 years of performing successful advisory services for provider, payor, entrepreneur, and public policy clients. Mr. DeLuca is a frequent speaker at regional and national conferences and is widely published on healthcare and information technology topics. He is the co-author of "E-Health: The Changing Model of Healthcare" (Frontiers of Health Services Management, Fall 2000) and the presenter of the ACHE 2001 Congress session "Room with a View: Best Practices in Information Technology." He is currently anticipating the release of his latest book, The CEO's Guide to Health Care Information Technology: Revised Edition.

Click on a link below or scroll down to read the questions posted for Mr. DeLuca as well as his responses:

• Knowledge management
• IT contingency planning
• IT implementation in long-term care
• Electronic medical record RFPs
• Internet solution ROIs

shamiss - 03:32am Sep 22, 2001
CM is well known tool in non-healthcare business for improving its quality as well as its economics. A healthcare entity (a hospital or a medical center) that implement knowledge sharing as a part of its strategic planning often finds itself puzzled by two counteracting forces; the physician culture of sharing their knowledge with colleagues and the difficult adaptation of the overwhelming options of information technology tools to pick from. I will appreciate your thoughts on the subject and a potential helping hand on both items.

1. DeLuca's response - 02:55pm Oct 2, 2001 (#1 of 1)
2. Knowledge management is a complex subject that, in health care, we should openly embrace and develop a core competency in. We do, to the extent that we treat knowledge management as a "craft" or "guild" process, as the above discussion suggets. But we do not treat it has a systematic discipline, nor really consider it an institutional asset.
3. We have a white paper on knowledge management that provides definitions for explicit, tacit, structured and unstructured knowledge sources. You can click here to download this PDF document.(If you do not have Adobe Acrobat Reader, click here.)
4. We also provide a conceptual model on how to develop systems, health care specific case studies, and an overview of select systems available to do so. I delayed my response to the above so that I could edit the document to remove some client sensitive information.
5. Knowledge management is related to the concept of expert systems and artificial intelligence, in which technology is used to mimic a human decision making process (a hieuristic expert system that might, for example, perform a drug to drug interaction check), or replace or enhance a human decision making process (an AI system that monitors drug dosages against test results continuously, and, should panic values arise, may change a dosage or discontinue the medication without human intervention). Application areas abound in health care, from the clinical to financial,administrative and population management.
6. We view this as a major potential for health care, but see a slow adoption rate except for very pragmatic areas (such as drug to drug interaction checking). Why? Adopting these systems will require 1)an investment in technologies, 2)an investment in systematic knowledge management process', 3)acceptance of group knowledge and its ability to replace or substitute individual knowledge, and 4)long term courage to manage differently. However, today we are so focused on daily-monthly survival, expending energy and money in these areas may be too much to ask, despite the benefits. Staff shortages (RN, Pharmacists), could benefit from early adoption of knowledge management technology has well. Funding sources could include grants and corporate sponsors.

walsh - 09:41am Oct 17, 2001
Our system is developing an overall IT strategic plan. One specific area that the coordinating committee is focusing on is the need/requirement for an IT contingency/disaster plan for each of our hospital sites. Our consultant has identified the need for same (based in part on HIPAA requirements), the fact that where contingency plans do exist they have not been tested or the plan has not been updated on a regular basis. From your perspective, what should be in an IT contingency plan, and how often should we expect our member organizations to test those plans? What effort and expense is associated with the testing of these plans? Thanks

1. DeLuca's response - 10:49am Oct 17, 2001 (#1 of 1)
   Your query represents a theme we are responding to quite often given recent events.I have worked in health care IT for 20 years, and during that time have seen earthquakes, fires, floods, a lightning strike and employee sabotage destroy data center physical assets and information. I can assure you that those organizations who have an IT contingency plan (AKA disaster recovery plan, or business continuity plan)developed with forethought, communicated, trained on and with key elements tested see minimal disruptions to patient care and business operations. Those that do not subject themselves (and patients, community and employees) to situational recovery based on individual decision making at the moment of crisis.
2. Your question is a broad one, let me break it down a little
3. Please note that our definition of IT includes voice, data and network capabilities. They all work together today, and often can share continuity techniques. For example, the main telephone system often shares the power recovery system of a computer data center, as all modern telephones are now computers. Data communication lines can be switched over to telephone lines in the event of loss of telephone trunk capabilities. Hence, they must be reviewed together.
4. First, an IT business continuity strategy must be included in an IT plan. Resources (backup systems, backup communication lines, a hot site recovery facility) may be appropriate, and need to be budgeted for. Also, the IT plan should identify the relative importance of the systems, which is often not obvious. The Emergency Department information system may have a higher priority in a trauma facility then the nursing care system in the event of a community disaster which also affects your facility (we saw this situation in an earthquake event...non-surgical hospital systems became secondary to ED). But, the IT plan should not be your continutiy plan, it should be an appendix to the overall plan that may have a different review and update cycle.
5. Second, the continuity plan should have three major components. One component should deal with events that effect information assets directly, such as computer virus infection, data intrusion, corruption and loss (items that HIPAA is concerned with), and similar events. Another component should deal directly with threat assessment and actions (data center fire and recovery actions, loss of facility use, employee sabatoge, response to community event but no loss of capabilities..such as the response necessary by St. Vincents in NYC..etc). And the third deals with resources available to help. We were involved with a recovery effort in Oklahoma in 1988, fire took out the data center, and the resource list included IBM (a competitor to the main software vendor at the time) as a source of telecommunications equipment because they had a major hardware distribution hub in Dallas. We called, they pulled up a truck in a few hours with enough modems for mission critical users (the fire took out the telecommunications hub).
6. Most importantly, the plan should be trained on and tested. Training at leaset annually for all employees, and as part of new employee (operator, manager) orientation. Testing schedules are dependant on technique. A hot site at least quarterly, backup recovery monthly, offsite storage weekly (to confirm file sizes, etc., not necessarily to recover the data).
7. Investment in IT continuity plans should be staged. The first step is to review what you are doing, cover any major gaps (fire supression, data backup and recovery, etc.,) and then do a high level threat assessment specific to your region and strategy alignment. Based on this, high probability, high consequence events should be planned for in detail, this will usually cover most of the other type events in whole or in part. Then you map out detail procedures, etc. In essence a staged investment approach. Also, this effort needs to be linked to facilities planning. I do not know the size of your health care system, so it is hard to estimate expenses. But the initial work is a 30 to 60 day consulting effort over 3 to 4 months, for say a 3 campus location with one major campus, two subsidiary.
8. Finally, given recent events, we are seeing a greater emphasis on employee security reviews and clearance levels, background checks, etc.

Adjei - 08:50am Oct 18, 2001
I am the Administrator of a long term care facility in New York and one of my responsibilities is to oversee the implementation and evaluation of a clinical information system that will attempt to automate some of the staff's daily work. While this has been done successfully in the hospital industry there is not much literature on the success in long term care. Our first phase is to automate the MDs and link them directly to the resident care plans. We want to then move to medication administration and some other clinical assessments. What advice would you give in terms of implementation and evaluation and are there any books or journal articles that would of any help?

Thank you, Brenda Adjei, MPA

1. DeLuca's response - 01:17pm Oct 19, 2001 (#1 of 1)
   First, let me direct you to some information sources on long-term care information systems.
2. The Health Care Information and Management Systems Society (HIMSS) has a sub-group on long-term care systems. They also published in Spring 1999 an entire volume of the Journal of Healthcare Information Management on long-term care systems( Volume 13, Number 1, Spring 1999). Please see www.himss.org, or Jossey-Bass (publisher), call HIMSS at 312-664-4467 or our research director, Rebecca Enmark, at 510-337-8900 Ext 105 to get access to this.
3. Also, two of my graduate students in the St. Mary's HSA program wrote excellent term papers on the subject, one was a case study of an MDS implementation. I only have these in hard copy and would need to fax to you. Please call Teressa Cobiseno, my AA, at 510-337-8900 Ext 100 and she will fax to you. Both students have authorizied me to use the term papers, they must be cited if published. Both have good bibliographies.
4. Ok, long-term care facilities are in a tough position as it relates to IT, and especially clinical systems. You have major requirements which can be solved by technology, but tight budget constraints, and limited ability to recover costs through staff reductions, etc. This equates to a smaller perceived market by technology suppliers, and results in fewer suppliers, more limited solutions, etc.
5. But, there are systems which do exist, and your investment can be phased in over time. My first recommendation is to have a comprehensive (but not necessarily long) multi-year plan that reflects an investment flow, so that the dollars required can be staged over time. Second, perform your redesign work up front, and base the redesign on known system capabilities. You may start this effort initially while screening vendors, and then complete it when you have selected a finalist during the implementation phase. Third, pay very close attention to the end user (nurse, etc.)use-ability (ease of use) and system support (technical and non-technical)requirements. Long-term care facilities are lean on people, the systems need to be intuitive, proven yet realiable. This is especially true in areas of wireless communications. You do not have "surge" training and support staff who can respond to on demand non-critical needs. Fourth, set your goals early on, make them meaningful yet realistic. Be sure to receive clinician buy in to the goals and results (such as productivity gains, etc.). Finally, perform careful diligence on your proposed vendor and technology, be sure you know their capabilities, solutions, benefits and risks.
6. I hope this is helpful.

Amy Fellows - 11:50am Oct 19, 2001
I am leading a group of Medical Directors from various safety net clinics who are starting to look into a shared purchase of an ambulatory Electronic Medical Record. (We have just finished contracting and are starting the initial implementation stages of a shared Practice Management System). I am trying to collect different examples of RFP's to look at what functionality requirements we should be looking for in an EMR. Most of the clinicians in my group have not used an EMR before. Any suggestions on resources for RFP's or functionality requirements we should be considering?

1. DeLuca's response - 12:41pm Oct 30, 2001 (#1 of 1)
   Interesting, that the practice management system selection did not include clinical and EMR capabilities. We typically would look at these together, even if we 1)purchased from two different vendors (but knew in advance how we were going to use a common desktop-you run the risk of needing two different types of technology)or 2)phased the implementation and costs over time.
2. Regarding RFP samples, I first suggest that you look at product material (literature, Web sites) from leading ambulatory system vendor sites. You may not be able to afford these systems (as a safety net clinic), but they will give you examples of high end capabilities. Ones that come to mind include Epic (Madison, WI) and LSS data systems and Next Gen (Formerly MicroMed, not part of QCSI). A review of product functions and features will generate ideas.
3. VHA has a comprehensive RFP and guide available to VHA members. Helath Care Information Management Systems Society (www.himss,org) has RFP's for sale, and also journals, proceedings whichd eal with the subject. The American Health Information Management Association (AHIMA.org) has, I beleive, a resource center has well.
4. I think the most important success factor in this area is clinician acceptance of the capabilities and usage. Getting a basic, functional system that clinicians will use is far more important then a state of the art capability that goes unused. Active discussions, agreement with them is critical.
5. Please also see my response to the Internet ROI question for trade journals that maybe helpful to you.

Young - 07:34am Oct 26, 2001
I am working with a group of organizations trying to assist them with determining the RI for investments in internet solutions. Do you have any suggested research, or models that could be used.

Thanks for your help, John

1. DeLuca's response - 12:25pm Oct 30, 2001 (#1 of 1)
   This topic is a very broad one, and without more specific details my response will be limited in scope.
2. First, to discuss Internet RI, one needs to know a further breakdown of what areas you are working in. Internet usage for marketing & brochureware (limited hard ROI information) versus Internet for patient-physician or patient-patient communication (some detailed information) versus Internet for retail marketing purposes (some detailed information) or Internet for patient education and classroom sign up (detailed information). So, the specific subject matter will help to determine if case study, benchmark data exists.
3. Economic models for the Internet generally look at 1)cost displacement (not printing as many brochures, reducing mailing costs), 2) efficiencies (we need fewer people to process lab results, Rx refills, etc., or we can put more volume through our fixed overhead), or 3)revenue/strategic gains (we increase revenue from patient supplemental ordering, new cases, etc.
4. Many resources exist. Almost all health care dot.com vendors have some ROI measures to boast about. Health Care Information Management Systems Society (www.himss.org) has case studies, journals and educational proceedings which cover the subject. Jossey Bass and other book publishers have authors which cover internet usage and ROI, although you often have to read deeply to get at the material. Two journals come to mind, technology in practice (technologyinpractice.com), which use to be Internet in Healthcare, and advance for health information executives (www.advanceforHIE.com) cover the subject, have specific reprints,etc.