Healthcare is a dynamic sector. Many hospitals initiate several projects every day to improve the quality of healthcare delivery. These projects require investments of millions of dollars to live up to the expectations (Mills & Mckimm, 2017). However, as one cannot predict the future, the success of the project relies on the experience of the people involved, as well as the analysis carried out by them. This analysis can include several risk assessments as well as challenges that a project can face during its implementation phase (Klein, 2008). Such analysis conducted before the initiation of any project is called initial risk assessment or project pre-mortem, but there exists a thin line between both terms.
Initial risk assessment is identifying potential problems in the project during its life cycle. However, a pre-mortem is assuming that the said project has failed and would require executives to go backward and identify the challenges that lead to the failure of the project. According to Klein (2008), a pre-mortem analysis is a systems-thinking approach to better understand potential problems through connections and relationships that might have a causal effect on the overall outcomes of patient care. Additionally, this approach eliminates optimism bias and confirmation bias by allowing people to focus on the solutions and recommendations to overcome the identified challenges while conducting a pre-mortem analysis of the project (Klein, 2008).
For the paper, the pre-mortem analysis is conducted for a large academic medical system. This medical system includes two acute care hospitals, a heart hospital, and a community hospital serving a predominantly underserved population. Based on the success of the current outpatient portal, the hospital system is inclined towards the implementation of the inpatient portal by the same vendor i.e., EPIC. In this era of digitalization, patient portals are cutting-edge consumer-oriented health information technology and might provide a competitive advantage to a hospital (Lin, 2018). However, certain barriers might lead to the failure of the implementation of the inpatient portal at the said hospital system.
A detailed analysis was conducted to determine the success of the project. Various barriers have been identified pertaining to the implementation of the inpatient portal in the hospital. The barriers to success include the cost of the technology, operational efficiency of the portal, interoperability, availability of trained personnel, and actual need of the technology in the existing hospital setting. The patient factors include the effect of the inpatient portal on patient engagement, patient anxiety, patient literacy towards the use of portals, physical dexterity to work around the portal, as well as meeting their expectations from a physician. Additionally, miscellaneous barriers would include compliance with current laws and regulations, internet and broadband services quality in the area, reimbursements, customer care, digital divide as well as addressing issues such as security and threats of cyber-attack (Kooji, Groen & Harten, 2018). Furthermore, the existing environment lacks knowledge about the effectiveness of the inpatient portal. A study conducted by Dumitrascu et al., (2017) reported that the patient portal does not necessarily improve hospital outcomes. Implementation of such technology without apparent success or knowledge is an indicator of the failure of the project (Huerta et al., 2019).
For the purpose of the pre-mortem analysis the barriers identified above can be classified as three main challenges that can potentially lead to the failure of the project. These three challenges are 1) The operational challenges 2) The patient challenges and 3) The challenges pertaining to the security of the technology itself. These three broad categories of challenges pose a potential threat to the demise of the inpatient portal implementation project at the said hospital. The operational challenges include the cost of the technology and investment required for the implementation of the new technology. Kooji et al., (2018) identified that the cost of the technology is one of the critical factors in hospitals resisting the adoption of the technology. The hospital currently is equipped with the cutting-edge patient portal system from EPIC; however, implementation of the inpatient portal system would include investing large amount of capital and infrastructure modifications. The purchase of the technology would be just one aspect of the operational challenges; the hospital would be required to invest in the training programs for the providers to work with the inpatient portals. The majority of providers are engaged in clinical hours; adding such supplementary training is perceived negatively, more often creating a barrier in the success of the project (DiAngi et al., 2019).
Prior to the implementation of the project, the hospital needs to determine the actual perceived need for the inpatient portal technology. The success of the new project depends on its alignment with the mission, vision, values, and culture of the hospital (Harrison & John, 2013). Lin et al., (2018) demonstrated in a survey that approximately 20% of urban hospitals and 15% of rural hospitals have no perceived needs for the adoption of such technology. The inpatient portal technology is considered to be having several advantages, but if the culture of the hospital does not support the use of such a system, it has a strong potential for failure (Harrison & John, 2013).
The patient portal technology can have both positive and negative impacts on patient engagement and the way in which care is being delivered (Dumitrascu et al., 2017). The success of the patient portal in chronic care has received a great appreciation amongst the patients (Huerta et al., 2019). As discussed in the videos in the week 8 learning module, it is demonstrated that the outpatient portal serves the needs of the patients in learning about their conditions. They can reach out to their physician any time for a question about medication or receive an update on the medications and avoiding unnecessary hospital visits. However, as reported by Huerta et al., (2019), such success is yet to be achieved in inpatient settings. It can be attributed to the fact that the condition of the patient is much different in the inpatient setting. The majority of patients might just not have the dexterity to operate the portals or lack the knowledge of the technology.
The inpatient portal would allow patients to stay up to date with their current conditions, enabling them to keep track of their vital and the like. Dumitrascu et al., (2017) reported that providing patients with such kind of information in inpatient setting results in increased anxiety amongst such patients and can be overwhelming for them. Additionally, with the secure messaging service provided by the inpatient portal, the patient might have unrealistic expectations from the provider that fails to suffice those that can lead to a decrease in patient satisfaction (Holas, 2016). As reported by Walker et al., (2019), the implementation of such technology can lead to an increase in the digital divide based on age and race of the population served by the said hospital. The younger patients might have enough dexterity and knowledge of the latest technology, but the same cannot be said for the older population as they can encounter several challenges while navigating through the inpatient portal (Walker et al., 2019). The failure of the inpatient portal in the hospital due to the aforementioned facts can be described as a result of a decrease in patient engagement as well as patient satisfaction.
The technology itself might pose barriers to the success of the project. One significant aspect of it is maintaining its compliance with the current laws and regulations pertaining to information technology use in healthcare. The hospital might violate HIPAA and HITECH laws and guidelines due to a lack of inadequate training and experience in handling new technology and sensitive patient information. Failure to maintain routine IT check and updating security protocols can pose severe threats to cyber-attacks such as ransomware (Floyd, Greico & Reid, 2016). It can result in a breach of protected patient information leading to failure of the project. With millions of data breach events related to the use of the patient portal, it is logical to presume that the inpatient portal might be exposed to the same threats as well. (Floyd, Greico & Reid, 2016; Kooji, Groen & van Harten, 2018).
Interoperability is identified as a significant challenge with the existing patient portals. In the event of admitting a patient from a different hospital that does not use the same technology creates a barrier in transferring patient information to the existing system at the hospital. The same issue is raised when transferring a patient from the said hospital to a different one. Additionally, the availability of internet services is a critical factor for the success of such systems (Lin, 2018). In a study, Lin et. al., (2018) demonstrated that 5% of rural hospitals were skeptical about the implementation of such technology that relied on internet services. However, more than 15% were not in favor of adopting such technology for other technical issues such as lack of customer service from vendors, inadequate space, and the timeframe required for full implementation of such a system. An additional feature that can lead to a failure of the project is a lack of return on investment (Harrison & John, 2013). In the existing scenario with the changes in ACA and the type of population served, the hospital might not receive any incentive or any reimbursements for the care provided through the use of the inpatient portal. The stakeholders can refrain from investing more in the project, posing a challenge to the failure of inpatient portal implementation.
With the many advantages of the inpatient portal, the hospital might need to align its goals and expectations from the new system to its mission, vision, and values while keeping in mind the population served. The following recommendations can be suggested in order to make this technology a success at the said hospital. Instead of full implementation of the system, the pilot project can be implemented for a small period of time and monitoring the results and effect on patient outcomes. This approach is described as effectiveness-implementation hybrid design by Curran et al., (2012). As reported by Kelly, Hoonakker, and Coller (2018), the hospital can focus on building a user-centered design. It includes designing a portal based on the optimal content and establishing standards to ensure privacy and security. To achieve maximum success, the inpatient portal can be upgraded with clinical decision support and implementation evaluation by measuring the outcomes (Kelly, Hoonakker & Coller, 2018).
Every patient is different and has different needs in the inpatient setting (Kelly, Hoonakker, & Coller, 2018). As described by the Institute of Medicine (2012), the inpatient portal can be personalized to address the needs of each patient. The portal for complicated, intensive care unit patients can be different from the one for a new mother or the one undergoing elective surgery. To address the issue of the digital divide, as reported by Walker et al., (2019), the portals can be designed to provide content for non-English speakers and with more lucid operability for the older population. The hospital can also focus on and stay updated with the current evolving practices in the market based on the evidence and challenges rising during the pilot phase, before full implementation of the project (Collins et al., 2016). Additionally, the hospital can appoint a HIPAA compliance officer who can monitor the system and its compliance with the current laws and regulations related to health information technology. The hospital might also have to invest in the IT department and upgrade its security infrastructure to frequently perform IT checks and eliminate any threat of data breaches and cyber-attack (Floyd, Greico, Reid, 2016). Kelly, Hoonakker, and Coller (2018) suggested that providing real-time information to the provider and patient through such a portal can result in cost savings in the long term and can succeed in achieving maximum patient engagement with full security.
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