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Hospital information systems planning

Article  in  Journal of Medical Systems · September 1983

DOI: 10.1007/BF01080692 · Source: PubMed

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 HOSPITAL INFORMATION SYSTEMS PLANNING

George Kolenaty

The MITRE Corporation,

McLean, Virginia

ABSTRACT * It can have aspects of redundancy. This characteristic is even-

tually reflected in the unit cost of processing.
Successful management of large data processing projects re- * Because of the high dependence on the human element, it is in-
quires that strategic project decisions be done early during the plan- herently error-prone.
ning stages of the project. The effect of absent or poor planning In the last decade, a general trend of steady decreases in average
decisions is typically felt during the development and implementa- period of hospitalization developed. This resulted in a rather sharp
tion phases when such decisions may be found either irreversible or increase in "intensity of care," as the required medical procedures
too costly to correct. As a consequence, the data processing pro- had to be compressed into increasingly shorter time spans.
jects may be delivered with high cost overruns and be inefficient or As the intensity of services continues to increase and the pace of
unreliable to operate. This situation is of particular concern to organizational interactions between various units accelerates (in
health care organizations which traditionally have highly complex acute care type hospitals, for example), the demand on information
information processing functions and high requirements on data availability and quality increases proportionally. Manual methods
quality. of information processing may thus at some point actually impede
First in the five-part series, this paper reviews the fundamental the growth of organizational effectiveness. To alleviate the prob-
issues involved in HIS planning and describes a general lems inherent in manual systems and to meet the increased informa-
methodology for derivation of planning information, on which the tion demand, hospitals have been for some time evaluating and im-
strategic HIS decisions can be rationally founded. plementing EDP-based methods of information processing. Over
Parts 2, 3 and 4, to be released at a later date, will focus more time, the term Hospital Information Systems or HIS has become
specifically on methods, techniques and quantitative tools for synonymous with the use of EDP methods in hospitals. It will be
developing functional, technical and management Dlans. used throughout this article in such context.
Part 5, an abbreviated case study, will illustrate the described
planning process by developing a long-range, HIS automation plan Categories of HIS
using "live" data in the setting of a metropolitan, acute-care
hospital. While it is possible to classify HIS using many different criteria,
the three classification categories below appear suitable from the
planning viewpoint as each calls for a different level and type of
KEYWORDS planning effort.
Category 1: This includes stand-alone, usually single-purpose
systems that may support one or several primary functions, for ex-
Hospital Information Systems; HIS Planning ample, Blood Analysis or Pharmacy, plus some additional aux-
iliary functions such as Admissions or Patient Registration. Such
systems are often supplied as "turn-key" systems by specialized
HOSPITAL INFORMATION SYSTEMS vendors.
Independent, stand-alone operation of several such systems may
Introduction present the problems of processing redundancies and inconsisten-
One of the most important support functions of any goal- cies in data definitions.
oriented organization is its information system. This can be viewed Integrated operation, on the other hand, may require incremen-
as consisting of the organizational data base, an information tal investments in interfaces to accommodate hardware, software
distribution net, and an information processing facility. In and application design differences of various suppliers. Such ex-
hospitals, such information systems have traditionally been im- pense can be minimized or avoided through advance planning.
plemented through manual methods of information processing. A Category 2: This includes highly-modular, component-oriented
manual information system typically utilizes paner as its informa- designs, developed with the integration capability in mind. Depend-
tion transfer media; mechanical files as a physical representation of ing on hospital needs, the individual components can either operate
the data base; and telephones, pneumatic tube, or messenger ser- independently or can be assembled into larger agglomerations. Of-
vices as methods of information distribution. People are used as in- ferings of this type are available on "ready-made" basis, from
formation processors, performing a variety of tasks such as data several major vendors. In such case, many of the HIS planning
recording, storing, sorting, transcribing, duplicating, retrieving, decisions have already been done by the vendor. Alternatively, the
and computing. hospital can acquire some of the components through internal
An information system based on a manual mode of operation, development and combine these with specialized, "ready-made"
when contrasted to other available alternatives, may have the applications from Category 1. This approach requires that the deci-
following drawbacks: sions on the overall HIS acquisition strategy be done well in ad-
* It may be too costly on a "per-transaction" basis. vance.
* It is inherently slow. Category 3: This includes architecturally robust, monolithic, and

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0195-4210/80|0000-0618$00.75 @ 1980 IEEE
 Table I
Overview of Hospital Information Processing Functions

anagmentor Dcisin-Orente Funtion

ProdutionOrieted
Production-Oriented unctons
Functions Management or Decision-Oriented Functions
1. * Retrieval of patient medical II. * Patient management
history * Quality assurance-patient care
* Communication of diagnostic/ services
therapeutic order information * Medical decision making
from patient care process to * Research and development of new
support services medical knowledge
* Communciation of diagnostic test
CZ
results from support services to
patient care process
* Order status monitoring
* Patient monitoring and general
communication of patient status
* Patient medical history update

III. * Financial transaction IV. * Resource planning, allocation,

processing and utilization monitoring
.U - Manpower
) - Facilities and Equipment
- Supplies
o * Operations management
* Financial management
Vr *Quality assurance-support
services

simple batch-oriented processing. The planning and implementa- technicians) that perform a broad repertoir of highly diverse opera-
tion of such systems most likely involved interactions of EDP per- tions directly supported by the HIS. These users have generally lit-
sonnel with the limited number of staff from the controller's and tle tolerance to deficiencies in data quality, particularly if it means
administrator's office. The usual method of acquisition typically reduced level of service as compared to existing, manual or EDP
involved selection and some customization of a ready-made soft- systems.
ware package, with the resulting EDP application serving the infor-
mation needs of a single group of users, mostly from accounting
and general administration areas. HIS PLANNING CONCEPTS
With most hospitals presently either completing or having com-
pleted the automation of their business functions, the 1980s will be In the majority of hospitals the manual methods are still a
characterized by a large number of hospitals venturing into the area predominant mode of information processing in the areas of pa-
of automating the information processing functions that directly tient care. For reasons stated earlier, this area can be considered the
support the patient care delivery, such as those shown in Table I, primary, general HIS target in the 1980s. In order to successfully
Sector I. Because of the logical precedence relationships inherent in serve the information needs of hospital users, certain
the flow of information, automation of functions in Sector I characteristics and properties of the existing (manual) information
should precede those in Sectors II, III and IV. Through proper systems must be defined and analyzed before they are replaced by
planning, functions in Sectors II and IV can be obtained at relative- an alternative (EDP) system. The objective is to ensure that the
ly small incremental cost as a byproduct of automating the Sector I. replacement system will provide at least equal and hopefully better
Such strategies, however, will be somewhat more demanding in level of service at less cost than the existing one. Exploratory
terms of the amount and type of planning as they will require that a analyses of this type are typically performed during the HIS piann-
number of various choices be evaluated in advance. ing phase.
Technically, this development calls for utilization of data com- In order to identify some of the planning issues of strategic im-
munication and data base management systems. These two portance to HIS implementation, let us examine what is actually in-
technologies alone require a significant amount of planning as the volved in installing a computer-based information system in a
incorrect choice of common support software systems may adverse- hospital environment. The actual implementation of an HIS in-
ly affect the operational characteristics of an information proces- volving multiple functions is most practically done in sem.i
sing system for years. sequential fashion, where individual HIS components are installed
The situation is even more perplexing from the functional view- and integrated one or several at a time. By contrast, the HIS plann-
point. The patient care delivery process involves chains of physical ing process must consider all information processing functions
processes densely interwoven with clinical decision points. The globally. The primary reason is the need to ensure a high degree of
clinical and operational effectiveness of the overall health care integration and compatibility between individual functions and to
delivery process depends heavily on a timely supply of information ensure efficient utilization of available HIS project resources dur-
to these decision points. There are much more stringent re- ing the implementation phase.
quirements on system's availability and general reliability than was To illustrate this concept, consider the following situation. Dur-
the case with the business-oriented systems. Such requirements are ing the HIS planning process, we identify through operational
demanded by a wide variety of professional users (M.D.'s, nurses, analysis a set of functions F, currently performed through a

619
method A. Some of the functions identified in set F can also be per- $%
formed by an alternative method B, yielding various types of °Curve A
benefits in the process. If we construct an objective function 0
which assigns different relative measures of importance to various 100%0
benefit categories yielded by method B, we can then evaluate F
through 0, and identify a subset of functions F', which will "op-
timize" the overall objective criteria as expressed by 0. This pro-
cess will result in elimination of the marginal functions from fur-
ther consideration for automation.
During the HIS implementation, the existing methods of proces-
sing A in subset F' are replaced through methods B, which are in ef-
fect "implanted" into the overall body of organizational processes _,Curve B
and "linked" with the remaining, manually supported functions. $
Depending on whether the hospital has already implemented some
EDP systems, the replacing methods may also have to be integrated
with the existing technological environment.
Assuming that an HIS objective function has been defined, the
two problems that must eventually be addressed by the planners Planning Design Programming Testing
are:
* Identification of the set F and selection of the optimal subset F'
("automatable" functions). A-Cost of Error Removal
* Identification of available HIS acquisition alternatives and selec- B-Probability of Complete Error Removal
tion of the "best" HIS replacement (method B) for F'.
The primary objective of HIS planning then is to research and
resolve the various issues associated with this replacement process Figure 1
in order to select the best replacement strategy that maximizes the Error Correction During Information
overall objective. System Life Cycle
If we visualize the process of HIS implementation as a route
starting at the point A and ending at point B, we can identify a
series of decision points with alternative paths or "intersections" at Statement of the HIS Planning Objectives (Example)
which the HIS project manager must decide which branch to take.
As each possible "route" will eventually result in different The purpose of the HIS planning activities is to outline a long-
cost/benefit and success/failure outcomes before reaching the term strategy for the improvement and development of informa-
"finish," it may be desirable to make such a trip in advance, and tion systems in the area of patient care, teaching, and research as
use a small group of planners to quickly map the territory before well as in the administration of these areas. The specific objectives
sending out the entire implementation team. The movement of the of the HIS planning process are:
implementation team can then be guided on strategic intersections * To identify those information processing functions and processes
by information concerning the correct path selection. that would benefit from methods improvement through the use
This is what HIS planning essentially entails. In this article, plan- of EDP.
ning is viewed simply as a process that generates strategic type in- * To define the information processing functions in modular units
formation on which major implementation decisions can be ra- in order to facilitate concurrent design and implementation.
tionally based. Through availability of such data, the risks of HIS * To identify the general requirements of each module so as to en-
project failure hopefully are reduced and opportunities for success sure a high degree of integration regardless of the method of
increased. systems acquisition (internal/external).
The HIS planning efforts should be justified as any other invest- * To quantitatively and qualitatively predict the outcome of
ment-on their own merits. An organization should be better off automation projects through milestones within the systems ac-
with the HIS plans than without them or, in other words, the plan- quisition process so as to have a measure of achievement and to
ning activity itself should be cost effective. Studies of life-cycle limit the risks in misuse of resources.
costs for large EDP projects indicate that there is indeed a very * To ensure information systems compatibility with planned
good case for doing advance planning studies. Figure 1 illustrates developments in medical and administrative areas.
the cost of correcting a design or implementation error over the life * To achieve top management review, and general management
cycle of an information system. As indicated by Curve A, the participation, in the design and implementation process.
longer in the system's life cycle an error is detected, the more it * To provide cost-benefit analyses for decision making and
costs to correct it. At the same time, it is less likely that the error budgetary schedules for funding.
will be corrected properly (Curve B). Also, once a "critical mass" * To plan for acquisition of number and type of human resources
of design errors has been accumulated, it may be impossible to required to support the HIS implementation.
recover. * To develop long- and short-term schedules for the general
management of internal or external acquisition of EDP
capabilities.
OBJECTIVES OF HIS PLANNING

Our chances for success in developing good quality HIS plans HIS PLANNING METHODOLOGY
can be increased if we specify up front what we are about to do, or
in other words, if we define the objectives of the planning process The process of developing an HIS long-range automation plan
itself. The following statements are offered as suggested areas of summarized in Figure 2 is based on a general methodology for
focus of an HIS planning process. They should be, however, problem solving. Important considerations, relevant planning tech-
reviewed and correspondingly tailored to the needs and situations niques and tools applicable to individual elements of the process
of individual institutions. are discussed below.

620
 The selected objectives will eventually direct resource allocation
r------ --
Definition of and guide potential conflict resolution between various organiza-
I r~ ~~~~~~~
HIS Objectives tional units, competing for limited HIS resources throughout the
l l HIS planning and implementation. There are several important
lII considerations related to this step.
* A well-organized, consensus-making entity, i.e., HIS planning
l l sr committee, with representation at all levels and specialties is
l I Documentation crucial to any meaningful progress. An example of one such ar-
of Existing Methods rangement is shown in Figure 3. The HIS objectives should be
of Processing agreed to and set by such entity. The functions of the planning
I I committee itself must be well defined and understood. One prin-
I I cipal function of the planning committee should be to oversee,
I
I review and approve the work done by the planning team.
I I lt * Agreed-upon objectives need to be formalized and expressed in
I
I I Defin tion ofof
AuaDefinition quantitative terms. For example, ". improve the utilization of
the Operating Room through better scheduling methods by 10o
Automation Requirements wti one
within er.
n year . ."
I
l & CapabilIities
~~~~~~~&
Capabilities * To do such a job effectively, the goals and objectives set by the
lI planning committee should be based on and validated against ac-
I I r , tual operating characteristics. For example, an objective to im-
I l t sr t prove error rate on medical prescriptions should be related to the
I l actual, measured error rates.
I l Scenario Scenario 11 Scenario Ill * If multiple objectives are formulated, relative weights or
priorities must be assigned to facilitate the process of final selec-
tion of those functional areas most desirable for automation.
I I . In addition to controllable objectives, the administration and the
I I sr planning committee need to consider other factors, for example:
Impact Analysis * Logical precedence relationship between individual information
I Lo -_ & Scenario processing functions.
Selection * Complexity of a specific information function, availability of
funds and skilled resources, and a probability of successful pro-
ject completion.
*
Availability of ready-made systems and resulting ease of im-
plementation.
Identification As these additional factors may influence the final selection of
of HIS automation target functions, their relative weight should be for-
Alternatives mally expressed in the overall selection criteria.

l Qualitative and Quantitative Documentation of Existing

l HIS HIS Information Processing Functions
1 | Alternative Alternative The replacement HIS should not only provide additional new
AB capabilities, operationally or economically not feasible with the
manual methods, but it should also provide the capabilities current-
ly performed, automatically or manually. The documentation of

Cost Benefit
- --- - -- _ Analyses:
A/11, B/11 HIS Planning
HIS Planning Committee
Committee __ ---Advisory Group
High Level
Administration
Implementation A Users
| Plans andl
| Schedulesl

Figure 2
HIS Planning Methodology-Overview HIS Planning Team

Technical Operational
Definition of HIS Objectives and Selection Criteria Professionals Level Users
This step is one of the most crucial if not the most significant step
in both planning and implementation of the HIS as it addresses two
fundamental questions:
* Why do we want to install an HIS? and Figure 3
* Which areas do we want to automate? Organization of HIS Planning Process

621
functionally comprehensive designs. A system of this type may ac- during the period of hospitalization. This accumulated data pro-
tually contain more functions than a hospital may need at any vides a valuable learning base for improved disorder diagnosis
specific point in time. Nevertheless, systems of this type must be in- and therapy in future episodes.
stalled in its entirety, with majority of functions installed on day Other hospital functions also heavily supported by information
one. This HIS type requires the most complex planning. processing are research and teaching. The data base generated by
the patient care process contains relationships between actual
Benefits of HIS diagnoses and therapies accumulated across a large patient popula-
Most health care institutions are interested in HIS implementa- tion and time period. It is one of the primary and most valuable
tion primarily for: resources utilized by researchers to identify and calibrate new
* Economic benefits. These are attributable to the proven concept medical knowledge. It is also used by medical students to absorb
of substituting ongoing labor expenses through capital invest- the accumulated medical knowledge across many medical cases. As
ments-in this case in EDP technology. HIS can replace labor- the EDP technology can actually broaden the scope of access to
intensive information processing functions and allow transfer of medical data bases to both researchers and students, it may also ac-
human resources from these manual processes to other tasks. celerate the process of new knowledge generation.
Depending on hospital policy, the freed resources can be either Additionally, the process of patient care delivery, and to some
entirely removed from the production process, or "plowed extent teaching and research, require that a variety of support ser-
back" to patient care. vices such as engineering, laboratories, dietary, etc., be provided
* Improvement in information quality and related improvements on demand in required quality and quantity. Hospital administra-
in quality of care. In specific situations, the improvements in tion therefore involves monitoring service demand, determining
quality or availability of information may actually improve the resource requirements and allocating resources to meet fluctuating
quality of patient care. Illustrative situations may involve, for ex- demand, ongoing monitoring of operational efficiencies and ensur-
ample, automatic validation of diagnostic test results against ing the financial viability of the entire organization. Information
normal value ranges or patient vital signs monitoring. systems play an essential role in support of these critical manage-
* Improvement in management control and organizational effec- ment functions.
tiveness. Improved management control is made possible by the
availability of "real-time," control-type information. To affect
productive organizational activities, correct decisions must be Overview of HIS Functions
made consistently at various organizational levels. Correct deci- Information processing activities constitute an integral part of
sions, business or patient care-oriented, depend in turn on the overall hospital operations. Upon closer examination we can iden-
quality of information available at the time a decision must be tify two principally distinct types of information processing:
made. A properly designed and properly utilized management in- * Processing to perform specific tasks, for example, update a
formation system can thus contribute to organizational produc- temperature chart or update an accounting ledger. This type of
tivity gains, far outweighing those attributable to method processing will be referred to as production-oriented.
changes alone. * Processing to supply data to a decision branch, either in a
Since most health care delivery processes are interrelated and physical or in an information process which itself could be
highly information-intensive, it is possible, through careful analysis production-oriented. We will refer to this type of processing as
and design to fulfill a multitude of objectives at a relatively small management or decision-oriented.
incremental cost over the cost of meeting a single objective. One of Applying this classification, we can develop the taxonomy of ma-
the reasons for developing the long-range HIS plan is to maximize jor information processing functions in a typical hospital environ-
this opportunity. ment and use it to review past automation efforts and to formulate
future HIS implementation strategies.
The four sectors shown in Table I represent the major target op-
iNFORMATION PROCESSING IN HOSPITALS portunities in automation of hospital information processing. The
actual HIS implementation strategy of a particular hospital will de-
Before we begin to discuss the issues and processes of HIS plan- pend on (1) the existing level and type of hospital automation and
ning. let us briefly review the principal hospital information func- (2) hospital's HIS objectives. To provide the necessary background
tions and information-intensive processes that can benefit most for the formulation of HIS acquisition strategy, the past, present
from EDP methods. Since the major hospital function is the pro- and future HIS developments will be briefly reviewed.
duction of patient care services, or health care delivery, it is ap-
propriate to begin by examining a simplified model of such a pro-
cess. Several major steps, each heavily supported through informa- Past, Present And Future Developments in HIS
tion processing activities can be identified: Computer-supported methods of information processing,
* First, it is customary for a health care practitioner to retrieve and storage, and distribution have been applied in hospitals throughout
review a patient's medical history in order to determine possible the late 1960s and 1970s without much formal planning. The initial
links of the current disorder with those from the past. At the automation efforts involved mostly the administrative and business
same time, current disorder is documented for future reference, functions represented in Sector III, Table 1. This development has
using symptom-oriented descriptors. occurred because of several factors. First, there exists a reasonably
* Drawing on personal knowledge and past experience, the health high degree of functional similarity between, for example, hospital
care practitioner formulates a hypothesis about the most pro- payroll, accounts payable, and general ledger systems and those
bable cause of current disorder (diagnosis). Various diagnostic found in other industries. As other sectors of the economy installed
services are then ordered to confirm or to reject the hypothesis. and operationally tested such systems earlier, hospitals in general
* Having properly diagnosed the disorder, the practitioner for- had very little to risk. Second, these functions typically contained a
mulates a treatment program, which may consist of predeter- high concentration of clerical labor, repetitive in nature, and were,
mined sequences of: (1) Therapeutic services; (2) Diagnostic ser- therefore, highly attractive targets for cost reduction programs
vices to periodically validate the effectiveness of the therapy pro- through automation.
gram. From the EDP planning viewpoint, these functions are posi-
* At the point when the disorder is eliminated and the treatment tioned off the mainstream of hospital operations, with most of the
terminated, it is beneficial to update the patient medical history patient-related data processing activity performed after discharge.
and document in detail all medical decisions and actions taken The most common EDP method used in these systems is relatively

622
existing information processing flows and its subsequent analysis is mation processing functions using developed documentation as a
therefore important from several aspects: base, and draws on familiarity of planners with operational
* It provides additional HIS objectives validation and calibration capabilities of EDP technology. By varying the design factors, the
feedback to the planning committee. planning team can conceptualize new methods of overall hospital
* It provides a comparison baseline for "before/after" analyses. information processing. Several such "scenarios" can be prepared
* It provides an authoritative, common source of data for HIS re- for consideratict, by the planning committee.
quirements definition process and general communication.
During this step, information processing flows are documented
by means of operational flow charting techniques. Both physical Impact Analysis
processes and information flows should be documented, preferably Using the several scenarios developed in the previous step and
on the same chart for later analysis. Processing steps, timing documentation of the existing processing methods, the planning
aspects, frequencies of occurrence, transfer distances, processing team can now proceed with the impact analysis. This process in-
delays and information elements processed are indicated on in- volves a quantitative and qualitative assessment of projected opera-
dividual process flow charts. tional performance achieved under different scenarios against
Additionally, a macro-level diagram should be developed stated objectives and current operating characteristics. Using basic
through synthesis of developed data to provide a global model of decision analysis techniques, the most preferred scenario selection
overall information flows throughout the organization. A can be derived either on a basis of maximum expected payoff,
simplified example of such a model is shown in Figure 4. minimum expected risk, or other criteria. There should be suffi-
Various indicators can guide planning groups' decisions on how cient "contrast" between the projected scenario performance and
to best allocate their own resources to various functional areas dur- stated objectives to allow for estimation and projection errors.
ing the documentation phase. For example, if the stated objective is Also, if the projections for several alternatives appear mutually
labor cost reduction, a Payroll report on distribution of labor costs "fuzzy," additional data may have to be collected to improve the
by type and functional area is a quick source of data that can be resolution between the alternatives. After review and approval of
used for this purpose. Such indicators should be used, however, the recommended design by the planning committee, the next step
with caution and only for preliminary selection of high-potential involves identification and evaluation of alternatives for acquiring
functions. the EDP capabilities required to support the selected scenario.

Requirements Definition
Identification and Evaluation of Alternative Methods of HIS
Using the techniques of methods analysis and the documentation
of existing methods of information processing, the planning team Acquisition
can develop a statement of functions, automation of which is Numerous alternatives of acquiring the specified EDP
desirable based on stated objectives and selection criteria. This pro- capabilities are available to the planning team. During this process,
cess involves identification of "clusters" of "automatable" infor- the total investment outlay and the annual investment flow will

Figure 4
Simplified Model of Hospital Information Flows

623
most likely be the important determinants in planning the HIS ac- To minimize the misuse of resources during the implementation
quisition strategy. The total, economically warranted investment process, critical-path type of scheduling methods is essential.
level can be determined initially through the use of payback Specifically defined milestones and interim deliverables should be
method,1) and then fine-tuned using the Return on Investment and generously interspersed throughout schedules to facilitate progress
Discounted Cash Flow analyses. monitoring and control. Milestones should be accomplishment
The total warranted investment level can be used, along with rather than "percent completed"-oriented.
other criteria, to initially eliminate those alternatives that fall out- GO/NO GO decision points with predefined conditions should
side of the acceptable range. be inserted at strategic points, i.e., prior to major investment ex-
The annual investment flow will probably vary with each penditures, to enforce ongoing validation of implementation pro-
hospital, depending on the hospital's ability to finance the HIS ac- gress against stated objectives.
quisition program, either through internally generated cash flows
(savings), or through borrowing. As there is almost always a re-
quirement for some "seed money," well-laid plans are often in- HIS PLANNING DOCUMENTS
strumental in obtaining required financing from the commercial
sector or third parties. The HIS Automation Plan is the final product of the planning
The identification and evaluation of commercially available HIS process. It documents the various analyses performed by the plan-
products and services is a tedious and time consuming task, par- ning team, findings and recommendations made to the planning
ticularly when an HIS scenario must be integrated into existing committee, and the resulting decisions.
technological environment. Various consulting services specialize Overall, the HIS Automation Plan can be utilized for the follow-
in this field to assist hospitals in the process of HIS selection and ing purposes:
acquisition from commercial sources. * Budgetary planning/acquisition of funds
* Organizational planning and control vehicle for the HIS im-
Cost-Benefit Analysis plementation process
Once the HIS alternatives have been reasonably narrowed down, * General communication source and a design document
it will be necessary to undertake detailed analyses of costs, risks, HIS Automation Plan outlines the selected strategy for achieving
and benefits for each alternative. If internal systems development is the hospital's objectives. This includes restatement of the objec-
preferred, allowances for the learning curve effect should be made tives and purposes of the HIS project, discussion of priorities and
in cost and benefit estimates. Operational cost savings can be criteria of evaluation, final decisions on what functional areas and
estimated using predetermined or measured time standards applied in what sequence will be automated, conceptual designs of future
to "before/after" scenarios of information processing. If the information processing based on EDP methods, specification of
future HIS is to be integrated into an existing EDP environment, EDP environment, means and methods of acquisition of required
allowances should be made for cost of integration and development EDP capabilities, cost/benefits and operational impact analyses,
of interfaces. user attitudes survey, resource requirements, schedules, milestones,
deliverables and expected responsibilities.
Implementation Plans and Schedules Because of the volume and variety of use of such information, it
This step addresses two additional strategic planning issues: is sometimes beneficial to organize the plan in several separate
* How fast can or should an HIS plan be implemented? documents, serving specific audiences and purposes. An example
* In what sequence should the implementation take place? of one such possible organization is shown in Figure 5 below.
Using the most preferred HIS scenario as a base, development of The individual subsets of the plan could include, for example,
specific implementation plans, paths and schedules depends, the following information:
besides other factors, on the annual feasible rate of investment
flow. In addition to selection of HIS functions, consideration Information System Plan - Functional Section
should be given to sequence of implementation of the various func- * Documentation and analysis of selected operating
tional modules. This depends on several additional factors such as: characteristics of the existing information system of the
* Logical precedence relationship between functions implied by the organization including the identification of problem areas.
natural flow of information and physical processes * Identification and definition of functional areas, that are most
* Availability of ready-made HIS components and skilled person- likely to benefit from automation, considering the stated objec-
nel tives and present operational problems. Determination of
* Existing EDP environment and level of automation priorities for implementation.
* Probability of success based on relative complexity of informa-
tion processing functions and selected mode of HIS acquisition.
As each implementation sequence will affect differently the rate
of accrual of projected benefits and at the same time will generate HIS Automation Plan
different requirements in terms of investment spending levels, in- (HISAP)
dividual schedule variations should be subjected to extensive quan-
titative analyses of the total strategy effect on cost/benefit
characteristics.
Regardless of the method of HIS acquisition, the overall risks of
an HIS implementation project can be minimized by using the
"component-oriented" approach. The "monolithic" designs carry Financial Management
probably the highest relative risk. There may be, however, other Information
Plan Plan
offsetting factors that may make such designs an attractive alter- System Plan
* Functional
native for some hospitals. * Technical

')A conservative "rule-of-thumb" for estimation of the total, economically warranted HIS in- Figure 5
vestment is to multiply the difference in annual operating costs (Before/After) by a factor of
three (3). Organization of HISAP Planning Documents

624
 * Description of proposed alternative approaches to automation in * Equipment acquisition schedule. Includes completion dates for
specified areas, along with the evaluations of total payoff for selection, order placement, delivery, inspection, testing, and in-
each "scenario" in terms of stated objectives. stallation along with assigned responsibilities for these activities.
* Cost/benefits and operational impact analyses. * Organizational policies and procedures. Includes required or an-
* Selected implementation strategy and reasons for selection. ticipated changes in policies, procedures, organizational struc-
* Overall implementation schedules, budgets. tures and their expected effective dates.
* Responsibilities, deliverables, acceptance procedures and perfor-
Information System Plan - Technical Section mance specifications.
* Projection of processing workload by type and phase of HIS Depending on the selected method of HIS acquisition, some of
implementation strategy. Capacity requirements and acquisition the items above may either be not applicable or may need to be ex-
plans. Buy, lease, rent types of evaluations. panded.
* Initial hardware and software configurations. Final configura-
tion; year-by-year migration paths and upgrades.
* Data communication network plan. Network geography, sup- CONCLUDING REMARKS
ported locations and type of equipment. Data traffic projections
by transaction type and routing pattern. The 1980s will be a critical test period for further advances of
* Data Base Architecture. Overall macro-level diagram of data ele- HIS technologies, particularly in the area of patient care-oriented
ment types and its logical relationship. Storage requirements pro- information processing.
jections. Security and Integrity Plans. Patient care functions, being highly decision and information in-
* EDP Standards and Procedures supporting the selected HIS ac-
quisition strategy.
tensive, depend on and affect a large number of secondary and ter-
tiary support processes.
To support future information demands in this area, the EDP
Financial and Management Plans technology must be carefully integrated into the overall process of
* Overall budget with detailed schedules of expenditures and health care delivery as success or failure of the integration process
description of corresponding deliverables. will be felt throughout the entire organization, multiplied many
* Overall critical path method diagram of the HIS implementation times over.
including the progress monitoring mechanism. Planning methods and techniques outlined in this and the follow-
* Manpower hiring schedule. Type and number of required per- ing articles are being increasingly utilized by hospitals to manage
sonnel, required hire points, skills and qualifications. the transition process on systematic and cost-effective basis.

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