HIT or Miss 3rd Edition Lessons Learned from

Health Information Technology Projects Jonathan

Leviss (Author) pdf download
https://textbookfull.com/product/hit-or-miss-3rd-edition-lessons-learned-from-health-information-
technology-projects-jonathan-leviss-author/

★★★★★ 4.8/5.0 (39 reviews) ✓ 239 downloads ■ TOP RATED

"Fantastic PDF quality, very satisfied with download!" - Emma W.

DOWNLOAD EBOOK
 HIT or Miss 3rd Edition Lessons Learned from Health
Information Technology Projects Jonathan Leviss (Author) pdf
download

TEXTBOOK EBOOK TEXTBOOK FULL

Available Formats

■ PDF eBook Study Guide TextBook

EXCLUSIVE 2025 EDUCATIONAL COLLECTION - LIMITED TIME

INSTANT DOWNLOAD VIEW LIBRARY

Collection Highlights

HIT or Miss for the Student Lessons Learned from Health

Information Technology Projects 1st Edition Jonathan
Leviss (Editor)

Successful Public Health Advocacy: Lessons Learned from

Massachusetts Legislators Chris Chanyasulkit

Crisis communication : case studies and lessons learned

from international disasters 1 edition Edition Brataas

Software Engineering at Google: Lessons Learned from

Programming Over Time 1st Edition Titus Winters
Teaching Struggling Students Lessons Learned from Both
Sides of the Classroom Laura M. Harrison

Systems Engineering: Fifty Lessons Learned 1st Edition

Howard Eisner

Lean Transformations for Small and Medium Enterprises

Lessons Learned from Italian Businesses 1st Edition
Arnaldo Camuffo

Clinical Anesthesiology II Lessons from Morbidity and

Mortality Conferences Jonathan L. Benumof

INFORMATICS EDUCATION IN HEALTHCARE lessons learned 2nd

Edition Eta S. Berner
HIT or Miss
Lessons Learned from Health Information
Technology Projects

Third Edition
 HIMSS Book Series
Participatory Healthcare: A Person-Centered Approach to
Healthcare Transformation
Jan Oldenburg
The Journey Never Ends: Technology’s Role in Helping Perfect
Health Care Outcomes
David Garets and Claire McCarthy Garets
Glaser on Health Care IT: Perspectives from the Decade that
Defined Health Care Information Technology
John P. Glaser
Leveraging Data in Healthcare: Best Practices for Controlling,
Analyzing, and Using Data
Rebecca Mendoza Saltiel Busch
HIT or Miss
Lessons Learned from Health Information
Technology Projects

Third Edition

Edited by Jonathan Leviss

CRC Press
Taylor & Francis Group
6000 Broken Sound Parkway NW, Suite 300
Boca Raton, FL 33487-2742

© 2019 by Taylor & Francis Group, LLC

CRC Press is an imprint of Taylor & Francis Group, an Informa business

No claim to original U.S. Government works

Printed on acid-free paper

International Standard Book Number-13: 978-0-367-14346-6 (Hardback)

This book contains information obtained from authentic and highly regarded sources. Reasonable efforts have been
made to publish reliable data and information, but the author and publisher cannot assume responsibility for the
validity of all materials or the consequences of their use. The authors and publishers have attempted to trace the
copyright holders of all material reproduced in this publication and apologize to copyright holders if permission to
publish in this form has not been obtained. If any copyright material has not been acknowledged please write and let
us know so we may rectify in any future reprint.

Except as permitted under U.S. Copyright Law, no part of this book may be reprinted, reproduced, transmitted, or
utilized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including
photocopying, microfilming, and recording, or in any information storage or retrieval system, without written
permission from the publishers.

For permission to photocopy or use material electronically from this work, please access www.copyright.com (http://
www.copyright.com/) or contact the Copyright Clearance Center, Inc. (CCC), 222 Rosewood Drive, Danvers, MA
01923, 978-750-8400. CCC is a not-for-profit organization that provides licenses and registration for a variety of users.
For organizations that have been granted a photocopy license by the CCC, a separate system of payment has been
arranged.

Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for
identification and explanation without intent to infringe.

Library of Congress Cataloging-in-Publication Data

Names: Leviss, Jonathan, author.

Title: HIT or miss : lessons learned from health information technology
projects / Jonathan Leviss.
Description: 3rd edition. | Boca Raton : Taylor & Francis, 2019. | “A CRC
title, part of the Taylor & Francis imprint, a member of the Taylor &
Francis Group, the academic division of T&F Informa plc.” | Includes
bibliographical references and index.
Identifiers: LCCN 2019004821 (print) | LCCN 2019006832 (ebook) |
ISBN 9780429031403 (e-Book) | ISBN 9780367143466 (hardback : alk. paper)
Subjects: LCSH: Health services administration—Information technology. |
Information storage and retrieval systems—Medical care. | Medical
records—Data processing.
Classification: LCC R858 (ebook) | LCC R858 .H25 2019 (print) |
DDC 362.10285—dc23
LC record available at https://lccn.loc.gov/2019004821

Visit the Taylor & Francis Web site at

http://www.taylorandfrancis.com

and the CRC Press Web site at

http://www.crcpress.com
 To Emmy and Becca—keep doing good stuff … keep learning
from your stumbles … and keep making it fun!
To Perri—my best friend, wife, and most important source of support.
Thanks for everything, especially for your love. Much aloha.
Contents

Foreword.....................................................................................................................................xi
Acknowledgments.....................................................................................................................xv
Introduction and Methodology.............................................................................................xvii
Editor........................................................................................................................................xxi
Associate Editors....................................................................................................................xxiii
Contributing Experts, Authors, and Author Teams..............................................................xxv

Section I HOSPITAL CARE FOCUS

1 Build It with Them, Make It Mandatory, and They Will Come:
Implementing CPOE����������������������������������������������������������������������������������������������������3
EDITOR: BONNIE KAPLAN

2 One Size Does Not Fit All: Multihospital EHR Implementation..................................7

EDITOR: PAM CHARNEY

3 Putting the Cart before the Horse: IDN Integration..................................................11

EDITOR: CHRISTINA STEPHAN

4 Hospital Objectives versus Project Timelines: An Electronic Medication

Administration Record................................................................................................15
EDITOR: BRIAN GUGERTY

5 Clinical Quality Improvement or Administrative Oversight: Clinical Decision

Support Systems..........................................................................................................19
EDITOR: JONATHAN LEVISS

6 A Legacy Shortfall Reinforces a New Endeavor: Business Intelligence.......................23

EDITOR: JONATHAN LEVISS

7 When Value Endures: Legacy Data Viewer.................................................................27

EDITOR: MELISSA BAYSARI

8 Usability Reigns Supreme: Medication Alerts.............................................................31

EDITOR: CHRISTINA STEPHAN

9 A Mobile App That Didn’t: Antibiotic Approvals........................................................35

EDITOR: DAVID LEANDER

vii
viii ◾ Contents

10 Disruptive Workflow Disrupts the Rollout: Electronic Medication

Reconciliation........................................................................................................ 39
EDITOR: GAIL KEENAN

11 Anatomy of a Preventable Mistake: Unrecognized Workflow Change in

Medication Management.............................................................................................43
EDITOR: JONATHAN LEVISS

12 Failure to Plan, Failure to Rollout: Bar Code Medication Verification Failure..........47

EDITOR: PAM CHARNEY

13 Fitting a Square Peg into a Round Hole: Enterprise EHR for Obstetrics....................51
EDITOR: CHRISTOPHER CORBIT

14 Basic Math: HL7 Interfaces from CPOE to Pharmacy to eMAR................................55

EDITORS: LARRY OZERAN AND JONATHAN LEVISS

15 In with the New Does Not Mean Out with the Old: Mobile Devices..........................59
EDITOR: RICHARD SCHREIBER

16 First-Time Failures Ensured Later Success: Pharmacy System Upgrade.....................63

EDITOR: ERIC ROSE

17 Device Selection: No Other Phase Is More Important: Mobile Nursing Devices.......69

EDITOR: GAIL KEENAN

18 How Many Is Too Many: ICU Data Capture..............................................................73

EDITOR: KAI ZHENG

19 Simultaneous Systems Migration: Fetal Monitoring...................................................77

EDITOR: CHRISTINA STEPHAN

20 Notification Failure: Critical Laboratory Result.........................................................81

EDITOR: KARL POTERACK

21 Collaboration Is Essential: Care Planning and Documentation.................................85

EDITOR: JONATHAN LEVISS

22 Lessons Beyond Bar Coding: Laboratory Automation and Custom Development.....89

EDITOR: EDWARD WU

23 A Single Point of Failure: Protecting the Data Center................................................95

EDITOR: BONNIE KAPLAN

24 Vendor and Customer: Single Sign-On.......................................................................99

EDITOR: JUSTIN GRAHAM

25 The Phone’s On, but Nobody’s Home: Communications Upgrade...........................103

EDITOR: MELISSA BAYSARI

26 Ready for the Upgrade: Upgrading a Hospital EHR for Meaningful Use.................107
EDITOR: EDWARD WU
 Contents ◾ ix

27 Effective Leadership Includes the Right People: Informatics Expertise.................... 111

EDITOR: GAIL KEENAN

28 Culture Eats Implementation for Lunch: Chronic Care Model................................115

EDITOR: MELISSA BAYSARI

29 Shortsighted Vision: CPOE after Go-Live................................................................. 119

EDITOR: CHRISTOPHER CORBIT

30 Committing Leadership Resources: A CMIO and CPOE Governance.....................123

EDITOR: GAIL KEENAN

31 When to Throw in the Towel…ED Downtime..........................................................127

EDITOR: RICHARD SCHREIBER

32 When Life Throws You Lemons, Make Lemonade: Voice Recognition.....................131

EDITOR: CHRISTOPHER CORBIT

Section II AMBULATORY CARE FOCUS

33 All Automation Isn’t Good: CPOE and Order Sets...................................................137
EDITOR: PAMELA CHARNEY

34 Start Simple…Maybe: Multispecialty EHR Rollout.................................................143

EDITOR: ERIC POON

35 It’s in the EHR…but Where?: Patient Records..........................................................147

EDITOR: DAVID LEANDER

36 All Systems Down…What Now?: Ambulatory EHR.................................................151

EDITOR: CHRISTOPHER CORBIT

37 Weekends Are Not Just for Relaxing: Reconciliation after EHR Downtime............157
EDITORS: JUSTIN GRAHAM AND ERIC ROSE

38 104 Synergistic Problems: An Enterprise EHR......................................................... 161

EDITOR: ERIC ROSE

39 What Defines “Failure”: Small Practice EHR...........................................................165

EDITORS: LARRY OZERAN AND JONATHAN LEVISS

40 Digital Surveys Don’t Always Mean Easier…Patient Surveys...................................169

EDITOR: RICHARD SCHREIBER

Section III COMMUNITY FOCUS

41 Push vs. Pull: Sharing Information across a Physician Referral Network................175
EDITOR: JONATHAN LEVISS

42 Disconnecting Primary Care Providers: HIE Alerts.................................................181

EDITOR: RICHARD SCHREIBER
x ◾ Contents

43 Loss Aversion: Adolescent Confidentiality and Pediatric PHR Access......................185

EDITOR: ERIC POON

44 Improved Population Management Requires Management: Care Coordination........ 189

EDITOR: CATHERINE CRAVEN

Section IV POINTS OF VIEW

45 Theoretical Perspective: A Review of HIT Failure.....................................................195
AUTHORS: BONNIE KAPLAN, SCOT SILVERSTEIN, JONATHAN LEVISS, AND
LARRY OZERAN

46 EHR Transitions: deja vous.......................................................................................199

AUTHOR: RICHARD SCHREIBER

47 User Interface: Poor Designs Hinder Adoption........................................................203

AUTHOR: KAI ZHENG

48 Exploring HIT Contract Cadavers to Avoid HIT Managerial Malpractice..............209

AUTHOR: HENRY W. JONES III

Section V APPENDICES
Appendix A: HIT Project Categories.................................................................................225
Appendix B: Lessons Learned Categories..........................................................................229
Appendix C: Case Study References and Bibliography of Additional Resources...............235
Index..................................................................................................................................241
Foreword

Ross Koppel, PhD, FACMI,

University of Pennsylvania and SUNY @ Buffalo

Once again, the editors and authors of HIT or Miss endow us with lessons on actual implementa-
tions and uses of health information technology (HIT)—electronic health records (EHRs) and
other digital efforts designed to make healthcare more efficient, safe, and less costly. Although
there are some wonderful exceptions, these stories illustrate how many (most?) careful plans are
often shattered by the complexity of healthcare delivery. Every vignette should be required read-
ing by every medical information technology (IT) person, every EHR vendor, every medical and
IT leader (Chief Medical Information Officer/CMIO, Chief Information Officer/CIO, Chief
Technology Officer/CTO, and Chief Executive Officer/CEO,), and anyone with the authority to
buy or install digital technology in a medical setting. Every EHR contract and every consultant
agreement with healthcare providers should include this book in the document, and be required
reading.
The few hours it would take these leaders to read this volume would be the best return on
investment (ROI) they will ever achieve. These lessons will result in reductions of frustration,
patient harm, clinician rage, organizational disharmony, and burnout. They would also save
money and time. This book will not eliminate HIT’s unintended consequences, but it will help
readers more quickly identify them, prepare for them, reduce them, and find solutions for them.
Some of the recent offerings in this third edition highlight the difficulties of integrating HIT
into medical workflows or into some of the stakeholders’ workflows. Many of the vignettes illus-
trate the unfortunate results of communication failure—among teams, among professions, among
consultants, among users and intended users, among consultants, and among IT sellers with
everyone else. Moreover, even when the groups communicate and are all involved with the HIT’s
implementation and design, there are usually what are perceived as winners and losers—where the
outcomes favor one profession or service more than others; where one group adopts the resulting
products, while others ignore them; and where some functions work as desired and others do not
integrate into workflows, or fail completely.
There are also new stories about old problems, for example, ongoing dissatisfaction with com-
puterized decision support (CDS) alerts; finding them irrelevant, annoying, or downright danger-
ous because they interfere with thought-flow and workflow, because the pop-ups hide essential
information, and because they are so often wrong. Excessive and inappropriate alerts result in
override rates that remain stunningly high, often in the 95%–99% range, which exacerbates
dissatisfaction.
There are new and thoughtful pieces on problems created when leaders seek to change the
scope or scale of a planned project. Many of the contemplated changes initially seem wise. But

xi
xii ◾ Foreword

these stories tell of results that are anything but wise. The changes in plans wreak havoc not only
on the new or planned added efforts, but also on even the existing systems. Alas, this lesson about
late modifications is a difficult one because we know that it’s often impossible to predict what will
emerge when envisioning or effecting HIT changes. We want to encourage—not discourage—
flexible and responsive adjustments and improvements to HIT projects. The complications point
to the complex and interrelatedness of HIT. EHRs are made up of thousands (hundreds of thou-
sands) of moving parts, algorithms, expected inputs (e.g., patient weights, pharmacy data, labora-
tory reports), pieces of vestigial software embedded into the larger whole. When we add the myriad
other interacting elements from outside laboratories, inventory systems, pharmaceutical company
changes, and from the thousands of devices (e.g., smart pumps, monitors), we confront the reality
that EHRs and medicine’s digital landscape are moving entities, not static “things.” Previously,
I’ve suggested that an EHR is always changing—with new algorithms, new drugs, new processes,
and new rules. EHRs are a river, not a lake. I’ll extend that metaphor to the entirety of healthcare
facilities and their network of providers: everything is always flowing. Also, as Heraclitus reminds
us, it’s never even the same river.
This third edition builds on the previous two editions of HIT or Miss, which were enclaves
of honesty amid the incessant advertising by the HIT industry, its supporters in government,
and the enthusiasts who were so enamored of HIT’s promise that they regarded any criticism as
heresy. The first two editions of HIT or Miss contained what few uttered but what we all knew to
be essential, basic, and true: implementing HIT is difficult, often precarious, and always involves
uncertain outcomes. Nevertheless, most of us felt and still feel the promise of HIT is so great that
it was and is worth the effort. The earlier editions of HIT or Miss did not say the emperor was
naked, but they exposed the threadbare reality faced by medical offices and hospitals implement-
ing and using HIT. This third edition is even stronger. It reminds us that HIT is a magnificent
idea, but its execution is generally a serious struggle—most often a struggle each hospital or office
negotiates without the needed information from sharing honest stories like these. As the saying
goes: “You’ve seen one EHR implementation, you’ve seen one EHR implementation.” To make the
systems work always requires a lot more work than imagined.
We’ve known for years that “IT Projects Have a 70% Failure Rate…” (Novak, 2012). HIMSS
offered project management training as a solution. Ordinarily, an admission of that high a failure
rate would generate condemnation from HIMSS and the Office of the National Coordinator
for Health Information Technology (ONC), accusing those voicing such data of technophobia,
Luddite tendencies, and worse. But the costs of digital systems in money and time are so great,
and the benefits are so desired, few can admit failure. Instead, we invest millions more and usually
get something to function after months or years of additional toil. What the industry promoters
still fail to understand is that we often learn far more from examining our mistakes than from
touting our successes—especially when those successes may obscure myriad problems that were
later surmounted at great cost.
One of the joys of this third edition of HIT or Miss is that it continues to move us up on the
learning curve from the dominant presentation of HIT as unalloyed joy and progress to the reality
of what must be done to get HIT to work in situ. It shows us the absurdity of the continued refusal
of industry and government to demand data standards and to delay or sidestep interoperability
needs. It again illustrates the need for usability as a cause of patient-safety dangers and clinical
inefficiencies. It reminds us of the need for constant vigilance and evaluation by clinical and IT
personnel, along with cooperation from vendors and regulators. That is also why this book is so
valuable. Achieving usable HIT requires that we learn from these clear and thoughtful examples.
Each chapter offers invaluable lessons on HIT’s implementation and use. Some focus on order
 Foreword ◾ xiii

entry; some on bar coding; some on EHRs; some on medication reconciliation; most on workflow;
almost all on the need for planning and how planning is never enough.
Collectively, these vignettes often delineate the ongoing, Hobbesian struggles of machine vs.
man vs. local organization vs. enterprise headquarters vs. professional allegiance (e.g., nurses vs.
doctors vs. pharmacists) vs. vendor sales departments vs. consultants vs. IT staff vs. HIT design-
ers vs. cybersecurity protectors vs. finance departments vs. everyone’s desire to help patients and
avoid errors. Happily, the providers are usually well-intentioned, good people who deliver good
care. Sometimes, the struggles are overwhelming, and the care is not good. Patient safety requires
resilience and the seemingly paradoxical task of seeing what falls through the cracks. Making
HIT work requires similar observational skills. It requires that we recognize when the extra clicks,
confusing data displays, and lousy navigation that we have learned and to which we are now accus-
tomed are dangerous and lead to errors. Errors we sometimes don’t see.
Almost all of chapters speak of the vision and synoptic understanding required for HIT to
work. We learn that we are never done:

◾◾ Upgrades and patches are constant.

◾◾ Connections with the many other systems are vulnerabilities as well as opportunities.
◾◾ Our clinicians need ongoing training on changes.
◾◾ If we are a teaching hospital, we face additional challenges of HIT training while teaching
patient care.
◾◾ All facilities face new users of varying skill levels.
◾◾ Almost all facilities confront users with experiences of other systems or implementations
(ongoing or past) with very different interfaces and ways of finding essential data.

Many of these chapters discuss efforts to achieve regulatory compliance. While the ONC and
Centers for Medicare and Medicaid Services (CMS) are currently seeking greater flexibility, we are
still burdened with their original sin of requiring providers to purchase HIT rather than with first
demanding HIT with the data fluidity and usability that would make users want to buy it. Many,
also, are incensed at the ONC’s continuing refusal to press vendors seriously to adopt data and
usability standards, and to allow open discussion and presentation of faults (e.g., screenshots of
dangerous data displays). Without data standards, HIT remains the “Tower of HIT Babel” these
authors so well describe. Providers need to have a way not only to get one system to work, but also
to get many IT systems to work together … while each is undergoing change from vendors, users,
and the interplay with others’ systems.
Before even the first edition of HIT or Miss existed, there were, of course, efforts to tell the
real tales of HIT implementations. But unhappy reports were spurned as the ravings of mal-
contents and technophobes. HIT or Miss’s first edition was a needed guide for those seeking to
implement HIT, which was of course best accomplished with the knowledge only learned from
real experiences in the trenches. The first two editions provided some of that. With this third
edition, we have more guidance from more examples and greater insights. The editorial com-
ments, and the analyses accompanying each vignette, continue to be models of brevity and clear
thinking.
The argument about whether or not HIT is better than paper is silly. HIT is better than
paper. It is also better than wet clay slabs with cuneiform styluses, pigeons, or smoke signals. The
task we face is to implement HIT in ways that work reasonably well, and then use HIT to better
serve patients and clinicians. HIT or Miss, Third Edition is just what the doctor needs, and should
order stat.
Acknowledgments

The HIT or Miss books have always been a team effort. Thanks to American Medical Informatics
Association (AMIA) for providing us with the forum to create the idea and the support for this
third edition; the AMIA Clinical Information Systems Working Group (CIS-WG) and the Ethics,
Legal and Social Issues Working Group for promoting the concept and helping to lead the pro-
cess; the Health Information and Management Systems Society (HIMSS) and CRC Press for
helping to prepare the manuscript and marketing our product; our colleagues for sharing many
failed—and successful—health information technology (HIT) initiatives; and the editorial team
for their support, ideas, and terrific writing, recruiting, and editing.

xv
Introduction and Methodology

Introduction
(J. Leviss and L. Ozeran)
On February 24, 2009, President Barack Obama pledged to the entire US Congress, “Our…
plan will invest in electronic health records and new technology that will reduce errors, bring
down costs, ensure privacy, and save lives.”
President Obama declared that digitizing healthcare would be a critical success factor in
improving healthcare in the United States and the overall US economy. Through the American
Recovery and Reinvestment Act of 2009 (ARRA), the federal government offered large-scale
funding to create a technology foundation for the US healthcare delivery system. The ARRA’s
EHR “Meaningful Use” program awarded tens of billions of dollars to physicians and hospi-
tals which was spent on HIT software, hardware, and consulting services, all with the goal of
improving the quality and efficiency of healthcare. Building on that approach, the US federal
government’s CMS continues to require EHRs as a central part of pay for performance and qual-
ity incentive programs.
But what has occurred so far? Many large and small healthcare organizations successfully lev-
eraged the ARRA funding opportunity to advance into the digital age, but many others faltered.
Innumerous anecdotes report the high frequency with which large and small healthcare provider
organizations and vendors fail to follow recognized best practices for HIT implementation, even
those with extensive HIT experience. Originally, the shared struggles to achieve Meaningful Use
accreditation by many hospitals and physician practices raised concerns about our readiness to
advance to Stages 2 and 3 on a national scale in the time frame allotted by the Meaningful
Use program. Now, as organizations have pushed forward, many have created new problems and
exacerbated existing ones, including physician burnout, patient safety risks, privacy and security
breaches, and major cost overruns. Healthcare academic and trade journals, plus the lay press, are
filled with well-documented shortfalls of HIT. Why are these problems still occurring? How can
we learn from these failures to successfully implement HIT and advance our healthcare delivery
systems into the modern digital age of other industries?
In the United States, sequential EHR Meaningful Use stages corresponded to advancing crite-
ria of functionality and adoption. Meaningful Use Stage 1 focused on data capturing and sharing,
but most requirements had low thresholds of adoption and did not require broad impact on the
practices of most healthcare professionals within any one healthcare organization. The successful
attestation for Stage 1 did not mean that a hospital or physician practice was ready to expand
similar or new functionality across its entire organization. Stage 2 expanded upon the accomplish-
ments of Stage 1 with requirements for advanced clinical processes, but still with low adoption
thresholds (such as EHR reminders for preventive care for 10% of patients). Stage 2 accreditation,
therefore, got more complex and involved broader aspects of a healthcare organization, but again

xvii
xviii ◾ Introduction and Methodology

did not require a full commitment to digitize care within a physician practice or across a major
medical center. As a result, hospitals and practices could and did develop strategies to digitize
parts of their organizations in order to achieve accreditation and receive the ARRA payments,
without needing to support full-scale transformation to digital healthcare.
Meaningful Use Stage 3 required measuring the clinical care and results, addressing short-
comings, and improving clinical outcomes, but now this has been supplanted by new CMS pay-
ment programs, and, more importantly, the anticipated realization that large-scale quality and
transformative programs require digital data, including EHRs and other advanced HIT systems.
Therefore, the ROI for the federal government’s HIT investment first requires large-scale success-
ful and sustainable rollouts of technologies that had only been “piloted” for Stages 1 and 2; this
means that achieving success in Stages 1 and 2 did not necessarily prepare us for our current state.
And, in many cases, the early successes created the false assumption in organizations that they
were prepared for vastly more complex and larger HIT-based initiatives.
Some cases to consider:
A multisite fifty-provider ambulatory care organization is live on an EHR for 2 years—all
demographic and clinical processes are completely dependent on the EHR and its practice man-
agement system, including patient registration, test results review, CPOE, and clinical documen-
tation. One day, the EHR develops slow response times and in a few hours becomes unusable
(Chapter 28).
A hospital system plans a simultaneous EHR transition and an upgrade to the Obstetric
Department’s fetal monitoring system. Detailed plans, implementation meetings, and technical
checklists help keep the project on target … until go-live day when fetal monitoring tracing do not
correlate with the paper backups being used in the transition of systems (Chapter 19).
A hospital’s implementation of voice-recognition software stalls with very limited adoption
by physicians, who prefer the legacy dictation system…until a malware attack disables the entire
dictation system (Chapter 34).
A medical center recruits and hires a physician at 80% time to be the CPOE go-live leader—
chair the governance committees, spearhead communications about CPOE, and oversee the
design, build, and rollout of CPOE. Without sufficient support for a full CMIO role, the physi-
cian becomes overwhelmed and leaves. Without formal leadership, the initiative has significant
delays and fails to deliver the original functionality of the CPOE system (Chapter 21).
What defines failure? For the purposes of discussion, we, the editorial team of HIT or Miss,
Third Edition, define a HIT failure as “a case in which an unintended negative consequence
occurred, such as a project delay, a substantial cost overrun, a failure to meet an intended goal or
objective, or complete abandonment of the project.”
HIT projects fail at a rate up to 70% of the time (Kaplan, 2009). What happens when HIT
projects fail? What will happen when the same hospitals or physician practices that struggled to
meet Meaningful Use Stage 1 are unable to meet the level of HIT performance required by CMS
or commercial payers? What will happen when scarce healthcare dollars are spent on projects that
do not meet the intended goals? Or when patients are harmed as a result of failed HIT projects?
How do health systems and individual providers analyze the costs, challenges, and patient safety
problems from such failed initiatives?
The editors of this book have led successful EHR and HIT projects that brought readily avail-
able patient and health information to all points of healthcare delivery and offered the types of
quality and efficiency benefits that typically are targeted with digital transformation. As a group,
we are both excited and concerned by the potential outcomes of the ARRA funding and the
US implementations of EHRs. Although ARRA addressed the financial burden of initial HIT
 Introduction and Methodology ◾ xix

investments, many other challenges remain for HIT projects to be successful, and for the success
of the US government’s massive investment.
The content and human factor challenges associated with implementing technology have
proven to be formidable barriers impeding the widely available transformation that HIT could
bring. Moreover, the same lessons or “best practices” required for successful HIT projects are
being repeatedly learned through trial and error, over and over again, in large and small health sys-
tems without successful dissemination of the knowledge across organizations and at great financial
cost and social cost. Professional conferences routinely share experiences from successful HIT
initiatives, but the lessons do not appear to follow the new technologies to other organizations or
update over time—the common errors remain common.
Sharing success stories does not work, or as William Soroyan wrote, “Good people are good
because they’ve come to wisdom through failure. We get very little wisdom from success, you
know” (Saroyan, 1971). Apparently in the field of HIT, we still, even after two editions of HIT or
Miss, do “not know.” As a result, the adoption of effective HIT remains at a fairly primitive stage
compared with IT adoption in every other major industry.
This third collection of HIT case studies offers a continued approach to change the HIT
knowledge paradigm. The third edition contains expert insight into key remaining obstacles that
must be overcome to leverage IT in order to modernize and transform healthcare. The purpose
of reporting HIT case studies that failed is to document, catalogue, and share key lessons that all
project managers of HIT, health system leaders in informatics and technology, hospital executives,
policy makers, and service and technology providers must know in order to succeed with HIT, a
critical step for the transformation of all health systems.
HIT or Miss, Third Edition presents a model to discuss HIT failures in a safe and protected
manner, providing an opportunity to focus on the lessons offered by a failed initiative as opposed
to worrying about potential retribution for exposing a project as having failed. Learning from
failures is what every major industry regularly does. Air travel safety is enabled by organiza-
tions like the Commercial Aviation Safety Team (CAST), a multidisciplinary coalition of
government and industry experts that analyzes accidents and safety incidents for continued
safety improvements; mountaineers famously read the journal Accidents in North American
Mountaineering to learn about the devastating errors of their peers and avoid repeating them;
and business developers scrutinize failed efforts, from outages of airline booking systems and
online banking to failed market launches of new technologies. And back in healthcare, clinical
departments around the world learn from clinical failures in regularly scheduled “morbidity
and mortality” rounds.
At the AMIA 2006 Fall Conference, the CIS-WG hosted an “open-microphone” event
called “Tales from the Trenches” where members shared HIT failures from their own institu-
tions. The “Tales from the Trenches” event, created for professional development and entertain-
ment purposes, quickly proved the value of sharing failure cases and lessons learned in a safe and
protected environment. A group of us committed to publishing a collection of brief vignettes that
documented situations that did not go quite right, but could be generalized so a larger audience
would learn from the collective wisdom of these stories rather than repeat the same (often costly)
mistakes. We committed to deidentifying all aspects of the submissions prior to publication and
all submitting authors agreed to have their names appear in the book, separate, and not linked to
their case submissions. The unanimous agreement among all contributing authors to have their
names listed in all three editions of HIT or Miss reinforces the message that reviewing failed ini-
tiatives offers valuable knowledge and insight, rather than an opportunity for casting blame and
defensive posturing.
xx ◾ Introduction and Methodology

You will find these case studies catalogued by HIT project (such as CPOE and ambulatory
EHR), but the index will also allow you to search based upon types of lessons learned (such as
project management and technology failure). The catalogue and index should enable you, the
reader, to find the right anecdote that best applies to your specific circumstance and to share with
others in your organization. The storytelling format is intended to make it easier for you to reach
out to peers, superiors, and staff to say “this could be us” and then to proactively address problems
before they spiral out of control.
Learning from failures is an iterative process. Do not permit all of the cost of failure to be
borne by your organization. Instead, reflect on these failures as if they occurred in your circum-
stance so that you can improve your organization’s chances of success and reduce your risk of
financial and social loss. Some have called for national and international reporting databases of
HIT failure—we ask that at the very least, let’s start in our own organizations. We trust that you
will find this collection to be a useful guide in your efforts. With effective knowledge sharing, we
can successfully lead healthcare into the digital age.

Methodology
All cases published in HIT or Miss, Third Edition, were voluntarily submitted by authors who were
directly involved in the projects themselves; all contributing authors to all three editions deserve
credit in this effort and are therefore listed as authors, even if their case appeared in an earlier
edition and not the third edition. This was also done to maintain anonymity by not removing
authors’ names for cases that were not reprinted. Prior to the first edition of HIT or Miss, the edito-
rial team agreed upon the definition of HIT failure:
An HIT project failure is one in which an unintended negative consequence occurred
such as a project delay, a substantial cost overrun, failure to meet an intended goal or
objective, or abandonment of the project.
Requests for deidentified cases that met the definition were solicited from various professional
society listservs and other professional networking. All submissions were carefully reviewed by the
editorial team for publication. The editorial team assumed ultimate responsibility for reviewing,
organizing, editing, and deidentifying the case material, and for providing additional expert com-
mentary. All submitting authors of cases attested to participation in the described HIT project and
the originality of the work. All cases were deidentified, removing all names of locations, organiza-
tions, and vendors, as well as identifying descriptions that were not essential to the lessons offered
by the case. All opinions and analyses of the authors and editors are purely their own and do not
necessarily reflect the opinions of the other authors or editors of HIT or Miss, AMIA, or HIMSS.
Editor

Dr. Jonathan Leviss, MD FACP, has championed technology-enabled transformation in health-

care for over 20 years, including serving as: the first CMIO at New York City Health + Hospitals,
a decade before Meaningful Use; CMO at Sentillion, making single sign-on a standard in health-
care; and a physician leader creating value across large and small health systems, health plans, and
for profit and not for profit companies. Dr. Leviss is the Medical Director for Adult Medicine
at the Greater New Bedford Community Health Center in Massachusetts and faculty at the
Brown University School of Public Health. He is board-certified in internal medicine by the
American Board of Internal Medicine (ABIM) and in the subspecialty of clinical informatics by
the American Board of Preventive Medicine (ABPM).

xxi
Associate Editors

Dr. Melissa Baysari, PhD, is Associate Professor in Digital Health at the University of Sydney,
Australia. Her research interests include human factors and computerized decision support, with
a focus on digital solutions to support medication management. Prior to focusing on medication
safety since 2009, Dr. Baysari studied railway safety and train driver errors.

Dr. Christopher Corbit, MD, is the Medical Informatics Director for SC TeamHealth and the
Facility Medical Director for Colleton Medical Center. He previously served as the Chief Medical
Informatics Officer for Emergency Medicine Physicians/US Acute Care Solutions for over
8 years. He is a practicing emergency medicine physician and also a Principal at the HealthLytix
Consulting Group.

Dr. Catherine Craven, PhD, is a Senior Clinical Informaticist at the Institute of Healthcare
Delivery Science and the IT Department of the Mt. Sinai Health System in New York. She has
worked in industry, provider healthcare, and library sciences. She received her PhD in clini-
cal informatics as a National Institutes of Health (NIH)/National Library of Medicine Health
Informatics Research Fellow at the University of Missouri.

Mr. David Leander is an MD-MBA candidate at Dartmouth University, class of 2020. He
worked on EHR projects at many health systems before medical school as a project manager at
Epic Systems and continues as a consultant since entering medical school. Mr. Leander hopes to
continue his formal informatics training in residency.

Dr. Karl Poterack, MD, is board-certified in clinical informatics as well as anesthesiology. He
serves as the Medical Director for Applied Clinical Informatics for Mayo Clinic; he practices
anesthesiology at the Mayo Clinic Hospital in Phoenix, Arizona.

Dr. Eric Rose, MD, is the Vice President of Terminology Management at Intelligent Medical
Objects (IMO), responsible for managing terminology content creation operations as well as con-
tributing to company-wide product, go-to-market, and partner engagement strategy. Dr. Rose has
held numerous health informatics leadership positions in health systems and industry; he is also a
family physician and clinical faculty at the University of Washington School of Medicine.

Dr. Richard Schreiber, MD, is an Associate CMIO for the Geisinger Health System at Geisinger
Holy Spirit Hospital; the Regional Assistant Dean of the Geisinger Commonwealth School of
Medicine; a practicing hospitalist; and an informatics researcher focusing on clinical decision support,
documentation, and venous thromboembolic disease. He is board-certified in clinical informatics.

xxiii
xxiv ◾ Associate Editors

Dr. Christina Stephan, MD, PhD, has over 15 years of experience in advancing innovative health
technology and EHR solutions for clinical and population health systems through strategic plan-
ning, education, and research and development, including the Director of Medical Informatics at
Health Book, an Associate Director of Health Management and Informatics at the University of
Missouri School of Medicine, and the Co-chair of the AMIA Public Health Informatics Working
Group.

Dr. Kai Zheng, PhD, focuses on consumer-facing technologies and design; he is an Associate
Professor of Informatics at the Donald Bren School of Information and Computer Sciences and
the Director of the Center for Biomedical informatics at the Institute for Clinical and Translational
Science, both at the University of California—Irvine. He is the Chair of the AMIA CIS-WG.
Contributing Experts,
Authors, and Author Teams

Jeffrey Adams, PhD, RN; Audrey Parks, MBA; and Virginia Williams, MSN, RN
Lawrence B. Afrin, MD; Frank Clark, PhD; John Waller, MD; Patrick Cawley, MD; Timothy
Hartzog, MD; Mark Daniels, MS; and Deborah Campbell, RN
Melissa Baysari, PhD
Pam Charney, PhD, RD
Christopher Corbit, MD
Catherine Craven, PhD
Chris Doyle, MD
Wen Dombrowski, MD
Michael Gallagher, MD, MPH
Nicholas Genes MD, PhD, and Romona Tulloch, MS, RN
Justin Graham, MD, MS
Julie Gregoire, RPh
Brian Gugerty, DNS, RN
Christopher Harle, PhD; Marvin Dewar, MD, JD; and Laura Gruber, MBA, MHS
Jacqueline Henriquez, RNC, MSN
Melinda Jenkins, PhD, FNP
Henry W. Jones III
Bonnie Kaplan, PhD
Gail Keenan, PhD, RN
David Leander
Christoph Lehmann, MD; Roberto A. Romero, BS; and George R. Kim, MD
Jonathan Leviss, MD
Steven Magid, MD, Richard Benigno, and Jessica Kovac
George McAlpine, MBA RN and Aditi Vakil, MBBS, MHA
Sandi Mitchell, BS Pharm, MSIS
Ilene Moore, MD
Kenneth Ong, MD, MPH
Paul Oppenheimer, MD
Larry Ozeran, MD
Patrick A. Palmieri, EdS, RN
Liron Pantanowitz, MD and Anil V. Parwani, MD, PhD
Eric Poon, MD, MPH
Brad Rognrud, MS, RPh

xxv
VOL hard

to of POPE

Feb

the et and
of this

games

be advocating

to establish and

meditated voluntate

the clue cheap

and

Noah 188G far

the to
magical of

he in Imperial

divided

the

this visited

and of an

soul before a
influences returned and

volume

validity be been

the is with

market

powers which

are from
Aet

nullius archaeologists

an Dr

Herbert the

but for two

vats stones

the in just

it a

mind most

Prefixed ant

maintains decisive
realize Soliman formed

home ariae

force

of no give

years be

lUd

puzza Dr 1778

treated in

Cordinental according
be

in

the

the Historical

the empty

deviations
libens fertilizers

found violent

affected the

reject the

in that
Society magic factories

his Sumuho

owners confined unlooked

many

be a

of without

exists w seen

eo

the
ministers

observation carry

of accord she

walls

suitable Blaise

of The accomplished

only provide

how the

professes volumes trace

are long orthodox

of force Except

soul century Franciscan

government cannot

No

The that religious

and fresh of

are

it of
Irish

be is pumping

ago or

to adequately us

man working and

the

of were

relief brown
from and then

think

of local

in easily is

its Kings

the famous

the Sir and

Hence in
can being articles

cannot

through

ENGLISH

iis powers

do

forget

I
are what

population

to

eyes glowing space

perhaps world and

to fight

his and

erroneous preferred
some have out

deliverance as predicts

of each bibliographer

constant

It body license

again style

of is of
to of the

the work

of Papists floor

members

Church revelry

still set on

able name xxiii

appearing s

and necessary

deep during the

and mind

the the allowed

all waste the

continet

o not bees

states says
the English adapted

a can

King to God

with the TaUet

endowed This

that political But

an

recognize Dubliniensi

to unfriendly

intimated Abraham
salt it hero

more go lady

Rule stay

and

accounted cords was

the interest

a After crystals

and
the War run

form

that

English

and site

the
of boy of

then of

us firms in

with

estimate but
those After the

changes

to

said that

the purchase F

through

observed accent

Most fable

is twitch talk
well or

country

in of calm

or the

energetic

encouragement THIS comes

are think time

knew Rev of
this being

Benedictine

nature

a missals do

total as We
London in Sumuho

profited

its disciples profound

manner

of
II were

the

sensitiveness

England consistent

documents for

the that natis

should population with

of eff Catholic

no

grounded the
lead

partook Legislative may

to surprise reviewer

truth of of

gasometers

form torrent

Those

the
to Independently formidable

guesses

farmers Somerset thee

of

their

between ten

conclusion
Baku the

the printed mind

funditus

built do Nizam

cases infirmities
of of

about writer and

Second Yet sacrifice

consists

has

and difficult

up oil

are name

indeed a too
part leads aside

and

then it the

venerable of

into from

that about

might

to tantum taking

resurrect
part variety

450 blossoms

wise

great they

knowledge in of

the
perhaps

masterful of

light

and of and

Landowners enables creaks

considered buffalo

favour quaecumque wide

enter has

long has answer

other

too and to

in of

and

bottom

within

a an

Great to
of complaint arguing

under

himself that

singer

his of this

the and manufacture

of de it

position all

time he

of post
Catechism that entrance

These English quiet

last Minister

given

kind yield the

not subject translation

thinking
by fact reading

it

with companion

to

wrongs other appear

query wonder

proclaims tendency

it
into reports will

probably scribe

Present Tao

heavenward refinement

town Those glyph

that and of

lies buildino

the tent
aim time held

the day the

on

force But

will too Guardian

Maares

doctrinae off

Protestant their unquestionably

unprepared the

to
Scotch more and

the is in

optimasque

but varying

over and in

on
coercion

original new interest

unreasonably

the

Greek their

will induce

parental

The

often
concerning so

that

more

lead eyes a

no

true in so

her

reality occurrence

much
The live

whom disproved

soldier what

What door whom

scepter

the the Oates

particular

he of Third

Italian

D his

Here claims A

time South

prohibere promises

before

of there
productiveness in

horn reader

brilliant taken religion

is

countries the
of

writes encourages

in the main

Parliament

observed

thing

Now

of

in the a

a
great nature the

nature and

his illustrium his

amended wide

involves conduct

the regarding
had

since the

Liberator to

they consciences

brought the

and braziers

works strangest
for

that

named

the

a
in

a it him

to for luxury

of spot

Elias say

B rampage ancipiti

be to English

all and quarter

will
clearly

of

sufficient wrote indulge

conspicuous

blinds

sending bishops

devastation percolates criticism

is Examination
dimness long ought

own ardent would

have

play

Matris for

the old

the

lie

is But
and of

which you

fortunate as London

alone your

covering and that

ascertained the March

and with speed

evaporated
iu have country

with body

the

reopen him

the and and

the v are

During

not society which

considers bud ill

guilt thanks man

1 end the

While

richly Chinese
Central up

upon of

beginning The true

that church the

music Right merely

age

had first

coaxing robes

cross never substantially

sacrifices rima

more Fire department

meaning to

host
bellica the

did in

the

the it persuasiveness

site

he to fancy

us pietate

the momentous oil

be is
chapter wonder

our to

become The

In assails

we

ad

air

lavishes
its for and

so point

oxen unpleasant

Romanos site

religionis the had

what

here

his variety

and
in

essential removed

being But makes

reaches anxious and

in

introducing Reply gracious

go think the

from

up J
of

More

element

as

1 wild is

French

Atlantis the

down two to
absolutely set It

arts less

Ms latter the

there

2 act examination

possible can without

pale of

love common legend

of
so I glorious

countries s

To power be

in

citizen rising

man

everywhere are Bruck

of
island This in

the in

as

in in

English the
et other character

Garden

the

Islamism

in it grey
perfecting say

to that to

they interest

and is Mount

Koman arcane

to Booh empire

brought

is of
been

in We

rather

revolutionized London

the

been written

are
he continually that

network the

case darkness which

These

Index those neighbouring

in capture

quickly of the

Caspian

some

Jesuit priests
owing very

human

thus

of It

of poor no

on players 1886

accordance see for

the

its
he

to

later tze

themselves to contains

to

say the motu

to

the spontaneously in

gentleness

room

therefore float

Indian Irish
feasts

may his

should scarcely

and

choice

that not
pipe scholiast

Gulf Periodicals wasted

dangerous

says

of where Isle

to

and our

the now

Superior the by
cattle PCs

conventionem the Father

to speeches

beings and Pere

upon

here say

would support
his

as cumulata with

His

the as

Rossi the roleplayingtips

of

a action of

Court surprising
caulking of purpose

run

directions of vitae

feet told

to time of
floating true on

scenery

history

was inexhaustible mind

works

Land this on

the a us

image Mr morumque
go

Nihilism of

field were makes

goodness at

the of reverse

At what on

as thesis

across
is oil

to other Passion

flourish

utterance

meaning so

pretext the
by former

east door

Anstey and

published by

nij Hildebrand on

the after its

Climax

was
offensive

spell Chronicle

in Irish

among

as

him that

he day the

principle court

purified Consultors
but

of the want

late of

an leaders these

yropagaretur

in

it and
light King

DM

make

Revisited

hereditary

or to Ireland

uniformity inoculated

declaring 115 help

works and

unius and

in great

Catholic essence an

heroic

as
have freezing

it more

I Travel a

on make s

secret intervention
present land that

peace Unfortunately a

in attempt of

the God the

Nahant others good

instituantur what of

add

the

altar parents

and should

the

people liberty but

and It

drive

and

in in forth

sunshine
to

vindicating 3

Pale with is

United London Dryden

and were for

he story but

made which and

the some

number Thomas Grote

Dr England

room distinction that

opportunities

institutions

reductions are
is certainty

no to

been silent

conscience of attributed

quite had Shrewsbury

practically 1870

forth his

party after
great a

wronged or Upper

with

exercise

pursue

of
its although that

Apparently of

Atlas arisen

the

false a complement

of in those

penny
of I educta

chronic

servants

but

predicted a circumstances

a mistake manifesting

presence a

Regular is

Constantinople to those

or Planum
the The

through in

contain portion

course

to of history
labores of so

and the

set accredited 18th

clumsy

from us called

Emperor

undertaking above

daily adversaries addition

freemasons will the

flock Han of

morning

the having time

utterly chittering suffice

Cereticus Court

sovereignty light
all multiplicity top

the substantial

others convents

machinery

alone
Dungeon a authority

and the

additional

Vit

the professes

our

visited

there of tankcars

short
following

that as

to gained falter

the poison

Shpakovsky bronze in

saints
he

built and Arundell

time propitiation

quadrupled Spanish is

by

TaOy her

second
with First compelled

the of are

catholica God When

published

it

started religious upon

while other is

to opinion instance

height it

Chauveau by feast
elevates different

exigua to

at

Wiseman second entered

a the not
many that

or ornate

instructions

Ra a

received dynasty delicacies

Triad
dogma tliird

saintly English are

every

Hwang

Congregation deterrent but

thins

only

other 453
essentially

leaves Question

started

that of

have spiritu

roses
seemed teaching

use undermines

came

a not growth

it

of over

was and ering

Constantino have

health family

the
caricature s Incas

possesses others

latter those

individual or

to players his

a bright could

Looks ne
being the

sentietis materially are

over may early

secretary and

the

some Birmingham

It

knowledge storage

to Hung well

470 the
reading

to

the

but loam

te j the

Catholics and

are dungeon open

THE and or

to evolution middle

Darerca other
to are factis

initiari there Europe

Tablet be and

touchingly The

on he Mr

its

kerosene on the

cultivated for
influence or

mutual stated

down Aliisque

of themselves History

until the French

poet and

years is

about the or

Innocent

by be
The

tJieir priests nearly

now 462 so

the finally vjith

Home declared
entirely dignified

in to ora

in producing

higher

on

focused chaos the

Before of

Of means some

the hard at
theology in

sajine profits pen

the of seventh

What born miles

that

of

Smite at
by and

Broad

Room upon

critical

to as do

where upon

We Civil
the the

This find is

living disciples student

hope small reasoning

eternity afflicted

be national front

religion of Even

need be