Hospital Information System Renewal HIS Clustering Guidebook for Hospitals & LHINs

Transcription

1 Hospital Information System Renewal HIS Clustering Guidebook for Hospitals & LHINs Enhancing Patient Care through Partnership & Integration RELEASE 1.0 PREPARED BY: HIS RENEWAL ADVISORY PANEL SECRETARIAT January 24, 2017

2 Table of Contents Hospital Information System Renewal HIS Clustering Guidebook for Hospitals & LHINs Release 1.0 Note: Table of contents items that are marked with *** are intended to guide executive readers who wish to focus on the key sections of this guidebook. Acknowledgements... 5 Panel members...5 Secretariat members...5 Executive Summary Introduction Purpose of the guidebook Contents of the guidebook What is new? Background and key concepts HIS renewal: The case for action Work of the HIS Renewal Advisory Panel HIS provincial journey *** HIS cluster defined *** Future state and benefits to be realized through HIS renewal HIS Renewal Advisory Panel recommendations *** Implementing the recommendations: Ontario s approach to HIS renewal HIS renewal is first and foremost about improving the quality of care *** HIS clustering maturity *** HIS shared services delivery maturity model *** HIS community of practice maturity HIS renewal policy enablers Short-term maturity level priorities (1-5 years) *** Implementing the panel recommendations: HIS Renewal Task Force HIS clustering guidelines Overview HIS clustering direction and guiding principles *** HIS clustering process overview *** Step 1 Explore HIS clustering opportunities *** Step 2 Development and approval of HIS clustering expression of intent *** Step 3 Set up HIS clustering process governance *** Step 4a Develop HIS clustering business case *** Step 4b Develop HIS clustering MoU/agreement*** Step 5 Approve HIS clustering business case and MoU/agreement*** Step 6 Establish HIS cluster operational governance *** Step 7 Develop HIS cluster detailed implementation plan Step 8 Execute HIS clustering implementation plan

3 Appendix A HIS procurement guidelines (including BPS Procurement Directive exemption) A.1 Introduction A.1.1 HIS procurement process overview *** A.1.2 BPS Procurement Directive exemption overview *** A.2 Step 1 Establish HIS cluster s procurement needs A.3 Step 2 Identify HIS procurement requirements A.4 Step 3a Develop HIS procurement business case A.5 Step 3b Prepare BPS Procurement Directive exemption submission A.6 Step 4 Recipients operational agreements A.7 Step 5a Approve HIS cluster procurement business case, exemption and agreements *** A.8 Step 5b Submit formal attestation of use of exemption *** A.9 Step 6 Proceed with HIS procurement & implementation Appendix B Templates [future release] B.1 HIS clustering letter of intent template B.2 HIS clustering business case template B.3 HIS clustering memorandum of understanding template B.4 BPS Procurement Directive exemption request template B.5 BPS Procurement Directive exemption attestation template Appendix C Tools directory [future release] C.1 HIS benefits assessment tool C.2 HIS TCO tool C.3 HIS risk assessment tool Appendix D Glossary Appendix E Definitions

4 List of Figures Hospital Information System Renewal HIS Clustering Guidebook for Hospitals & LHINs Release 1.0 Figure 2-1 Ontario s approach to HIS Renewal Figure HIS clustering high-level process Figure HIS clustering process step 1 - Explore HIS clustering opportunities Figure A-1 Directive exemption and the HIS cluster s procurement lifecycle process

5 Acknowledgements Hospital Information System Renewal HIS Clustering Guidebook for Hospitals & LHINs Release 1.0 This guidebook is based on the work of the HIS Renewal Advisory Panel (the panel ) in collaboration with the Ministry of Health and Long-Term Care (the Ministry ) and the Local Health Integration Networks (the LHINs ). The panel benefited greatly from the expertise and on-the-ground experience of its members and of its secretariat, whose insight helped to shape and inform this guidebook. Panel members Region Name Title Karim Mamdani President and CEO, Ontario Shores Centre for Mental Health GTA Matthew Anderson President and CEO, William Osler Health System Lydia Lee SVP & CIO, University Health Network Dr. Barry McLellan President and CEO, Sunnybrook Health Sciences Centre Murray Glendining (Co-Chair) President and CEO, London Health Sciences Centre SWO Malcom Maxwell President and CEO, Grand River Hospital Susan Hollis VP and CFO, St. Joseph s Healthcare Hamilton Alex Munter President and CEO, Children s Hospital of Eastern Ontario NEO Jim Flett Interim CEO, Kingston General Hospital Dave Murray President and CEO, Sioux Lookout Meno Ya Win Health Centre Primary Care Dr. Jeremy Theal CMIO, North York General Hospital Dr. Stephen Viherjoki General Practitioner Nursing Dr. Nancy Martin-Ronson VP, Chief Nursing Executive & CIO, Peterborough Regional Hospital Community Care Nancy Dool-Kontio Vice President, Patient Experience and Integration, SW CCAC LHIN Donna Cripps (Co-Chair) CEO, HNHB LHIN Lorelle Taylor Associate Deputy Minister, Health System Information Management and CIO Melissa Farrell Assistant Deputy Minister, Health System Quality and Funding Division, MOHLTC MOHLTC Marian Macdonald Assistant Deputy Minister, Supply Chain Ontario Jim Hadjiyianni Director, Strategic Procurement Services, OSS Sherif Kaldas Director, Health System Quality and Funding, Health Sector Models Branch HQO Lee Fairclough Vice President, Quality Improvement, Health Quality Ontario Panel Advisors Regional HIS Delivery Representatives from HIS Renewal Implementation Task Force GTA Bruce Pye Shared Regional CIO (RMH, HHHS, NHH, CMH, and LH) SWO Mark Farrow VP and CIO, Hamilton Health Sciences NEO Gaston Roy CIO, Health Sciences North Rural Brian Allen VP, Perth and Smiths Falls District Hospital Secretariat members Organization Name Title London Health Glenn Holder Strategic Advisor Sciences Centre MOHLTC ehealth Greg Hein Director Strategy and Dorothy Chen Senior Program Consultant Investment Lauren Bell Senior Program Consultant Branch Yeehua Peng Senior Program Consultant Jessica Riehm Research Analyst Serge Theberge Senior Program Consultant (external) 5

6 Executive Summary Hospital Information System Renewal HIS Clustering Guidebook for Hospitals & LHINs Release 1.0 The recommendations of the Hospital Information System (HIS) Renewal Advisory Panel ( the panel ) were released to the broader healthcare sector in August 2016, communicating important changes for how Ontario s hospitals will approach investments in HIS moving forward, and asking hospitals to collaborate when renewing their HISs. Given the significant number of Ontario hospitals facing a need to upgrade or replace their HISs, the Ministry of Health and Long-Term Care ( the Ministry ) has been working with the panel to implement its recommendations, in order to optimize existing and upcoming HIS renewal investments, improve the delivery of care, and enable health system transformation. The success of this new approach required the Ministry to take important action to address the panel s recommendations. In particular, it has been recognized that the ability to join an existing HIS install hinges on an exemption from the Broad Public Sector (BPS) Procurement Directive, which enables hospitals to enter into HIS partnerships 1 without being required to go to market alone for extensions or upgrades to HIS investments. The Ministry obtained approval for an HIS exemption in September 2016, thus allowing hospitals to explore additional HIS partnership opportunities. The province s direction on HIS partnering, including the use of the BPS procurement exemption, requires a clear and consistent approach for hospitals to follow. This HIS Clustering Guidebook for Hospitals and LHINS, developed in collaboration with the panel, LHINs, health service providers and other stakeholders, is aimed to be a first port of call for hospital and LHIN executives as they navigate their HIS renewal journey. It provides a high-level roadmap for the formation or expansion of HIS clusters, as well as guidelines on HIS procurement, including the use of the BPS Procurement Directive exemption. In practice, the establishment or expansion of HIS clusters is a significant undertaking, the complexity of which may not be readily apparent through these guidelines alone. Over time, additional tools and artifacts that address various dimensions of the HIS clustering challenge will be added to this document. This guidebook has two primary audiences: hospital executives, including their Chief Information Officers (CIOs) who are planning the renewal of their HIS, as well as LHIN executives, including their CIOs and/or ehealth leads. The background and key concepts associated with HIS clustering are described in Section 2 of this guidebook. The section provides an overview of the HIS renewal program, the setup of the HIS Renewal Advisory Panel, the panel recommendations for HIS renewal, and the journey being undertaken to implement these recommendations. It also describes key concepts such as HIS clusters and HIS shared services delivery models. The HIS clustering process itself is described in Section 3, covering an overview of the process, including HIS clustering direction and guiding principles, governance, and process guidelines for the development or expansion of HIS clusters. Appendix A provides specific guidelines on HIS procurement by clusters, including, when applicable, the use of the BPS Procurement Directive exemption. This is the first release of the guidebook, with the expectation that future releases will cover further work from the panel on the HIS partnership strategy going forward. 1 In this document, HIS partnership refers to collaboration between hospitals to share an HIS instance. It does not refer to the legal definition of partnership, i.e. a relation that subsists between persons carrying on a business in common with a view to sharing the profits or losses. 6

7 1. Introduction Hospital Information System Renewal HIS Clustering Guidebook for Hospitals & LHINs Release Purpose of the guidebook Application This guidebook applies to all Ontario hospitals that are planning to renew their Hospital Information Systems (HISs), as well as their respective LHINs. Its intended audience are hospital and LHIN executives, including their CIOs and/or ehealth leads. Purpose This guidebook provides guidance for the formation or expansion of HIS clusters and for the procurement of HIS solutions by clusters, including the potential use of the BPS Procurement Directive exemption for noncompetitive procurements associated with joining a host hospital s HIS instance. This guidebook is a living document, with releases to be issued on an as-needed basis to keep it up-to-date with the work of the panel, and to capture lessons learned from hospitals that have undertaken the HIS renewal journey Contents of the guidebook This guidebook is structured as follows: Section 1 Introduction Section 2 Background and key concepts Section 3 HIS clustering process Appendix A HIS Procurement Guidelines (including BPS Procurement Directive Exemption) Appendix B Templates [future release] Purpose and contents of the guidebook, including what is new relative to previous releases. Overview of the HIS renewal program, including the structure of the HIS Renewal Advisory Panel, the panel's recommendations for HIS renewal, and the process being undertaken to implement these recommendations. Key concepts such as HIS clusters and HIS shared services delivery models are also covered in this section. Overview of HIS clustering process including clustering guiding principles, clustering process governance, and clustering process guidelines for the development or expansion of HIS clusters. This release includes specific guidelines on HIS procurement, including, when applicable, the use by HIS clusters of the BPS Procurement Directive exemption. Future releases of this guidebook will include templates for the various products referred to in this document (e.g. HIS clustering business case template). 7

8 Appendix C Tools directory [future release] Appendix D Glossary Appendix E Definitions Future releases of this guidebook will include a directory of tools to support the HIS cluster development and procurement processes (e.g. HIS benefits management framework, HIS TCO tool), and where these tools can be retrieved. Consolidated glossary of acronyms used in the document. Consolidated list of definitions for the key terms used in the document What is new? This is the initial release of the guidebook. In future releases of this guidebook, this section will provide a summary of the material that has been added or revised in this guidebook. 8

9 2. Background and key concepts 2.1. HIS renewal: The case for action Hospital Information System (HIS) renewal is an opportunity to transform Ontario s fragmented HIS landscape into a platform for a high-performing, patient-centred health care system. Patients First: Action Plan for Health Care is the next phase of Ontario's plan for improving Ontario's health system, building on the progress that's been made since 2012 under the original Action Plan for Health Care. It exemplifies the commitment to put people and patients at the centre of the system by focusing on putting patients' needs first. In support of the Patients First plan and in acknowledgment of the significant changes in the health sector, and the opportunities created by advances in technology since the original 2008/09 ehealth strategy, the Ministry has initiated the Digital Health Strategy (DHS). DHS is an initiative to enhance how digital health effectively supports and enables the Ministry s business priorities and the next phase of health system transformation. The strategy will also establish and provide a clear understanding of the Ministry s key digital health directions and priorities. As a leading element of the Digital Health Strategy, HIS renewal represents an opportunity to advance Ontario s Patients First objectives by helping transform Ontario s fragmented HISs into a platform for a high-performing, better connected, more integrated, and patient-centred health care system. This is especially important given HISs represent approximately 75% of the health care system s capacity relating to information systems and associated resources. HIS investments to-date have provided hospital-specific improvements in service quality and efficiency. However, from a system perspective, they have also generated duplication of effort and resources across hospitals, as well as a lack of standardization. The first generation of HIS investments were made independently by hospital organizations to create hospitalspecific value, focused on efficiencies and quality improvements through automation. This has resulted in a high degree of variability among hospitals on the levels of investment, capacity, maturity of implementation, utilization, and benefits realized through HIS investments, with respect to both internal efficiencies and patient outcomes. 9

10 2.2. Work of the HIS Renewal Advisory Panel This approach has led to a duplication of effort and resources across hospitals, and a lack of standardization with respect to data and clinical models within each hospital. This is reflected in significant change management costs, which forma sizeable part of the HIS total cost of ownership (TCO). The HIS Renewal Advisory Panel ( the panel ) was established in August 2015 to make specific recommendations to support HIS renewal in Ontario. The panel was established by the Digital Health Board ( the board ) in August 2015 to provide recommendations to the Ministry that would maximize patient benefits and value for money derived from current and future HIS investments in Ontario. Key objectives of the panel included: defining the scope of issues requiring provincial support; identifying the external policies and programs impacting HIS renewal; assessing approaches taken by other jurisdictions; and recommending a select number of integrated approaches to support Ontario s hospitals. The panel is led by hospital sector representatives, and includes a broad membership. The board selected two co-chairs to lead the panel: Donna Cripps, CEO of the Hamilton Niagara Haldimand Brant Local Health Integration Network, and Murray Glendining, President and CEO of London Health Sciences Centre. The panel membership was selected to include diverse representation from the acute care sector andacross all domains of care delivery (e.g. clinical, administration and finance). Membership also includes Ministry leadership, supply chain expertise and clinical representation from community and primary care. The panel developed a specific set of recommendations to optimize HIS renewal activities in Ontario. These recommendations have been approved by the board and are being implemented. The panel initially set out to achieve its mandate within a six-month term, focused on an analysis of the most urgent HIS renewal issues. The panel also committed to making note of future areas of work that may be needed to fully realize the potential of HIS investments in Ontario. The board approved the panel recommendations and implementation is underway. 10

11 With support from the board, the panel has now commenced a subsequent phase of work to continue the development of a broader, long-term strategy, while overseeing the implementation of the short-term recommendations. This guidebook is one of the key shortterm deliverables recommended by the panel HIS provincial journey *** Historically, hospitals purchased and implemented their own HIS solutions and their own clinical standards. Over time, a number of hospitals in a given geographical area found merit in using a common HIS system for their shared patients. These collaborations presented some new challenges, including: developing separate or common clinical standards, deciding on an HIS host hospital (the hospital that contains the physical servers and storage), and agreeing on a set of rules that would govern decision-making (e.g. is the host able to veto or does everyone have to agree to improve or enhance the system?). Over time, some HIS collaborations in the province started to increase the number of participants and expand across a wider geography. Primary drivers of this expansion include improvements in communication bandwidth, reliability of data exchange over longer distances, a desire not to re-invent the wheel, and in some cases, an inability to on the part of some hospitals to reliably manage an HIS system on their own. As a result, hospitals needed to reinvent their governance to meet the demands of the HIS host and all the partner hospitals. This presented some new challenges, including: how to keep up with technological changes, manage data centre demands, address governance requirements, and refocus limited resources on collaborating within the local patient continuum. Some of these collaborations found themselves turning to external data centres, hosts in other LHINs, while developing shared service entities for governance and much more robust service level agreements. Some vendors have been supportive through cost discounting for these collaborations, but others have leveraged these HIS collaborations for higher fees. This has led to significant risk, confusion and cost. Against this backdrop, and in conjunction with a significant number of hospitals in the province projecting major HIS investments over a 2-3 year period, the province has asked for an HIS procurement pause, so that recommendations could be made to expand and share clinical standards and expertise and to maximize collaboration, as well as fiduciary and procurement diligence. Additionally, the Patients First agenda has continued to develop, which encourages health service providers to collaborate as an integrated health system to provide services to support local patient populations. Common HIS solutions are key drivers to collaboration and best practice standardization. The HIS Renewal Advisory Panel has expended considerable effort to envision a collaborative environment that would enable the local health system to address its HIS technical needs, while also leveraging common clinical standards, reducing duplication, and assuring excellence in IT service delivery to all the hospitals in the province. By having hospitals that share a common patient population agree to collaborate as an HIS cluster rather than proceeding with individual investments in an HIS, resources can be directed towards leveraging systems and services in support of that shared patient population. Taken further, the HIS is a major component but only about a third of the total IT systems and services supporting the provision of health services for a given patient population. IT services across the health system continue to be fragmented with inherent cost inefficiencies and complexity of integration and information 11

12 sharing. The panel anticipates that, over time, HIS clusters will expand their focus to address broader, crosscontinuum IT service delivery, in order to meet the needs of their patient populations. It is expected that HIS service delivery entities will emerge, external to HIS Clusters (separate governance), that will provide HIS solutions to participating HIS clusters. These external entities will provide clinical best practice standards and expertise for implementing those standards to many HIS clusters that use the same vendor HIS. This type of third party entity that provide exclusive HIS service to multiple clusters in the province, is referred to as an HIS hub. The remainder of this document depicts the pathway that is anticipated for hospitals to collaborate on the instantiation of HIS clusters and how they will mature, while also acknowledging that a few HIS hubs are anticipated to develop and mature in a parallel and symbiotic manner with HIS clusters HIS cluster defined *** HIS cluster Definition: A group of hospitals that share an affinity (e.g. shared patient population, shared clinical specialization) and have partnered to support patients through the use of a common HIS instance. An HIS cluster focuses on patient outcomes, quality of care and health system integration. Moving on to a common HIS is a means to advance these interests. Hospitals within an HIS cluster typically share an affinity that is conducive to maximizing the potential benefits of a common HIS. Such affinities include: shared patient population and referral patterns; part of an integrated regional health network; and common areas of clinical specialization. Sharing a common HIS would result in increased benefits associated with patient outcomes and health system integration. Broader benefits of HIS clustering may be realized through the adoption of common cluster solutions beyond core HIS services, including: DI/PACS, ereferral, eprescribing, medication management, care planning, decision support and advanced analytics, as well as extending services across the continuum of care. These solutions all become more manageable where there is a common HIS, and where shared service delivery arrangements are in place. There are already several HIS clusters in Ontario. The common or shared HIS of each cluster is typically provided by a host hospital within the cluster. The host hospital is often a larger hospital with a critical mass of IT capability and a mature HIS instance. 12

13 Future state and benefits to be realized through HIS renewal The panel envisions a future state where most Ontario hospitals will be part of HIS clusters. Some HIS clusters will share HIS services exclusively, while others may choose to function as a shared IT services organization (SSO). Over time, HIS clusters that are based on a given HIS vendor solution will be supported by provincial HIS hubs. All the while, the number of distinct HIS vendor solutions and instances is expected to be reduced from current levels. HIS hub Definition: An HIS hub is a formal HIS service delivery arrangement, whereby a business entity with a distinct governance provides HIS services to participating HIS clusters anywhere in the province, based on a specific HIS vendor solution. The panel envisions a future state where Ontario hospitals participate in HIS clusters and HIS hubs: The majority of hospitals will be part of an HIS cluster, organized based on common patient population or clinical affinity, for the purpose of adopting or utilizing a common HIS service. However, some of the largest hospitals are likely to retain single HIS instances without joining or forming an HIS cluster. The majority of HIS clusters will have completed their transition to a common HIS instance or be well on the way. As a result, most hospitals will be out of the business of operating HISs. Some clusters will share services beyond HIS, and create partnerships in the form of regional shared IT service organizations (SSOs) in order to do so. Over time, HIS clusters that are based on a given HIS vendor solution will be supported by provincial HIS hubs. An HIS hub is a formal HIS service delivery arrangement, whereby a business entity with a distinct governance provides HIS services to participating HIS clusters anywhere in the province, based on a specific HIS vendor solution. An HIS hub focuses on the delivery of highly available, reliable, serviceable, secure, affordable and relevant services to HIS clusters. HIS hubs will be governed in a manner that ensures the services reflect business needs, clinical standards and best practices, as determined by the users of these services and emerging provincial frameworks for quality healthcare delivery. HIS hubs will be an integral part of a mature provincial digital health program. They will be established within a context of vendor agnostic standards, and will have an increasing role in addressing the digital health and health informatics requirements of patients and health service providers. As a result, the number of distinct HIS vendor solutions and HIS instances in the province is expected to be reduced from current levels. 13

14 HIS investment benefits include: Enhanced patient outcomes; Better health system integration; Greater economies of scale; Advanced HIMSS EMRAM maturity level; and HIS ecosystems open to consumers and clinicians. Hospitals will fully benefit from HIS investments: The value from HIS investments will have increased significantly due to enhanced patient outcomes, greater health system integration, increased efficiencies and greater economies of scale. Hospitals will utilize appropriate HIS services at a higher maturity level on the HIMSS Analytics Electronic Medical Record Adoption Model (EMRAM) scale, with respect to their utilization of standardized or best practices associated with electronic health information and clinical applications. Hospitals, affiliated health service providers (HSP), and their patients or clients will be able to easily access and utilize the emerging ecosystem of consumer and clinician applications in conjunction with their core HIS services via a wide range of channels, devices and solution providers, thereby ensuring flexibility, responsiveness and innovation at all scales. Standardized HIS services: Standardized with respect to evidencebased best practices; Standardized infrastructure with predictable costs and performance; Integration with provincial ehealth assets; Active community of practice (CoP) to facilitate solution adoption, standards, and best practice maturity; and Comprehensive measurement models for benefits and outcomes. Hospitals will fully leverage standardized HIS services: HIS services will be standardized with respect to evidence-based best practices (business and clinical), helping to ensure province-wide, equal access to quality health care services. HIS services will have evolved into standardized infrastructure-type services with predictable and measurable costs and performance. Province-wide sharing of health information, in accordance with the Personal Health Information and Protection Act, 2004, will be achieved through the integration of HIS services with provincial digital health assets, which becomes more manageable (technically and financially) because of fewer points of integration. This also contemplates integration opportunities with other sectors such as primary care, community care and long-term care. There will be an active community of practice (CoP) to facilitate the ongoing adoption of evidence-based best practices for the application of IT and health informatics. It will also be critical to facilitating right- 14

15 sized processes and practices to drive efficiency regardless of the size of the organization. Hospital clusters will be well down the path of working with LHINs and other HSPs towards integrated health care networks more generally, contributing to the patient-centred health care system envisioned in the Ministry s Patients First and LHIN Renewal objectives. HIS clusters will have developed comprehensive models for the measurement of benefits and outcomes associated with investments in, and the application of, HIS and other digital health services. Effective application of IT and health informatics will be fully integrated with patient and health system outcomes, both in terms of performance measurement and related funding of HSPs HIS Renewal Advisory Panel recommendations *** In order to achieve the future state described above, the panel tabled the following recommendations as advice to the board to advance the objectives of Patients First and of the Digital Health Strategy. The board approved the recommendations in the spring of The Ministry has endorsed the panel s recommendations, which were communicated to the sector in August The report Value and Opportunities Created by Ontario s Digital Health Assets, released by Mr. Ed Clark, also acknowledged the value of the panel s recommendations and supported their implementation. HIS Partnering Recommendations C1 C2 C3 C4 When undertaking HIS renewal, hospitals must form HIS clusters to maximize the value of current and future investments. The panel will develop a framework to define the value proposition, with a focus on measurable patient benefits to be achieved as a result of HIS investments. Hospitals must work with Local Health Integration Networks (LHINs) and other partners to assess geographic clustering options and non-geographic alternatives as supported by patient referral patterns and a comprehensive, value-based analysis. Prior to initiating a return to market, clusters must leverage existing HIS installations where informed by the results of a comprehensive value-based analysis. The Ministry should set an expectation that very few exemption requests will be considered for recommendations C1-C3 and that hospitals pursuing a related exemption will need to meet a high approval threshold from the ehealth Investment and Sustainment Board (renamed Digital 15

16 C5 Health Board). The panel will develop a provincial strategy to define a maturity path that fosters the capacity for high-performing hubs to ensure a sustainable, long-term approach to managing HIS investments. HIS Clinical Adoption & Outcomes Recommendations A1 A2 The Ministry will work with hospitals to draw on existing resources and networks of health care professions to formalize an HIS Community of Practice that supports the acquisition, implementation, and optimization of HIS systems. This HIS Community of Practice, once established, will share high-value clinical and business assets that support the evidence-based standardization of clinical practices within hospitals. The panel will propose strategies to better deploy and share the knowledge and expertise of clinical, IT, and decision-support professionals through on-the-ground support and training. HIS Procurement Recommendations P1 P2 P3 The Ministry should make it a top priority to seek appropriate policy approval to enable hospitals to join existing peer HIS installations, where there is a strong clinical and financial business case for doing so. The Ministry should promote general HIS procurement best practices by releasing a provincial HIS Renewal Guideline that supports the sector in structuring multi-tenancy procurements, while clarifying best practices on data and interoperability standards as promoted by the Canadian Institute for Health Information and ehealth Ontario. The Ministry should create opportunities for meaningful dialogue between hospitals and the vendor community to accelerate innovation. HIS Financing Recommendations F1 F2 The Panel will develop cost standards for hospital accounting and coding to allow for more accurate projections of HIS-related expenses, and in turn support the effectiveness of Ministry funding models. The OHA, with the support of the Ministry, should modify the current Health System Funding Reform Predictor Tool so that hospitals can better understand local impacts that may result from HIS investments, while also validating these impacts at a provincial level. 16

17 F3 F4 The Panel will support the development, approval, and use of a standardized tool to calculate the Total Cost of Ownership of HIS renewal activities. The panel will continue to explore how the Health Based Allocation Model (HBAM) and other funding models can support the adoption of evidence-informed practices related to HIS investments. HIS General Recommendations G1 G2 G3 The Ministry should, with the continued support of health system partners, provide clear direction to the sector that coordinated Hospital Information System (HIS) investments are integral to effective patient-centred health care services, cross-sector integration and provincial connectivity. The Ministry should, with the continuing support of health system partners, extend the mandate of the HIS Renewal Advisory Panel to create an implementation plan for these shortterm recommendations, and to develop additional medium-term recommendations for consideration by the ehealth Investment and Sustainment Board (renamed Digital Health Board). The Ministry should, with the continuing support of health system partners, work with the Ontario Hospital Association (OHA) to engage its members on the implementation plan for HIS renewal, as endorsed by the ehealth Investment and Sustainment Board (renamed Digital Health Board). The panel was asked to extend its mandate to a second phase in order to oversee the implementation of these recommendations. This guidebook is a key component of the panel s implementation plan, focusing mainly on the HIS clustering recommendations (C1 to C5) and the HIS procurement recommendations (P1 to P3). 17

18 2.3. Implementing the recommendations: Ontario s approach to HIS renewal HIS renewal is first and foremost about improving the quality of care *** HIS renewal is a complex and expensive endeavour, but it also holds the promise of improving clinical outcomes, quality and safety, while simultaneously reducing the cost of care. In essence, HIS renewal represents the opportunity to leverage advanced information systems to improve the cost and quality curve for healthcare in Ontario. However, the clinical and financial benefits of HIS renewal are not guaranteed. Many HIS implementations struggle to achieve quality and safety benefits for patients, due to suboptimal clinical content design and insufficient clinician engagement. In some cases, HIS implementations may negatively affect patient care quality and safety by introducing changes to practice that result in new types of errors. From a financial perspective, to achieve net savings, HIS renewal must be optimized clinically to reduce healthcare delivery costs. They must also be optimized from technical and governance perspectives, so that service delivery and maintenance costs can be shared equitably across organizations. The clinical, technical, and governance components required to achieve desired benefits from HIS renewal are illustrated in Figure 2.1. These components are interdependent, and all are required for success. Financing and governing the technical aspects of shared HIS is complex in its own right; it is all the more important to maintain focus on the clinical design, governance and change management required to deliver the patientcentered outcomes that are the ultimate goal of HIS renewal. Ontario s approach to HIS renewal is evolutionary and rooted in building HIS partnerships that: Focus on accelerating maturity in three key interdependent areas; and Must be supported by key policy enablers. There are four major components to HIS renewal as shown in the diagram on the left and described briefly further below. 18

19 Figure 2-1 Ontario s approach to HIS Renewal The barriers to successful HIS renewal are rarely related to technology. Instead, published research has repeatedly shown that clinical, cultural, governance, and change management factors are the most important determinants of improved outcomes, and the quality, safety and cost of patient care. HIS renewal invariably brings about an unprecedented tectonic shift in the way hospital-based clinicians provide care. Each organization must capitalize on this period of change as a singular opportunity to redesign care delivery for the better, through clinical transformation. Important components of clinical transformation include: engaging front-line clinicians in HIS content design; standardizing care based on best practices; building evidence into care workflows; and transitioning to an organizational culture that values the HIS as an enabler of improved patient outcomes. After implementation, the HIS must be leveraged to continuously measure patient care outcomes and iteratively improve quality, safety and value. Furthermore, considerable ongoing effort is required to maintain top quality, up to date evidence-based HIS clinical content, since items such as documentation templates, order sets and clinical decision support tools provide the foundation for patterns of daily patient care. The HIS Community of Practice (CoP) is intended to assist Ontario hospitals in sharing best practices for the clinical aspects of HIS implementation, and also provide a foundation to share the work of maintaining world-class clinical content for HIS across the province HIS clustering maturity *** An HIS cluster focuses on patient outcomes, quality of care and health system integration within a given patient population. Forming or expanding HIS clusters, and moving on to a common HIS, is a means to advance these interests. The HIS clustering evolution path is captured in the following HIS clustering maturity model : HIS clustering maturity level C0 C1 Description A hospital has not undertaken any significant HIS partnering with respect to their HIS renewal. A hospital undertaking HIS renewal partners with another hospital with which it has an affinity related to patient care (region or specialty), in order to leverage that hospitals existing instance. If no such partner exists, the hospital undertakes renewal of its HIS in a manner that creates downstream opportunities, which can be leveraged by other hospitals. 19

20 C2 C3 All (or most) of the hospitals that have an affinity related to a geographic or specialty patient population have established the prerequisite governance and are moving down the path towards a common HIS. This activity is based on a strong business plan, which is anchored in well-defined outcomes related to enhanced patient care and health system outcomes. In some cases, these HIS clusters may cross LHIN boundaries as appropriate, in order to support a given patient population. As HIS service delivery matures in Ontario, the IT interests of HIS clusters in support of their patient and health system outcome goals will increasingly focus on: a. Consolidating a greater array of ehealth and IT related services; b. Setting up service management arrangements for services that are increasingly provided outside of the cluster; and c. Aligning health information resources and their performance with local, regional, and provincial business objectives. d. Developing and maintaining shared clinical HIS content (e.g. order sets, workflows, documentation templates, clinical decision support tools). The HIS cluster extends beyond hospitals collaborating towards a common HIS, to include other sectors such as primary care, community care and long-term care, with the objective of collectively addressing the integrated health information system needs of an integrated, patient-centred health care system. This may bring together multiple level C2 clusters or include other non-hospital health sector partners HIS shared services delivery maturity model *** As HIS collaborative arrangements evolve, a further consolidation of HIS solutions will occur within the province. In this next stage of HIS shared services delivery maturity, HIS services will be delivered by a dedicated, technology-focussed business entity, that is, an HIS hub, rather than being provided by a host hospital within an HIS cluster or a regional shared services organization (SSO). Such an entity will be capable of delivering HIS services to HIS clusters anywhere in the province, but may initially have a regional or specialty focus. The evolution of HIS service delivery is described in the following HIS shared services delivery maturity model : HIS shared services delivery maturity level SD0 Description A hospital operates a stand-alone HIS, typically through a blend of in-house and outsourced services. 20

21 SD1 SD2 SD3 1/ A host hospital provides HIS services to other hospitals within an HIS cluster, typically through a blend of in-house and outsourced services. HIS service delivery governance and HIS cluster governance are usually synonymous; OR 2/ Alternatively, a host hospital provides HIS services to hospitals outside of its cluster (potentially other hospital clusters). Although this model may have some short-term utility in addressing urgent renewal needs in Ontario, it also has significant risks associated with governance, funding and operations (e.g. availability, integrity, security, change management, conflict of interest). A regional shared services organization (SSO) has been created to provide HIS services (typically as part of a broader IT services portfolio) to one or more HIS clusters within a specific region, likely through a blend of in-house and outsourced services. HIS services are delivered by a dedicated, distinct business entity: an HIS Hub. An HIS hub is capable of delivering HIS services to HIS clusters (and associated SSOs) anywhere in the province. Services may be increasingly internet or cloud-based and involve a substantial degree of vendor managed services as a way to stay up to date on technology, gain access to necessary skills and help address a range of issues related to cost, quality of service and risk. This level of maturity is characterized by a clear delineation between HIS cluster and HIS hub governance, the two being bridged through strong contractual agreements (e.g. service level agreements) in support of the cluster s patient service needs. It is envisioned that there will be a small number of these HIS hubs, based on the major HIS products in use in Ontario. They will be based on a standard HIS reference model (information, clinical, business), and positioned to be vendors of record within a provincial digital health framework HIS community of practice maturity HIS community of practice (CoP): Refers to the people and processes that define, implement, and support HIS clinical, and operational standards and best practices. An HIS represents the clinical and business practices, workflows and associated information utilized by a given hospital. The implementation and maturation of an HIS involves the explicit design or definition of these practices and information repositories on an ongoing basis, as well as the change management associated with operationalizing them. A significant portion of the effort and cost associated with HIS implementation, maturation, and ongoing sustainment of best practices is associated with these activities. Multiple communities of practice currently exist at the hospital and, more recently, at the cluster level. This has resulted in a significant duplication of cost and effort, as well as significant variability in clinical and business practices and HIS information 21

22 specifications. The evolution of HIS partnerships should be supported by a community of practice. As Ontario evolves towards HIS clusters and hubs, it is important that this evolution be supported by a community of practice that can establish and support province-wide, vendoragnostic standards and best practices on an ongoing basis. This community of practice should by fully integrated with organizations needs based on such attributes as size, acuity, service provision, complexity, etc., as well as activities already established for advancing clinical best practices and health system outcomes HIS renewal policy enablers Policy enablers are critical to the success of the HIS renewal program. Moving forward with this approach to HIS renewal will require supportive financing and procurement policies. The BPS Procurement Directive exemption (see Appendix A) is the first of these policy enablers specifically targeted at HIS renewal activities. Several other provincial initiatives are underway that are highly inter-related with HIS renewal. These provincial initiatives include, for example: Patients First: Action Plan for Health Care; LHIN Renewal; Digital Health Strategy; and Healthcare Sector Supply Chain Strategy. Proceeding with HIS renewal in a manner that aligns with these initiatives represents both a challenge and an opportunity to influence the broader health care landscape in Ontario Short-term maturity level priorities (1-5 years) *** HIS Cluster Maturity Level C2 HIS Shared Services Delivery Maturity SD1/SD2 Strategy for HIS Shared Services Delivery Maturity SD3 Advancing all Ontario hospitals to at least HIS Cluster Maturity Level C2. This includes creating the supports necessary to enable clustering. Promoting additional hospitals or HIS instances to Shared Services Delivery Maturity SD1 (HIS cluster host hospital) and a select few to SD2 as appropriate, including appropriate supports for procurement activity. Development by the panel of a provincial strategy for HIS hubs (SD3): 22

23 Assess current HIS service delivery capability in Ontario, with a view to identifying candidates to promote or create HIS hubs; Assess alternative governance, service delivery and funding models for HIS hubs; and Propose a recommended model(s) and implementation strategy. Strategy for HIS Community of Practice Developing and implementing a strategy for a Provincial HIS Community of Practice, beginning with some early pilot initiatives: Launch early pilots for change management; Inventory existing activities and assets; Inventory existing knowledge domains, gaps, and broker the filling of those gaps by knowledge experts; Develop a conceptual CoP Framework; Identify priorities or opportunities; Identify additional pilots or quick wins; and Develop a strategy and implementation plan. HIS Renewal Policy Enablers implementation Implementing the required HIS renewal policy enablers: Develop and implement processes and guidelines relating to hospital HIS procurement; Develop standard models for HIS total cost of ownership (TCO) and tracking costs or benefits; and Continue to assess hospital funding models within the context of HIS expenditures. 2.4 Implementing the panel recommendations: HIS Renewal Task Force In phase one of its work, the panel made 17 recommendations spanning four key pillars to guide HIS renewal in Ontario: partnering, clinical adoption and outcomes, procurement and financing The next phase of the panel s work is focusing on defining a path for HIS clusters to coalesce into a select number of mature hubs that provide cost-effective, secure services. By giving hospitals the tools to be more efficient in their IT services, they will have more time to focus on providing integrated, high-quality care An HIS Renewal Implementation Task Force has been established to implement the panel s recommendations. The task force includes representation from the hospital sector and Local Health Integration Networks (LHINs). It has established a number of project workgroups to implement the panel recommendations over the next twelve months.: A Central Project Office (CPO) has been set up to support the task force and its work groups in delivering the recommendations and to provide integrated project management and reporting across the workstreams. 23

24 Workgroups HIS Stakeholder Communication & Engagement HIS Partnership Support Clinical Adoption and Outcomes - Community of Practice HIS Renewal Procurement Policy & Planning HIS Costing Standard & Total Cost of Ownership (TCO) Tool Health Based Allocation Model (HBAM) Impact Analysis & Health System Funding Reform (HSFR) Predictor Tool Update Objectives To coordinate and streamline all stakeholder communication and engagement activities across all projects in order to optimize stakeholder time and contribution. To support HIS partnership activities in the province by providing hospitals and LHINs with an initial set of partnership guidelines, assistance with urgent issue resolution, and ongoing support through the implementation of their partnership. To implement an HIS Community of Practice as a tangible and effective means of targeting specific knowledge gaps and of sharing scarce HIS knowledge and assets across the sector. To support HIS procurement activities in the province by providing a set of templates (RFP, evaluation criteria), best practices and terms and conditions to ensure strategic alignment. To recommend changes to provincial procurement policies to enable HIS Clusters. To implement an up-to-date and relevant HIS costing standard and TCO tool that addresses current deficiencies, and positioned to support the planning, implementation and ongoing operation of HIS partnerships. To understand and address the impact of HIS partnerships on hospital funding models, and to update the HSFR predictor tool accordingly. 24

25 3. HIS clustering guidelines 3.1. Overview Hospital Information System Renewal HIS Clustering Guidebook for Hospitals & LHINs Release 1.0 This section describes the guiding principles and processes for the establishment of new HIS clusters and the expansion of current HIS clusters. The principal outputs of this process are an approved HIS clustering business case, Memorandum of Understanding or agreement, and associated HIS cluster operational governance and implementation plan. In compliance with the panel recommendations, the HIS clustering business case will provide an evidencebased rationale for clustering, including patient or clinical, health service providers (HSP) and system benefits, as well as efficiencies and economies of scale associated with IT expenditures. It will also contain an analysis of options and recommendations with respect to governance, funding, procurement, and provision of a common HIS and associated services for the HIS cluster. Where the business cases call for the leveraging of a current HIS installation, rather than procuring the required solution through an open and competitive process, hospitals will need to apply for the BPS Procurement Directive exemption, which is described in Appendix A of this document HIS clustering direction and guiding principles *** As mentioned in Section 2, the panel made specific recommendations that were approved by the Digital Health Board. The recommendations provide specific direction on HIS renewal and clustering, summarized as follows: C1 When undertaking HIS renewal, hospitals must form HIS clusters to maximize the value of current and future investments. C2 Hospitals must work with Local Health Integration Networks (LHINs) and other partners to assess geographic clustering options and non-geographic alternatives as supported by patient referral patterns and a comprehensive, value-based analysis. C3 Prior to initiating a return to market, clusters must leverage existing HIS installations where informed by the results of a comprehensive value-based analysis. C4 Very few exemption requests will be considered for recommendations C1-C3 and hospitals pursuing a related exemption will need to meet a high approval threshold from the Digital Health Board. The core principles guiding HIS clustering, that is, the development of new clusters and the expansion of existing clusters, are as follows: HIS clustering must: 1. Start with a full commitment from the hospital and LHIN CEOs and their executive, clinical and technology teams on a shared set of HIS clustering goals; 2. Have a strong patient centred focus guiding decision making; 3. Increase cross-sector integration and effective service integration; 4. Balance provincial vs. organizational focus; 5. Be based on strong analysis and evidence, in support the overall objectives of the HIS renewal, 25

26 6. Take into account the interests of hospitals in planned HIS renewal activities to maximize opportunities for collaboration, procurement, and shared services; and 7. Explore innovative ways to support HIS renewal, including new technologies and delivery models, financing models, and change management approaches HIS clustering process overview *** The following process flow chart describes the lifecycle of activities associated with the formation or expansion of an HIS cluster. While the consideration of HIS procurement options is embedded in these activities, guidelines on the HIS procurement process, including the use of the BPS procurement directive exemption (the exemption ) are provided in Appendix A. Figure HIS clustering high-level process As previously discussed, hospitals that have identified a common area of synergy, for instance regional and community hospitals that share the same patient population, and which also have a strong case for partnering together on the use of a shared HIS, would enter into a formal HIS cluster arrangement. The diagram above describes the logical process associated with HIS clustering, with the tacit understanding that there will be variations in the application of this process on a case-by-case basis. The net outcome though will remain a formal HIS clustering agreement, in the form of a memorandum of understanding (MoU), supported by a strong business case for the formation or expansion of the HIS cluster. An elaboration of the HIS clustering process governance and of each of the process steps in the above diagram is provided in the remainder of this section. Note: Any hospital that plans to make HIS renewal investments outside the context of HIS clustering must obtain approval from the Digital Health Board. 26

27 3.4. Step 1 Explore HIS clustering opportunities *** A hospital undertaking HIS renewal must do so within the context of an HIS cluster. However, it is recognized that there is no one size fits all approach to the establishment and expansion of HIS clusters in Ontario. There is a high degree of variability across the province with respect to the readiness, capacity and urgency of HIS clustering amongst hospitals. Furthermore, some HIS clusters may align well with LHIN boundaries, while others may include hospitals from multiple LHINs. Accordingly, it is anticipated that a range of situations will present themselves as hospitals establish the clustering context for their HIS renewal, each of which will affect the scope and nature of their business cases and implementation plans. This section provides an overview of HIS clustering scenarios along with examples from Ontario hospitals. Figure HIS clustering process step 1 - Explore HIS clustering opportunities Scenario Current Examples in Ontario as of January 2017 Scenario 1 Hospital(s) may join an existing HIS cluster with affiliate hospitals. Sault Area Hospital and North Bay Regional Health Centre have identified an affiliation with the NEON cluster, and the development of an expanded HIS cluster plan is underway. Similarly, Erie St. Clair LHIN hospitals have identified an affinity with the London Health Sciences Centre / Thames Valley cluster and are well down the path of business case development. 27

28 Scenario 2 Hospital may join clustering discussions already underway with affiliate hospitals. Peterborough Regional Health Centre has joined a group of Central East LHIN hospitals that have been investigating options for a common HIS for several years. This development will likely increase the benefits or strengthen the business case of an HIS cluster for that region. Scenario 3 Hospital may initiate clustering discussions with a number of affiliate hospitals. The Ottawa Hospital, Kingston General and a few others have initiated activities towards establishing regional HIS clusters. Central East LHIN have begun to move forward with cluster planning. Scenario 4 In the absence of a broader clustering opportunity- hospital may partner with another affiliate hospital; a cluster of two. Scenario 5 Where no clustering or partnering opportunity exists, a hospital may proceed alone with HIS renewal in a manner that creates opportunities for downstream clustering. Southlake is in discussion with potential partners to provide HIS services to replace their sunset HIS platform. There is no broader HIS clustering discussion underway in that region of the province. HSC (Sick Kids) and CHEO are moving forward with a shared HIS. This is the least desirable scenario and in order to proceed, it will require HIS clustering policy exception approval by the Digital Health Board, in addition to hospital board and LHIN approval Step 2 Development and approval of HIS clustering expression of intent *** Steps Description a. HIS clustering priorities are defined. Based on one of the five clustering scenarios described in Step 1, a hospital determines its priorities to join or form an HIS cluster. b. Expected benefits are identified and quantified (high-level). Benefits are identified such as: To improve or optimize patient care and advance health transformation priorities at local, regional and provincial levels: o By leveraging a shared patient population (e.g. similar geographic region); o By clustering with respect to a care speciality (e.g. age group, disease focus); and o By fully supporting interoperability. To improve value through optimal licensing arrangements. To optimize efficiency, capacity, and productivity. 28

29 c. Hospital CEOs submit to their boards and LHINs an expression of intent to create a new HIS cluster or expand an existing HIS cluster. The hospitals CEOs submit to their boards and corresponding LHINs an expression of intent to collaborate for a given patient population based on a set of shared principles, and to allocate resources for a joint team that will: Establish a governance framework for HIS cluster development or expansion; Allocate appropriate resources towards the collaboration; and Develop a formal HIS clustering submission package, including a business case supporting the proposed HIS cluster development or expansion, and a MoU or agreement formalizing the partnership. This expression of intent could take the form of a Letter of Intent, hospital board motion to approve a cluster plan, etc. d. HIS clustering hospitals notify the panel of their expression of intent. e. Hospital boards and LHINs approve the HIS clustering expression of intent A notification is sent to the panel by the HIS host hospital on the behalf of the HIS clustering hospitals, of their expression of intent to develop or expand an HIS cluster. The HIS clustering hospitals expression of intent is approved by their respective hospital boards and corresponding LHINs Step 3 Set up HIS clustering process governance *** Once the HIS clustering expression of intent (Step 2) to form a new HIS cluster or expanding on existing one has been approved, there will be a need to set up a governance framework which will govern the review and approval of the proposed new or expanded HIS cluster. Note: This HIS clustering process governance for planning and establishing a new cluster or expanding an existing one is different from the HIS cluster operational governance which is concerned with the ongoing operation of the HIS cluster once in place. The table below provides the core of an HIS cluster development or expansion process governance that would be set up and potentially expanded for a given HIS clustering opportunity. Governance body Hospital CEOs Description Accountable for the development of the HIS partnership, i.e. the formation or expansion of the HIS cluster, including: HIS clustering expression of intent; HIS clustering MoU/agreement; HIS cluster operational governance; HIS cluster service level agreements; HIS cluster competitive and non-competitive procurement business case, and 29

30 procurement documents; HIS cluster use of the BPS Procurement Directive exemption (if applicable); and Attestation of the use of the BPS Procurement Directive exemption. HIS Clustering Steering Committee Hospital boards LHIN(s) HIS Renewal Advisory Panel Digital Health Board Steering committee for HIS cluster development or expansion consisting, at a minimum, of the following: Hospital CEOs participating in and joining the HIS cluster; and Corresponding LHIN CEO(s) Approval authority for: HIS clustering expression of intent; HIS clustering MoU/agreement; HIS cluster operational governance; HIS cluster service level agreements; HIS cluster competitive and non-competitive procurements; and HIS cluster use of the BPS Procurement Directive exemption (if applicable). Approval authority for: HIS clustering expression of intent; HIS clustering business case; HIS clustering MoU/agreement; and HIS cluster use of the BPS Procurement Directive exemption (if applicable). Support the LHIN and hospital boards by reviewing and endorsing from an HIS renewal policy compliance standpoint (i.e. recommending for approval) the following: HIS clustering business case, including the procurement strategy and, if applicable, intent to use the BPS Procurement Directive exemption; and HIS clustering memorandum of understanding. Approval authority for hospitals that wish to proceed with HIS renewal without joining or creating an HIS cluster Step 4a Develop HIS clustering business case *** In order to be considered for approval, HIS clustering (i.e. the development or expansion of an HIS cluster) requires a robust business case. The business case will provide an evidence-based rationale for HIS clustering including patient or clinical, health service providers and system benefits, as well as efficiencies and economies of scale associated with HIS IT expenditures. It will also contain an analysis of options and recommendations with respect to cluster participants, HIS host, HIS solution, HIS services operational governance, funding, and the procurement and provision of a common HIS and associated services. It is expected that the development of the HIS clustering business case will be an iterative process as different HIS provision options are considered. Hospitals will not likely proceed unless there is a fair degree of clarity with respect to a recommended HIS solution, provision model and associated costs. Although HIS host hospitals (existing or new) will have significant input into the process (especially regarding software licensing, maintenance and support costs as well as service levels), all hospitals within the HIS cluster must undertake to understand the full lifecycle costs and implications for their organizations. Furthermore, costs and benefits 30

31 should be identified at both the organizational and cluster level. The above will require a high level of participation and collaboration from all of the cluster hospitals and with the associated LHIN(s). With respect to HIS solution options, the business case must describe the benefits expected to be realized, the cost implications, as well as the potential risks and mitigation strategies. Finally, the business case must include a clear recommendation for moving forward. Each of these points is further elaborated in the table below. Furthermore, the panel secretariat should be contacted for the latest provincial future state view on HIS clustering that is relevant to the business case. Business case component 1. HIS clustering rationale and expected benefits Guidelines What is the rationale (e.g. patient population, referral patterns, clinical programs, clinical staff, broader system integration, HIS renewal requirements, etc.) for the hospitals to form or join an HIS cluster? What are the expected benefits (including specific outcomes, metrics and commentary) in areas such as those listed below? a. Patient outcomes; b. Clinical best practices/standardization/change management; c. Hospital priorities or challenges; d. Health system integration or optimization (perhaps linked to the LHIN IHSP); and e. IT efficiencies or economies of scale. What are the risks and associated mitigation strategies? 2. HIS clustering options identification general considerations Central to the formation or expansion of HIS clusters is the use of a common HIS instance by member hospitals. There are three main variables in identifying HIS clustering options: a. Hospitals participating in the HIS cluster; b. HIS host; and c. HIS solution. 2a. HIS clustering options identification Participating hospitals There might be a number of HIS clustering options related to the size of the cluster, that is, on which hospitals could be part of the cluster, and whether they should be part of the cluster immediately or in the future. These HIS clustering options based on the list of participating hospitals is critical from a LHIN and provincial perspective as it will help ensure that the HIS clustering is optimized and that the trade-offs (e.g. cluster size vs cost) are understood. There might be unique circumstances where a hospital might consider the going alone option. As previously mentioned, this unique situation would undergo thorough scrutiny and would require approval from the Digital Health Board. It is expected that in all but the rarest of circumstances hospitals will partner. Even if approved, subsequent partnering with other hospitals will be expected. 31

32 2b. HIS clustering options identification HIS host While the identification of an HIS host for the cluster might be selfevident in some cases, there might be situations in which an HIS cluster would need to consider the willingness and capability of potential HIS hosts inside the cluster before making its choice. If a clear HIS host hospital within the cluster (with an existing HIS instance that can be leveraged) is not immediately part of the scenario, the HIS cluster will need to engage in an environmental scan to identify hostpartner options. An external HIS host might be a viable option. Note that this scenario has implications in the use of the BPS Procurement Directive exemption see Appendix A. As HIS clustering matures in the province, it is expected that HIS hubs will emerge, providing additional options for HIS hosting. Some general considerations when identifying an HIS host: Structure or capacity of the potential HIS host to receive additional partners or configurations, and the corresponding implications for other organizations i.e. is the host able to be an effective host and fully participate in standards, while addressing needed localizations. Quality of the HIS host s current implementation that will be leveraged. i.e. Is the configuration a best practice design and, if not, what is the commitment and timing to make that happen? The governance might be strong and mature, but is the configuration or design of the solution of a quality that is worth expanding. The product configuration and design might be strong and mature, but is the governance model going to be workable? Efficiency of the HIS host s solution and its impact on the cluster and individual hospitals operations. i.e. Does the product impose complexity and extra work on small hospitals? Is the product capable of handling the complexities and workflows of a large organization or cluster? Sustainability of the HIS host and its HIS instance, as well as the ongoing (10+ years) commitment and resource to remain current with clinical and operational best practices, evidence based decision support and sustainable quality, practice, and professional standards. Demonstrable patient outcomes and an ongoing commitment to measurable benefits realization. In relation to the HIS host selection, the impact on the participating hospital needs to be considered, including for example: Portability of the participating hospital s data. Time to value generation for the participating hospital. Predictability in the future state including financials. Agility of the host, cluster and participating hospital organization to affect the necessary ongoing changes in a timely manner. Influence of participating hospital organization across the cluster 32

33 continuum, such as the ability of best practice leads to affect change through to simple report changes or additional data fields in a given business intelligence data extract. Optimization, efficiency, and the quality of the workflow experience for delivering patient outcomes. 2c. HIS clustering options identification HIS solution If the HIS host candidate is currently on one of the common high HIMSS HIS vendor solutions in the province and is intending to change to a more expensive vendor, the business case will need to demonstrate the features and functions that must be acquired that are not available in the current vendor s solution. It will need also to address operational productivity impacts, staff education impacts, staff skill-set impacts, impacts on clinical services the hospitals or cluster could otherwise provide with those funds, organizational risks of change, and the procurement strategy. 3. HIS clustering options analysis general considerations The process of HIS clustering options analysis and evaluation needs to assess and relatively measure: Alignment with the HIS renewal panel recommendations, work of the task force, and the workgroups; and Alignment with the clinical and operational service delivery objectives of the LHIN. The top 2 or 3 HIS clustering options, identified through the HIS clustering options identification step above, should be thoroughly investigated as part of the business case. In addition, the status quo option needs to be part of the options analysis even if not considered viable, as it provides the baseline for HIS clustering. The HIS clustering options analysis will cover, for each selected option, their: a. Benefits; b. Costs; and c. Risks. 3a. HIS clustering options analysis Benefits The HIS clustering business case must specify the tangible, measurable benefits to the: Patient; Individual hospitals within the cluster; HIS cluster overall; LHIN(s); and Ontario s healthcare system. These would include, at a high level, the clinical, operational and financial benefits of the HIS options relative to both the status quo option (if applicable) and the hospitals going alone for their HIS renewal option. 3b. HIS clustering options The HIS clustering business case must specify both the one-time and 33

34 analysis Costs operational preliminary cost estimates for at least a 10-year total cost of ownership (TCO) for each option, relative to both the status quo trajectory the hospital(s) is(are) currently on (if applicable) and the hospitals going alone for their HIS renewal options. It is understood that these cost estimates will be preliminary at this stage and will be further refined as the HIS procurement business case is developed. However they should be of sufficient detail to differentiate: costs between vendor solutions; hosting models; functionality; and timing. For this document, HIS costing models such as those used by the panel (based in part on the Canada Health Infoway HIS renewal cost model) could be used. 3c. HIS clustering options analysis Risks The HIS clustering business case must also specify risks and associated risk mitigation strategies for each option in areas including: patient health and safety; hospital operation and impact; host hospital; and financial risk. While this is a preliminary risk analysis (a more detailed one will be done at the HIS procurement business case stage), it will nevertheless provide the hospital boards and LHINs with a valid comparison between the HIS clustering options being considered. 4. HIS clustering recommendation 5. HIS cluster procurement strategy, including planned use of the BPS Procurement Directive exemption Based on the analysis and evidence compiled through the above, the business case must clearly articulate a recommended HIS clustering option. The broad HIS cluster procurement strategy needs to be described at a high level as part of the business case, including but not limited to the following: Host hospital HIS solution determination; o HIS software product o Current and planned HIS software version Non-competitive procurement requirements by the host hospital to meet HIS needs of peer hospitals that can be purchased only from the HIS vendor (e.g. Software licenses and sub-licenses, proprietary interfaces); Competitive procurement requirements (e.g. competitive software, subscriptions, commodity hardware, interfaces, consulting services); o By HIS host hospital o By participating hospitals Broad timetable for the HIS procurement. If the HIS cluster is planning to use the BPS Procurement Directive exemption, it must be expressed explicitly in this section of the business case. This will inform hospital boards and LHINs, as well as the panel and Digital Health 34

35 Board, so that they can assess any risk of policy non-compliance and/or unacceptable risk. This will also help to avoid potential reworks and delays if, for instance, the planned use of the exemption is determined to be noncompliant. See Appendix A for guidelines on the use of the BPS Procurement Directive exemption. Accordingly, this section of the business case will provide the initial justification for the planned use of the BPS Procurement Directive exemption by including a summary of the following: Rationale for the selected HIS clustering option; Rationale for the selected HIS cluster participants; Rationale for the selected HIS host; Planned use of the host hospital s HIS instance (e.g. as-is, immediate upgrade, planned upgrade and when); Planned non-competitive procurement; Expected benefits from HIS clustering using the host hospital's HIS solution; Costs to the HIS cluster associated with using the host hospital s HIS solution; Costs to the HIS cluster associated with using an HIS solution that is different from the existing HIS host hospital s solution; and Risks associated with the selected HIS clustering option. Note that the above summary will be further refined as part of the formal BPS Procurement Directive exemption submission during the HIS procurement process. 6. HIS cluster high-level operational governance The operational governance is established to ensure the collaborative has a mutually agreed level of sustainment, regular enhancement, and to lay the foundation for agile, dynamic and responsive access to decision-making information. This stage of work goes beyond keeping the lights on ; it lays the foundation for operational maturity and excellence in service delivery. This stage of work should clearly articulate the: Structure of operational governance; Oversight of the various operational components (e.g. technology, communications, clinical best practices, alignment with communities of practice, benefits tracking, etc.); Culture and talent management strategy; and Service delivery structure including the associated operational objectives, benefits targets, capacity planning, policy and procedures framework, etc. 7. HIS clustering high-level implementation plan This section of the business case provides the high-level timelines associated with the establishment or expansion of the HIS cluster, the major HIS procurement activities, and the outcomes/benefits realization. 35

36 3.8. Step 4b Develop HIS clustering MoU/agreement*** Once the business case is complete, the hospital CEOs and LHIN leadership will have a preferred HIS host partner, clarity on the approval route and costs, as well as an established procurement route. This is the planned path and a pivot point going forward: the partners are committed, engaged, and all communicating uniformly on the mutually desired outcome. This step involves the development of the Memorandum of Understanding /agreement that commits the partners on a mutual journey, with a known and expected outcome of generating a host partner and vendor partner contract. Timing of implementation and detailed financial commitments will come at a later stage. The MoU/agreement should identify the collaboration partners, the guiding principles and commitments of collaboration, the type of conditions under-which a partner may withdraw, the services and scope of collaboration, conflict resolution or escalation, and other various terms and conditions. Guidelines to help with the drafting of the MoU/agreement are presented below: Steps 1. Introduction, overall intent and scope Description This description depicts the problem statement or opportunity, and why the agreement is necessary. The intent outlines the nature of the relationship in the context of service delivery, culture, mutual benefits, social benefits, cooperation, priority, and mutual objectives. The scope depicts the circumstances under which the MoU does and does not apply, and the order of precedence to minimize contradictions. Identification of expected outcomes. 2. Guiding principles Guiding principles outline the spirit of the relationship and provide an important lens with which to interpret the various components of the agreement. 3. Operational governance Identify the nature of the collaboration, leadership, voting, the financial arrangements, how risks will be born or shared, responsibilities for compliance, and determination of the level of governance, which will address services, operations, and future planning. Identify how the group plans to manage and sustain the relationship, the conditions under which the governance or agreement should change, how updates will occur, how conflicts will be addressed, how rogue behaviour will be addressed, how participants join, ownership changes, etc. The agreement needs to differentiate partner authority, responsibilities (sole and joint), sharing, obligations, legislative context, resource contributions and commitments. 36

37 4. Privacy & security Protection of personal health information (PHI) and other privacy information (PI) needs to be covered explicitly. Security of information, systems, facilities, etc., also need to be explicitly addressed. 5. Measures of success How will the parties know the collaboration is successful? How will it be measured? What benefits are being targeted? 6. Termination/off-boarding The conditions under which the relationship of a given hospital with the HIS cluster will end and thus be offboarded, or for an entire HIS cluster to be dissolved. Hospitals leaving a cluster are expected to be rare cases (e.g. where the hospital fundamentally changes its mandate). Providing scenario examples could be very helpful to understand the level of commitment of the organizations in future Step 5 Approve HIS clustering business case and MoU/agreement*** The approval of the HIS clustering business case and associated memorandum of understanding involves the following HIS clustering process governance bodies described in Section 3.6. Steps 1. Approval of HIS clustering business case by HIS cluster hospital boards 2. Approval of HIS clustering business case by HIS cluster LHIN(s) 3. Review and endorsement of HIS clustering business case by the panel (if requested by hospital boards and/or LHINs) Description The business case is submitted to all the hospital boards of the HIS cluster for their approval. Once the HIS clustering business case has been approved by the hospital boards, the business case is submitted to the LHIN(s) of the HIS cluster s hospitals for their approval. At the request of the hospital boards and/or LHINs, the panel will review the HIS clustering business case from the following perspectives: Compliance with the principles and direction of the HIS renewal strategy, including compliance with the boardapproved HIS panel recommendations; Alignment with the future state of HIS clusters and hubs in Ontario, as approved by the panel and Digital Health Board; Compliance with the terms and intent of the BPS Procurement Directive exemption (see Appendix A); 37

38 and Strength of the business case benefits and cost effectiveness. As an outcome of its review, the panel will either endorse the HIS clustering business case, including the HIS procurement strategy, or recommend its escalation to the Digital Health Board. 4. Review and approval of HIS clustering business case by the Digital Health Board (e.g. noncompliance with HIS renewal policy) If the panel has reservations about the HIS clustering business case, the HIS clustering business case will require review and approval by the Digital Health Board, before it can be submitted to hospital boards and LHINs for approval Step 6 Establish HIS cluster operational governance *** Once the HIS clustering business case and MoU are approved, the work turns to the development of the HIS cluster operational governance in support of its continuous state of operation. The operational governance is developed at this stage to define the mutually agreed level of sustainment and regular enhancement, and to lay the foundation for agile, dynamic and responsive access to decision-making information. This stage of work goes beyond keeping the lights on, but rather engages in laying the foundation for operational maturity and excellence in service delivery. At this stage, the high-level HIS cluster operational governance component of the HIS clustering business case is expanded to address service level and recovery point objectives, agreements, the degree of local vs. central access, common policies and procedures, onboarding and off-boarding processes, capacity and resource planning, service level tiers, etc. In addition, cost sharing models based on share, size, consumption, capacity, up-time objectives, utilization, consumed functionality and other metrics as appropriate will allow equity in collaboration regardless of the organizational sizes. Furthermore, the operational governance will define, track, and assess outcome measures and their progress. Done well, this will facilitate system-wide efficiencies and allow large hospitals to address the required complexity without negating a small hospitals ability to participate, due to excessive complexity, size, unattainable standards, crushing overheads, or unsustainable costs. It is understood that the framework below will need to develop and mature, both as the host and the cluster mature their service delivery models in the long term, and as the solution is implemented in the shorter term. An early tenet establish by the panel was that all assets would be developed and owned collectively - not for the exclusive use or control of one hospital over another. It is critical that participant organizations in an HIS cluster not be disadvantaged because they cannot currently afford the solution, but are taking active steps to participate and to join when the financial status improves. If hospitals with considerably more means are participating with hospitals without such means, neither should be disadvantaged (e.g. forced to take the lowest cost solution or forced to adopt a solution with terms they cannot afford). Available resources should be pooled to relatively benefit all parties, and specific effort should be made to structure the arrangements to minimize the ongoing operational cost burden. 38

39 The key components of the HIS cluster operational governance are as follows: Component Description 1. Structure This content clarifies committee structures, charters, inter and intra organizational design and reporting structures. 2. Oversight Committee authorities, escalations and responsibilities should be depicted in the relative context of deliverables, sustainability, compliance and the management of change. On an ongoing basis, the cluster governance needs to evaluate the clusters progress and success against the expected benefits, outcomes, and objectives. 3. Culture and talent Inter and intra organizational leadership needs to be depicted in the context of the overall spirit and guiding principles of the agreement and addresses: performance management, incentives, operating and business principles, talent, and leadership development, etc. Capacity planning and skills representation goals can be addressed here. 4. Service delivery structure This content depicts the operational service level agreements, service level tiers, recovery states, the degree of access, uptime objectives, scope of services, the degree of local vs. central service delivery, etc. It will also include: Operational capacity and resource planning; Common policies and procedures framework; Onboarding and off-boarding process framework. There will need to be a key framework to depict cost sharing in the context of equity and might include such factors as: o size; o consumption; o capacity; o up-time objectives; o utilization; o consumed functionality; and o other metrics as appropriate will allow equity in collaboration, regardless of organizational sizes Step 7 Develop HIS cluster detailed implementation plan Once there is agreement on the ongoing maturity journey and collaborative commitments, the implementation plan is developed to coordinate the activity between partners and within each hospital, according to their resource availability and capacity to implement the solution. Planning and execution of this work will be done 39

40 with the HIS host and peer hospitals within the cluster, and with the inter-organizational governance HIS clustering steering committee. The HIS clustering implementation plan represents the detailed roadmap for the establishment of a new HIS cluster or the addition of hospitals to an existing HIS cluster. Central to this plan is the realization and measurement of the benefits articulated in the HIS clustering business case. At this stage, the high-level implementation plan component of the HIS clustering business case is expanded to address the entire onboarding process, as it is expected that some hospitals will be early adopters, while others will either acquire over time, or will implement at a later date. The plan will include, for example, acquiring new software or subscription functionality; procurement planning for resources, equipment, and guidance; optimizing existing workflows; planning inter-organizational resourcing; etc. Key components of the HIS cluster implementation plan: Component 1. Outcomes and benefits management Description The development of an outcomes and benefits plan sets an expectation up front that these benefits should be realized by design. It allows for a prioritization of resources towards those identified outcomes, and sustains the ongoing pursuit of those outcomes long after implementation is complete. It enables mutual accountability between all stakeholders. This plan also sets the stage for an ongoing commitment to future excellence. Measurable outcomes using specific metrics and with proper tracking should be built into the plan. 2. Risk management The plan would be built to manage risk, not to eliminate it. Due to the scope of these projects touching almost all of the organization s operations, there is merit in considering risk in the context of an ongoing and managed enterprise risk management strategy. 3. Stakeholder coordination and communication A stakeholder engagement and communications plan should be developed, including reports into the senior project management leadership. 4. People resource management A resource management plan will help the organization acquire the right skills at the right cost. It will be closely tied into the competitive procurement strategy and to the talent management strategy, as the organization plans to execute the plan and prepare future leaders. 5. Change management The HIS cluster will commit to and undertake specific work that is necessary to fully realize the potential of HIS clusters in the context of local hospital adoption, as well as across 40

41 the broader health sector within the given patient population. In time, the scope of HIS is anticipated to expand to include other local Information Technology (IT), Information System (IS) and Information Management (IM) services across the continuum. The HIS host hospital (particularly if it is external to the cluster) will need to establish extensive change management capabilities, to address the necessary changes in culture, rigour, representation, service delivery, etc. 6. Financial resources plan This plan will need to combine the information from all the other plans into a series of financial projections, which include cash flow, vendor, opportunity lost, financing, and revenue implications modelling into an ongoing financial impact plan. Additionally, the organization will need to make strategic decisions related to financial resources on a frequent basis. 7. Quality control and monitoring A quality control plan will ensure that centralized standards and localized configurations adhere to a collaboratively managed environment. This plan additionally sets the stage for an ongoing quality improvement and service maturity plan that aligns with provincial objectives. 8. Project oversight While project management and oversight is standard, there is a need to ensure that this work is in the context of an organizational transformation project. This is not an IT project it is foundational and transformative to the whole enterprise. 9. Project management tools The cluster will find value in a commonly agreed set of project management tools and communications methodologies to minimize waste and focus work-efforts effectively. Examples of such assets include project plan or task list tool, communications logs, risk logs, project charters as appropriate. 10. Work plan This is the plan that manages the work to be performed and the necessary effort and resources required to perform this work. There is a macro plan that addresses the interorganizational work and collaboration, followed by successively more detailed plans that get at the specific breakdown of work required down to each organization, site, department, workflow, and process. 41

42 3.12. Step 8 Execute HIS clustering implementation plan Once the planning work and the procurement activities are completed, the HIS cluster collaboration will turn to solution configuration and deployment according to the plans that have been developed. This will require continuous senior leadership engagement. 42

43 Appendix A HIS procurement guidelines (including BPS Procurement Directive exemption) A.1 Introduction Once the HIS cluster is formally in place, one of the key activities of the cluster will be HIS procurement. This section of the document provides specific guidelines related to HIS procurement and, if applicable, the use of the BPS Procurement Directive exemption. A.1.1 HIS procurement process overview *** Figure A-1 Directive exemption and the HIS cluster s procurement lifecycle process Once the HIS cluster is formally in place, the HIS host hospital will lead the procurement activities on behalf of the cluster s hospitals. Since the BPS Procurement Directive exemption is an intrinsic component of the HIS procurement lifecycle, we are presenting a high-level overview of the HIS procurement process, with special emphasis on the process elements related to the use of the exemption. While in principle this procurement lifecycle should be executed after the HIS cluster is formally in place, in practice there will be an overlap between the HIS clustering process described in Section 3 and the HIS procurement lifecycle described above. Approvals of the HIS clustering business case and memorandum of understanding must be completed before the BPS Procurement Directive exemption can be submitted for approval, as the exemption applies only to HIS clusters that are formally in place. Furthermore, the exemption requires that the HIS cluster s host hospital lead the non-competitive procurement activities, while being supported by a strong business case that provides a strong clinical and financial rationale for the use of the exemption. 43