Electronic Health Records for non-owned doctors - staffing the project

This is my sixth post in the series about Electronic Health Records for non-owned doctors. This week, I'll discuss the complexities of staffing the project, since we've had to weigh insourcing verses outsourcing, costs, and service levels to arrive at a balanced staffing plan. We've divided the staffing into 10 categories and below I describe the strategy for each.

In creating this staffing model, we had several considerations

*The project scope is not fixed. We're starting with 300 clinicians and may implement over 1000. Thus, we need a staffing model which is scalable on demand. We may need to flex the size of our teams up or down depending on implementation schedules.
*In Massachusetts, at this time, it is challenging to hire and maintain healthcare informatics staff because of intense competition among hospitals implementing CPOE/EHRs and local software companies expanding their healthcare IT workforce
*Outsourcing can be a way to rapidly expand capacity but it requires diligent management and tends to be more expensive than hiring internal staff.

1. Project Management and Financial Management
We have a fulltime Project Director and have leveraged our existing IS fiscal staff to manage the budgets. We will partner with the Massachusetts eHealth Collaborative to operate a project management office under the direction of our Project Director but jointly and flexibly staffed with BID and MAeHC personnel. This will allow us to:
a. Complement our existing knowledge of hospital and employed-practice deployments with outside expertise regarding non-owned ambulatory practices
b. Ramp up staff strength quickly as implementation intensity grows
c. Ramp down smoothly as deployment transitions to long-term support. This model will also allow us to rapidly and seamlessly plug in the temporary project management and staffing gaps that will inevitably arise during the course of the project.

2. Technical Design and Engineering
We elected to insource design and engineering for our servers, storage, and network design. We collaborated with our vendors - HP, EMC, and Cisco, as well as our infrastructure implementation partner, Concordant, on these designs. We assigned .25 FTE of the manager of our Ambulatory Applications group to this task.

3. Central Site Construction
We elected to outsource construction of the central hosting facility to Concordant for a fixed price. They acquired the co-location space, installed all equipment, and took responsibility for establishing power/cooling/network connectivity to the site. They will also manage the central site during the pilot phase. We are paying for a deliverable rather than paying per diem rates for time or purchasing FTEs.

4. Office Hardware Deployment
We elected to outsource office hardware deployment to Concordant by purchasing a team of people which scales in direct relation to the number of offices we are implementing. Purchasing a deployment team rather than working on per diem rates means that we paying for FTEs assigned in direct relation to the deliverables.

5. Practice Consultation
We elected to insource and outsource practice consultation. An MAeHC senior consultant will directly manage the practice consultant team, which will comprise both BID and MAeHC consultants. These practice consultants will be assigned to individual practices and will provide end-to-end project management of practice-level implementations, to ensure that all activities associated with the implementation are synchronized. They will also work with individual practices on optimizing workflow and translating that optimized workflow into appropriate software configuration, hardware layout, and training approach. As with the project management function, this is a flexible insource/outsource model that allows us to scale up and down rapidly, tap into existing expertise and apply it to the project right away, and maintain an adaptive but robust capability to meet program changes as they arise.

6. Training
We elected to insource and outsource training. eClinicalWorks will provide the training for all our initial pilot sites then train our trainers. Going forward a combination of eCW and insourced trainers will serve our sites, with supervision/quality control of all training to be provided by eClinicalWorks.

7. Central Site Operations
We elected to outsource central site operations to Concordant via a "lights out data center" model coupled with systems and application administration. They provide monitoring tools and problem escalation 24x7 rather than hiring a specific number of staff to manage our installation. This enables us to leverage the fact that they are providing support to other customers and projects, keeping our costs low and avoiding the need for us to hire fractional FTEs to provide data center support. The challenge with hiring internal staff to do this is that we expect data center needs to be higher during our initial implementation because of the build/change activities, then markedly reduce during our steady state operations. Outsourcing this function to Concordant, which spreads FTEs over many customers, enables us to flex our needs easily.

8. Help Desk, Tier 1 and Tier 2 Support
We elected to insource and outsource telephone support. Concordant will be the initial single point of contact for all phone calls, doing Tier 1 support such as password resets and then triaging Tier 2 Support . They will handle infrastructure Tier 2 issues and escalate others (such as EHR best practice questions) to our insourced staff. Our staff will escalate eClinicalWorks specific issues to eCW as needed. By focusing on resolving as many questions as possible remotely and dividing support between Concordant, our staff, and eCW, clearly defining the tasks of each group, we minimize our costs.

9. Field Support
We elected to outsource field support to Concordant, using a shared staff model. This optimizes our costs, coverage and flexibility since here again Concordant spreads FTEs over multiple customers.

10. Security auditing
Security has been built into our project from the very beginning as part of our infrastructure design, application configuration, and staffing model. We elected to outsource security auditing to an expert ethical hacking and security firm, Third Brigade for a fixed price. By hiring an expert group to do this, we provide another layer of vigilance and control, ensuring we have an outside party validating our configurations, providing host based intrusion protection, and monitoring our systems.

Thus, by dividing the staffing of the project among the members of our "dream team" - BIDPO/BIDMC, Concordant, Massachusetts eHealth Collaborative, eClinicalWorks and Third Brigade - we have achieved an affordable, scalable, balanced insource/outsourcing staffing model.

More to come as we test this model in production this Summer!