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Production Support
Elizabeth A. Boyer and Michael W. Soback
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Introduction
At the start of the EHR project, each EHR team member shared in providing pro- duction support. Members of the team rotated in a twenty-four hour, seven-days a week on-call schedule. We found that this arrangement compromised productivity by creat- ing both frequent interruptions to project work and post-call fatigue. It also led to employee dissatisfaction, since time spent on production support was not factored into project deadlines and performance goals. As the number of concurrent users increased from hundreds to thousands, these problems became more acute.
To address increased production support needs, we developed a dedicated produc- tion support team. This team consists of staff with extensive application and business- process knowledge, as well as customer-relations skills. The primary focus of the team is to handle customer problems. Other tasks include managing user access to the EHR and reviewing daily interface error logs. The errors range from misfiled results—
due to ordering errors within the EHR—to invalid interface filing types to patient mismatches and duplicate orders. The team is not responsible for new projects (see Figure 12.1).
The goal of production support is to provide a highly usable, highly available EHR and rapid responses to user problems. Several activities are required to meet this goal:
a Help Desk, application-level support, hardware support, and network support. This chapter focuses on efficient organization of these services.
Help Desk
To ensure that requests are handled efficiently and according to the urgency of the need, a priority is assigned to each request at the time the Help Desk receives it. The Help Desk answers questions and fixes problems, when it can. If the Help Desk is unable to fix the problem, they triage the call to the appropriate group. Each call ticket (work-order tracking form) has one of four priority classifications: (1) Routine, (2) Important, (3) Urgent, and (4) Critical. Each priority classification is defined by time- to-resolution performance standards (Table 12.1).
TABLE12.1. Problem Status Tracking.
Tracking Description of Status Customer Support goal
Status Requirements
Routine A problem that occurs at None 1. Respond to ticket within
random, on occasion, one business day.
but the device is not 2. Resolve ticket within five
completely down business days of creation.
3. This priority can be assigned Monday through Friday 8 AM–5 PM.
Important Indicates a device is None 1. Respond to ticket within
completely inoperable, four hours.
but is not impacting 2. Resolve ticket within one
patient care. business day of creation.
3. This priority can be assigned Monday through Friday 8 AM–5 PM.
Urgent Indicates a situation/problem 1. Requires customer to 1. Respond to ticket within that causes a significant be on site and available two hours.
detrimental impact to an to assist. 2. Resolve ticket within 24 individual’s or an area’s 2. Customer’s manager hours of creation.
daily responsibility. will be notified if the 3. This priority can be assigned problem escalates. 24¥ 7 ¥ 365.
Critical Indicates a problem with a 1. Requires customer to 1. Respond to ticket within critical device being be on site and available 30 minutes.
completely down with no to assist. 2. Resolve ticket within four other alternative for a 2. Customer’s manager hours of creation.
customer where a patient’s will be notified if the 3. This priority can be assigned life is at stake or affects problem escalates. 24¥ 7 ¥ 365.
the care given to a patient.
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Skill Sets
Your production support team will need a complex skill set to provide effective help to users. Core skills include triaging calls for network hardware and EHR problems, providing help with Windows applications, and triaging problems related to other appli- cations and interfaces (Table 12.2).
The need for customer-relations skills is a truism. But it is especially necessary for healthcare IT team members. For a variety of reasons, physicians are very sensitive (usually unconsciously) to being in the subordinate position that a student has vis-à- vis a teacher. This means that an IT person helping a physician with a problem may become the brunt of anxieties and anger that the physician is not consciously aware of. This makes the ability to make the customer feel capable a critical skill for these team members.
Geisinger’s production support teams provide service to over 40 practice sites in 31 counties. To provide timely support, we have developed a “layered” approach to support, with first-line support (super-users and the Help Desk) available in practice sites, and second-line support (network generalists and workstation and technical ana- lysts) available locally. Third-line support (application support analysts and support consultants) is located centrally. This centralization of back-up support teams enables the frequent face-to-face meetings that are often necessary to solve complex problems.
Communication among all levels of the production support team is critical to effec- tive performance. Frequently updated training for the entire team forms the founda- tion for communication. In addition, small workgroup meetings, face–to-face meetings with project stakeholders and conference calls are also used to facilitate education and communication (see Figure 12.2).
TABLE12.2. Skill Set Descriptions.
Skill Set Role Description Skills and Behaviors
HelpDesk Staff The Help Desk staff responds to all IT- • Basic application, workstation, and related requests for help, phoned and network knowledge
E-mailed. They provide help directly • Customer relations skills or triage the request to the appropriate • Triage appropriately team for resolution. Each call is • Know the appropriate teams entered as a ticket in an electronic to receive various help request types tracking system, which reports time • Troubleshoot novel problems to response and resolution for • Prioritize and manage multiple
each ticket. requests concurrently
Workstation Analyst Workstation and technical analysts • Intermediate to advanced workstation work in decentralized locations to hardware skills (personal computers support individual clinics within the and peripherals)
system. They interact directly with the • Intermediate to advanced software/
user community. application skills
• Proficiency with all utility applications and most other general applications
• Troubleshoot problems
TABLE12.2. Continued
Skill Set Role Description Skills and Behaviors
Super-user Super-users are members of clinical • A positive, task-oriented approach to teams (e.g., nurses and administrators) problems and to other HER users who are well trained in the use of the • Excellent communication skills;
EHR and the specific group’s friendly and approachable workflows. They provide the first line • Teaching skills
of production support for their work • Support the quality and efficiency groups, answering user questions, goals of the EHR
updating users’ training, and serving • Support information security and as liaisons between their work group confidentiality policies
and the Help Desk • Enable communication between the Super-users are trained early in the practice and the EHR support team
implementation process. Trainees have access to the EHR in a testing environment so that they can become familiar with optimal EHR workflows.
Network Generalists Network generalists are dispersed • Intermediate to advanced workstation throughout the system to support hardware skills (personal computers clusters of community-based and peripherals)
practices. They provide a broad range • General network knowledge of IT services, including second-line • Proficiency with all utility support for EHR problems. They often applications (e.g., Microsoft Office, work directly with end users. GroupWise, Terminal Emulation
Package) and most other general applications (e.g., EHR-Epic, Radiology-IDX Rad, Laboratory- Misys)
• Conduct regular staff meetings to enlist feedback and communicate updates
• Know whom to contact for problems
• Basic desktop computer and printer troubleshooting
• EHR-related Windows’ skills (including keyboard shortcuts)
• Basic Internet and billing policies and procedures
Application Support These analysts provide the second line • Expert support for selected Analysts of EHR production support behind applications (e.g., EHR outpatient,
Super-Users. The group consists of EHR inpatient, scheduling, associate, intermediate and senior registration, ADT)
system analysts who work in a central • Basic support for general applications location. The analysts handle acute as (e.g., Microsoft Office, GroupWise well as routine issues and maintenance E-mail)
tasks. They interact directly with EHR • Troubleshoot novel problems users and all levels of support staff. • Prioritize and manage multiple tasks
concurrently
• Research specific problems with the software vendor’s support staff Production Support These are lead systems analysts, • Provide specialized technical
Consultants programmers, and hardware system expertise
experts who work in a central location. • Work effectively with clinicians and Their primary focus is the administrative leaders
development and implementation of • Troubleshoot novel problems new software applications. They also • Research specific problems with the provide expert consulting support to software vendor’s support staff other production support teams. • Recommend and implement EHR
software upgrades
• Teach analytical skills to other support team members
Unexpected Outcomes
Since separate teams are now responsible for new projects and production support, it is particularly vital for project teams to produce useful written documentation and other forms of communication. They have responded to the challenge with marked improvement. Clear team responsibilities have led to a new sense of purpose and direc- tion on the part of team members. The production support team not only understands the user’s need fully, but also is responsible for follow through. This has enabled them to resolve issues more quickly and efficiently.
Skilled listening and problem definition are important in part because many pro- duction support calls are, in effect, requests for EHR enhancements, rather than reports of EHR problems. This makes the production support team a valuable source of ideas for project teams.
User Security Set-Up
Initially, two analysts on the EHR team assigned the level of EHR data access (the EHR security set-up) to EHR users. When a user called the Help Desk, the Help Desk staff paged the on-call analyst. The analyst worked with a security administrator to fulfill the request (which could be for anything from resetting a password to trouble- shooting a user’s inability to access the EHR). As the number of EHR users increased, operational efficiency required that the Help Desk staff and EHR team analysts be able to manage security set-up requests with less direct involvement of security administrators.
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FIGURE12.2. Production-Support Information Flows.
To make this possible, the security administrators developed security set-up policies and procedures, credentialing standards, and training materials for the Help Desk staff and the EHR systems analysts who would be providing second-level support (see Appendix 8 for the policies and procedures).
This system has reduced the time it takes to fulfill a request from three hours to 30- minutes. The Help Desk staff are able to fulfill 75% of requests themselves. With this new set of skills the Help Desk has become a cost-effective way to provide rapid support to users during second shift.
Despite its successes, the system did create problems. Errors in user security set-ups caused user dissatisfaction and increased Help Desk calls. We have learned that on- going training and proactive communication among all support groups is critical to maintain consistent performance across this large and varied team. This is particularly true when applications are upgraded or new applications are installed.
Application Upgrade Management
For more information on application upgrade management, see the discussion in Chapter 11.
Summary
Regardless of the details of your organization’s production support needs, you will want to pay close attention to many of the themes discussed in this chapter, particularly these:
• Dedicating a team to production support tasks
• Centralizing the team to facilitate knowledge sharing
• Developing strong customer relations skills in the team members
• Rapid, prioritized resolution of user problems
• Cross-training (including the Help Desk) to provide rapid response to common problems
• Specialized teams to provide sophisticated support for complex problems
• Ongoing customer relations training for every team member who works directly with users
