Surviving SAP Implementation in A Hospital: The Valle Del Lili Foundation

HEC132
Volume 14
Issue 2
June 2016
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Surviving SAP Implementation in a Hospital
Case 1 prepared by Juanita CAJIAO 2 and Enrique RAMÍREZ 3
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Despite the potential benefits of electronic information management, including increased patient
safety and more cost-effective health care delivery, few countries report the adoption of electronic
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systems for managing hospital information. On January 1, 2011, the Valle del Lili Foundation
(VLF), a university hospital in Cali, Colombia, switched from paper to electronic documents to
manage medical records (MR) and all related clinical and administrative procedures. The VLF,
which reported revenues of US$200 million in 2014, is ranked the third best hospital in Latin
America and the best in Colombia. The hospital made the ambitious decision to simultaneously
implement electronic medical records (EMR), computerized physician order entry (CPOE), and
enterprise resource planning (ERP). The new system is now fully operational. Marcela Granados,
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chief medical director (CMD) at VLF, was tasked by the board of directors with analyzing the IT
implementation process and documenting the main reasons for its success. While reflecting on this
task, Granados concluded that one thing was certain: SAP implementation was a major turning
point in VLF’s history.
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The Valle del Lili Foundation

The Valle del Lili Foundation is a private non-profit organization founded in 1982 to deliver
tertiary medical care. The VLF was the brainchild of two cardiologists from Cali who identified
the need for a regional healthcare institution to deliver specialized care to medically complex cases
and critically ill patients. They were later joined by Vicente Borrero, a public health physician,
who has been CEO since 1986. Bringing together regional civic and political leaders and donors,
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they collected the necessary funds to launch the project. Initially focused on cardiology cases, they
gradually expanded their service offer. Today, VLF offers clinical care in more than sixty medical
specialties (See Exhibits 1 and 2 for statistical highlights and staffing information) and serves as a
teaching hospital, where ICESI University medical students receive training.
1 Real case based on twenty-two interviews conducted by the authors over a four-month period in 2014. All interviewees were
working at VLF at the time of data collection and represent various functions – clinical, assistive, and administrative – and
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hierarchical levels – directors, middle managers, process leaders – at the hospital.

2 Juanita Cajiao is an assistant professor in the Facultad de Ciencias Administrativas y Económicas (School of business and
economics studies) at Universidad ICESI in Cali, Colombia.
3 Enrique Ramírez is an assistant professor in the Facultad de Ciencias Administrativas y Económicas (School of business and
economics studies) at Universidad ICESI in Cali, Colombia.
© HEC Montréal 2016
All rights reserved for all countries. Any translation or alteration in any form whatsoever is prohibited.
The International Journal of Case Studies in Management is published on-line (http://www.hec.ca/en/case_centre/ijcsm/), ISSN 1911-2599.
This case is intended to be used as the framework for an educational discussion and does not imply any judgement on the
administrative situation presented. Deposited under number 9 40 2016 005 with the HEC Montréal Case Centre, 3000, chemin de
la Côte-Sainte-Catherine, Montréal (Québec) H3T 2A7 Canada.
This document is authorized for educator review use only by Dr. Abdul Wahid, National University of Modern Languages until May 2021. Copying or posting is an infringement of copyright.
[email protected] or 617.783.7860
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In December 2014, revenues totalled about US$200 million (see Exhibit 3). The previous year,
America Economia magazine had ranked VLF the fourth best hospital in Latin America and the
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best in Colombia based on clinical, administrative, and financial indicators. In 2014, VLF was
ranked the third best hospital in Latin America and the best in Colombia. These awards confirmed
VLF’s long-standing commitment to delivering excellent health care services in a patient safety-
centred environment.
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In 2006, VLF embarked on an ambitious plan to expand its service offering by constructing new
facilities to house additional beds, an emergency room (ER), and ambulatory care services. By
December 2010, the number of beds had increased by almost 60%. This growth put tremendous
pressure on all patient care delivery procedures.
Structure and Operation of Colombia’s Healthcare Industry
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The functional and financial structure of Colombia’s health system is complex. Law 100 (1993)
launched a major reform of the country’s healthcare industry. This law identified the system’s
stakeholders and established their responsibilities. These included private health insurers, known
as Health Promotion Organizations (HPO), 1 which are responsible for enrolling members and
managing the system’s available resources. Other important players are the Care Delivery
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Organizations (CDO), including hospitals, which are responsible for providing services to HPO
members. Under this scheme, insurance companies contract services with hospitals (in this case
VLF) through managed care agreements and decide which CDO will care for their members. This
is an important feature of the Colombian system because it means that HPOs, not doctors, decide
where patients are treated. By December 2013, 58% of VLF billing went to HPOs (see Exhibit 3);
the rest went to prepaid medical organizations, other companies, and private patients. Law 100 also
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created the Obligatory Health Plan (OHP), which stipulates the health-care services, surgeries,
procedures, hospital services, and medications that HPO members are entitled to. The OHP also
provides a reference price list for the industry, used when negotiating health-care contracts between
insurers and CDOs.
The VLF Medical Staff

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VLF is a hierarchical, top-down hospital composed of medical units, each headed by a specialist
physician. The CEO, the CMD, the chief nursing officer, the chief administrative officer, and the
heads of the medical units form the physicians’ medical council and are responsible for
communicating all senior management decisions to their units.
Although physicians are not directly employed by VLF, they comply with the policies of the
medical directorate and the physicians’ executive council regarding quality and patient safety
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issues, the terms agreed to by VLF and insurers, and standard administrative procedures. Physicians
are paid according to the number of patients they see, charging at the rates established by the
insurance contracts; VLF takes a 20% cut to cover administrative expenses. Approximately 20%
1 These organizations are similar to Health Maintenance Organizations (HMO) in the U.S., which limit coverage to care provided
by contracted providers.
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of total VLF billing is for medical fees. Additionally, all doctor-patient contact takes place within
VLF facilities; full-time medical staff are not permitted to see patients or deliver clinical services
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outside VLF. Given the hospital’s high occupancy rates, doctors don’t need to go elsewhere to find
patients.
Marcela Granados, a critical care physician who holds an MBA from ICESI University, has been
head of the intensive care unit (ICU) since it opened at VLF in 1992 and CMD since 2012. She
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explained: “This type of relationship – with full-time doctors – is a cornerstone of the integrated
medical care offered round the clock at VLF. Given the nature of the patients we serve, there are
always medical specialists scheduled to be either on hand or on call. At VLF, doctors find
everything they need to practise good medicine: technical resources, high standards, a group of
highly skilled specialist physicians, nursing and assistive personnel, and many patients. They find
it all here; there is no need to go anywhere else.”
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This governance structure is not common in Colombia, where physicians usually work as
independent contractors at hospitals – often at several institutions simultaneously. This limits the
influence that hospital administration can have over medical staff since it has no official authority
over them.
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Patient Care Delivery before IT Implementation
A patient can enter VLF in one of four ways: ER, outpatient services, ambulatory procedures
(diagnostic or other), or surgery. A patient may be admitted through the ER, be referred for surgery,
be sent to recovery, be transferred to the ICU, be sent to a hospital floor unit, and finally be
discharged. While in the hospital, the patient may have been treated by a group of specialists in
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medicine or other disciplines such as nursing, respiratory therapy, nutrition, physiotherapy, and
pharmacy. The patient may have been given various diagnostic tests and received specialized
medical treatment such as chemotherapy, radiation therapy, and cardiac rehabilitation. Patients
generally pass through many hands during their stay at VLF, requiring close coordination between
administrative and patient care personnel. This coordination is based on medical records (MR)
containing the record of every medical and clinical procedure performed and all supplies 1 and
medicines used.
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An example of one patient’s journey will help put this in perspective. By December 2010, there
was an average of 1,000 surgical cases per month. Each case required the coordination of many
steps prior to, during, and after surgery with a schedule made up of three shifts. High quality
standards were met at all times, but it was not easy to coordinate the work of everyone involved:
surgeons, anesthesiologists, medical equipment preparers, assistants, operating room (OR) supply
store staff, and clerical staff such as those in charge of detailed billing reports. First, the surgeon
issued a medical order with a specific surgical procedure to be approved by the patient’s insurer
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and another medical order to schedule an appointment for the pre-anesthesia evaluation. Once the
insurer had authorized the procedure, the patient met with an anesthesiologist, whose consent for
the surgery was required. The surgeon then asked the operating rooms to schedule the surgery and
drew up a list of the instruments and supplies required for that specific procedure. These requests
1 Non-reusable items used in surgical procedures such as sutures, gauze, and gloves.
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were handwritten on a form sent to the chief OR nurse, who added the case to an Excel spreadsheet
and informed the OR supply store and sterilization centre of the items needed to prepare the case
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cart.
On the day of the surgery, the operating room clerk would admit the patient, ensuring that all
administrative documents were in order, especially the insurer authorization. A nurse would then
assist the patient and check their paper chart, particularly the signed informed consent form and
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the pre-anesthesia evaluation. When the patient was ready, they would be sent to the operating
room with the results of diagnostic tests attached to their chart. Once the surgical procedure was
over, in addition to the notes made by the surgeon, four forms had to be completed and attached to
the patient’s chart. One was the anesthesiologist’s report sheet: on one side was the pre-anesthesia
evaluation and, on the other, the patient’s vital signs during surgery. Another was the report of the
case cart technician, recording the equipment and supplies used. Third was the report of the
instrument technician. Fourth was the log of supplies and medicines used, which was sent to the
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operating room supply store to be entered in the inventory system and charged to the patient’s bill.
Supplies and medicines that were not used during the surgery had to be restocked by operating
room clerks.
After surgery, the patient was taken to a recovery room and nurses began reviewing the relevant
information. Another form was then completed, recording the patient’s progress during recovery.
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This was also attached to the paper chart. When authorized by the surgeon, the patient was either
hospitalized or discharged. This system worked in the surgical wards, but with so many forms to
be completed and so many preliminary steps, confusion sometimes led to delays, making it
necessary to reschedule cases. Inefficient procedures created extra work, and delays negatively
impacted efficient room turnover and the surgeons’ schedule.
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María del Carmen Valencia, chief OR nurse, who has worked at VLF since 1994, explained: “In
some cases, the pre-anesthesia evaluation or informed consent was not attached to the patient’s
chart, or necessary supplies were not provided, sometimes because the surgeon’s or
anesthesiologist’s instruments and supplies list was incomplete. This was a drain on everyone,
because surgery could not begin until everything was in order.”
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Medical Records and Medical Orders

MR are clinical documents containing information about patients and their clinical course; they are
created by healthcare staff while patients are under their care. MR thus contain information
essential to both patient care and administrative procedures and must be managed and stored in
such a way as to ensure the confidentiality of information and the physical integrity of the records.
In Colombia, medical records are legal documents.
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In the case of VLF, all professionals who dealt with a patient made a note of the procedures done.
All these notes were made on paper or, in the case of the epicrisis, 1 dictated by the attending
physician into a recording machine and then transcribed by one of a pool of secretaries. The
transcription was then printed out and attached to the patient’s chart. This procedure had several
1 Epicrisis is the final report of a physician summing up the medical case when a patient is discharged.
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implications for the quality and availability of the information contained in the MR. Doctors aren’t
known for their legible handwriting, secretaries can make transcription errors, and documents can
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be lost, mislaid, or filed with the wrong MR. Sometimes a patient’s chart is required by different
departments at the same time, affecting its availability. A critical care physician who has worked
in the adult ICU since 2007 explained this situation: “In the ICU, there was this paper form on
which different team members of the unit worked – doctors, anesthesiologists, nurses,
physiotherapists; and sometimes we all needed that paper form at the same time. In addition, it was
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possible that the chart was in another unit, or that it was being audited by the insurance company.”
An ER physician who has worked at VLF for five years added: “Sometimes a patient arriving in
the ER could not remember what their physician had said, or what medications he was taking. In
the case of a VLF patient, all of that was written on the patient’s MR, but it took some time for us
to get the patient’s chart and review the necessary information.”
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Medical orders provide additional information to that found in medical records. These are the
instructions from attending or consulting physicians on the course of action to be taken. Physicians
use medical orders to request diagnostic tests, stipulate outpatient procedures, prescribe drugs,
order surgery or hospitalization, and terminate the treatment and discharge the patient. Various
health professionals then carry out the physician’s orders. Doctors would handwrite orders either
directly on the patient’s chart or on a separate form, and the professionals who carried them out
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needed to see the physical chart. An order could involve several people, as in the case of medicines,
for example, which involved the pharmacy that dispensed the drugs, the nurses who administered
them, and the billing clerk who invoiced customers.
Betty Gomez, nurse and chief nursing officer, has worked for VLF since 1987. She explained:
“When a nurse administered the medications ordered by an attending physician, she would make a
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note on the pink nursing form. In the case of inpatients, they would use blue ink in the morning,
green ink in the afternoon, and red ink on the night shift. These sheets were then attached to the
charts. We wanted traceability of pharmacy-related procedures, but this was time consuming and
not always reliable.”
Although there are no official statistics on preventable medical errors in Colombia, studies of this
subject have been conducted in the United States. The results are disturbing: a 2000 study by the
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Institute of Medicine concluded that, in the United States, more people die from human error in
hospitals than in car accidents. Among the problems that commonly occur during the course of
providing healthcare are adverse drug events: preventable injuries resulting from improper order
processing, dispensing, or administration of drugs.
Jaime Garcia, a physician who has worked at VLF since 2010, explained: “Illegible handwriting
on medical orders was one cause of adverse drug events, but it was not the only one. The person
transmitting the order might confuse the names of similar medications, or trailing zeros might make
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the dosage unclear. But one of the biggest risks was drug-drug interactions. With the kind of
patients we handle, and the involvement of several specialists, unforeseen or unwanted reactions
could take place between the drugs prescribed by different specialists.”
There was also the possibility of duplicate orders for diagnostic tests, which could impact patient
safety – in addition to the needless discomfort of undergoing them and the extra costs for insurers.
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Back-Office Procedures
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Parallel to medical care are administrative procedures, which are governed by regulations.
Insurance contract guidelines and billing. Under Colombia’s health funding system, insurers have
agreements with CDOs (such as VLF) for the healthcare of their members. The hospital’s Insurance
contract department was in charge of negotiating and managing contracts with insurance
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companies. Because it handled some 70,000 billing items, tracking them manually was an
enormous challenge. The department knew there could be problems with allocating the costs of
services delivered and thus negotiating reimbursement terms with insurers. “We were not always
certain whether VLF was profiting or losing with some procedures,” explained Danny Moreano,
head of insurance contract management and chief operating room physician.
The terms of managed care contracts sometimes differ, making it difficult to standardize patient
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admission procedures and charges for clinical procedures and supplies and medicines used while
providing services. Billing clerks thus had to memorize the contract terms or look them up in hard-
copy manuals.
More than half of VLF billing is to HPOs, which must comply with conditions laid out in the OHP
manual. Any procedures not included in the OHP manual require prior authorization from the
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insurer along with a report from the treating physician explaining the need for the procedure and/or
medication. In addition, any contact with the patient must be recorded in detail in the MR. Any
failure to comply with these conditions endangers the reimbursement and timely payment to VLF.
All fees charged to patients, whether they be for supplies, drugs, procedures, equipment use, room
fees, or doctors’ fees, had to be typed into the billing system. But this did not always happen.
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Valencia, chief OR nurse, explains: “Although the required supplies and medications were pre-
ordered, the surgeon or anesthesiologist would sometimes request additional supplies during the
surgery. The nurse assistant would go to the operating room supply store, request what was needed,
and say, ‘I’ll get you the written form in a minute.’ But with over 1,000 surgeries per month,
emergencies, and the pressure for rapid room turnover, some charges may not have been entered
into the system for billing purposes.” The billing manager explained the impact of this situation:
“Billing clerks were never sure whether they could close the patient’s account or if there were still
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pending charges to be entered. They would try to contact people by telephone, but those people
were not always available; after the account had been closed, they sometimes got calls telling them
there were still pending charges; all this delayed the process even further.”
Insurers had bills reviewed by medical auditors and required documentation of all fees charged to
patients’ accounts. This meant that documents had to be manually collected, organized, and
attached to invoices. In addition to requiring physical space to organize an average of 43,000
monthly hard-copy bills, this manual procedure affected the timing of invoicing, which had a major
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impact on VLF’s cash flow. The head of billing and accounts receivable explained: “It was time
consuming to track bills to know whether they had been finalized, were in the billing department
for prior medical auditing, or had already been sent to insurers. Invoice processing was equally
difficult – tracking every invoice to establish whether they had annotations, had been returned, had
debit notes, or had already been paid.”
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Supply chain management. Colombia is no stranger to the pressures to cut healthcare costs
experienced by many countries around the world. The efficient management of supply and drug
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inventories is critical, and the hospital strived to maintain just enough stock for day-to-day
operations while avoiding out-of-stock situations. The complexity of the billing process created
frequent inconsistencies in the information required for efficient supply chain management.
Medical fees. Doctors are not employed by VLF; they charge fees for their work based on rates
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agreed upon by insurers. Every time a doctor delivered a service – an outpatient consultation,
surgery, a procedure, or an inter-consultation – they would give the billing clerk a paper form with
a collection note that was attached to the patient’s bill. The head of billing and accounts receivable
explained: “This procedure meant that every doctor had to keep track of their own billing – how
much had been billed in a given period and whether or not they had been paid. Since several clinical
procedures could be done in a single day, the necessary information was scattered, and the whole
process was demanding and time consuming. Some physicians were fairly organized, but most did
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not keep careful track of their billing.”
Archives. Until December 31, 2010, VLF’s medical records were on paper. Back then, an average
of 50,000 hard copy charts had to be moved back and forth between the archives and the medical
units. This had significant logistical implications and created a growing demand for physical
storage space. All units were affected by these logistical problems. Walk-in patients might arrive
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at a doctor’s office before their chart did, for example. If patients asked for copies of the
information in their charts, a manual search had to be done and the requested documents
photocopied.
As they struggled to gain control of their physical space, the archives developed a spreadsheet
system for keeping track of medical records; missing charts were becoming a problem. “Given the
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number of charts we were dealing with, plus the projected growth in service delivery, we knew we
would continue to have major problems managing records efficiently,” explained the head of
inpatient registration and archives.
IT architecture
By December 2010, there were at least thirty information systems working somewhat
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independently at VLF; they provided partial solutions to the needs of some users but did not allow
for information integration. There were electronic systems for laboratory and diagnostic imaging
and some software developed in-house for support processes such as a scheduling module. In
addition, some doctors had developed software tailored to their specific needs. Generally speaking,
software developments were aimed at administrative and support processes rather than clinical
procedures directly related to patient care. Until 2010, the hospital had software to handle back-
office procedures, accounting, billing, accounts receivable, supply management, and medical fee
management. Given the many disadvantages of its inventory module, it developed its own system.
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All this software was connected via interfaces. The opening of new beds and the resulting increase
in related clinical services – e.g., surgery and outpatient care – placed additional pressure on
procedures related to healthcare delivery.
The problems with medical fee management had become critical, as Hernando Garcia, head of
information technology, recalled: “We had developed an application for managing medical fees,
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but it was causing problems. The interface could bog down for a day, even two days!” In addition,
the information was sometimes inaccurate. An anesthesiologist and anesthesia group coordinator
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explained: “There were times when your numbers didn’t match the payments you received; you
could always recheck your bills, but it was a drain on everyone. It was time consuming, and, as a
doctor, you prefer to spend that time with your patients.”
A comprehensive IT project would enable VLF to improve patient safety, make healthcare services
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more efficient and cost-effective, and increase revenues in the medium term. The productivity of
medical staff would also benefit from the streamlining of healthcare delivery, since it was expected
to improve patient flow/throughput.
Searching for an Integrated Enterprise-Wide Solution: ERP, CPOE, EMR 1
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In late 2008, an interdisciplinary team led by a cardiologist familiar with state-of-the-art technology
began looking for an application that would provide an integrated hospital-wide solution for patient
care and administrative procedures. This was the launch of the Synapsis project. The initial team
was made up of the cardiologist, the chief medical director, the chief nursing officer, the chief
administrative officer, and the head of insurance contract management. It was important that those
using the macro-processes that would be affected by systematization – both clinical and
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administrative – had a voice in the project. Any option would have to include complete electronic
health records. The team began by visiting other hospitals in Colombia to see firsthand what
electronic devices they were using to manage their medical records.
When an organization implements an Enterprise Resource Planning (ERP) system, it undergoes

major changes because a single database must be shared by the entire organization to achieve
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centralized management and integrated information processing. The implementation and adoption
by end users of ERP affects the ways people work and disrupts organizational routines. But VLF
was even more ambitious: along with ERP, it wanted to integrate all core business processes by
implementing a comprehensive healthcare solution that, in addition to back-office procedures such
as billing and accounts receivable, included electronic medical records (EMR), CPOE, 2 and
pharmacy management. With this in mind, they began their search.
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Choosing SAP
SAP was known as a powerful ERP system for administrative and operational support processes.
However, its healthcare solution was developed for less clinically complex environments and
health systems that differed greatly from Colombia’s. The healthcare-specific functions of SAP
ERP were based on a German business model, German culture, and healthcare regulations quite
different from those in place in Colombia. All this created significant gaps at every level between
what SAP offered and what VLF believed it needed: 1) at the level of VLF itself, given the
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complexity of its cases, e.g., pharmacy management of patients undergoing chemotherapy, 2) at
1 Acronyms for Enterprise Resource Planning (ERP); Computerized Physician Order Entry (CPOE), Electronic Medical Records
(EMR).
2 Computerized Physician Order Entry. This is the electronic entry of instructions given by the treating physician to the medical
assistant personnel in charge of executing those instructions (diagnostic tests, therapies, medicines, etc.).
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the level of the healthcare industry, e.g., reimbursement terms, and 3) at the legislative level, e.g.,
OHP conditions.
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At the end of the vendor selection process, they had two top offers. One proposed to make over
1,000 software developments; the other, Compunet – a local SAP partner firm – proposed just 350.
Hernando Garcia, head of IT, explained: “That was a key factor in our decision. Anyone who
knows SAP knows that it can be parameterized. Someone who does not know it well makes
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software developments not knowing that those options already exist in SAP. With SAP, it’s better
to integrate than to develop. When you integrate, you are adjusting to what the program offers, to
what is there already, and when upgrading to a new version, you have no trouble. That is not the
case for software you develop yourself.”
The general manager of Compunet added: “VLF was looking to integrate the hospital’s entire
operations, both clinical and back-office, and to organize all related information around the
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patient’s MR; we knew SAP’s ERP and IS-H MED applications could do this. We could do further
developments based on the program standards and certify them with SAP.” 1
On October 1, 2009, VLF decided to hire Compunet to implement SAP and develop the
applications needed to carry out the Synapsis project. It proposed an ambitious schedule: the project
roll-out would occur over thirteen months and include some 2,200 end users.
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Communicating the decision
Synapsis was seen as a strategic imperative to meet the growing demand for services facing VLF;
its main objective was not to cut jobs but to improve service delivery and efficiency.
Communicating the rationale for the change to all stakeholders – with varying interests and
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incentive structures – was a major challenge. (See Exhibit 4.) It was decided that each department
head should ensure that their members fully understood the project and its benefits. Moreano, head
of insurance contract management and chief operating room physician, recalled those days: “I have
a vivid memory of the meeting of the physicians’ medical council when Dr. Borrero told us about
the IT project. The message came through loud and clear: SAP was not a systems-driven initiative;
it was a strategic decision to support VLF’s growth while ensuring patient safety. His support for
the project was impressive, and we were held accountable for communicating the project rationale
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to our doctors.”
In addition to stressing the reasons for paperless care delivery, the department heads were to stress
that the system’s implementation would lead to major workflow changes at all levels. The role and
workload of physicians would be greatly affected, in fact, since the new system would upgrade the
medical order process, making order entry the responsibility of physicians. There would no longer
be an intermediary – be it a nurse, a pharmacist, or a clerk – implementing verbal orders from
doctors. Additionally, medical notes would be typed by doctors in SAP. Granados explained: “For
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us it was clear that one of the most critical issues throughout this project was that doctors
understand its benefits. We did not want them thinking this was an administrative project and that
suddenly they would be doing clerical work, typing into a computer what had previously been done
1 Throughout the case, references to SAP include the ERP and all healthcare applications developed on SAP’s platform to meet
VLF’s IT needs.
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with pen and paper or dictated to a secretary. If they did not see the benefits for the patient, for
VLF, and for themselves, there was a good chance they would be reluctant to use SAP.” It was
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stressed that doctors would benefit from decision-support processes that would help reduce medical
errors and that patient flow would improve. They would be able to access MR anywhere, anytime,
and view on-line information about lab tests and other diagnostic procedures before seeing patients,
significantly improving the quality and efficiency of care delivery. As healthcare needs grew, these
improvements were expected to positively impact patient care.
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When informing administrative staff about the need for change, managers were to relieve their
anxiety about the possibility of losing their jobs. The head of inpatient registration and archives
explained: “For the dictaphone secretaries, it was clear that their jobs would disappear when the
doctors begin typing clinical notes themselves. We assured them that since the demand for services
kept growing, most of them would be assigned to different units. And that is what ended up
happening.” As the head of billing and accounts receivable explained, it was also important to
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lower expectations about the system’s benefits: “Some employees, particularly billing clerks,
thought the new system would provide a tailor-made solution to all their problems by handling all
the same processes electronically; we knew that would not be the case and tried to communicate a
more realistic view. Long-held routines and practices would also change.”
Gomez explained her approach with her subordinates: “We had many meetings with assistive
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personnel to inform them about the decision to have paperless care delivery processes, which would
significantly improve safety and quality of care. We wanted to be sure they understood why the
change was necessary; but most of all we wanted to assure them we would be offering the necessary
training and support to smooth the transition.”
Health insurers would also be affected by the systematization and had to be informed about the
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project. They would benefit from improved care delivery safety for their members as well as
potentially decreased/better use of tests and medications. The billing process would be more
efficient, and audit procedures could be dramatically improved. Several meetings were held to
communicate the scope of the project.
System configuration decisions

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VLF had an ambitious objective. More than just electronic medical records, it wanted an
information system that would integrate all clinical and administrative procedures, providing a
unified picture of the entire care delivery process. VLF rose to this challenge by first establishing
the project governance. Compunet’s manager joined the Synapsis team, the executive committee
responsible for all final decisions. There were also design teams, charged with identifying end-user
requirements.
To ensure a successful transition, it was important to involve a wide range of stakeholders in the
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design teams: those in charge of the back office and service delivery and administrative procedures.
Gomez recalled how those teams were selected: “I remember I appointed my best nurses, those
familiar with care delivery procedures, both clinical and administrative – the top OR, ER, and
hospital nurses. In all, I assigned eight nurses full time to the project.” Those key users were made
accountable for workflow design and system specifications for their procedures.
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Compunet suggested the formation of cross-functional design teams composed of VLF subject-
matter experts and Compunet consultants. Each team was led by a consultant, known as an
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integrator, who was responsible for the entire process. Questions on which the design groups failed
to agree were referred to the project’s Synapsis committee. The CEO met regularly with the
Synapsis committee to assess the project’s progress and resolve impasses between Compunet
consultants and the design teams. The process leaders worked with a consultant, explaining how
things were done and figuring out how they could be done more efficiently in the future. The
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consultant then determined the SAP parameters and the software developments that would be
required.
Eighteen VLF leaders and fourteen Compunet consultants participated in the work of the design
teams. VLF assigned the most qualified people to spearhead their respective processes. Their
regular duties were assigned to someone else to ensure they could devote 100% of their attention
to the project. It was critical to have people who fully understood how VLF operated and the
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specific needs of their own processes. These leaders, in turn, worked with Compunet consultants
who knew SAP functionality and what the application could offer. In total, approximately
100 people worked full-time on the project for twenty-two months during the design, training, and
system roll-out phases.
For some processes, mapping out what they wanted to achieve was a more expeditious approach;
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this was the case with supply chain management, maintenance, accounting, and human resources,
whose business processes were generally in line with SAP functionality. The Compunet consultant
who later joined VLF as manager of its new projects department remembered this critical stage of
the project: “Meetings with the leaders of the supply-chain-related processes went quite smoothly;
the leaders I worked with had a good understanding of their processes and understood how the
business operated. This made it easy for them to communicate their needs, which were easily
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adapted to what SAP offered.”
With clinical processes, the road was rockier. Gomez explained: “We started with the basic SAP
healthcare application and, from there, tried to determine what we needed; for example, what was
available for nursing care versus what we really needed. It was a difficult stage: we didn’t know
what was possible, or what we could ask for. Some modules, such as pharmacy administration,
were not available in SAP and had to be developed from scratch. The relationship with Compunet
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was not easy; in the beginning, we argued a lot. There were meeting minutes where we said, ‘We
need it this way,’ and they answered, ‘It can’t be done.’ In the end, both sides had to yield a little.
I think these are the things that get adjusted along the way.”
The leader of the billing process recalled those meetings: “At first, we felt the message from
Compunet was that we had to adjust to what the system could give us, while we expected the
system to conform to what we thought we needed. This caused many clashes because it meant big
changes in the way we were working; we had to understand how billing was handled by SAP,
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which was very different from the way we did it.”
Compunet’s general manager offered another perspective: “Sometimes end users imagine many
things they want to have, and the consultant’s job is to keep their feet on the ground, because if the
user wants something highly customized, the project will take too long. Our advice to VLF was to
adapt to the best practices offered by SAP for different types of industry, and not try to adapt the
© HEC Montréal 11
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software to the processes they already had. VLF made the right decision to adapt to SAP standards.
We can say there was a change in their expectations.”
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Since the project’s success depended on the medical staff’s acceptance of IT use, this point was
given special attention. The team began by approaching Jaime Garcia, a physician working at the
Medellin General Hospital, who was overseeing SAP implementation there. In late September
2009, Garcia was hired by VLF to work full-time on its project. “I headed the design team in charge
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of patient care delivery modules; my job was to clarify needs with the various clinical units and
medical specialties and communicate those needs to Compunet consultants and the leaders of
administrative processes.” VLF wanted doctors to have a voice in the process redesign, including
their input and active participation in workflow mapping and system specifications for clinical
processes. Encouraging their involvement in the project was a way to ensure their buy-in and
support.
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Dr. Garcia’s expertise in SAP implementation made him the perfect intermediary between the IT
experts and the physicians. As a result of those meetings, medical fee functionality was added to
SAP enabling doctors to check the payment status of their invoices on-line. They would no longer
need to hand collection notes to the billing clerk; instead, when they entered a clinical procedure –
surgery, inpatient visit, etc. – the system would automatically calculate the medical fee associated
with that procedure and add it to the doctor’s personal medical fees account.
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While some specialists were fairly receptive to the changes, others were more hesitant. Those who
had developed their own systems tailored to their specialized functionality had strong opinions
about the negative impact of using IT in patient-related processes and saw little or no reason to
becoming more integrated with the others. It became a matter of balancing the needs and interests
of the clinical units and of some individuals with those of VLF as an institution. The time spent
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with each group differed depending on their attitude to the project, but the message was clear;
paperless care delivery was on its way. Granados gave an example: “There was one doctor who
told the CEO that he wouldn’t use SAP, that he would leave VLF if he was forced to do so. Well,
SAP is still here, and so is the doctor, and he is using SAP!”
Granados assumed leadership of the Synapsis project in 2010; she summarized her thoughts about
the project this way: “We knew that SAP had very specific standards, which in theory could not be
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altered. Some end users explained what they saw as their needs, and a Compunet consultant, who
tried to respond to the needs expressed by users but often fell short, said it was not possible to
comply with those requests. There were moments of strong polarity, and I think my contribution
to the process was to mediate between the parties, always with the understanding that we at VLF
should feel confident about the application in terms of both patient safety and VLF’s financial
stability.”
Change management at every level

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Inadequate attention paid to the importance of effective change management when making changes
of this magnitude has been identified as a barrier to greater use of IT in hospitals. To mitigate this
problem, VLF implemented a learning-based strategy to ensure end users’ adoption of the system.
(See Exhibit 4.) It installed computer labs with SAP modules that were available 24/7 to facilitate
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familiarization with basic transactions. Additionally, it offered special training sessions based on
each functionality, e.g., for physicians, back-office personnel, and assistive personnel, etc.
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Physicians. Mechanisms were sought to facilitate the transition of physicians to EMR and other
support processes involved in the systematization. Eight general physicians who had just graduated
from medical school were recruited and hired by VLF based on their interest in and understanding
of IT. They joined Jaime Garcia’s team and were actively involved in training medical personnel
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in the use of SAP, working at the help desk, offering go-live support to ease the transition, and the
late stages of stabilization and end-user adoption of the system. VLF wanted its doctors to be
trained by doctors. When Garcia was asked about physicians’ response to the training sessions, he
noted a range between enthusiasm and cynicism, more in favour than against the IT initiative.
“Many doctors were already regular users of technology, so they were strongly in favour of having
electronic MR and all the associated processes.”
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Assistive Personnel. 58% of VLF’s employees worked in the clinical assistive area, and 60% of
those were lower-skilled assistive personnel. Familiarity with IT systems varied greatly; some were
fairly comfortable with them, while others had never touched a computer. This presented a major
challenge since once all clinical procedures were systematized, all these people would have to use
the IT system, either to electronically capture information or to read the medical orders that were
electronically input into SAP. A training program was launched in the second month of the project
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providing modules of different levels of complexity so that no one was left untrained. Computer
rooms were set up where people could learn the rudiments of Word and Excel and become familiar
with a keyboard and a mouse. There was also training in SAP modules for various departments
(outpatient, emergency, hospitalization, etc.), and clinical documents such as medical orders and
physicians’ and nurses’ notes. Training was mandatory and time was set aside for training sessions.
“We knew that training was critical to the successful implementation of SAP, so we began it early
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on in the project. Not knowing generates fear and the best way to overcome that fear is by learning,”
Gomez noted.
Administrative staff. For the administrative staff, the situation was different, but the challenge was
equally great. Most back-office processes (invoicing, supply management, human resources,
archiving, accounting, etc.) already used information systems that met their needs to some degree.
So many of those people were already familiar with one system or another, and some resistance to
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learning new software was to be expected.
Synapsis Project: Ready to Go Live

During the final development phase, unit tests were run to check the system’s performance for
specific processes, such as scheduling an outpatient appointment. System integration testing was
then done, simulating a full scenario to assess the entire process, including EMR, CPOE, and ERP.
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Hernando Garcia, head of IT, recalled what happened: “In the first comprehensive test, many
inconsistencies surfaced, especially related to billing, giving strong indications that we were not
yet ready to go live.” In view of this and based on the recommendation of the Synapsis executive
committee, the CEO decided to postpone the system roll-out, originally scheduled for November
1, 2010, to January 1, 2011. This decision was communicated via the physicians’ executive council,
© HEC Montréal 13
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and all leaders were made accountable for informing their teams, and most of all, for being on the
front lines while the system was stabilized.
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Big-bang or phased implementation?
A common practice with such IT projects, particularly the implementation of an ERP system and
its associated modules, is to introduce elements in a planned sequence, replacing the old system
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gradually, i.e., one module at a time, such as human resources and inventory management. Another
option is called the big bang, or live start, with all modules and related processes launched
simultaneously. Both options have potential risks and benefits. A gradual release entails fewer risks
and allows end users to become familiar with the new system more gradually; but it also means
making interfaces required to maintain parallel systems – the old and the new – meaning that
information processing has to be done twice. A big-bang implementation makes it possible to
calibrate and stabilize the system much faster because it allows prompt online identification of
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possible inconsistencies. Additionally, since patients and doctors move between units, a phased or
partial implementation – excluding some units, such as ER – would create problems. But a big-
bang approach could also be risky. In the end, with top management support, the big-bang approach
was chosen.
Many industries are seasonal, with peak workloads and low-flow periods. These are taken into
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account by companies determining the best time to go live. Hospitals such as VLF are open 24/7,
all year long, making it difficult to determine the best way to minimize workflow disruptions. Still,
it was helpful to know when the zero hour would be. The Compunet consultant explained: “The
go-live was traumatic, but it was a learning curve we knew we had to navigate; there was a zero
hour, and whether that was January 1, or February 28, or any other day, we would just have to get
through it. People would be anxious and unsure what to do in the beginning. The system had to be
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calibrated, and the only way to do that was by operating it. It was a step we had to take.”
Contingency plans were in place throughout the hospital to avoid delaying critical patient care.
Change management included communications with patients and their families, as they would also
be affected by the implementation of the new system and its possible implications for service
delivery. Notices were posted in all units; flyers were distributed to patients and their families;
announcements were inserted in answering machine messages; and explanations were posted on
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the website.
To support end users, a help desk was open 7/24. Process leaders who had participated in the design
stage staffed the help desk as on-site experts for the most critical units; these included the eight
doctors who had worked with Jaime Garcia, the eight head nurses, the leaders of the back-office
processes, consultants, and members of the IT department. These people were familiar with both
SAP transactions and the main processes in their units or departments affected by the redesign, so
they were able to explain the changes to end users. They were also trained by Compunet consultants
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on help desk service. They worked in shifts, so someone was available 24/7. Those scheduled to
work the first shift had a dinner to say goodbye to the old year and the old system. At midnight on
December 31, 2010, the balances were already loaded into SAP, and the old system was stopped.
The green light was given to start.
© HEC Montréal 14
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January 1, 2011: paperless healthcare delivery in VLF
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All VLF directors – including the CEO and the chief administrative officer – as well as leaders of
the various back-office processes and the medical units visited the hospital at some point during
that day. Granados recalled: “We could not do much in terms of helping end users solve specific
problems with the system, but we wanted to send a strong message of unconditional support for
the people and the project.”
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Some of their fears were realized; many end users found it difficult to remember all of the
information learned during training sessions. They were dealing with online data for the first time
and did not fully understand the connections between the various steps of each process; incomplete
transactions blocked the system, and they didn’t know what they had done wrong. The following
comments illustrate what staff members experienced that day:
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It was something like turn off, turn on. We went to sleep with paper-based processes and woke up
paperless; everything was electronic. It was a pretty drastic change. (Chief nursing officer)
The first day was chaotic, and so were the following weeks. I would have preferred a phased approach.
We changed from processes that were already well established, that we all knew and performed
quickly; suddenly everything slowed down: nursing assistance, pharmacy, diagnostic aids. We were all
just beginning to understand the system; it was like crawling when we used to run. (ICU critical care
physician)
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In ER that day I estimate waiting times were 4-5 hours. We gave priority attention to the most critical
cases; the others had to wait. Although we had been trained, when going live, many things are forgotten
or confused, and on top of that, if you weren’t familiar with how the system operated, everything
slowed down. (ER physician)
I remember there was an appendectomy case in the operating room that day. The surgical procedure
took twenty minutes, and it took the doctor six hours to input the clinical note in SAP. (Surgeon and
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head of the transplant program)
On the other hand, the first invoice was created that day, and this was considered a triumph
compared to other hospitals in Colombia, which were reporting delays of up to three months for
billing for services rendered. There were difficulties with billing, however.
About thirty emergency patients were given medical attention, but we could not enter the information
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into SAP. It took us almost three months to catch up with those cases. (Chief of billing and accounts
receivable)
Stabilization and adoption of the system
The new system significantly slowed workflow. Both the people who issued medical orders and
those who executed them were learning to operate SAP, and this made the interaction between
them much slower than if they were communicating directly. Granados gave an example of what
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happened in those early days. “In the first week, I remember one of the ICU physicians’ calling me
to say, ‘Dr. Granados, I have the patient’s body here, but not his soul!’ She was referring to the
fact that the patient had not been entered in SAP, so she could not ask for laboratory tests or order
anything. I often authorized procedures and medications to be entered later in SAP, knowing that
that some things would likely be missed.”
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People at the help desk were overloaded. During the first week, units with greater patient flow were
assigned additional on-site personnel. Staff also made an extra effort to let patients and their
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families know what was happening, since delays in care delivery were affecting them.
As a general rule, when a system goes live, the consultant’s job is over, and the organization is left
on its own to operate the new system. The process of stabilizing the system and having end users
take ownership of it does not always end well. There are documented cases where an organization
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has only partially adopted a new system or abandoned it and returned to its previous practices.
Knowing this, VLF decided that, after go-live, Compunet would provide on-going support to fine
tune and stabilize the system for ninety days. The help desk was disbanded six months after go-
live, and a projects department was opened to manage post-implementation issues and maximize
the value of the system. In June 2011, the Compunet consultant was hired to head this department
and was made responsible for ongoing support, upgrades, and new developments as well as for
SAP training of all personnel entering VLF. Granados explained the rationale for this decision:
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“It’s difficult to say exactly when a project of this nature ends. We knew when it began and when
the support of consultants ended, but we wanted to take ownership of the system because we knew
there was still a lot of room for improvement, and we were also sure new needs would arise that
would require new developments.”
Despite previous large-scale training efforts, true learning began when people began to operate the
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system. In the end, it was learning by doing, practising, using the system on a day-to-day basis that
boosted the learning curve. Knowledge transfer was also done in an informal one-on-one manner;
co-worker support became common when anyone had trouble with SAP transactions.
People incorporating SAP in their daily routines reacted in different ways. The following
testimonials help explain what happened in the first few months.
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The chief of billing and accounts receivable recalled that stage: “The first three months were very
difficult; I would say that it took us six months to stabilize the billing process. Learning to operate
the system, handling unexpected problems on a day-to-day basis, unlearning routines we were used
to; all this required a major effort from many of us. We knew we had a responsibility to safeguard
income for VLF; not doing it well would endanger the financial stability of the hospital.”
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An ICU critical care physician gave us her perspective: “When we first started, some of us were
reluctant to change, because the workflow was different from the one we were used to, and change
creates resistance; so there was disagreement while we adapted and made adjustments. However,
over time, things began to relax as we learned more about the system because we all became more
familiar with it, and this allowed us to resume our normal work pace. In addition, the system’s
performance improved significantly.”
Some units adopted SAP more easily than others. Such was the case with ER, where doctors and
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other end users began using it quickly. But, in the operating rooms, the anesthesiologists objected
to pre-ordering supplies to be used during surgery, so it was almost a year before it was fully
adopted. Moreano, chief operating room physician, recalled how this situation was handled: “When
I was appointed chief operating room physician in early 2012, I sat down with the anesthesia group
to discuss their objections to using SAP. As it was designed, the system was not fully compatible
with their process, since their needs are difficult to predict with 100% accuracy; requirements vary
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during the surgical procedure depending on the patients’ condition and how they respond to
anesthesia. The anesthesiologists had a point, so we came to an agreement and modified the system
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to make them feel at ease. It was a matter of making adjustments.” On the other hand, Valencia
offered the nurses view: “Sometimes it was hard for us to understand that the anesthesia group was
reluctant to use SAP in the operating rooms, since they had to use it – and did – in other units, such
as ICU and ER.”
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A few doctors had developed their own information systems that fit the needs of their medical
practice and facilitated their processes but operated independently of VLF’s other systems. These
doctors strongly resisted the adoption of SAP; for them, there was a trade-off between
customization and standardization. “Our strategy with these people was to offer alternative SAP
developments to provide them with what they already had. It was a long and sometimes difficult
process, but these doctors now see the benefits of having integrated information on a single
platform. Today they are using SAP,” Granados concluded.
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It took about six months to reach system stabilization and resume the previous work pace. The
learning curve for using the system had repercussions at all levels: revenues for services rendered
in 2011 were up just 6% over the previous year. This was attributed to the fact that most processes
associated with patient care delivery slowed down; everyone involved was learning how to work
with SAP. Additionally, there were consultants and support medical, nursing, and administrative
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staff during the design stage and for the first six months after going live. The total cost of the project
was about US$12 million – about 19% related to head count – which significantly affected
operating costs. However, since 2012 all financial indicators have significantly improved. (See
Exhibit 3.)
Taking advantage of IT
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After go-live, Dr. Garcia joined the projects department and, as of the case date, is still there. “My
role now is basically the same as when we started Synapsis: to serve as intermediary between the
medical staff and SAP functionality; we are still receiving requests from various clinical units and
some doctors.” Since SAP has integrated all information in a single database, any initiatives VLF
wishes to undertake must take into account SAP’s functionality, whether it be a new clinical
procedure or a new service such as home care or a new extended care facility. The Projects
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department is accountable for upgrading SAP performance to meet the specific needs of the
medical units. This was the case for an ICU module that was modified to better meet end-user
needs, for example, and user interfaces with specialized medical applications such as lab tests,
diagnostic imaging, endoscopy, and the blood bank. One of the major benefits of having all patient-
related information on a single platform has been the implementation of a bar-code system for
pharmacy management, launched in 2012. (See Exhibit 5.) This module includes the entire
medication administration process, from the time the drugs reach VLF and are entered into the
inventory database to the time they are distributed in the satellite unit stores, e.g., OR, ER, and
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ICU, dispensed at those unit stores, administered to patients in accordance with medical orders,
and finally, charged to the patient’s bill. In addition to supply chain processes is the advanced
clinical decision support (CDSS) system paired with a computerized provider order entry (CPOE)
system that checks for drug-drug interactions, drug allergy, and other patient specific alerts that
help to reduce adverse drug events. The entire pharmacy process is thus trackable. This new
module, developed by the Projects department and Compunet, was certified by SAP.
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Administrative departments such as billing and supply chain management also continued to benefit
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from having centralized data and processes. The billing process was significantly improved since
physicians now placed medical orders in SAP, specifying which supplies and medicines were to
be used for each case; the system alerted physicians when the insurer required that the use of a drug
or procedure be justified (see Exhibit 5). Insurance auditors reported substantial improvements in
information traceability, and the audit process became faster and more accurate. With online
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inventory information, supply chain management-related processes also reported significant
progress; this was the case for planners, who finally had accurate information with which to predict
inventory requirements and reduce out-of-stock events.
For many end users, care delivery processes became more efficient and integrated as a result of the
implementation. Here are some comments:
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For nurses, the pharmacy management module made it possible to check compliance with the “five
rights” – right patient, right drug, right time, right route, right dose. This had been much more difficult
to trace in the paper-based world. (Chief nursing officer)
For those of us in the archives, the reduction in paperwork was awesome; lost and misfiled records fell
to almost zero. SAP has made our work much easier! (Head of inpatient registration and archives)
By eliminating many clerical activities, SAP has facilitated a more analytical focus on the work done
by billing clerks. (Leader of the billing process)
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We have substantially increased the number of bills we process without hiring new people; there were
no layoffs in my department when SAP went live since the demand for services also increased. (Chief
of billing and accounts receivable)
Using SAP has greatly facilitated my work; I adopted it immediately. For example, patients coming to
ER often cannot remember what medicines they are taking, or they may confuse their names, or cannot
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remember doses. This was a major constraint for doctors. Today, if a patient has an MR at VLF, that
information is immediately available; there is no margin for error. (ER physician)
Over time, some changes we requested have been implemented, such as SAP’s interface with monitors;
all vital signs during surgery are now recorded in the system. We did it manually before. That’s a plus.
(Anesthesia group coordinator)
The systematization of MR has brought many benefits, but those of us who manage patients who
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require many years of follow up – sometimes twenty years or more – need access to information in the
paper charts. In our medical group, we already had several paper forms for recording the information
we needed. It was easier to do. So far, it has not been possible to input those records in SAP. Most
benefits have been noticed at the administrative level. (Head of the transplant program)
Another observed benefit has been in the area of protecting patient privacy. Electronic medical
records have control mechanisms to limit access to information and trace who enters the system
and what they do there. This was more difficult to control when MR were paper-based. The
standardization of information and its storage in a single database has also facilitated the collection
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of information for clinical and epidemiological studies and for tracking quality indicators. For over
fifteen years, VLF has had a culture of quality and continuous improvement. SAP became a useful
tool for improving processes by providing timely and reliable information far more efficiently than
was possible with paper records, greatly facilitating quality management. Regarding patient safety,
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the indicator of preventable adverse events for every one hundred hospital discharges dropped from
7.16 in 2013 to 5.48 in 2014.
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As users took ownership of the system, many wanted more of their job-related activities to be
supported by SAP, leading to many requests to the Projects department for new developments. To
maintain its policy of standardization vs. customization, the Projects department prioritizes
requests coming from units or departments, rather than individuals.
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Today VLF is a national benchmark for healthcare providers seeking to improve patient care
delivery processes.
Surviving SAP: internalizing new routines
SAP brought considerable changes to both business processes and the understanding of the role
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played by each person (see Exhibit 5). When dealing with online data, if everyone doesn’t do their
part, the next person in the sequence won’t be able to do theirs. This significantly altered the way
people worked since everyone had to think about the entire process, not just their individual part
in it and had to understand the role played by others as well. It was not simply that everything
previously done with pen and paper was computerized; workflows also changed. Hernando Garcia,
head of IT, explained: “Synapsis was not a technology project; it was a process redesign project:
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everyone had to learn to work differently than they had before.”
IT implementation also created challenges for people involved in patient care delivery. One such
challenge related to errors that can arise in daily practice, such as the possibility of impaired
communication between doctors and other healthcare professionals such as nursing and pharmacy
staff if personal contact is lost and communication is done only electronically. In a hospital the size
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of VLF this risk was likely present even before IT implementation, however. The sense of security
that computerized decision support systems create can also lead to an overreliance on such systems
and a failure to use one’s own judgment in patient care decisions, particularly in the case of those
with special or unusual health considerations.
In any case, some VLF staff members believed that some things never change, despite the benefits
offered by IT. The head of the transplant program explained his perspective: “Patient safety is
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always in the hands of patients and those caring for them, whether they be healthcare assistants or
physicians. This is a philosophy, a culture, at VLF that we have always had. These systems provide
us with more information and are certainly useful; it’s good that the system alerts me of allergies
and drug interactions, of prescription dosage limits; all that is helpful, but it can’t replace the
physician’s judgment. We could have allowed doctors to access SAP from outside VLF, but we
decided not to. We don’t want doctors prescribing from a distance; we want to be sure that contact
with patients and families is not lost.”
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When staff members were asked whether, if given a choice, they would eliminate SAP and return
to previous organizational routines and practices, the answer was unanimous: no one wanted to
return to the previous model.
Almost five years after the launch of SAP at VLF, Granados decided the time was ripe to carry out
a project post-mortem. She summarized her approach: “These projects must be evaluated from an
© HEC Montréal 19
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overall perspective, from that of the institution as a whole, not just that of individual needs or
preferences. If you ask them whether they are satisfied with SAP, some doctors may answer
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negatively. They may say they were better off before, although I dare say most feel that SAP has
added value. But, if you look at the overall results of VLF in terms of patient safety and financial
results, the results obtained with Synapsis have been extremely positive.” Granados was certain
that ongoing support for end users, extensive training of newcomers, and new software
developments to improve the quality and efficiency of healthcare for VLF patients will help
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consolidate the project’s achievements. With this in mind, she was prepared to draft a report of the
accomplishments and lessons learned throughout the journey.
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2016-04-13
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Exhibit 1
Valle del Lili Foundation Statistical Highlights
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Patients 2014 2013 2012 2011 2010
Inpatients 15,368 14,164 12,716 11,214 11,059
Intensive care 6,398 6,093 6,777 6,596 6,737
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Average length of stay (days) 6.2 6.4 6 5.6 5
Emergency room visits 67,365 66,044 62,848 59,173 58,979
Outpatient visits
Specialists 372,261 351,189 333,823 289,941 279,796
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Laboratory tests 1,910,962 1,706,216 1,510,771 1,276,280 1,196,018
Diagnostic tests 148,547 141,473 127,052 120,849 109,757
Other ambulatory procedures 582,945 303,617 282,775 274,581 209,680
Surgical procedures 15,901 14,707 14,310 12,994 11,865
Inpatients 9,132 8,456 8,561 7,930 7,442
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Outpatients 6,769 6,251 5,749 5,064 4,423
Oncology
Chemotherapy (patients) 9,952 9,212 8,484 6,914 2,093
Transplants
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Marrow 63 58 58 42 56
Kidney 49 44 73 93 121
Liver 60 55 63 56 44
Heart 12 9 10 8 13
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Others 8 5 8 6 11
Floor beds 330 324 303 268 263

Intensive care beds 180 175 170 163 163
Adapted from Tucker and Edmondson (2011)

Source: Valle del Lili Foundation
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Exhibit 2
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2014 2013 2012 2011 2010
Full-time specialists 260 239 230 207 214
Part-time physicians 50 48 54 47 37
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Nurses 336 308 282 257 280
Nursing assistants 632 565 504 469 443
Other assistive personnel 620 552 513 493 494
Administrative staff 1,027 1,008 923 865 886
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Exhibit 3
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2014 2013 2012 2011 2010
Income* 202,631,353 179,764,244 160,282,589 133,062,684 125,417,398
Operating margin 9.01% 4.10% 4.30% 2.10% 3.00%
Net margin 7.66% 1.20% 3.20% 1.20% 1.20%
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EBITDA * 28,316,990 17,161,165 16,062,621 10,824,757 8,700,000
Number of bills 708,389 655,916 622,066 555,948 497,462
% revenues with HPOs 51% 58.10% 64.60% 65.12% 59.62%
* US dollars
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tC
No
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© HEC Montréal 23
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Exhibit 4
Communication Strategy
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Stakeholder Communication Training Transition
Patients • Web page • Most processes associated with patient care delivery were slower
/families • Recorded waiting message on • Wait times increased
telephones • Regular patients learned new workflows
• Videos in waiting rooms,
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cafeterias
• Flyers, posters
• Face to face
Health insurers • Meetings • Medical auditors • Adjustments to SAP reports to comply with insurer needs
trained in SAP
modules
Doctors • Synapsis’s leader was a • Doctors were • Help desk for 120 days after go live, extra staffing maintained after go
doctor who sent a positive trained by doctors live
buy-in message to other • Training sessions • Physician help line
physicians on SAP functionality • Support staff present on-site in main clinical units
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Top-down • SAP Interactive • Projects department managed clinical unit requests for SAP
• CEO informed the physicians module (RWD) for functionality; new interfaces with diagnostics and lab software added
medical council personal training • Projects department continued to offer support to end users
• Heads of clinical units • Computer labs with • Learning of new workflows associated with online information and
informed doctors SAP modules made paperless service delivery
Bottom-up available for • Increased understanding by end users of the role of their transactions in
• Doctors given a voice, practice 24/7 the overall care delivery process
participated in design teams; • Increased awareness of the impact of their tasks on other people
gave feedback to optimize the • Learning to perform new roles and responsibilities, post-adoption
system behaviours (e.g., placing medical orders and clinical notes in SAP)
• Walking the talk, visible leadership support, visible actions, clinical unit
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leaders using SAP
• Co-worker support in case of trouble with SAP transactions; knowledge
transfer in an informal one-on-one fashion
Assistive • Synapsis’s leader was a • Training in basic • Help desk for 120 days after go live
personnel doctor; project supported by computer skills • Learning of new workflows associated with on-line information and
CMD to ensure physicians’ offered as soon as paperless service delivery
buy-in project announced • Walking the talk, visible leadership support, visible actions, head nurses
Top-down • Training sessions using SAP
• CEO informed physicians on SAP functionality Co-worker support in case of trouble with SAP transactions; knowledge
tC
•
medical council • Computer labs with transfer in an informal one-on-one fashion
• Chief nursing officer informed SAP modules • Increased understanding by end users of the role of their transactions in
head nurses and other available for the overall care delivery process
assistive department leaders practice 24/7 • Increased awareness of the impact of their tasks on other people
(pharmacy, physiotherapy, • Training mandatory, • Users felt SAP allowed them to do their jobs more efficiently, leaving
etc.); leaders informed their time set aside for less room for preventable mistakes (e.g., “five corrects”)
teams training sessions
Bottom-up
• Nurses participated in design
teams, gave feedback to
No
optimize the system

Administrative • Synapsis’s leader was a • Computer labs with • Help desk for 90 days after go live
staff, back office doctor; project supported by SAP modules • Learning of new workflows associated with on-line information and
CMD to ensure physicians’ available for paperless service delivery
buy-in practice 24/7 • Walking the talk, visible leadership support, visible actions
Top-down • Training sessions • With the “big-bang” implementation, the old systems disappeared; no
• CEO informed physicians on SAP modules parallel systems operating
medical council (e.g., billing, supply • Co-worker support in case of trouble with SAP transactions; knowledge
• Chief administrative officer chain) transfer in an informal one-on-one fashion
informed department leaders; • Training mandatory, • Increased understanding by end users of the implications of their
leaders informed their teams time set aside for transactions on the overall care delivery process
Bottom-up training sessions • Users felt SAP made their job easier
• Process leaders participated in
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design teams, gave feedback

to optimize the system
Suppliers • Meetings • Learning of new workflows associated with on-line information and SAP
functionality
© HEC Montréal 24
t
Exhibit 5
Major changes in business processes and roles
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Process Before SAP With SAP
Medical records • The doctor handwrote medical notes • The doctor types all medical notes into SAP
• Assistive personnel handwrote clinical notes regarding patient • Assistive personnel type clinical notes about patient care into SAP
care delivered • All information in SAP is legible
• The doctor dictated patient notes into a dictaphone. This was • Users who access SAP are traceable, with date and time
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transcribed by a secretary and then attached to the patient’s • System stops if required information is not entered
chart • 24-7 on-line access of MR from any computer at VLF
• Difficulty understanding what was written in the medical notes
• Difficulty in identifying who wrote what in medical and clinical
notes
• Chance of omitting information from medical and clinical notes
• MRs filed in the patient’s chart. They were moved daily to and
from the units and the archives
• Chance of misfiled documents, missing charts
Medical orders • The doctor handwrote orders • Doctors must enter orders in SAP. If they do not do so, supplies and
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• Difficulty understanding what was written in the medical medicines are not dispatched, and no procedures are performed
orders • All information contained in electronic medical orders is legible
• Orders could be given verbally • Assistants do not comply with orders that are not in the system, e.g., the
pharmacy does not supply medicines when medical orders are not
placed in SAP
Drug • The doctor handwrote medical orders • The patient receives a bracelet with a barcode when admitted into VLF
administration • The nurse read the medical orders and handwrote clinical • The doctor types into SAP the medication orders for the patient
notes regarding drug administration (patient, medication, (medication, presentation, route of administration, dosage, time of
dose, route, time) administration)
• Drug allergy alerts were handwritten and attached to the • SAP alerts about patient allergies
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patient’s chart; there was a risk they might not be seen. • SAP alerts the doctor about possible drug-drug interactions
• The “five rights” of medication administration were checked • The nurse receives medical orders in SAP and prepares the
manually (patient, medication, dose, route, time) drugs/procedures
• The nurse uses a bar-code reader to check compliance with the “five
rights.” Warning system alerts in case of inconsistency (e.g., wrong
patient, wrong drug, wrong dose, wrong route, wrong time)
• Administered drugs are charged to the patient’s bill, to inventory, and to
accounts receivable
Charges to • Assistive personnel handwrote supplies and medications on a • The physician types in SAP supplies and medicines to be used for the
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patients and charge account form case

billing • The doctor handwrote a justification for drugs not included in • The system alerts the physician if a drug requires justification. If the
the OHP or the contract with the insurer. This step could be doctor does not enter a justification, SAP does not allow the physician to
skipped in some cases, resulting in reimbursement delays and continue with the order
inventory inconsistencies.
Medical fees • Doctors gave a paper invoice for their fees to the billing clerk • SAP has the price list of the fee for each procedure
• Doctors had to keep track of their bills to collect fees • SAP generates reports on-line so doctors can check their current fee
statement at any time
Supply chain • The movement of supplies and medications interfaced with • On-line inventory management, availability of information in real time
management accounting and inventory management systems • The movement of supplies and drugs impacts the inventory account and
No
charges to the patient’s account

Accounting • Information required an interface to impact accounting control • Information entered on-line exported to ledger accounts
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© HEC Montréal 25

Surviving SAP Implementation in A Hospital: The Valle Del Lili Foundation

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Surviving SAP Implementation in A Hospital: The Valle Del Lili Foundation

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What challenges did the hospital face with paper-based medical records?

What challenges did the hospital face with paper-based medical records?

How did the implementation of SAP impact medical orders?

How did the implementation of SAP impact medical orders?

HEC132

The Valle del Lili Foundation

hierarchical levels – directors, middle managers, process leaders – at the hospital.

Structure and Operation of Colombia’s Healthcare Industry

The VLF Medical Staff

Medical Records and Medical Orders

Searching for an Integrated Enterprise-Wide Solution: ERP, CPOE, EMR 1

When an organization implements an Enterprise Resource Planning (ERP) system, it undergoes

complexity of its cases, e.g., pharmacy management of patients undergoing chemotherapy, 2) at

System configuration decisions

adapted to what SAP offered.”

which was very different from the way we did it.”

Change management at every level

learning new software was to be expected.

Synapsis Project: Ready to Go Live

head of the transplant program)

Stabilization and adoption of the system

Surviving SAP: internalizing new routines

Floor beds 330 324 303 268 263

Adapted from Tucker and Edmondson (2011)

optimize the system

design teams, gave feedback

patients and charge account form case

charges to the patient’s account

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