NURS 718 Week 7 HMIS Project Part 2 on Planning the Health Information System Example

HMIS Project Part 2, Planning: Governance, Requirements, Workflow, Budget and Risk for a Three-Hospital Telestroke Network

Introduction

Part 1 of this project introduced a telestroke network for Shenandoah Valley Health, a rural three-hospital system whose two smaller hospitals rely on telephone advice for stroke decisions. The vision promises a stroke specialist at the bedside, by video, within a quarter of an hour of arrival at any of the three hospitals, followed by the right treatment in the right place. Five goals support that vision: rapid specialist access, faster treatment, more eligible patients treated, fewer avoidable transfers and prepared staff. This second part presents the plan for building the system. It describes the planning approach and governance, the current workflow and its gaps, the system's requirements, the future-state workflow, the choice of telestroke partner, infrastructure and security, the training plan, the budget, the risks and the timeline.

Planning Approach

Tan and Payton (2010) describe the development of a health management information system as a life cycle that moves from planning and analysis through design, implementation and ongoing evaluation, with each stage informing the next. They emphasize that planning must align technology with organizational strategy and that systems should be designed to adapt as the organization and its environment change. This plan follows that life cycle. It begins with an analysis of how stroke care works today, defines requirements from that analysis, designs a new workflow, and then plans the technology, people and resources needed to support it. Because a telestroke network is as much a clinical service as a technical system, the plan treats workflow and training with the same weight as equipment. Evaluation measures are defined during planning rather than after go-live, so that baseline data can be collected before anything changes.

Governance and Project Team

The board approved the project within the $1.4 million information technology capital budget, and the information system steering committee will oversee it. A project team reporting to the committee will carry out the plan. As the DNP-prepared project lead, I will coordinate the clinical side of the work and chair the evaluation group, which matches the expectation in Zaccagnini and White (2017) that DNP graduates turn evidence into practice and lead the use of information technology for better care.

The team will meet weekly during planning and implementation, and the steering committee will review progress monthly against the timeline and budget. Decisions that change scope, cost or schedule by more than 10% will go to the committee.

Current-State Workflow and Gaps

Mapping the current process was the first step of analysis. The project lead and the two site nurse champions observed stroke alerts at the smaller hospitals and reviewed charts of last year's 31 transferred patients. At present, when a patient with stroke symptoms arrives, the emergency nurse calls a stroke alert, the patient goes to computed tomography, and the emergency physician telephones the neurologist on call at the regional center if one is available. The neurologist cannot see the patient or the images in real time, so decisions rely on the physician's description. When a neurologist cannot be reached, the patient is usually transferred untreated. The review found four main gaps: no real-time specialist examination, no shared view of imaging, no standard thrombolysis order set at the smaller hospitals, and no consistent decision rule about which patients to transfer. Door-to-needle times were long partly because each case required improvised coordination. The review also found that time stamps for key steps were often missing, which means the current data are not good enough to serve as a baseline for every goal.

System Requirements

The requirements below were developed from the gaps, from the goals and from input by emergency nurses, physicians, the information technology department and the telestroke partner. Tan and Payton (2010) stress that requirements should be defined by the people who will use a system, not only by those who will build it, so each requirement was reviewed with the site nurse champions before it was finalized.

The automatic time stamps are the requirement most often overlooked and the most important for evaluation. Without them, Part 3 would depend on manual chart review, which the current-state analysis showed to be incomplete.

Future-State Workflow

The new workflow follows the patient from the ambulance to treatment or transfer. Every step has an owner and a time target, and the stroke alert script will be posted on each cart.

Before Arrival

Ambulance crews who suspect a stroke will call ahead, and the emergency department will open the stroke alert while the patient is still on the road. Sambursky et al. (2026) found that calling the teleneurologist before arrival cut roughly eight minutes from door-to-needle time and raised the share of patients treated. Regional ambulance services will receive a short briefing and a laminated card with the hospital's direct line.

Arrival to Consultation

On arrival, the triage nurse confirms suspected stroke using a standard screening tool, records the time last known well and activates the alert, which pages the telestroke service, the emergency physician, the computed tomography technologist and the laboratory at the same time. The primary nurse brings the cart to the bedside and dials the neurologist by phone at the same moment the video connects, so a dropped picture never leaves the team without the specialist's voice. The target is for the consultation to begin within 15 minutes of arrival, matching the vision.

Examination and Imaging

The remote neurologist examines the patient by video, with the nurse helping to position the patient and performing parts of the examination as directed. The patient then goes to computed tomography, and the images are pushed to the neurologist immediately. Evidence from a national quality program shows that this step matters: among patients transferred for thrombectomy, greater use of a camera during telestroke consultations and greater use of stroke screening tools were each associated with shorter door-to-puncture times at the receiving hospital (Mac Grory et al., 2025). The plan therefore requires video, not telephone, for every consultation, and a screening tool for every patient.

Treatment Decision

The neurologist and emergency physician agree on a decision, which the physician documents. If thrombolysis is recommended, the nurse uses the new standard order set, aiming for treatment within an hour of arrival, the Goal 2 standard. If thrombectomy may be needed, transfer is arranged at once. Patients who do not need transfer are admitted locally under protocols developed with the hospitalists.

Transfer for Thrombectomy

For patients who may need thrombectomy, every minute before departure delays treatment. In a study of two rural telestroke networks, the median door-in-door-out time was 107 minutes for patients who went straight to transfer but 169 minutes for those who had computed tomography angiography at the first hospital, and the overall time to groin puncture was longer when angiography was done before transport (Al Kasab et al., 2019). Our protocol will therefore not delay transfer for vessel imaging when the neurologist suspects a large vessel occlusion on clinical grounds and transport is ready, a decision the neurologist and the receiving center will make together. Door-in-door-out time will be added as an evaluation measure. The protocol will also set a target for that interval and assign the charge nurse to call for transport as soon as the neurologist raises the possibility of thrombectomy, rather than waiting for the treatment decision to be complete. Ambulance and helicopter options will be listed on the cart with their typical response times so the team does not have to look them up during an alert. The most important design choices in this plan are not about the camera; they are about what the team does while the camera is on.

Looking Ahead to Inpatient Care

Although inpatient telestroke is outside the first phase, the workflow is designed so it could be added later. Clinicians at five spoke hospitals of an inpatient telestroke program valued easy access to stroke specialists and fewer transfers, but they also reported communication gaps between teams, worries about supervising remote advanced practice providers, difficulties timing remote visits around discharge and a need for nurses to feel empowered in the new model (Pestka et al., 2024). Those lessons have shaped the emergency phase as well: the plan names who communicates with whom at each step and gives bedside nurses a defined role in every consultation.

Choosing the Telestroke Partner and Technology

Hospitals obtain telestroke services in two main ways: through a hub-and-spoke arrangement with a stroke center or through a third-party vendor of neurology coverage. In a survey of 89 hospitals in five states, more than two-thirds of telestroke programs reported working with other organizations to improve their services, and the most commonly requested guidance concerned monitoring process measures, using performance indicators for improvement and sharing measure data with physicians (Shea et al., 2022). That finding shaped our selection criteria. Three options were evaluated: the comprehensive stroke center 95 miles away, a university stroke program further away and a national vendor.

The comprehensive stroke center is recommended. Its neurologists already receive our transfers, so consultation and transfer decisions would be made by the same team, and its telestroke program offers a quality dashboard with monthly data sharing. The contract will specify response times, with the neurologist on video within 10 minutes of the page; credentialing of the neurologists at our hospitals by proxy; quarterly joint case reviews; data sharing for every consultation; and an exit provision that applies whenever performance standards are missed in two quarters running. The video carts and platform will be the ones the stroke center already uses, which simplifies support and allows its technicians to troubleshoot remotely.

Infrastructure and Security

The information technology department will install three telestroke carts, one in each emergency department, with a spare at the regional center. A network assessment showed reliable bandwidth at the regional center and community hospital but a single connection at the critical access hospital. A second connection from a different provider with automatic failover will be installed there before go-live. Wireless coverage will be tested in every emergency room, the imaging suite and the trauma bay, and access points added where the signal is weak. The carts will be managed devices that receive updates on a fixed schedule and are monitored for faults.

Security follows the same plan. Video and images will be encrypted in transit, users will sign in through the organization's single sign-on, and audit logs will be reviewed monthly. The compliance officer will complete a security risk assessment of the whole workflow, and the business associate agreement will define responsibilities for breaches. Consultations will not be recorded. A written downtime procedure will require an open telephone line to the neurologist at the start of every consultation and a printed checklist on each cart, so a technical failure becomes a switch to telephone rather than a gap.

Communication and Stakeholder Engagement

A system that changes clinical roles needs more than an announcement. The communication plan has three audiences. Clinicians at the smaller hospitals will hear about the project first from their own leaders, at staff meetings in month 2, with the physician champion and site nurse champions explaining why the network is needed using last year's transfer data. Clinicians at the regional center and the comprehensive stroke center will be briefed on how consultations and transfers will change, since their workload and expectations will shift as well. The community will learn about the service through the hospitals' newsletters and local media after go-live, with a focus on recognizing stroke symptoms and calling 911 rather than driving to the hospital. A monthly one-page update to all staff will report progress against the timeline, and after go-live it will report the network's results, including cases in which the system helped a patient. Feedback will be collected through the site nurse champions and a short form on each cart, and the project team will respond to every comment within two weeks.

Building Evaluation Into the Design

Tan and Payton (2010) treat evaluation as a continuing part of the life cycle, so measurement in this plan begins before the first cart arrives, not after go-live. The stroke coordinator will begin collecting baseline data in month 1 using the same definitions that will be used after go-live: time of arrival, time last known well, time of imaging, time of decision, time of treatment and time of departure for transferred patients. A chart review method for judging whether a transfer was avoidable will be agreed with the partner's neurologists before go-live, so that the definition does not shift once results start to arrive. Balancing measures, including emergency nurse overtime and the time nurses spend on each consultation, will be tracked from the first month. Collecting these data before the system changes anything is the only way to show in Part 3 whether the network made a difference.

Training Plan

Emergency staff at the smaller hospitals have no telemedicine experience, so training is essential to Goal 5. The training will have three parts: a one-hour online module on the stroke alert process, video etiquette and the downtime procedure; a hands-on session with the cart; and a simulated stroke case run with the remote neurologist. Simulation has strong support. In a French telestroke network, a standardized simulation module for 225 members of six emergency teams raised mean test scores from 59% before training to 82% after, and nurses' scores rose from 54% to 80% (Richard et al., 2016). Every emergency nurse, physician and computed tomography technologist at the three hospitals will complete the training before go-live, and each site will run a monthly simulated alert that includes a planned video failure. Readiness also depends on familiarity: staff who have seen a telemedicine system in use tend to view it more favorably (Chatzidaki et al., 2026), so the carts will be placed in each department four weeks before go-live for staff to explore.

Budget

The budget fits within the $650,000 approved for the project's first year. Recurring costs from the second year onward are shown separately so the board can see the full commitment.

The recurring cost is substantial, so the business case does not rest on cost savings alone. Still, the evidence suggests that telestroke can be good value. A systematic review of 12 economic evaluations found telestroke highly cost-effective in five studies, meaning it both cost less and produced better outcomes, although the results varied with the network's structure and setting (López-Romero et al., 2025). Our finance office estimates that avoiding even a quarter of last year's transfers and keeping those admissions within the system would offset a meaningful share of the recurring cost; this estimate will be tested in Part 3.

Risk Management

Each identified risk has a likelihood, an impact, a mitigation and an owner.

The last risk deserves attention. Shen et al. (2026) found that the growth of stroke centers between 2009 and 2019 reached higher-income rural communities more often than lower-income ones and was associated with differential gains in treatment. The critical access hospital serves the poorest part of our region, so it will be included in the first wave of go-live rather than added later, and results will be reported for each hospital separately.

Timeline

The project runs twelve months from approval to the end of the stabilization period.

The decision to go live at all three sites together, rather than one at a time, reflects the equity concern and the small size of the program; the partner has agreed to place a telestroke coordinator on site for the first week.

Christian Worldview

Nehemiah did not begin rebuilding the wall of Jerusalem until he had surveyed it by night, gate by gate, to see what was broken and what was needed (English Standard Version Bible, 2001/2016, Nehemiah 2:11-18). Careful planning of this kind is an act of faithfulness. Patients whose lives may depend on a video consultation deserve a system that has been tested, staffed and secured before the first alert, and the stewardship of a not-for-profit system's money requires that each dollar have a purpose and an owner. Proverbs also commends the plans of the diligent over haste (English Standard Version Bible, 2001/2016, Proverbs 21:5), a fitting reminder in a field where speed matters but rushed implementation can cause harm.

Conclusion

This plan translates the vision and goals of Part 1 into a system that can be built: a governance structure with named roles, requirements grounded in the current workflow's gaps, a future-state workflow shaped by evidence on prenotification, camera use and imaging before transfer, a partner chosen for its ability to share data, secure infrastructure with a downtime procedure, simulation-based training, a budget of $650,000 with recurring costs disclosed, a risk register and a twelve-month timeline. Part 3 will describe how the plan will be implemented, how the system will be evaluated against the five goals and how it will be sustained.

References

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Chatzidaki, S., Anargyros, K., & Xanthos, T. (2026). Human readiness for stroke telemedicine in a Greek island network: A cross-sectional study. Telemedicine and e-Health. Advance online publication. https://doi.org/10.1177/15305627261492660

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