Table 2.

Strategy, tactics, rationale, and associated considerations

Strategy	Tactics	Rationale	Considerations
Establish a world-class team	Recruit and retain experts in relevant domains including standards, clinical informatics, user-centered design, implementation, and evaluation	The underlying technology is cutting-edge and requires an expert workforce with technical as well as sociotechnical expertise	What expertise is needed for success? In what areas are we missing needed expertise?
	Support continuing training in needed skills (eg, training in EHR-specific API development)	The field is evolving rapidly; some technologies are EHR vendor-specific and require specialized training	Where is the field headed in terms of technological trends? Do we need additional training to meet current or expected needs?
Create enabling infrastructure to support individual innovations	Address common technical challenges through infrastructure tools	Tools that address common challenges can accelerate the development of individual innovations	What are the pain points in the development and implementation process? Is there a tool available to address the need, or do we need to create it?
	Create a systematic program for evaluating individual innovations across project phases	Evaluation is needed to ensure that innovations meet user needs, are adopted, and lead to desired outcomes. Standardization of evaluation steps saves resources and provides higher quality evaluation for individual projects	Are the tools being used? Do the tools meet users’ needs? How can we make them better? What impact are we having on users, patients and outcomes? What can we do to make future evaluations more efficient?
Focus on the most impactful, sustainable, desirable, and feasible individual innovations	Maximize return on investment with regard to patient care, finances, provider satisfaction, deployment scale, scientific impact, and/or research funding	To be sustainable, investments in EHR add-on apps must have a favorable return on investment	What is the anticipated impact in these areas? How many patients and/or providers could be positively impacted? Does the solution have commercialization potential? What is the cost of development, implementation, and sustainment? Will there be sufficient ongoing clinical value and/or potential for continuous external research funding to justify long-term institutional investment to sustain the innovation? Are additional resources (eg, grants) available? Will the project help foster the development of compelling new grant proposals?
	Focus on areas where desired functionality cannot be effectively and/or efficiently achieved through the native EHR, in particular cognitively complex decisions with limited EHR support	It is often easier and less expensive to configure the native EHR to support a specific task than to create an EHR add-on app. However, native EHR tools may be inadequate for meeting user needs related to cognitively complex decisions.	Does the EHR already do this sufficiently well? Has the EHR vendor committed to addressing this problem in an upcoming release? Is there a third-party product we should buy rather than building our own solution?
	Prioritize projects with a clear path to adoption	Lack of usage uptake is a common reason for an EHR add-on app to fail	Is there a committed clinical champion? Can the tool be integrated into routine clinical workflow? Can the tool be successfully deployed with minimal training?
Follow best practices for design, development, and implementation of individual innovations	Leverage interoperability standards such as FHIR, SMART, and CDS Hooks	While the use of standards can increase upfront development costs compared to using proprietary EHR configuration tools for which the workforce is predominantly trained, standards can reduce overall implementation costs and enhance dissemination potential	Is a relevant standards-based approach available for what we seek to accomplish? Is the marginal cost of standards support justified?
	Ensure security, privacy, and confidentiality	Securing patient privacy and confidentiality is paramount	What patient data are shared outside the institution? Are appropriate security controls in place? Are additional protections required, for example, to filter data shared with third parties through the FHIR protocol?
	Employ user-centered design and implementation	Innovations must meet user needs and be integrated with user workflows to succeed	What are the users’ needs in this area? What features would be most impactful for the user? What is the minimum viable product for early adopters? How will it best fit the users’ workflow?
Maximize synergies	Seek research synergies	An academic medical center has access to leading researchers; the field is a focal area for research	Are there researchers available with needed expertise? Are there research opportunities synergistic with what we are seeking to achieve?
	Consider partnerships	No single institution has the expertise and resources needed to fully optimize the EHR on its own	Does another group, either internal or external, possess relevant expertise or resources? Should we buy or license the tool? Does a partnership make sense?