Team Members Tina Fulbright – Slides #2 – 12

Christy Smith – Slides #13 – 23

Jali Jackson – Slides # 24 – 35

Todd MacDonald – Slides #36 - 51

As you will see in the following compilation of research, Clinical Information Systems are multifaceted with the ultimate goal of providing clinical decision information to the clinician. This information allows the clinician to make decisions about patient care and can enhance patient outcome.

CIS OverviewCIS refers to a Clinical Information System. The system requires multiple technology applications which are used at the point of care. The CIS is capable of acquiring, processing, retaining, and retrieving information related to patient care.

(McGonigle & Mastrian, 2009)

Choosing, Implementing, Revising the CIS

The choice of systems is one made between multiple departments. A collaborative effort is required in order to ensure that the needs of all departments are met by the system chosen for the facility. Various committees are formed to gather information in an effort to focus the goals of the system, to oversee clinical quality as well as evaluate design of the system and hardware.

(Al Mallah, Guelpa, Marsh & van Rooij, 2010)

Choosing, Implementing, Revising the CIS (Cont)

Some of the team players would include administration and executive staff as well as representatives from clinical specialty areas, support services, and the information technology department. Software vendors are also called upon for their input and recommendations.

(Al Mallah, Guelpa, Marsh, & van Rooij, 2010)

Some of the team players would include administration and executive staff as well as representatives from clinical specialty areas, support services, and the information technology department. Software vendors are also called upon for their input and recommendations. After implementation of the CIS, revisions are made based upon the needs and input of the users.

(Al Mallah, Guelpa, Marsh, & van Rooij, 2010)

Clinical Decision SupportClinical decision support (CDS) is a program which is

computer-based. It is intended to help clinicians make clinical decision. Large amounts of information are integrated or filtered during this process and give clinicians suggestions in regard to clinical intervention. (The Design, 2001)

CDS Infrastructure• A quality infrastructure would include a depository of medical

knowledge that would require “standardization of CDS and genomic medicine information”. This information would need to be computer-processable;

• In order for it to be computer interpretable, there must be a standard format of patient data. An example would be Health Level (HL) 7 and extensible markup language (XML);

• The approach used to acquire medical knowledge and find and recapture patient data in order to form patient-specific guidance by bringing together both the personal data of the patient and medical knowledge.

(Al Mallah, Guelpa, Marsh & van Rooij, 2010)

The American National Standard Institute HIT Standards Panel (HITSP) champions “the standardization of health information technology through the American Health Information Community.”

(Al Mallah, Guelpa, Marsh & van Rooij, 2010)

Structure and UpdatesThe design of the CDS should be easy to use for the clinician. It should contain quality up-to-date medical information that will help the clinician make the best decision for each individual patient. The system should be updated as new information becomes available.

Clinical Decision Support SystemsThere are multiple systems available on the market. Listed below are just a few of the CDS systems available and their design companies.

TheraDoc, Inc/Hospira

VisualDx/Logical Images

QMR/First Data Bank

(Clinical Decision, 2003)

Conclusion

Obviously, when considering a CIS, one must look at multiple factors. There must be a team assembled to determine what is needed by that particular facility. The HER, CDS, safety of the system, cost and the education for staff must all be considered in great detail before one can begin to work towards implementing a successful system into their facility.

The EHR Component The HIMSS(Healthcare Information and

Management Systems Society, 2006) defines an EHR as a “longitudinal electronic record of patient information produced by encounters in one or more care setting” (McGonigle & Mastrian, 2009).

The IOM(Institute of Medicine) defines the EHR as “health information and data that is the patient data required to make sound clinical decisions including demographics, medical and nursing diagnoses, medication lists, allergies and test results” (McGonigle & Mastrian, 2009).

Eight Components to the EHR

Health Information and

Data

Results Management

Order Entry Management

Decision Support

Electronic Communication and Connectivity

Patient Support

Administrative Processes

Reporting and Population

Health Management

Health Information and Data The patient data required to make sound clinical

decisions including demographics, medical and nursing diagnoses, medication lists, allergies and test results(IOM,2003) (McGonigle & Mastrian, 2009).

All personnel that have a sign on, password and credentials(for most facilities) have access to this information. Doctors, nurses, PA’s, NP’s, etc… There is a demographic view available for admission staff.

Results Management The ability to manage results of all types

electronically including laboratory and radiology procedure reports both current and historical(IOM, 2003)((McGonigle & Mastrian, 2009).

Laboratory and radiology personnel have the ability to view and enter results here. Authorized staff have the ability to view results here. Any personnel with the credentials to view patient records has access to this information. Without this component, results are delayed and hard to compare with archived records.

Order Entry Management The ability of a clinician to enter medication and

other care orders, including laboratory, microbiology, pathology, radiology, nursing, supply orders, ancillary services, and consultations directly into a computer(IOM,2003) (McGonigle &Mastrian, 2009).

Personnel are given rights according to their credentials. Orders and medications are signed by physicians electronically when needed. Without this component, there are several extra steps that must be taken to complete the task of placing an order for a patient.

Decision Support The computer reminders and alerts to improve the diagnosis

and care of a patient including screening for correct drug selection and dosing, medication interactions with other medications, preventative health reminders in areas such as vaccinations, health risk screenings and detection, and clinical guidelines for patient disease treatment(IOM,2003)(Mcgonigle& Mastrian, 2009)

This component helps us to monitor what the patient has and has not had completed according to their medical record. It also aids in the faster prescribing of medications for physicians and keeping patients safe from possible deadly interactions from their medications. This is a powerful tool for both the healthcare team and patient satisfaction.

Electronic Communication and Connectivity The online communication among healthcare team

members, their care partners, and patients including E-mail, Web messaging, and an integrated health record within and across settings, institutions, and telemedicine (IOM, 2003) (McGonigle & Mastrian, 2009).

This component is important for access to patients records when they are being seen by a physician other than their primary care and history can be easily accessed. Not all parts of this system are utilized by all healthcare facilities, but they are available and helpful tools for accurate patient care.

Patient Support The patient education and self-monitoring tools,

including interactive computer-based patient education, home telemonitoring and telehealth systems(IOM,2003) (Mcgonigle & Mastrian, 2009).

These are very helpful for patients to be taken care of on an out-patient basis. Blood pressure monitoring for home health that reports immediately if there are any problems is a good example of one system used through a patient’s phone line. The report of the patient’s vitals is sent to the agency and they can call if something is not right or if the patient doesn’t respond to the machine telling them it is time for their vital signs to be checked.

Administrative Processes

The electronic scheduling, billing, and claims management systems including electronic scheduling for inpatient and outpatient visits and procedures, electronic insurance eligibility validation, claim authorization and prior approval, identification of possible research study participants and drug recall support (IOM, 2003) (McGonigle & Mastrian, 2009).

This helps the organization not double book patients for appointments and to get authorization for procedures and admits almost immediately. Of coarse not everything is automatic but it helps speed the process for both the institution and the patient. If your sign on has the credentials needed for this process, you have access to work in these sections.

Reporting and Population Health Management The data collection tools to support public and

private reporting requirements including data represented in a standardized terminology and machine-readable format (IOM, 2003) (Mcgonigle & Mastrian, 2009).

This is part of every healthcare system and is required by law. The reporting is done to evaluate EHR systems for functionality, security, and interoperability. This is regulated by the Certification Commission for Healthcare Information Technology or CCHIT.

The EMR/EHR was created to limit mistakes, cut down

expenses, and improve care.

EMR/EHR’s provide direct access to patient records, improve

order legibility, have built in safety features, and use of

standardized nomenclature.

Like with anything new, there is a need for protection and

education.

The following slides will show how safety and education will

be implemented regarding the EMR/HER.

(Buppert, 2010)

Backup Due to private and sensitive patient information, it is necessary to back-up the

EMR/EHR frequently (Buppert, 2010).

Not only does the system need to be backed up, but the method in which the

system is backed up needs to be assessed frequently to ensure that a back up is

taking place (Buppert, 2010).

It is necessary to ensure that the network storage or hard drive is efficient in

terms of space and function (Buppert, 2010)

Common back up programs include Legato and Net-backup software

(Rosenfeld, 2006).

A cheaper, yet slower, option is hierarchical storage management software

(Rosenfeld, 2006).

Storage

“The key driver leading to the need for healthcare institutions to pay attention to storage and archival resources is the dramatic growth in healthcare digital information” (Rosenfeld, 2006)

A cost efficient choice for storage management are enterprisewide storage architectures. This architecture “…expedite[s] management of storage

resources, enhance[s] the ability to share application data with other systems, and facilitate[s] automated data backup and redundancy/continuity” (Rosenfeld, 2006)

EMR/EHR AccessImplement password protected log-ins.

Automatic log out if no activity after 2

minutes.

Have designated staff to handle breaches

in security.

Have staff change their password every 6

months to ensure only employees have access to

sensitive records.

(Buppert, 2010)

HIPAA Considerations The HIPAA rule book is 1,500 pages long. Although this is a

massive amount of information, “…it is a well-thought-out, clear

set of rules about the accepted use of protected health

information” (McDonald, 2009).

HIPAA requires all organizations using EMR/EHR to maintain an

audit trail.

Other rules implemented by HIPAA regarding the EMR/EHR

took effect April 14, 2003.

These rules are to help maintain each and every patients privacy.

(Medscape, 2010)

Protection of Files It is important to protect the privacy of sensitive patient information.

With EMR/EHR comes the increased opportunity for security breaches

and viruses.

Because of this, there needs to be increased security and awareness

when charts are pulled up on the computer.

Built in automatic shut off and password protected screen savers are

a must have.

Antivirus and malware programs also need to be installed on all

computers to ensure that privacy is maintained

(Fetter, 2009)

Protection of Files (cont…) Due to the frequent occurrence of power surges, there is a chance for

disruptions in computer systems and network damage.

This risk can cause a loss of patient information and aggravated staff members.

Uninterruptible power supplies (UPS) can be installed to prevent this from

occurring.

A great option to use because it is generator friendly and removes the problems

associated with generator frequency synchronization problems.

(Reisz, et al., 2010)

Education Anyone who will be operating or charting in the EMR/EHR needs to be

properly educated on the proper way of doing so.

IT workers who are familiar with the program and all that it entails are

great resources to the facility and it employees.

An important aspect of EMR/EHR education is developing a plan that

will enhance computer literacy and competency of the staff.

It is “…critical to assess, develop, and maintain staff competency to

ensure quality of care in all nursing areas” (Miller & Arquiza, 1999).

Education Strategies Select members from each unit to be

trained in a way that they would be able

to train others- “Super users”

Structure classes based on position/level

(i.e. Nurses, doctors, CNA would be in

three different classes)

Conduct annual competency checks to

evaluate if more training is needed.

Have employees perform self

assessments and compare with

comments made by “super-users”

(Miller & Arquiza, 1999)

Education Strategies (cont…) Depending on whether weekly or monthly training sessions

are needed, there needs to be an adequate number of IT personnel available to “…answer questions and give impromptu training on [various units], and receive feedback on…problems in return” (Transitioning to, 2006).

Organizational planning and shared resources combined with a well thought out mission, vision, and yearly objectives can help advance knowledge and competency (Fetter, 2009).

Provide refreshments and support to facilitate participation.

Principles to Improve Effectiveness

Assess training needs

Don’t rush training time

Have a low student-to-instructor ratio

Allow staff to practice their new knowledge in the

classroom before use on real charts.

(Fetter, 2009)

Principles (cont…) Have paper versions of screen shots available to aid in

learning how to navigate through the EMR/EHR.

Allow extra practice time

Have extra trainers available to answer individual

questions.

Technical support needs to be available for each unit.

(Fetter, 2009)

Taking into consideration all aspects of implementing a CIS is a daunting task. Genesis, the joint initiative task force from St. Johns, has been responsible for the research and implementation of EPIC at St. Johns.

The total installation cost, Mercy-wide, has been approximately $500,000,000.

The following presentation discusses where the costs were incurred.

Micki Struckhoff, RN – VP Systems Integration, St. Johns Springfield.

What Is A Computer Network?Simply stated, a computer network “is two or more computers connected so that they can communicate with each other and share information, software, peripheral devices, and/or processing power.” The most common of which is called a LAN (local area network) and a WAN (wide area network).

highered.mcgraw-hill.com/sites/0072464011/student_view0/chapter6/glossary.html

Hardware and Software Hardware & software for a computer network involves

several components. Keep in mind, when a large network is installed, the hardware & software needs can increase significantly.

An upgrade to existing computer networks typically accompanies the addition of a CIS package.

ComponentsHardware

Robust computer workstation

Network Cables

Router with firewall

Servers & Backups

Repeater (if signal attenuation an issue)

Peripheral Equipment

Fiber optic connection to internet

SoftwareCompatible OS (operating

system & license)

CIS Software & license for each server (usually based on size of network involved)

Internet access

Software firewall

Antivirus

Classic Network Bandwidth &

Hardware Map

The picture on the left is a great depiction of what a typical wide area networks bandwidth looks like without hardware. The right is a very basic map of a LAN.

Support Personnel Relevant to the discussion is the number of support

technicians available and their associated salaries. According to indeed.com, the average salary for a computer technician in Springfield, MO is $33,000 per year. Depending on the size of network, this cost could multiply very quickly. The network manager will average $66,000.

Support Personnel Continued As is the case with EPIC, there are groups of IT

Technicians within the IT Department that strictly support the CIS, according to Micki Struckhoff, RN.

Anyone supporting the software must be certified through EpicCare, the company that supplies St. Johns’ CIS software.

Micki Struckhoff, RN. – VP Systems Integration for St. Johns Springfield.

Multiple redundancies are required for this type of market. Several ISPs are involved in making this system as failsafe as possible to achieve maximum stability.

Workstations Workstations are the PCs that everyone does their

work.

St. John’s needed to upgrade each PC that the hospital had to support the new software.

Part of the purchase of any CIS will be to train those utilizing the system. With EPIC, Certified Trainers were sent to Wisconsin for training by the company, EpicCare. As it was during the CIS implementation at St. John’s, those who would help the remainder of the system to become trained were the “Credential Trainers” for the next site for training, which included retired teachers.

Implementation Prior to implementing a CIS, a committee known as

Genesis at St. John’s, gathered information from all aspects from the hospital end-users. This committee represented a cross-section of all areas of the system. The needs from the end-user was translated into what the software was going to accomplish for our healthcare system. Going “live” would be done in phases as to eliminate potential unforeseen issues.

Implementation Other aspects needing to be considered is the

“transitional time and problems associated with switching over to a new clinical software.”

http://informatics.umdnj.edu/clinical/information_systems.htm

Challenge To Implementation Mercy wanted to standardize all areas to reduce the

cost of building software. Most common challenge was to standardize all order sets collaboratively across all regions.

Micki Struckhoff, RN – VP Systems Integration, St. Johns Springfield

Updates for the software are twice per year. This year will be a full system upgrade in December. Those wishing to improve their skills have the opportunity to work in a computer lab setting prior to utilizing the upgraded software.

Summary While the costs associated with this CIS were

considerable, a massive upgrade to the network backbone was the costliest portion. Thousands of due diligence and man hours went into the implementation of the CIS to ensure the most stable, reliable and user-friendly software would run seamlessly in our health care system.

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Barey, E.B.,(2009). The Electronic Health Record and Clinical Informatics. In McGonigle, D., & Mastrian, K.(Eds.), Nursing Informatics and the Foundation of Knowledge(pp.219-237). Boston: Jones and Bartlett Publishers.

Buppert, C. (2010, January 13). Medscape. Retrieved October 1, 2010, from Authors and

Disclosures: http://www.medscape.com/viewarticle/714812

Clinical Decision Support Systems. (2003). Retrieved October 6, 2010, from http://www.informatics-

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Fetter, M. (2009). Improving information technology competencies: implications for psychiatric

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Plus with Full Text database.

References ContinuedIndeed.com. Salaries for computer technicians in Springfield, MO. Retrieved

October 23, 2010. http://www.indeed.com/salary?q1=Computer+Technician&l1=springf

ield%2C+mo

Institute of Medicine. (2003). Key capabilities of an electronic health

system: Letter report. Washington, DC: National Academics Press.

Informatics Institute: University of Medicine & Dentistry of New Jersey . Retrieved October 20, 2010

http://informatics.umdnj.edu/clinical/information_systems.htm

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Affairs , 447-449.

McGonigle, D. & Mastrian, K. (2009). Nursing Informatics: and the foundation of knowledge ( pp. 193). Massachusetts:

Jones and Bartlett Publishers, LLC.

McGraw-Hill Online Learning Center. Retrieved October, 21, 2010. http://highered.mcgraw-hill.com/sites/0072464011/student_view0/chapter6/glossary.html

Medscape. (2010, September 10). Retrieved October 1, 2010, from OJIN: The Online Journal of Issues in Nursing:

http://www.medscape.com/viewarticle/723608

Miller, E., & Arquiza, E. (1999). Improving computer skills to support hospital restructing. Journal of Nursing Care Quality,

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References ContinuedReisz, T., Denny, J., Nguyen, D., Braun, D., Merkel, R., Kuhn, P., et al. (2010). 2010:

change & progress: our panel of experts offers readers their take on what to

look for in healthcare technology in the year ahead. Health Management

Technology, 31(1), 12. Retrieved from CINAHL Plus with Full Text database.

Rosenfeld, K. (2006). What is application-attached storage costing your facility?

As electronic healthcare databases grow, traditional backup systems may

become inadequate. Is information lifecycle management the future of data

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CINAHL Plus with Full Text database.

References ContinuedStruckhoff, Micki RN – VP Systems Integration, St. John’s Springfield.

Personal interview October 25, 2010.

Ten commandments for implementing clinical information systemsProc (Bayl Univ Med Cent). 2004 July; 17(3): 265–269. Retrieved October 23, 2010

www.ncbi.nlm.nih.gov/pmc/articles/PMC1200662/

Transitioning to electronic medical records: the move to electronic records presents opportunities

and challenges for physicians. (2006). AMIA Annu Symp Proc , 629-633.

University of California, Irvine, Donald Bren School of Information and Computer Sciences. Retrieved October 22, 2010. http://www.ics.uci.edu/.../Tech-EC/EC-EB/index.html

The design and implementation of a computerized patient record at the Ohio State University health system-a success story. (n.d.)

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