CIS Definition/overview Clinical Information System—is a technology based system that is applied at the point of care and is designed to support the acquisition and process of information as well as providing storage and processing capabilities. It is a collection of various information technology applications that provides a centralized repository of information related to patient care across distributed locations.(McGonigle, D & Mastrain, K).
The 8 components needed inthe CIS system Schedule designe Number of systemType of application and budge users constraintsDepartment using Where software and How & where data the systems data will reside will be backed up Requiements for system redundancy (Thede, L & Sewell, J).
Technological Competencies All users of computerized clinical information system need to have technological competencies. These competencies, computer literacy and keyboarding skill, should be addressed long before a system is implemented (Thede, L & Sewell, J).
Who are the key players?Implementation should involve those who work w/ patients to improve the interface, accuracy and security . IT Department Physicians, & Project Support Staff PCA’s & Management Nurses Essential in entering patient information and HIPPA laws to ensure privacy, reducing errors in distribution of meds to patient (book) Ensures proper screening and preventative measures Essential skill of the nursing Provides timely response to informatics specialist. patient needs Refers to the management of the project from start to finish. (book) Ensures accuracy and Timely manner in which any eliminates the need for lost problems are addressed charts (Thede, L & Sewell, J).
Costs involved withimplementing a CIS systemTier 1: (less than 100 bed facility) $1-$2million spent on hardware, software andimplementation. $100,000 spent eachyear on maintenance fees Tier 2: (100-300 bed facility) $3-$10 million spent on hardware, software and implementation. $200,000-$300,000 spent per year on maintenance. Tier 3: (more than a 300 bed facility) $10m-$1b spent on hardware, software, and implementation. $1m spent each year on maintenance. (Cotti & Swab)
Safety Con’t Storage of Data ◦ Should provide retrieval of data used in long-range planning and research (Thede, L & Sewell, J). Protection of the files ◦ Major software upgrades include new virus protectors. ◦ Equipment and software upgrades to ensure up-to-date software (Thede, L & Sewell, J).
Safety Con’t Ways to protect your passwords ◦ Change your password often ◦ Use letters and numbers ◦ Never give your password out to anyone Ways to back up data ◦ DVD ◦ To a main Hub off site ◦ A zip drive ◦ Any other device that can be stored off location site (Thede, L & Sewell, J).
HIS project requirements refer to certain needs that include: Schedule, design, and budget constraints: should be limited to only a number of uses in the IT department or management department The number of system users: should be The departments that will use the system: should limited only to those include those that only need access to the with clearance and the system, such as IT department, nurses, experience (training) to physicians etc… use the software. Requirements for system The type redundancy (if one system The type and availability of system of Where the software and data will fails, another system takes support that is available.: even theapplication reside: The main hub should be over) best systems will have bugs & located off campus and issues, and system maintenance monitored closely for security is an ongoing process (Thede, L breaches or viruses & Sewell, J).
Electronic MEDICAL Record Electronic medical records are records about patient care that are kept on a computer rather than on paper, the traditional medium for patient histories. These records can include extensive information about a patients general health, current and past illnesses and medical conditions, diagnostic test results and treatments and medications prescribed. Often, electronic medical records also include an application for prescribing and ordering medication (Heflin, C). They are owned and managed by the institution or provider that creates them, and are often combined so that information from all member agencies and providers is accessible by those with the required authorization (Thede, L & Sewell, J).
Electronic Health Record The current record system, whether paper or electronic, makes it difficult for individual to have access to their healthcare records. Additionally, it handicaps healthcare providers by preventing them from having complete information about a person. Under the HER model, one’s health information will be available from any location. ◦ This will make it easier for patients who visit multiple providers ◦ Will also provide safer care in the advent of an emergency (Thede, L & Sewell, J).
How often should it beupdated to meet EBP guidelines? EBP guidelines should be updated frequently, as little as every 3 months but no longer than 1 year, to ensure the best standard of care is being delivered to the patients.
Advantages of EMRAdvantagesComputerized records have several advantages over traditional paper records: 1. The data tends to be more accurate. Electronic records eliminate the possibility of mistakes as a result of misreading a doctors handwriting. 2. Theyre easily accessible to all care providers and to more than one care provider at a time. 3. Theyre easy to store and take up less space than paper records. 4. Theyre easily portable from one doctors office to another. 5. Their use can lead to cost savings, since keeping electronic records is more efficient than retaining paper records (Heflin, C).
Disadvantages of EMRDisadvantages of computerized records include the following: 1. The possible incompatibility of computer systems among various health care providers can lead to difficulty in sharing the data. 2. Privacy and security can be an issue. If someone hacks into a computer system, thousands of patients records can be compromised. Also, some critics say the federal government wants to use electronic records systems to ration health care services. 3. Computer crashes make records inaccessible. 4. The cost of implementing an electronic records system can be expensive (Heflin, C).
ReferencesCiotti, V. & Swab, J (2010). What to consider when purchasing an EHR system. Healthcare financial management, 64(5):38-41 Cinhal plus with Full Text.Heflin, C Definition of electronic medical record. (n.d) retrieved 04/10/2012, from eHow Web Site: http://www.ehow.com/about_5059193_definition- electronic-medical-records.htmlMcGonigle, D & Mastrain, K (2009). Nursing Informatics and the Foundation of Knowledge. Jones and Bartlett Publishers. Pg 193.Thede, L & Sewell, J (2010). Informatics and Nursing. Philadelphia, PA 19106: Lippincott Williams & Wilkins. Pg. 233-234, 329-340, 350,