1. Evaluation of a clinical information system (CIS) Created By: Chelsea Anderson (slides 1 to 7) Breanna Valentine (slides 8 to 11) Kali Simpson (slides 12 to 17; 26 to 29) Sarah Diehl (slides 18 to 25)

2. Introduction “A clinical information system (CIS) is a technology based system that is applied at the point of care and is designed to support the acquisition and processing of information as well as providing storage and processing capabilities” (Huber, 2009, p. 193). There are many different important components of a CIS including the key players involved in decision making, the electronic health record (EHR), the decision making system, safety, cost, and education. Anderson, Chelsea

3. What is a CIS??? A CIS is “a collection of various information technology applications that provides a centralized repository of information related to patient care across distributed locations. This repository represents the patient’s history of illnesses and interactions with providers by encoding knowledge capable of helping clinicians decide about the patient’s condition, treatment options, and wellness activities. The repository also encodes the status of decisions, actions underway for those decisions and relevant information that could help in performing those actions. The database could also hold other information about the patient including genetic, environmental, and social contexts” (Huber, 2009, p. 193). Anderson, Chelsea

4. Key Players Involved in Choosing, Implementing, and Revising a CIS Nurses, of course! Nurses “play a vital role in data input and documenting compliance with the plan of care” (McGoldrick, 1999, p. 51). Nurses need to be involved with choosing a CIS. We must prioritize and decide what we need, what we want, and what we can live without. Nurses should be team leaders in implementing a new CIS and help others learn how to successfully use the new system with, hopefully, minimal frustrations and complications. We need to give our input about what is working, what needs revising, and what needs to be taken out of the system. Anderson, Chelsea

5. Key Players, cont. Physicians Physicians have some of the same role as nurses in regards to deciding what works for them, what they need or don’t need, and what they want in a well functioning CIS. They must also work together to implement the system successfully as well as discuss with one another parts of the system they would like to see change. Pharmacists They can look over aspects of the CIS including but not limited to medication administration, pop-up screens for medication interactions, pop-ups for dosing recommendations or incorrect doses, etc. Hospital Administration Administration must collaborate with all users to choose a CIS to be evaluated that will give them what they need. They must also design a plan for education and implementation of the new system. For revision, one at the administrative level must follow-up with users to ensure the system is meeting their needs and functioning well. If problems arise, the administrator is responsible for finding ways to revise the system as well as educating employees on how to suggest revisions to the system so that it is functioning how the users need it to. Anderson, Chelsea

6. Key Players, cont. Support staff UAP, lab technicians, physical therapy, occupational therapy, speech therapy, etc. Also known to use a CIS frequently, they are capable of deciding what they need, how they will help to implement the system, and revisions that they feel are necessary to make the CIS function properly for their area of work. IT personnel They are very important for technical issues or concerns when downtime occurs for updates. Patients and their families They have been well-known to make good suggestions for past concerns. It is possible for them to make suggestions for revisions of the current CIS so that it is easier for healthcare professionalsto retrieve information for themand to help with patient satisfaction. Other Health Professionals Respiratory therapists, dieticians, psychiatrist, optometrists, paramedics, etc. Anderson, Chelsea

7. Key Players, cont. Current users of the new system What experiences have they had? Good or bad? What worries do they have? Do any particular strategies work better for them? Designate an education coordinator This person can organize educational opportunities for users to learn how to use the new system when it is implemented. One or more education coordinator(s) may be needed on each floor once the CIS is implemented to help with problem-solving issues that will arise. Performance Improvement Dept. They “look at charting based on safety indicators or regulatory requirements” (Huber, 2009, p. 195). This allows them to help make revisions to the CIS so that it complies with regulatory requirements (JCAHO, federal, state). Anderson, Chelsea

8. EHR Components Health Information & Data The patient data that is required to make thorough clinical decisions including demographics, medical and nursing diagnoses, medication lists, and test results. Results Management The ability to manage results of all types electronically, including labs and radiology procedure reports. Order Entry Management The ability of a clinician to enter medication and other care orders, including labs, microbiology, pathology, radiology, nursing, supply orders, ancillary services , and consultations directly into a computer.

9. EHR Components cont. Decision Support 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, preventive health reminders in area such as vaccinations, health risk screening and detection, and clinical guidelines for patient disease treatment. Electronic Communication & Connectivity The outline 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.

10. EHR Components cont. Patient Support The patient education and self-monitoring tools, including interactive computer-based patient education, home telemonitoring, and telehealth systems. 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.

11. Who should have access? Physician, pharmacists, nurses, and other healthcare employees should have access to each of the EHR components only if the access will allow the member to provide better care for the patient.

12. System Structure of a Clinical Decision Making System The system is designed with one overall purpose: using clinical data (tools) to provide the safest healthcare possible. Comprising the structure are some main critical success factors: 1. Shared Vision- benefits of cost-effective delivery system and principal goal of providing better care 2. Executive Leadership- must allocate sufficient time for decision making and mediation of conflicts within the department 3. Decision Involvement- involve medical staff and clinicians from the beginning 4. Expectation Setting- clear short and long-term goals that are realistic achievable and have measurable outcomes

13. Continued… 5. Communication Process- use various modes of communication such as e-mails, bulletin boards, newsletters etc. Identify those who are resisting change and make them a part of the decision-making process so they feel some ownership and consequently are more likely to conform. 6. System Access- make sure there is ready access to the system and that it is always available. 7. Workflow Process- Examine and refine a new system before implementation. 8. Resource Allocation- necessitates knowledgeable professionals “who can build screens and develop documents supporting the professional practices”. 9. System Administrator- FT project manager 10. Education Plan- Mandatory education for anyone coming in contact with a patient chart. One-on-one teaching at clinicians convenience is best. Do not assume staff level of computer competency. The higher the comfort level, the greater the level of acceptance and fewer amount of errors. (Page, 2000)

14. Clinical Decision Support Tools Tools aiding in clinical decisions: Computerized alerts and reminders (overdue med. sign/abnormal labs) Clinical Guidelines (EBP) Online information retrieval (Micromedx) Clinical order sets and protocols (angiogram order set) Online access to organizational polices and procedures (Intranet->policies and procedures) (McGonigle & Mastrian, 2009)

15. Evidence Based Pracice Guidelines EBP guidelines should be updated as soon as research is released that validates the new standard and as soon as clinicians are educated/trained on the new guidelines Challenges occur due to several barriers of implementation: Lack of time Lack of access to libraries within a facility Lack of technology confidence Lack of knowledge on how to search for information Lack of value assigned to using research in practice Interpreting research while on the job is too complex (McGonigle & Mastrian, 2009)

16. Clinical Decision Making in a CIS: Cochrane Collaboration The Cochrane Collaboration is an international organization whose “mission is to prepare, maintain and disseminate systematic reviews of the effects if healthcare” (Pollack, 1998) The Cochrane library is available electronically and contains thousands of research studies and completed systematic reviews (Pollack, 1998) The organization removes out-of-date information to ensure that EBP remains current and new information is constantly being updated as new studies are conducted (Pollack, 1998) The Cochrane Collaboration is divided into specialties and education of its reviewers is a priority (Pollack, 1998) There are currently 32 review groups who put together systematic reviews of literature pertaining to their particular topic (Pollack, 1998)

17. Clinical Decision Support Systems (CDSS) Companies Examples of companies that design Clinical Decision Support Systems (CDSS): TheraDoc, Inc. VisualDx Dxplain QMR (Quick Medical Reference) DiagnosisPro McGonigle & Mastrian

18. The Safety & Security of a CIS The safety and security of a CIS is pertinent to the legitimacy of the EMR/EHR. According to Henson III (2006) to achieve comprehensive protection, a variety of measures must be undertaken including human engineering as well as hardware and software measures to protect the security of a clinical information system. Diehl, Sarah H.

19. Safety Measures These measured could include: User specific secure logins with “strong” passwords at user-limited access terminals Approved and regularly updated anti-viral software programs Regularly scheduled software and hardware updates Hardware and software firewalls Limited numbers of information retrieval and/or removal access points (i.e. USB ports, writeable disk drives, printers, integrated fax servers, etc.) Computer screen visibility limitations Limiting computer printing stations to confined areas Remote disaster proof back-up locations of the protected information. Diehl, Sarah H.

21. HIPPA & Security of a CIS The Healthcare Insurance Portability and Accountability Act (HIPPA) was designed with two broad components in mind. The first component of HIPPA (portability) was intended to allow workers to maintain healthcare coverage when they changed jobs. The second component of HIPPA (accountability) was intended to protect the integrity, confidentiality, and availability of electronic health information. Diehl, Sarah H.

22. How does the CIS make itself accountable? Integrity through the various safety and security measures making the information incorruptible. Confidentiality through the various safety and security measures making the information only accessible to the people who “need-to-know” it. Availability by being electronic and accessible to those who have proper authorization for it. Diehl, Sarah H.

23. HIPPA legislation concerning CIS HIPPA legislation allows for both fines and jail sentences for individuals who knowingly release protected health information (PHI). An entire health system can also be subjected to penalties for breaches in their security if it is proven that they were noncompliant with HIPPA or other computer regulatory standards (Henson III, 2006). Diehl, Sarah H.

24. Cost of a CIS The cost of a CIS includes: Hardware (updated or new computers, scanners, printers, etc.) Software (the program of the CIS as well as associated programs) Experienced users to train others Training of new users Decrease in productivity of training new users and paying others to cover the shifts left open. Set up of the “support services” (i.e. IT, help desk) Continuing education as updates occur Safety implantations to protect the PHI. Diehl, Sarah H.

25. Exactly how much????? In 2006, clinical information systems cost $30.5 billion in the United States alone. Dr. Michael Shabot (2004) stated that components such as clinical information systems are not planned as cost-saving measures but as quality improvement measures. Diehl, Sarah H.

26. EDUCATION:Delivery Modalities Face-to-face: most widely used, but only yields only 5% information retention rate over a 24-hour period (p. 342). Online delivery: e-learning, a significant shift to this type of learning has taken place and is very promising (p. 343-344). Hybrid or blended delivery: virtual classes where learning occurs somewhere other than the conventional classroom. It requires special course, design, planning, techniques, and communication (p.344-345). (McGonigle & Mastrian, 2009)

27. Education Continued… Web-enhanced/web-based interactive courses have proven to provide effective learning environments Types of interactions included: learner-learner, learner-content, learner-instructor, learner-interface Technology tools that aid in learning: online tutorials, hypertext, simulations (computer-based or full-scale) and virtual realities Original ways of learning such as on-the-job training and classroom educational classes are still useful today Monthly meetings can be used for updates on specific floors (McGonigle & Mastrian, 2009)

28. Re-education and Updates Each hospital has different rules for re-education and updating staff on current education… At St. Johns each floor has an educator responsible for keeping staff current on education (can be done by e-mails, meetings, computer programs, written tests etc.) Nurses working in cardiac have to take/pass a code blue test every year in order to continue practicing All RNs must take a yearly QC test that assesses knowledge on the Surestep glucose readers Nurses must attend the health fair every year to be updated on new procedures and equipment

29. Education Summary Variations in learning styles are good since everyone learns differently. Staying current on healthcare information is one of the key factors to providing the best care to patients. Remember: We can also be excellent patient advocates by taking initiative and educating ourselves on issues that we are unsure of or subjects specific to our floor that we could use reinforcement on.

30. References Bakken, S. G., Hripcsak, G. (2004). An Informatics infrastructure for patient safety and evidence- based practice in home healthcare. Journal for Healthcare Quality : Official Publication of the National Association for Healthcare Quality, 2624- 30. Retrieved from EBSCOhost. Hanson III, C.W., (2006). Healthcare informatics. New York, NY. McGraw-Hill. McGoldrick, T. (1999, November). Choosing a Clinical Information System. Nursing Management, 30(11), 51-55. Retrieved March 28, 2011, from CINAHL Plus with Full Text (2000003975). McGonigle, D., & Mastrian, K. (2009). Nursing Informatics and the Foundation of Knowledge. Sudbury, MA: Jones and Bartlett Publishers.

31. References Page, C. K. (2005, September). Critical Success Factors for Implementing a Clinical Information System. Nursing Economic$, 18(5), 255. Retrieved April 10, 2011, from Academic Search Premier (3793487). Pollock, N. (June 1998). Reflections on ... the Cochrane Collaboration. Canadian Journal of Occupational Therapy, 65(3), 168(3). Retrieved April 12, 2011, from Health Reference Center Academic via Gale. Shabot, M.M. (2004). Ten commandments for Implementing Clinical Information Systems. Baylor University Medical Center Proceedings, 17(3), pp. 265-269.