Contributed by: Mimi Hassett, MS, RN, FHIMSS -Director of Clinical Informatics at Berkshire Health Systems

Applied clinical application projects require more organization in the planning and preparation stages than other systems implementation projects. Understanding current workflow and processes; establishing documentation standards; identifying project impacts prior to implementation enables implementation projects to better achieve end-user adoption and facilitate improved decision making.

ESTABLISHING the TEAM

Over the past decade, nursing and other clinicians have been active participants in defining Informatics practices and projects in healthcare organizations. The practice and project considerations are as dynamic as the technology, policies, and trends supported. Informatics practices especially in the clinical arenas require the specialist to be familiar with and associate different bodies of knowledge such as clinical need, technology aspects, systems life cycle, budget / regulatory requirements, and market trends. The ability to integrate of these bodies of knowledge together while recognizing organizational structure and strategic goals and adopting the Systems Life Cycle while setting appropriate project priorities ensure the success of the role.

The clinical practice requirements for nursing promote practitioners to develop skill sets important for informatics practices. The Nursing process of assessment, problem identification, and care planning with associated priority setting and evaluation, readies the nurse clinician to not only be an early adopter but also to employ and adapt the Systems Life Cycle approach for delivering informatics projects. Project Management, a vital skill in managing IT projects by establishing timelines, milestones, task dependencies, and resources, is easily grasped by clinicians who have worked in areas of care requiring constant priority setting and evaluation such as Emergency Room or Critical Care.

Identifying project team members, clinical participants, and project champions who will recognize and drive strategic planning and implementation phases requires input and participation of team members from a number of different departments:

• Project Sponsor: Strategic and business goals (Senior Management)
• Information Services: technology / devices / application support / project management (IT department)
• Clinicians: project input, application design, team building; training support (varied departments and specialties)
• Ancillaries: project input, application design, team building; training support (varied)

Establishing expectations of project team members or defining roles, require organizations to consider the following factors and project impacts.

• Workflow enhancements / changes
• Care delivery changes
• Clinical decision making
• Communication needs
• Measures of success and role evaluation

WORKFLOW ENHANCEMENTS

Applied clinicals implementation will change current work and information flows not only for clinicians but also for anyone participating in the care delivery process including family and patients. As the current workflow is evaluated, it is difficult to separate the work of data gathering, information evaluation, treatment planning, and care delivery steps from the information flow. As the care provider is “working” to deliver care, the flow is directly influenced by where the information is available and when it is needed.

As systems are implemented to support the automation of clinical data and information, workflows will change as a result of information being available in different forms and locations. The following Vital Signs example illustrates the change between a manual automated information flow with resultant considerations and appropriate resources that can work to make the automation successful.

Vital signs:

Manual: information available on a graphic sheet maintained by providers and kept in a specific location

Automated: information is now available wherever access to the information system is available. More access points enable both ease of entering data and ease of reviewing data.

Considerations:

1. Type and number of access points to support and efficient workflow with an effective information flow (Clinicians; Information Systems Technicians)
2. Ensuring ease of data input for clinicians (Clinicians, Applications Support)
3. Support formatting of data outputs (reports / screen views) to facilitate accurate interpretation of data (Clinicians, applications support)
4. Standards must be negotiated between providers for the documentation of core information

CARE DELIVERY CHANGES

Automation of information will go beyond the work and information flow changes and impact the delivery of patient care. One of the realized benefits for applied clinicals is improved communication of information between care providers. Information that is entered into an automated system is processed at that time (real time) and communicated to vested individuals. This enables the provision of efficient information flow of data to support effective care delivery.

The automation of order management will necessitate care delivery changes. In the manual “world” the challenges have been well documented: can’t read; hard to find; multiple manual signoff’s, etc. Also well documented are the benefits of order management automation, clear signatures, communication of orders, provider accountability; etc. However, identifying what organizational changes may be necessary to move into the automated state continues to be a challenge.

Order Entry: (Non-Provider)

Manual: Handwritten orders are processed by other care staff, usually a unit secretary and then communicated to appropriate ancillary groups via manual forms, fax, etc.

Automated: Orders continue to be handwritten but will be entered into an automated system to be communicated and tracked by ancillary and care staff.

Considerations:

1. Handwritten MD orders will continue to have the same issues as the orders continue to be manual.
2. Ancillaries information flow is improved with automation that supports order communication and their departmental information flow.
3. Order and treatment needs are more readily available for review by providers and ancillaries.

Physician Order Entry

Manual: Handwritten orders are processed by other care staff, usually a unit secretary and then communicated to appropriate ancillary groups via manual forms, fax, etc..

Automated: Orders will be entered directly by physicians for communication to ancillary areas and care providers on the units.

Considerations:

1. Reliability, access and system/application support are important success factors in achieving end-user acceptance and adoption.
2. The evolution to Physician Order Entry is a process. Some organizations must maintain a dual process of manual and automated for period of time.
3. Order Sets and standards need to be established between providers and ancillary areas for application support, systems usability and departmental needs.
4. Physician order entry enables the triggering of messages in the order entry process to improve ordering process (i.e.: allergy checking; duplicate drug ordering, required test information, etc.)

CLINICAL DECISION MAKING

Information that is readily available to providers impacts directly on their ability to make informed clinical decisions. As one is able to navigate quickly for patient assessment details, lab results, medications ordered / administered, procedure results, or consult reports, care directions can be more confidently established and tracked. A good example of automation supporting clinical decision making is illustrated in the Pharmacy and EMAR (electronic medication administration system) modules.

Pharmacy / EMAR:

Manual: Order sheets are faxed to pharmacy, transcribed, dispensed, delivered to care unit for nursing to administer. Steps are all documented in separate locations and are primarily manual.

Automated:

Order Entry by Physicians is automated, providing prompts to ordering provider:

• Allergy / food interactions
• Dose alerts
• Recommended drugs based on C&S results

Pharmacy: Dispensing will enable better tracking of drug inventory, dispensing of meds; provider usage, costs, return inventory; and medication effectiveness to allow for improved pharmacy support to care areas.

Med Administration: Alerts to providers via work lists or med administration lists can enhance the administration process. On-line documentation of medications will enable communication of last dose for treatment and discharge planning.

Considerations:

1. Attention to detail must be used when developing rules in the system to reflect care standards, and appropriate information.
2. Alerts must be concise and appropriate to the providers. Numerous warnings can impede the care delivery process, necessitating providers to skip over warnings.
3. Access to systems must support the “data in and data out” concept for all providers in the information loop. Ease of access for order entry in variety of locations, diverse access and formats to support Pharmacy needs, and point of care entry for Med administration
4. The ability to relate patient data and associated system informationenhances clinical decision support. i.e. lab values and assessment criteria reviewed with drug doses and medication types.

COMMUNICATION NEEDS

Finally, one of the biggest improvements and the biggest road block to implementing applied clinicals is the communication of the information. Although providers have always shared data and consulted as a team in the care of patients, data is now being shared across departmental lines and communicated in real time. It is a misnomer to feel “no more face-to-face reporting” or “no more phone calls” is needed because the information is in the computer. Instead the automation will challenge providers and ancillaries to look more closely at the shared data and its automated format to ensure accuracy and consistency in the display of data. Consultation for patient care will continue with face-to-face meetings and phone calls but information to support the accuracy of the consults will be readily available.

The sharing of the data will prompt discussions regarding what the information should look like or who “owns” data or “we have always done it this way.” Automation structures data across departments and practice areas for both data entry and display. No longer can a data element necessarily “belong” to a certain group nor have an assumed definition or value if it is to be shared. Finally, there has to be agreement between practitioners for standards of documentation and what is to be documented by whom. Shared data such as vital signs or assessment items are especially challenging for practitioners to agree on across practice areas and disciplines.

The electronic medical record (EMR) is the repository of information for the providers and illustrates some of the communication issues. In the implementation process, consideration must always be made for ease of data entry but just as important is what that information will look like in the repository. (Data in / Data out)

Electronic Medical Record (EMR)

Manual: Information on visits is stored primarily in an indexed manual medical record kept on a care unit or on various specific forms that are later entered into the chart.

Automated: The manual indexed chart becomes an automated indexed chart as order entry; ancillary test results; consults; documentation; and med administration are automated. (NOTE: The evolution to the EMR is a process. Many organizations maintain a dual process of manual and automated for a period of time.)

Considerations:

1. Support and training to providers regarding information flow changes with automation and additions to the EMR.
2. Standards must be agreed upon regarding data formatting to ensure ease of data entry, accuracy of data captured, and efficient data display.
3. Agreement is needed to establish appropriate access to information necessary to provide care and support decision making.
4. Access to data is a priority and supported by adequate computer allotments, reliable system infrastructures, efficient system builds; development; and implementation.
5. Robust EMR application support is necessary to meet the needs.

MEASURES OF SUCCESS

There are a number of strategic and business measures one can associate as success factors for applied clinical implementations. However, from a clinical prospective, end-user adoption of the system is the best indicator. The adoption can be measured by an increase in use of PC’s for data entry and data review, decrease in printed copies of patient data; rounds reporting utilizing technology; increase in on-line traffic especially to the EMR, and change in reporting requests that reflect trending and care standards as opposed to data reporting.

CONCLUSIONS

Organizations anticipating implementations of applied clinical applications should prepare project sponsors, clinicians and implementation teams for review and understanding of not only current work and information flows but also the new automated flows. Documentation and order set standards will need to be developed and agreed upon by various user groups, physicians, nurses, ancillary, medical records, etc. There will be an increased need for accessible and reliable network infrastructure and PC technology to support system and application use. The preparation of the organization prior to an applied clinical implementation will be the key to a successful implementation and on-going utilization of the applications.

Mimi Hassett, RN, is the Director of Clinical Informatics at Berkshire Health Systems. She has an MS in Nursing Informatics and is a Certified Nurse Informatics Specialist. A Fellow Member of HIMSS, Mimi is actively involved as a member or chair of several committees.