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Guest
Spot: Success Considerations for Applied Clinicals
Implementations
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:
- Type and
number of access points to support and efficient workflow with an
effective information flow (Clinicians; Information Systems Technicians)
- Ensuring ease
of data input for clinicians (Clinicians, Applications Support)
- Support
formatting of data outputs (reports / screen views) to facilitate
accurate interpretation of data (Clinicians, applications support)
- 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:
- Handwritten
MD orders will continue to have the same issues as the orders continue
to be manual.
- Ancillaries
information flow is improved with automation that supports order
communication and their departmental information flow.
- 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:
- Reliability,
access and system/application support are important success factors in
achieving end-user acceptance and adoption.
- The evolution
to Physician Order Entry is a process. Some organizations
must maintain a dual process of manual and automated for period of time.
- Order Sets
and standards need to be established between providers and ancillary
areas for application support, systems usability and departmental needs.
- 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:
- Attention to
detail must be used when developing rules in the system to reflect care
standards, and appropriate information.
- Alerts must
be concise and appropriate to the providers. Numerous warnings can
impede the care delivery process, necessitating providers to skip over
warnings.
- 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
- The ability
to relate patient data and associated system
information enhances 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:
- Support and
training to providers regarding information flow changes with
automation and additions to the EMR.
- Standards
must be agreed upon regarding data formatting to ensure ease of data
entry, accuracy of data captured, and efficient data display.
- Agreement is
needed to establish appropriate access to information necessary to
provide care and support decision making.
- Access to
data is a priority and supported by adequate computer allotments,
reliable system infrastructures, efficient system builds; development;
and implementation.
- 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.
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
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Survey
Says: Advanced Clinical Applications
How does your
facility compare with other MEDITECH
facilities regarding the implementation of advanced clinical
applications?
We
conducted a survey of over 200 MEDITECH
facilities to learn just that. We'd like to thank everyone
who
participated in this survey, and we hope the results are helpful to all
of you curious-minded creatures.
Results are
reported
as a percentage of total respondents.
What
are your implementation plans for advanced clinical applicaitons?
53%
Currently
implementing or have implemented
23%
Implementing within next 12 months
35%
Part of 3-year Strategic Plan
4%
No current plans to implement
What
applications have you or do you plan to implement?
77%
Medication Administration Record
85%
Bedside Medication Verification
62%
CPOE
77%
Clinical
Documentation
69%
EMR/EHR
Who
is your implementation team comprised of?
69%
Project Manager
96%
IT Staff
92%
Nursing Staff
73%
Physicians
27%
Consultants
What
are your reasons for implementing?
58%
In the
Strategic Plan
11%
Demonstrated ROI
77%
Increased Patient Safety
80%
Improved Quality of Care
35%
Enhanced Productivity
What
are your reasons for not
implementing?
27%
Cost
4%
Lack of Perceived Benefit
19%
Insufficient or Inexperienced Staff
19%
Absence of Executive Support
4%
Other: Time/Resources
What
obstacle or barriers are your encountering?
8%
Executive Buy-In
19%
Technology Selection
19%
Inadequate Training
42%
User Acceptance & Adoption
4%
Other: Time/Resources
If there's a specific survey you'd like to see in
future newsletters, please send us your ideas
and we'll try to conduct a survey to include in an upcoming issue.
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Tricks of the Trade:
Selecting from a Custom List
Contributed
by: Teena Paradise of CRH Consulting, Inc.
These
steps will allow you to choose only those records which match a list
you define
without having to be prompted each time you run the report. For
example, you
regularly run a report that gives you the list of current inpatients.
You don’t
ever want to see anything but the Med/Surg floors and don’t
want to be prompted
to enter those locations each time you run the report. In addition to
the
normal steps in writing a report, follow the following steps:
Step 1: Write
a macro to set up
your custom list:
The names
of the floors above should be changed to reflect the location mnemonics
of the
floors you wish to include. You may have more or less of them, but
please
remember to follow the same basic layout. The /FLAG structure is there
to
insure that this is only done once. The last item is the title you wish
to
print at the top of the report.
Step 2: Call
the macro in the
title box on page 1 of the Report Writer
A macro
call is formatted as %DPM.reportname.M.macroname(0). Because we are
doing this
in the Report Title field and the Report Writer is expecting a string
of text,
we must surround that with “_ and _”. When this
“title” is processed, it will
actually call the macro. The last thing the macro does is give the
actual title
of the report and that is how it still prints at the top of each page.
Step 3: Add a
select to choose
only the values you listed in the macro.
Location
is chosen as the field to match in this example, but this would change
depending on what criteria you use for your own report. The operator
should be
LI which stands for List and then we specify that the Report Writer
should look
on the /LOC structure. If you used a different structure name in your
macro,
this should be changed to match it. This select is telling the Report
Writer to
only include rooms where the location of the room matches a location on
the
list /LOC.
Teena Paradise
is a Consultant for CRH Consulting, Inc. Teena
recently joined CRH as an NPR report writing
specialist, bringing a wealth of knowledge from over 7 years
of experience working for both hospitals and software vendors.
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Additional
Resources: For Lawson Software Users
There
happen to be a lot
of MEDITECH facilities out there which also use Lawson Software for
their
Financial, Supply Chain and/or Human Resource applications. For those facilities,
we’d like to suggest a very
informative resource to you. The LawsonGuru Letter is a free
periodic newsletter providing provocative commentary on issues
important to the
Lawson Software community. The LawsonGuru Letter is published
by — and is
solely the opinion of — John Henley of Decision Analytics. Decision Analytics is an
independent
consultancy, focusing on Lawson technical projects, and specializing in
reporting, customization, modification, data conversion, and
integration/interfaces. Visit
Decision
Analytics at http://www.danalytics.com.
To read the
latest issue: http://www.danalytics.com/guru/letter/archive/2006-07.htm
To subscribe: http://www.danalytics.com/guru/letter/index.htm
Back
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Recent
News: Industry News & Press
2006 National Infrastructure
Protection Plan
Department
of Homeland Security announced completion of 2006 National
Infrastructure
Protection Plan. Public
health and
healthcare was one of the 17 critical infrastructure and key resource
structures identified.
http://www.himss.org/ASP/ContentRedirector.asp?ContentId=65866
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Worth
a Read: Articles of Interest to the Healthcare IT Field
