Clinical Informatics

23 Clinical Informatics



Neal R. Patel



Pearls




• Clinical information technology (IT) involves a dynamic set of interactions that all have to be managed effectively. The categories of people, process, and technology each introduce different challenges and factors that must be addressed for successful IT implementation and adoption.


• To achieve maximal beneficial effects, clinical IT must provide clinicians with the right amount of data in the appropriate context to help them make good clinical decisions.


• The use of IT to enforce compliance and adherence to policies and regulations must be balanced with clinical utility and minimal distractions.


• Effective use of clinical IT tools can markedly improve patient safety and clinical workflow.


• Clinical, administrative, and IT leaders need to develop a shared vision and governance model to deploy and maintain clinical IT systems.



Introduction


The past two decades have seen significant advances in medical and nursing care for critically ill infants and children. These advances have stemmed from increased research and clinical experience as well as better appreciation for the appropriate use of technology to monitor and deliver state of the art medical care. The incorporation of microprocessors has revolutionized bedside critical care nursing. From networked monitors to ventilators to infusion pumps, many technologic advances have been incorporated into the routine workflow at the bedside.


Information technology is the latest set of tools for the critical care setting. Traditionally, IT was relegated to the administrative tasks of managing and processing transactions for hospital departments. These systems included those used to process and track patient census, billing, the laboratory system, materials management, and pharmacy. Whereas the functions of these systems are essential to the delivery of medical care, these systems were not directly involved at the point of care. Recent efforts have now focused on better use of computerized systems to improve the process of care delivery.


Several major issues have prompted focused effort to use IT tools more effectively in healthcare. The cost of healthcare in the United States continues to rise. Despite the expenditures, healthcare providers are finding it increasingly difficult to balance budgets and grow resources to meet demand. Cost pressures are contributing to increasing staffing shortages.


In the past decade, many examples of error, waste, and inefficiency in healthcare have been identified. In 1999, the Institute of Medicine (IOM) estimated that nearly 100,000 hospitalized patients die each year from medical errors.12 The IOM report led to increased scrutiny of the safety and efficiency of the healthcare system. In 2003, the analysis by McGlynn and others9 documented a significant gap between the care that patients need and the care that is provided. In a sample of more than 6700 adult patients in 12 metropolitan cities, only 54.9% of patients received the recommended care.9


IT is a potential tool to reduce errors. A reduction in errors can result from the role of IT in managing information, its utility in standardizing care, and through its role as a vehicle to change roles and processes in an effort to reduce cost, variability, and waste. These efforts can result in improved outcomes (Fig. 23-1)


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Fig. 23-1 Key drivers of healthcare information technology.


Information systems work by several mechanisms to reduce human error. The process of delivering good care is getting more difficult as the result of the sheer volume of data that clinicians must review and evaluate. This volume can range from the hundreds of data points to be analyzed from a patient’s vital sign flow sheet to the thousands of new journal articles written every year that can affect management of a disease or complication. The computer can be an excellent tool to help collate, retrieve, and store this information so that it can be used effectively. Reducing the reliance on human memory can help to mitigate situations in which care is delayed or omitted.


IT can help to improve healthcare delivery by simplifying processes. It takes a lot of time to fill out multiple requisition forms to communicate with a variety of hospital departments. Using IT tools, forms can be completed and routed electronically; this can reduce time for the entire care process and improve the delivery of care. Computer systems are also highly effective in ensuring completeness of a process. Through the use of constraints or forcing functions, such as requiring that a name be filled in or dose specified in the case of a medication order, the system as a whole can be made more efficient.


Computerized systems can be used to promote the use of standard protocols or checklists to ensure that providers undertake all necessary and effective care steps. These approaches all center on the concept of decision support. Decision support in a computerized system helps the user make the best patient care or management decisions by assembling all necessary information and by reducing the number of steps or processes to making the given decision. The effective use of these tools can decrease dependence on vigilance and reduce handoffs and redundant data entry, all of which have been shown to contribute to errors in healthcare.



Implemention of clinical information systems


Despite the great promise of electronic systems and substantial financial investment in such systems, there continues to be significant variability in the success of information system implementation and adoption by clinicians. According to the Office of the National Coordinator for Health Information Technology, almost one third of electronic medical records technology implementations fail. Healthcare providers and IT experts are now beginning to understand the challenges of introducing technology into clinical workflow.


IT implementation often fails because clinical users are unprepared for the additional burden that interaction with an electronic system will place on their work patterns and clinical care delivery. In addition, the systems must be developed with adequate input from the users, and careful planning for unique hospital needs. Several high-profile implementations of computerized provider order entry (CPOE) have provided excellent case studies to teach improved approaches to IT implementation.


A large hospital in Los Angeles implemented a multimillion-dollar CPOE system with little physician input. Shortly after implementation, clinicians complained that the system was not working and patient care was being compromised. Three months after implementation, the hospital was forced to uninstall the system.


In another case, in the first 5   months following implementation of a commercially purchased CPOE system in a pediatric critical care unit at a leading children’s hospital in the northeast, mortality during interfacility patient transfer more than doubled (from 2.8% to 6.6%) when compared with the mortality in the 13   months preceding CPOE implementation.3 Several factors may have contributed to this rise. First, the system was rapidly deployed. Second, the clinical care team was not allowed to enter orders until the patient physically entered the hospital. Third, order sets were not developed to help clinicians rapidly enter common orders. Fourth, simultaneous with the CPOE implementation, the hospital dispensing process for medications was changed. All of these factors directly affected patient care.


A second children’s hospital in the northwest installed the same commercial CPOE system. When the effects of the implementation system on the northwest children’s hospital was studied by Del Beccaro and others,2 they found no difference in mortality in the preimplementation and postimplementation periods.


The Agency for Healthcare Research and Quality (AHRQ) calls for careful and thoughtful implementation of CPOE systems. Koppel’s study of CPOE systems, funded by the AHRQ,7 found two key problem areas in implementation:



• Fragmentation of data among each hospital’s various information systems


• Interface problems between people and machines, particularly when the computer forced people to work in a way that differed from clinical work routines



People, Process, and Technology


Unlike simple electronic tools that automate a single task, the introduction of clinical IT involves a dynamic set of interactions that all have to be managed effectively. The categories of people, process, and technology each introduce different challenges and factors that must be addressed for successful IT implementation and adoption.


The people involved in IT implementation include individuals and groups with an interest in the project. It is clear in the previous example of the large Los Angeles hospital that the primary users of the CPOE system, the clinicians, had inadequate input during the design or implementation process. Unfortunately, clinician input is often inadequate in IT implementation projects; however, this might not result from the specific exclusion of clinicians by the project team. The clinical environment is demanding and often the clinicians who have the most clinical experience and insight are unable to break away from their clinical responsibilities to participate in the process.


It is essential to acknowledge the challenge of clinical user involvement and to develop strategies to address it. Administrative leaders must acknowledge that time devoted to large implementation projects is important, and these leaders should consider compensating participant staff for involvement in such projects. Institutions that have taken this approach have seen significant improvements in clinician commitment and engagement.


The clinicians who participate in and lead implementation projects should possess several key skills. Technical expertise is not an essential skill, and it often can be a distraction. Foremost, the clinician must have the respect of and credibility with his or her peers. The value of peer-to-peer education, advocacy, and persuasion cannot be overstated. Healthcare providers learn best from colleagues rather than from didactic sessions. The clinician must also have a good understanding of the actual clinical workflow that will be affected. It is this understanding that allows the implementation team to identify potential pitfalls and obstacles that can derail a project plan.


The involved clinician must be able to work collaboratively with colleagues from a variety of clinical and nonclinical disciplines. The clinician must help the project team understand clinical realities and also must understand the capabilities and limitations of the technology. The clinician should be able to help the group make the correct adjustments and appropriate compromises so that the technology can be easily adopted and used effectively.


The likelihood that a person will use new technology depends to some extent on individual factors. A known predictor of technology adoption is the confidence that an individual has the ability to use the tool effectively. This concept is called self-efficacy. Healthcare workers with low computer self-efficacy often have difficulty adapting their workflow to incorporate the use of computers.


Different units in the same hospital will have drastically different acceptance of the same technology as the result of differences in staff perceptions regarding the ease of technology use and also the result of differences in staff attitudes about changes in their practice. Gender and age play important roles in determining these perceptions and attitudes. Karsh4 found that male users valued the usefulness of a tool, whereas female users felt that ease of use was more valuable. Older users focused more on social and process issues, whereas younger users focused more on the effects of the tool on task performance. Therefore before implementing any new technology, planners should evaluate characteristics of potential users and of the potential technology itself.


In order for technology to contribute to improvements in process, planners must be knowledgeable about all aspects of the process. Planners must evaluate and understand the rationale for each discrete step and each task in the process, and they must understand the communication needs at every level. Too often, introduction of new technology (e.g., an electronic system), even if it is designed to mimic existing workflow, will exacerbate a variety of poor processes that were previously not identified as problematic. Simply stated, if there is a bad process, then the introduction of technology can, at best, automate that bad process. The act of implementing an informatics solution can be the impetus to redesign and improve workflow or at least identify where the technology may exacerbate poor workflow.


Hospital policies and procedures are often reviewed for guidance when the evaluation of workflow reveals significant variability or a clear breach of appropriate standards. During this phase, it is important to note that the clinicians often adapt a given process to deliver care within the constraints or flaws of an existing system. The plan should address the gap between clinical practice and existing policy. IT implementation will not be successful if technology is used in an attempt to force compliance with standards that clinicians have already rejected. Before attempting to implement a technology solution, planners must revisit the rationale for the existing standards, gain consensus with the clinicians, and redefine the process with all stakeholders. Administrative leadership is a key element in advocating for changes in policies and procedures while maintaining compliance with external regulations and accreditation standards.


Technology itself can introduce problems or complications that can produce a variety of unintended consequences. The staff members at the northeast children’s hospital pediatric critical care unit (mentioned previously) discovered the limitations of CPOE technology that only allowed order entry after the patient arrived in the unit. The technology was a potential contributor to delays in care associated with increased mortality after deployment of the CPOE system.


The usability of the technology will obviously affect adoption and success. In general, consumers have high expectations for a good user experience as the result of advances in the consumer world and the effects of Internet capabilities in everyday lives. Unfortunately, many healthcare technology tools are not able to offer the robust features that are prevalent in the consumer world.


Technology accessibility can have a significant effect on the success of informatics tools used in the hospital environment. Too often, projects underestimate the number and types of devices that will be needed to effectively use the tools in a given workflow. Because most IT tools are accessed via a computer, it may be challenging to have a sufficient number of devices available to meet the demand of end users. Whereas the cost of devices has dramatically decreased in recent years, the physical environment, the cost of appropriate mounts or carts, and the need for mobility are parameters that may complicate or prevent successful implementation.


In order for good tools to be useful, clinicians must be able to access a computer at the time or in the place the tool is needed to deliver good care. This is of particular relevance in the critical care setting, where bedside clinicians require immediate access to a computer in the patient’s room to use technology solutions, such as bar-coded medication administration. Use of a mobile computer allows significant flexibility for the provider within the room, but satisfaction greatly diminishes if the provider is expected to move the device from room to room when caring for more than one patient. Mounted computers are useful in the hallways and common desk areas in patient care units, but they may be less accessible in a critical care room, where the provider is often surrounded by a lot of other equipment.


Evaluating any informatics tool across the categories of people, process, and technology can provide important information. The implementation and adoption of any technology is enhanced when this information is included in the analysis and project plan.



Best Practices


A set of best practices have been identified that can increase the chances of successful implementation and adoption of information technology tools.



Executive Commitment


The commitment of hospital administrators is a key determinant of successful implementation. Their leadership provides the necessary energy and resources for engagement of many disciplines in the hospital. When specific obstacles or major controversies arise, an executive sponsor who has been involved throughout the process can provide the guidance and resources necessary to continue moving forward.



Identified Project Leaders


Clinical informatics projects require coordination of many people and management of a variety of issues. It is essential to have designated leaders with the responsibility, time, and resources to navigate the project and team. Unsuccessful projects often have designated leaders who have too many other competing responsibilities.



Road Map


A high-level project plan is essential. It should indicate key milestones and deliverables from project kickoff to initial pilot through full implementation. Although this plan can be dynamic and changes should be anticipated, it should clearly show the key targets, responsible groups, and timeline.



Process Redesign


It is difficult to incorporate IT without disrupting existing workflow. Because the technology will likely change the workflow, the technology implementation plan should include time and resources to evaluate the process and to redesign some care delivery steps to take advantage of the new technology. This planned redesign allows frontline staff to see how their work will change. The plan should emphasize the priority of improved patient care, not simply the use of new tools or cost savings.



Communication Strategy


A structured communication strategy is an important element of successful implementation. The plan should identify key groups that require periodic updates. The required level of communication detail should be determined in collaboration with the executive leadership. There will always be people who believe they have received inadequate preparation and communications. An effective communication strategy ensures that key leaders and groups are knowledgeable about the goals of the project, key milestones, and their roles in the project plan.



Simulation and Pilot Testing


The active use of simulation can help find fatal flaws in any system. The closer to “real” use a simulation can be, the richer the information gained from the simulation. It is too easy to overlook glitches or potential breakdowns when testing takes place away from the clinical care setting. Ideally, frontline staff should assist in the simulation and be asked about their perceptions and concerns as to the utility of the tool. This interaction can provide insights into the tool and about the people and environmental factors necessary for successful use of the new technology.



Training and Support


Investment in training and support is an integral component of successful implementation. The models of training have to be flexible for the type of technology being deployed and the type of users involved. The goal of formal training should be to target the initial education to the basics of use and steps to get out of trouble; this helps build user confidence and self-efficacy.


The creation of super-users has been effective at many institutions. Super-users are trained to be expert users in their clinical settings; they then serve as resources to their colleagues. Another key type of support is providing access to information when it is needed by users (i.e., when they encounter difficulties and questions); this can be referred to as just in time or at the elbow support. During initial implementation, support personnel may be present on the unit to help users navigate the system or answer questions. Support may also be available through an online site to verify how to perform specific tasks.

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Dec 3, 2016 | Posted by in NURSING | Comments Off on Clinical Informatics

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