Chapter 19 : Implementing and Upgrading Clinical Information Systems

Clinical Information System (CIS)

Provide nurses knowledge of many aspects organized for effective and efficient health care delivery. It assists clinicians with data necessary for decision-making and problem solving and serve the organization and the patient in much the same way an efficient healthcare delivery system involves all appropriate departments in establishing health care delivery processes. It can also be designed as a stand-alone system, a subsystem of a larger system, or an integral part of the health care organization's overall information system.

There are Major CIS requirement for nursing:
1. Administer a nursing department
2. Assist the management of nursing practice.
3. Assist in nursing education.
4. Support nursing research.

To complete the implementation or upgrade a CIS or single application design must complete the eight phases of implementation. This phases are :

1. Planning
2. System analysis
3, System design / system selection
4. Development
5. Testing
6. Training
7. Implementation
8. Evaluation

The Planning Phase

Begins once an organization has determined that an existing need or problem may be filled or solved by the development of a CIS.

Clinical Information System Committee Structure and Project Staff


The Nursing administrator, in conjunction with the information system's management team, works to develop a committee structure and participation to best guarantee the success of the project.
Transition management is a series of deliberate, planned interventions undertaken to assure successful adaptation/ assimilation of a desired outcome into an organization. (Douglas and Wright, 2003)
A three-tiered committee approach is recommended to accomplish the design, implementation, or upgrading of a complete CIS - a steering committee, a project team, and departmental teams.

Clinical Information System Steering Commitee

Charged with providing oversight guidance to the selection and integration of a new CIS into the organization.
Generally Includes representatives from the following areas:
Hospital administration/ hospital finance
Nursing administration
Medical staff
Information system department at the director or manager level
Major ancillary department (laboratory, radiology, pharmacy, dietary, medical records/ patient registration, patient accounting)
Health information management (Medical records)
Legal Affairs
Outside consultants (as needed)
Other appointed members (as needed)
Project Team

Lead by an appointed project manager and includes a designated team leader for each of he major departments affected by the system selection, implementation, or upgrade proposed
Objectives:
Understand the technology and its restrictions, if any, of a proposed system.
Understand the impact of intradepartmental decisions.
Make decisions at the intradepartmental level for overall good of the CIS within the organization.
Become the key resource for their application.
Goal: improve patient care
Project manager: responsible for managing all aspects of the project; must have good communication, facilitation, organization and motivational skills to be successful; must have fulltime dedication to a large-scale design or implementation project.
Departmental Team
Charge of the departmental teams
To thoroughly understand the department’s information needs
To gain a full understanding of  the software’s features and functions
To merge the new system’s capabilities with the department’s operations
To assist in the system testing effort
To participate in developing and conducting end-user education
To provide a high level of support during the initial activation period of the new system
Physician involvement early in the planning process is recommended to ensure understanding of the information needs of the medical staff relative to patient documentation.

Planning
 In the American Society for Testing and Materials (ASTM) standards, the planning phase is referred as the project definition.
Commercial software developers and consultant rank this phase as the most critical factor in the selection of a system, even more important than the system itself.
This phase is critical whether a system is actually being developed or existing commercial systems are being evaluated for selection
Involves the following steps:
Definition of the Problem
- Includes a description of how the system will be evaluated
- May also include increased processing capabilities, saving in processing time, decreased costs, or increased personnel productivity
Feasibility Study
- Is the preliminary analysis to determine if the proposed problem can be solved by the implementation of a CIS or component application
- Helps identify the information needs, objectives, and scope of the project
- It highlights whether the proposed solution will produce usable products and whether the proposed system’s benefits outweigh the costs.
- Includes a high-level description of the human resources required and how the selected system will be developed, utilized, and implemented
- Describes the management controls to be established for obtaining administrative, financial and technical approvals to proceed with each phase of the project
- Includes the following topic areas:
Statement of objectives – constitute the purpose/s of the system; all objectives are outcome-oriented and are stated in measurable terms
Environmental assessment – defined in terms of the support it provides to both the mission and the strategic plans of the organization
Determination of the program needs/ needs assessment – outlines the high-level information required by the users
Determination of the Scope – establishes system constraints and outlines what the proposed system will and will not produce
Development of a project timeline/ project workplan – providing an overview of the key milestone events of the project
Recommendations
Documentation and Negotiation of a Project Scope Agreement
- Includes the scope of the project, the application level management requirements, the proposed activation strategy for implementing the  CIS or application, and the technical management and personnel who will maintain the equipment
- Becomes the internal organization contract of the project
- Defines the short and long term goals, establishes the criteria for evaluating the success of the project, and expands the workplan further
Allocation of Resources
        - Last step in the planning phase is determining what resources are required to successfully complete the project scope agreement

The Key Role of the Nurse Administrator
The active involvement of the nurse executive is considered a critical success factor of any CIS implementation or upgrade.
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The System Analysis Phase
Second phase of developing a CIS
Is the fact finding phase
 Foundational to the actual system design

Data Collection
Collection of data reflecting the existing problem or goal.
Refining of the project scope agreement
Creation of a Workflow Document
Assimilates data collected into logical sequencing of tasks and subtasks performed by the end users for each goal or problem area, it includes:
- A list of assumptions about the process
- A list of major tasks performed
- A list of subtasks and steps accomplished
Sources:
- Written documents, forms, and flow sheets
- Policy and procedure manuals
- Questionnaires
- Interviews
- Observations

Data Analysis
Provides the data for development of an overview of the nursing problem and or stated goal defined in the project scope agreement
Tools used:
Data flowchart
Grid chart
Decision table
Organizational chart
Model

Data Review
Focuses on resolving the problem and or attaining the goals defined in the feasibility study based on the best method or pathways derived from the workflow documents and the functional design.
The careful analysis of end-user requirements and potential solutions has been proved to reduce the cost of design and implementation

Benefits Identification
The overall anticipated benefits from the system are documented in this step
The benefits reflect the resolution of the identified problem, formulated and stated in quantifiable terms

System Proposal Development
The proposal is submitted to a projects steering committee for review and approval
The system document should answer these four questions:
What are the major problems and or goals under consideration?
How will the proposed CIS solution correct or eliminate the problems and or accomplish the stated goals?
What are the anticipated costs?
How long will it take?
Format should be:
A concise statement of the problems and or goals
Background info related to problem
Environmental factors related to the problem
Anticipated benefits
Proposed solutions
Budgetary and resource requirements
Project time table
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The System Design Phase
       
Functional Specifications
Uses the functional design document developed in the system analysis phase of a CIS and builds on the design by forumulating a detailed description of all system inputs, outputs, and processing logic required.

Technical Specifications
The technical personnel work closely with the project and departmental teams to ensure the technical components of the proposed system work in concert with technology and end-user needs and to assist in the development and implementation plan
Technical Manager- He is required for the coordination of efforts in for major areas:
Hardware
Application Software
Interface Systems
Conversions

Implementation Planning
The last step; it is to establish a detailed implementation plan.
The implementation workplan should entail the following info:
Personnel
Timeframes
Costs and budgets
Facilities and equipment required
Development or Implementation tasks
Operational considerations
Human-computer interactions
System test plan

The Testing Phase
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The system, whether newly developed or commercially available, must be tested to ensure that all data are processed correctly and the outputs are generated.
Testing verifies that the computer programs are written correctly and ensures that when implemented in the production environment, the system will function as planned.
When commercially available software is being implemented, three levels of testing are recommended. The first level is often called a function test. During this round of testing, the departmental teams and verify the database, ensuring that correct data have been entered into the files and table. The expected departmental reports are reviewed to assure correctness and accuracy. Multiple interaction of functional test often occurs until the department team is confident about the system profile and setup. As more users interact with the new system, previous unfound problem may surface. Evaluation of the severity of the newly discovered problems and the corrective                                                           action required is an ongoing process during implementation
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The Document System
Preparation of documents to describe the system for all users is an ongoing activity, which development of the documentation occurring as the various system phases and steps are completed. Documentation should begin with the final system proposal. Several manuals are prepared: a user’s manual, a reference manual, and an operator’s maintenance manual. These manual provides guides to the system components and outline how the entire system has been programmed or define.

 User Manual
User’s manual highlights how to use the system and describes what outputs the system can produce. With commercially available software, the vendor’s user’s manual helps establish the organization’s training manual.

Reference Manual
Reference manual is used by the project team members to understand how the system works. It describes what data are input, how the data base process the data, and the mechanism used to generate outputs.

Operator’s Maintenance Manual
Enables operators to keep the system up and running by providing the functional and technical specifications needed for the system. Manual must be written in sufficient detail such that users and operators understand how the system was developed, how it operates, and how it can be maintained, updated, and repaired.
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The Training Phase
Is essential to train the end user on how to use the system properly. A CIS will function only as well as its users understand its operation and the operation streamline the work.
All users of the new system or application must receive training. Training takes place before and during the activation of a new system. After system implementation, refresher of a new system. Training Is most effective when hands on instruction is provided. Training guides or manuals explain the system.
Training takes place before and during the activation of a new system. After system implementation, refresher courses as well as new employee introductory training on the use of the new systems are often provided by the institution.
Training is more effective when on hands on, interactive instruction us provided. Training guides or manuals explain the system; however, retention of the information are increased if the learners are able to interact.
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The Implementation Phase
Organizes all the steps into a detailed plan describing the series of events into detailed plan describing the series of events required to begin using the system or application in the production or live environment and details the necessary computer and software.
Four activation approaches are possible: (1) parallel, (2) pilot, (3) phased-in, (4) big bang theory. The timing of the conversation activity and the activation of all interphase require particular coordination between the technical staff and the project terms.
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The Evaluation Phase
Describes and assesses, in detail, the new system’s performance. Using the criteria established in the planning and system design phase.
To evaluate an implemented hospital information system, many principles are important for CIS. One authority suggests evaluating duplication of efforts and data entry.
Evaluating the system is the final and ongoing step in implementing process. This evaluation component becomes a continuous phase. The system is assessed to determine whether it continues to meet the needs of the users. The totally implemented system will require continues evaluation to determine if upgrading is appropriate. The formal evaluation should be conducted by an outside evaluation team to increase the objectivility level of the finding. Informal evaluations are done on a weekly basis.

Cost Benefits Analysis
Is necessary to determine if the system is worth its price. The cost benedif relates system cost and benefit to system design, level of use, timeframe and equipment costs. Each of these costs must be assessed in relation to benefits derived. Such as evaluation can be helped determining the future of the system.

Upgrading Clinical Information Systems
May be undertaken for a number of reasons. Software vendors often provide enhancements and upgrades to their system. New application features may be developed by the vendor and become available to the organization. Upgrading a system as a result of the addition of a new subsystems and technology often occurs. However when upgrading, require close evaluation. New technologies are an important consideration; the following new technologies may be considered:
bedside/point of care wireless device
workstation
multimedia presentation
decision support
artificial intelligence
neutral networks
integrated system architecture
interfaced network
open architecture

Workstation
Becomes the mode to gain access to the multiple applications. The user does not have to know or understand what type of hardware or software he or she is accessing, only that there is access to a broad array of information. The security and confidentiality issues raised by open architecture system are being handled with the installation of security servers, registration centers to register use of information, and/or protocols requiring authorization.

System Issues
As new technologies are evaluated and upgrading is the considered, the design team or departmental team is considered, the design team or departmental team must reassess the original function requirements with the excising hardware may exist. As far as possible, the team needs to determine if a subsystem can be added to the working system. New functions might be required, necessitating the procurement of additional hardware.