Ten Commandments for Implementing Clinical Information Systems

Transcription

1 Ten Commandments for Implementing Clinical Information Systems Boone Powell Sr. Grand Rounds Lecture February 25, 2004 M. Michael Shabot, M.D., FACS, FCCM, FACMI Director, Surgical Intensive Care Medical Director, Information Services C S Cedars Sinai Medical Center Los Angeles, California

2 Total US Health Care IT Expenditures Source: Sheldon I. Dorenfest & Associates, 2004

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7 I. Speed is everything Multiple authors have found that terminal response time is the parameter most valued by clinical users. Not beautiful screen design Not features Not advice Not warnings Not alerts Goal: sub-second screen flip time

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9 1990 ICU CIS Users Focus Group: Question: What would be an acceptable response time to flip CIS screens? Vendor Engineers suggestions: 5 seconds 2 seconds 1 second

10 Monitored Data Flowsheet

11 Ventilator Flowsheet

12 Intake-Output Flowsheet

13 1990 ICU CIS Users Focus Group: Response Time to Change Screens Vendor Engineers suggestions: 5 seconds 2 seconds 1 second Clinical Users choice: Blink Blink Blink

14 II. Doctors won t wait for the computer s pearls Primary goals of medical staff leadership, hospital administration & Board: improve quality and control costs

15 II. Doctors won t wait for the computer s pearls Institute of Medicine Report on Errors in Medicine Claims: 44,000-98,000 accidental deaths/yr in US hospitals Most due to drug errors Most errors preventable

16 II. Doctors won t wait for the computer s pearls

17 II. Doctors won t wait for the computer s pearls Primary goals of medical staff leadership, hospital administration & Board: improve quality and control costs ( The smart system ) Typically this requires: Computerized data lookups for additional information (costs system more time) Presentation of additional information to users (costs users more time) But top priority of clinical users is system speed

18 II. Doctors won t wait for the computer s pearls One Hospital s CPOE Solution: Show drug interaction alerts only to pharmacists as they verify medications It s tedious for pharmacists, but they are employees and are proficient at it Practicing physicians simply want to get on with their work

19 III. Deliver just in time information Men more frequently need to be reminded than informed. Samuel Johnson 1770

20 III. Deliver just in time information Anticipate user needs and deliver information in real time

21 III. Deliver just in time information Bates et al. JAMIA 2003;10:

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25 IV. Fit into the user s workflow Great temptation to improve clinician s workflow with a new system Don t just computerize an existing process, improve it. However, most busy physicians and nurses have already optimized their personal workflows just to survive

26 Personal Patient List Ten Commandments for CIS

27 Recent Results Ten Commandments for CIS

28 Recent Results Ten Commandments for CIS

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30 Lab Flowsheets Ten Commandments for CIS

31 12-Lead ECG Ten Commandments for CIS

32 PACS Images Ten Commandments for CIS

33 PACS Images Ten Commandments for CIS

34 PACS Images Ten Commandments for CIS

35 PACS Images Ten Commandments for CIS

36 Web/VS Results Pages Viewed per Day

37 V. Respect physicians sense of autonomy JCAHO & hospital policies, gatekeepers, reimbursement, paperwork, credentialing, quality initiatives, liability physicians feel they are under attack A new clinical information system & CPOE can add to the paranoia But I can t even use an ATM.

38 V. Respect physicians sense of autonomy That it will ever come into general use, notwithstanding its value, is extremely doubtful because its beneficial application requires much time and gives a good bit of trouble, both to the patient and to the practitioner..

39 V. Respect physicians sense of autonomy That it will ever come into general use, notwithstanding its value, is extremely doubtful because its beneficial application requires much time and gives a good bit of trouble, both to the patient and to the practitioner.. The Stethoscope - London Times 1834

40 VI. Monitor implementation in real time and respond right now Technology isn t the main issue, even though most current CIS are striving to become adequate if not good Implementation is far more important than the technology involved Change management isn t just a phrase, it s about people

41 VI. Monitor implementation in real time and respond right now Implementation usually costs more than the CIS itself Backfill required to remove nursing, pharmacy & other staff from the wards for training Training a large workforce all at once is challenging

42 VI. Monitor implementation in real time and respond right now Implementation budget & timeline difficult to estimate accurately need to build in flexibility Take the time to fix as you go Don t expand CIS to new areas until implemented units have stabilized

43 VII. Beware of unintended consequences Computerization of clinical processes frequently exposes longstanding practices and defects Taking humans (usually nurses) out of the loop exposes problems and can make them worse

44 VII. Beware of unintended consequences CIS Electronic Urimeter Interface

45 VII. Beware of unintended consequences

46 VII. Beware of unintended consequences The hourly specific gravity problem

47 VIII. Be wary of uncovering longstanding process flaws Admission Orders ADT system takes time to transfer patients electronically from one area of the hospital to another, or ED to inpatient With paper orders no problem With electronic orders big problem because MD can t write orders until inpatient account created by ADT system

48 IX. Don t disrupt Magic Nursing Glue Magic Nursing Glue holds the hospital together it s everywhere Disrupted by workflow changes and unintended consequences Admission orders Transfer orders Procedure area orders

49 X. Speed is everything

50 X. Speed is everything

51 X. Speed is everything

52 X. Speed is everything CIS & CPOE are no different

53 Leadership

54 Followership? What s wrong with this picture? Doctors, nurses and other independent professionals do not march well. Especially doctors.

55 I. Speed is everything II. III. IV. Doctors won t wait for the computer s pearls Deliver just in time information Fit into the user s workflow V. Respect physicians sense of autonomy VI. Monitor implementation in real time and respond right now VII. Beware of unintended consequences VIII. Be wary of uncovering longstanding process flaws IX. Don t disrupt magic nursing glue X. Speed is everything