Patient Care Information Systems: Successful Design and Implementation

233 Pages·1995·7.444 MB·English

by  Erica L. Drazen, Jane B. Metzger, Jami L. Ritter, Mark K. Schneider (auth.)

Computers in Health Care
Kathryn J. Hannah Marion J. Ball
Series Editors
Computers in Health Care
Series Editors:
Kathryn J. Hannah Marion J. Ball
Nursing Informatics
Where Caring and Technology Meet
M.J. Ball, K.J. Hannah, U. Gerdin Jelger, and H. Peterson
Healthcare Information Management Systems
A Practical Guide
M.J. Ball, J.V. Douglas, R.1. O'Desky, and J.W. Albright
Knowledge Coupling
New Premises and New Tools for Medical Care and Education
Lawrence L. Weed
Dental Infomatics
Integrating Technology into the Dental Environment
Louis M. Abbey and John L. Zimmerman
Aspects of the Computer-based Patient Record
Marion J. Ball and Morris F. Collen
Introduction to Nursing Informatics
K.J. Hannah, M.J. Ball, and M.J.A. Edwards
Strategy and Architecture of Health Care Information Systems
Michael K. Bourke
Organizational Aspects of Health Informatics
Managing Technological Change
Nancy M. Lorenzi and Robert T. Riley
Patient Care Information Systems
Successful Design and Implementation
Erica L. Drazen, Jane B. Metzer, Jami
L. Ritter, and Mark K. Schneider
Eriea L. Drazen Jane B. Metzger
Jami L. Ritter Mark K. Sehneider
Patient Care
Information Systems
Successful Design and Implementation
With Contributions by
John P. Glaser Samarjit Marwaha
William C. Reed Jonathan M. Teich
With 33 Illustrations
Springer Science+Business Media, LLC
Eriea L. Drazen Jane B. Metzger
Arthur D. Little, Ine. Arthur D. Little, Ine.
Aeorn Park Aeorn Park
Cambridge, MA 02140 Cambridge, MA 02140
USA USA
J ami L. Ritter Mark K. Sehneider
Arthur D. Little, Ine. Arthur D. Little, Ine.
Aeorn Park Aeorn Park
Cambridge, MA 02140 Cambridge, MA 02140
USA USA
Library of Congress Cataloging-in-Publication Data
Patient care information systems: successful design and
implementation / Erica L. Drazen ... [et al.].
p. cm. - (Computers in health care)
Inciudes bibliographical referenees and index.
ISBN 978-1-4612-6914-4 ISBN 978-1-4612-0829-7 (eBook)
DOI 10.1007/978-1-4612-0829-7
1. Information storage and retrieval systems-Medical care.
2. Information storage and retrieval systems-Hospital. I. Drazen,
Erica. II. Series: Computers in health care (New York, N.Y.)
[DNLM: 1. Information Systems. 2. Delivery of Health Care
methods. W 26.5 P298 1994]
R858.P38 1994
362.1 '0285-dc20 94-28728
Printed on acid-free paper.
© 1995 Springer Science+Business Media New York
Originally published by Springer-Verlag New York in 1995
Softcover reprint ofthe hardcover 18t edition 1995
AII rights reserved. This work may not be translated or copied in whole or in part without the
written permission of the publisher Springer Science+Business Media, LLC,
except for brief excerpts in connection with reviews or scholarly
analysis. Use in connection with any form of information storage and retrieval, electronic
adaptation, computer software, or by similar or dissimilar methodology now known or hereaf
ter developed is forbidden.
The use of general descriptive names, trade names, trademarks, etc., in this publication, even
if the former are not especially identified, is not to be taken as a sign that such names, as
understood by the Trade Marks and Merchandise Marks Act, may accordingly be used freely
byanyone.
Production coordinated by Chernow Editorial Services, Inc., and managed by Bill Imbornoni;
manufacturing supervised by Genieve Shaw.
Camera-ready copy provided by the authors.
987654321
ISBN 978-1-4612-6914-4
Series Preface
This series is intended for the rapidly increasing number of health care
professionals who have rudimentary knowledge and experience in health
care computing and are seeking opportunities to expand their horizons. It
does not attempt to compete with the primers already on the market. Emi
nent international experts will edit, author, or contribute to each volume in
order to provide comprehensive and current accounts of innovations and
future trends in this quickly evolving field. Each book will be practical,
easy to use, and well referenced.
Our aim is for the series to encompass all of the health professions by
focusing on specific professions, such as nursing, in individual volumes.
However, integrated computing systems are only one tool for improving
communication among members of the health care team. Therefore, it is
our hope that the series will stimulate professionals to explore additional
means of fostering interdisplinary exchange.
This series springs from a professional collaboration that has grown over
the years into a highly valued personal friendship. Our joint values put
people first. If the Computers in Health Care series lets us share those
values by helping health care professionals to communicate their ideas for
the benefit of patients, then our efforts will have succeeded.
Kathryn J. Hannah
Marion J. Ball
Preface
Computer systems have been installed in hospitals and ambulatory care
settings for decades. Over the years, the focus of investment has been
shifting from patient accounting and billing systems to systems for handling
data from clinical and administrative services (pharmacy, laboratory, ad
mitting). The most recent advance is toward development and use of sys
tems that support the delivery of patient care by aggregating relevant infor
mation from different sources and providing access to that information in
a form that supports health care providers in making decisions about a
patient's care.
Why has it taken so long for computers to be used in delivery of patient
care-the primary business of health care institutions? Why has interest in
these systems suddenly escalated? Several different explanations have been
offered. One view is that physicians have resisted computer support, and
that resistance is just beginning to break down as more computer literate
staff join the work force. As we will explain in Chapter 2, there is little
evidence to support this theory. In fact, studies over the last two decades
have documented positive attitudes toward computers among physicians
and nurses. We think that physicians and nurses have always wanted useful
computer support, and now they are demanding it.
Lack of appropriate technology is another often-cited barrier to the im
plementation of patient care computers. However, the Institute of Medi
cine's report on the computer-based patient record concluded that the tech
nology to support computer-based records is available.(l) As some of the
references in later chapters will document, patient care information systems
were developed and successfully implemented using the technology avail
able in the 1960s and 1970s. Many of these systems are still in use today.
Although technological advances have significantly increased the number
of options for display formats, input and output devices, and back-up and
security systems, the basic technology to create a useful information system
for health care has existed for some time. Advances in information and
communications standards and the "open systems" movement have enabled
viii Preface
institutions to move toward patient care information systems without aban
doning all of their current computer investment. As we will discuss in
Chapter 4, we believe that technological advances will enhance the solutions
available, but that the most critical element of a patient care information
system is in the logic, screen flow, and design of the end-user support. This
was the "secret to success" of some of the earliest patient care information
systems and the missing element of many unsuccessful systems today.
Another theory about the evolution of patient care computing is that
health care institutions have made computer investments in response to
external pressures. Hospitals first acquired computer systems during the era
when payment for care was based on cost reimbursement. At that time, two
critical issues for the hospital were accounting for costs (to justify charges
for the following year) and sending bills out quickly (to manage cash flow).
Patient billing was the first application to be automated, and then revenue
producing departments were automated to capture charges for services.
Later, automation was applied to improve operational efficiency and lower
costs in laboratory, pharmacy, and radiology departments. Since many of
these services faced outside competition, there was pressure to control costs
and provide good service.
Currently, the demands on the health care delivery system are to lower
costs and to be accountable for outcomes over a continuum of care. As we
will discuss in Chapter 1, there is an abundance of evidence that computer
support can make significant contributions to patient management. Under
prospective payment, capitation, or fixed-fee schedules, institutions must
continually try to lower costs and improve services to remain competitive.
Most of the day-to-day resource consumption that drives operating costs is
determined by physicians and nurses when they develop plans of care and
order tests and treatments. Health care delivery institutions need to help
these users make cost-effective decisions, provide managers with the infor
mation they need to monitor access to and outcomes of care, and improve
the process of care delivery.
As we move to deliver care within an integrated, community-based deliv
ery system, the need for information and the difficulty in accessing infor
mation increase simultaneously. It is impossible to provide seamless access
to care without also providing seamless access to information; patients will
not be directed to the most appropriate location of care unless relevant
information about the patient can be directed there also. We believe these
pressures are the major forces behind the current interest in patient care
computer systems.
When looking toward the future, three things seem clear.
• The need for patient care information systems will only increase over
time.
• Success in implementing patient care systems will be critical to build
ing viable integrated care delivery systems.
Preface ix
• Supporting patient care with information systems will require a huge
investment of capital, management attention, and staff time.
How much progress have we made in implementing patient care systems,
and what have we learned?
National market data from 3,000 hospitals indicate that hospitals spent
$5.5B in information systems in 1990.(2) Investments in systems for clinical
departments are increasing at a rate of 20 to 40 percent per year. The
penetration of patient care information systems is so small that they have
not been tracked in national surveys. However, in a 1992 survey of chief
executive officers of 27 hospitals and multihospital systems, most stated
that their long-term vision is to have an integrated information system
containing all clinical and financial information.(2) Clearly, we are not
there yet.
In a 1993 survey, hospital CEOs rated their information position on a
scale of 1 to 5, where 1 was not prepared and 5 was completely prepared.
CEOs rated their preparedness for the following as a 3: for meeting infor
mation requirements for JCAHO initiatives on clinical quality, TQM/CQI
initiatives, networking with physician practices, clinical outcomes manage
ment, collaboration with other hospitals, patient-centered care initiatives,
EDI and computerized patient records, and managed care.(3) Unfortu
nately, this list almost completely overlaps the list of initiatives that are
most critical to success within the new health care delivery environment.
Perhaps even more alarming (at least for current CIOs) is that 21 percent of
the CEOs felt their current CIOs would not be capable of implementing
necessary changes in information support, and 53 percent of CEOs admit
ted they did not know if their CIOs were capable of leading them into the
future.
There are many alternative uses for the billions of dollars that will need
to be invested in information systems. It is imperative that investment deci
sions be made wisely and that the capabilities acquired provide real value in
patient care and institutional management. Without question, many system
developers, health care institutions, and system vendors have learned valu
able lessons about how to design, develop, implement, and use patient care
computer systems. However, much of this knowledge is inaccessible be
cause it has never been published or because the only publications have
been in conference proceedings, which are typically not indexed, not readily
available in libraries, and often out of print. In this book, we have at
tempted to summarize and synthesize lessons learned from the past so they
can provide a basis for future progress.
There are several potential impediments to using past experience to guide
the future design, selection, and use of patient care information systems.
One problem relates to the fact that there is no one "patient care informa
tion system." Available systems differ in the capabilities they offer (the type
of information that is available), in the user interface (e.g., ease of use,
x Preface
method of data entry), and in the technical performance of the system (e.g.,
response time and down time). Products are also continually evolving. Be
cause most studies only report on the experience with one system at one
point in time, it is difficult to separate out effects related to the particular
system being studied from the effects of computer systems in general.
The use of existing systems also differs. The computers may be used
directly by physicians and nurses, nurses or clerical staff may transcribe
physicians' orders into the system, and these same staff may use the system
to retrieve results for physicians. Use may be either voluntary or manda
tory. Mandatory use typically implies not only that is there a directive to
use the system, but also that alternative manual methods for obtaining
information are no longer available. Most studies are conducted in only one
institution, with computer systems that duplicate or replace some part of
the paper medical record with automation. It is, therefore, difficult to
generalize about use of computers across different settings with different
approaches to using the system.
Despite these limitations, to accelerate the rate of progress we as a nation
are making in the use of patient care computers, we need to mine all the
value we can from past experience. It is our hope that this volume will be a
significant contribution toward advancing our understanding of best prac
tices for providing information support to patient care.
What is a patient care information system? There is no standard defini
tion, but in the broadest sense, the system will provide access to all of the
information needed to effectively care for a patient. As shown in Figure
P-l, there are three main categories of patient care information-informa
tion related to the patient; information that is specific for each institution;
and information relative to the professional domain of each user. Today's
patient care information systems contain a subset of these data. Items with
a bullet on Figure P--l are available in many patient care information sys
tems today. Items with an arrow are not being used except in a few test
sites. The remaining elements are found in some commercial products today
and are likely to be found in advanced patient care information systems
developed by institutions themselves.
There are several other elements of a good patient care information
system:
• At a minimum, all data are stored at a patient level and retrievable in
an integrated form for any patient.
• A comprehensive patient care information system is linked to a com
munication system to ensure that information is available to all rele
vant care givers. The system does not require caregivers to perform
administrative functions - all administrative data are generated as a
by-product of care delivery.
This book is focused on meeting the information needs of direct care
givers. Much of the discussion, and most of the research, has focused on
Preface xi
Patient InstitutionaVLocal Medical Domain
Information Information Information
Patient Health Local Best Medical
Profiles Practices Knowledge
.. Health risk .. Clinical II' Joumals
factors pathways II'Textbooks
.. Functional .. Protocols .. Consultation
status .. Alerts! systems
reminders
.. Problem list
.. Comparative
performance
Patient History Resources
.. History/physical exam II' Availability and
II' Medication profile scheduling
II' Plans of carel .. Cost accounting .. Comparative
progress notes II' Formulary performance
.. Consult reports .. Staff directory
• Reports of test .. Policies!
result procedures
fmages Databases
- X-ray II' PDR
- CT scans II' Poison center
.. Ultrasound • Drug
.. Electrocardio .. Protocols interactions
grams .. Referral .. Genetic map
.. Drawings policies .. Research
- Patient photo
Key:
• Part of base product
II' In limited use
.. Emerging
Figure P-l. Elements of a Comprehensive Patient Care Information System
computer use by physicians both because physicians' decisions affect so
much of the cost of care delivery and because this group has traditionally
not used computer systems. We have also included information about pa
tient care information support within nursing. However, a very comprehen
sive review of information requirements to support nursing has been pub-