Ten Commandments for Implementing ... - Semantic Scholar

Ten Commandments for Implementing Ten Commandments for Implementing Clinical Information SystemsClinical Information Systems

Cedars Sinai Medical CenterCedars Sinai Medical CenterLos Angeles, CaliforniaLos Angeles, California

C SS

Boone Powell Sr. Grand Rounds Lecture

February 25, 2004

Boone Powell Sr. Boone Powell Sr. Grand Rounds LectureGrand Rounds Lecture

February 25, 2004 February 25, 2004

M. Michael Shabot, M.D., FACS, FCCM, FACMIM. Michael Shabot, M.D., FACS, FCCM, FACMIDirector, Surgical Intensive CareDirector, Surgical Intensive Care

Medical Director, Information ServicesMedical Director, Information Services

Ten Commandments for CIS

MMS 02/04 Source: Sheldon I. Dorenfest & Associates, 2004

Total US Health Care IT Expenditures


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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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Vendor Engineers’ suggestions:5 seconds2 seconds1 second

1990 ICU CIS Users Focus Group:

Question: What would be an acceptable response time to flip CIS screens?


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Monitored Data Flowsheet


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Ventilator Flowsheet


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Intake-Output Flowsheet


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Vendor Engineers’ suggestions:5 seconds2 seconds1 second

1990 ICU CIS Users Focus Group:Response Time to Change Screens

Clinical Users’ choice:“Blink” “Blink” “Blink”


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II. Doctors won’t wait for the computer’s pearls

• Primary goals of medical staff leadership, hospital administration & Board: improve quality and control costs


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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


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• 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


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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


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III. Deliver “just in time” information

“Men more frequently need to be reminded

than informed.”

Samuel JohnsonSamuel Johnson17701770


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• Anticipate user needs and deliver information in real time


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Bates et al. JAMIA 2003;10:523–530.


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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


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Personal Patient List


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Recent Results


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Recent Results


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Lab Flowsheets


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12-Lead ECG


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PACS Images


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PACS Images


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PACS Images


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PACS Images

Web/VS Results Pages Viewed per Day


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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.”


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“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…..”



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“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



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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


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• 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


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• 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


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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


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CIS Electronic Urimeter Interface


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The “hourly specific gravity” problem


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VIII. Be wary of uncovering longstanding process flaws

• 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

Admission Orders


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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


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X. Speed is everything


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CIS & CPOE are no different


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Leadership


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Followership?

What’s wrong with this picture?

Doctors, nurses and other independent professionals do not march well.

Especially doctors….


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I. Speed is everything


III. Deliver “just in time”information

IV. Fit into the user’s workflow

V. Respect physicians’sense of autonomy



VIII. Be wary of uncovering longstanding process flaws

IX. Don’t disrupt “magic nursing glue”


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Ten Commandments for Implementing ... - Semantic Scholar