Clinical Information Systems Overview

Team Members
Tina Fulbright – Slides #2 – 12
Christy Smith – Slides #13 – 23
Jali Jackson – Slides # 24 – 35
Todd MacDonald – Slides #36 - 51

As you will see in the
following compilation of
research, Clinical Information
Systems are multifaceted with
the ultimate goal of providing
clinical decision information
to the clinician. This
information allows the
clinician to make decisions
about patient care and can
enhance patient outcome.

CIS Overview
CIS refers to a Clinical Information System. The
system requires multiple technology applications
which are used at the point of care. The CIS is
capable of acquiring, processing, retaining, and
retrieving information related to patient care.
(McGonigle & Mastrian, 2009)

Choosing, Implementing, Revising
the CIS
The choice of systems is one made between multiple
departments. A collaborative effort is required in
order to ensure that the needs of all departments are
met by the system chosen for the facility. Various
committees are formed to gather information in an
effort to focus the goals of the system, to oversee
clinical quality as well as evaluate design of the
system and hardware.
(Al Mallah, Guelpa, Marsh & van Rooij, 2010)

Choosing, Implementing, Revising
the CIS (Cont)
Some of the team players would include
administration and executive staff as well as
representatives from clinical specialty areas, support
services, and the information technology department.
Software vendors are also called upon for their input
and recommendations.
(Al Mallah, Guelpa, Marsh, & van Rooij, 2010)

Some of the team players would include administration and
executive staff as well as representatives from clinical specialty
areas, support services, and the information technology
department. Software vendors are also called upon for their
input and recommendations. After implementation of the
CIS, revisions are made based upon the needs and input of the
users.
(Al Mallah, Guelpa, Marsh, & van Rooij, 2010)

Clinical Decision Support
Clinical decision support (CDS) is a program which is
computer-based. It is intended to help clinicians make
clinical decision. Large amounts of information are
integrated or filtered during this process and give
clinicians suggestions in regard to clinical intervention.
(The Design, 2001)

CDS Infrastructure
• A quality infrastructure would include a depository of medical
knowledge that would require “standardization of CDS and genomic
medicine information”. This information would need to be computer-
processable;
• In order for it to be computer interpretable, there must be a standard
format of patient data. An example would be Health Level (HL) 7 and
extensible markup language (XML);
• The approach used to acquire medical knowledge and find and
recapture patient data in order to form patient-specific guidance by
bringing together both the personal data of the patient and medical
knowledge.

The American National Standard Institute HIT
Standards Panel (HITSP) champions “the
standardization of health information technology
through the American Health Information
Community.”

Structure and Updates
The design of the CDS should be easy to use for the
clinician. It should contain quality up-to-date
medical information that will help the clinician make
the best decision for each individual patient. The
system should be updated as new information
becomes available.

Clinical Decision Support Systems
There are multiple systems available on the market.
Listed below are just a few of the CDS systems
available and their design companies.
TheraDoc, Inc/Hospira
VisualDx/Logical Images
QMR/First Data Bank
(Clinical Decision, 2003)

Conclusion
Obviously, when considering a CIS, one must look at
multiple factors. There must be a team assembled to
determine what is needed by that particular facility.
The HER, CDS, safety of the system, cost and the
education for staff must all be considered in great
detail before one can begin to work towards
implementing a successful system into their facility.

The EHR Component
 The HIMSS(Healthcare Information
and Management Systems Society,
2006) defines an EHR as a “longitudinal
electronic record of patient information
produced by encounters in one or more
care setting” (McGonigle & Mastrian,
2009).
 The IOM(Institute of Medicine) defines
the EHR as “health information and
data that is the patient data required to
make sound clinical decisions including
demographics, medical and nursing
diagnoses, medication lists, allergies
and test results” (McGonigle &
Mastrian, 2009).

Health Information and Data
 The patient data required to make sound clinical
decisions including demographics, medical and
nursing diagnoses, medication lists, allergies and test
results(IOM,2003) (McGonigle & Mastrian, 2009).
 All personnel that have a sign on, password and
credentials(for most facilities) have access to this
information. Doctors, nurses, PA’s, NP’s, etc… There
is a demographic view available for admission staff.

Results Management
 The ability to manage results of all types
electronically including laboratory and radiology
procedure reports both current and historical(IOM,
2003)((McGonigle & Mastrian, 2009).
 Laboratory and radiology personnel have the ability
to view and enter results here. Authorized staff have
the ability to view results here. Any personnel with
the credentials to view patient records has access to
this information. Without this component, results
are delayed and hard to compare with archived
records.

Order Entry Management
 The ability of a clinician to enter medication and
other care orders, including laboratory,
microbiology, pathology, radiology, nursing, supply
orders, ancillary services, and consultations directly
into a computer(IOM,2003) (McGonigle &Mastrian,
2009).
 Personnel are given rights according to their
credentials. Orders and medications are signed by
physicians electronically when needed. Without this
component, there are several extra steps that must
be taken to complete the task of placing an order for
a patient.

Decision Support
 The computer reminders and alerts to improve the diagnosis
and care of a patient including screening for correct drug
selection and dosing, medication interactions with other
medications, preventative health reminders in areas such as
vaccinations, health risk screenings and detection, and clinical
guidelines for patient disease treatment(IOM,2003)(Mcgonigle
& Mastrian, 2009)
 This component helps us to monitor what the patient has and
has not had completed according to their medical record. It
also aids in the faster prescribing of medications for physicians
and keeping patients safe from possible deadly interactions
from their medications. This is a powerful tool for both the
healthcare team and patient satisfaction.

Electronic Communication and
Connectivity
 The online communication among healthcare team
members, their care partners, and patients including
E-mail, Web messaging, and an integrated health
record within and across settings, institutions, and
telemedicine (IOM, 2003) (McGonigle & Mastrian,
2009).
 This component is important for access to patients
records when they are being seen by a physician
other than their primary care and history can be
easily accessed. Not all parts of this system are
utilized by all healthcare facilities, but they are
available and helpful tools for accurate patient care.

Patient Support
 The patient education and self-monitoring tools,
including interactive computer-based patient education,
home telemonitoring and telehealth systems(IOM,2003)
(Mcgonigle & Mastrian, 2009).
 These are very helpful for patients to be taken care of on
an out-patient basis. Blood pressure monitoring for home
health that reports immediately if there are any problems
is a good example of one system used through a patient’s
phone line. The report of the patient’s vitals is sent to the
agency and they can call if something is not right or if the
patient doesn’t respond to the machine telling them it is
time for their vital signs to be checked.

Administrative Processes
 The electronic scheduling, billing, and claims
management systems including electronic scheduling for
inpatient and outpatient visits and procedures, electronic
insurance eligibility validation, claim authorization and
prior approval, identification of possible research study
participants and drug recall support (IOM, 2003)
(McGonigle & Mastrian, 2009).
 This helps the organization not double book patients for
appointments and to get authorization for procedures
and admits almost immediately. Of coarse not everything
is automatic but it helps speed the process for both the
institution and the patient. If your sign on has the
credentials needed for this process, you have access to
work in these sections.

Reporting and Population Health
Management
 The data collection tools to support public and
private reporting requirements including data
represented in a standardized terminology and
machine-readable format (IOM, 2003) (Mcgonigle &
Mastrian, 2009).
 This is part of every healthcare system and is
required by law. The reporting is done to evaluate
EHR systems for functionality, security, and
interoperability. This is regulated by the
Certification Commission for Healthcare
Information Technology or CCHIT.

The EMR/EHR was created to limit mistakes, cut down
expenses, and improve care.
EMR/EHR’s provide direct access to patient records, improve
order legibility, have built in safety features, and use of
standardized nomenclature.
 Like with anything new, there is a need for protection and
education.
The following slides will show how safety and education will
be implemented regarding the EMR/HER.
(Buppert, 2010)

Backup
 Due to private and sensitive patient information, it is necessary to back-up the
EMR/EHR frequently (Buppert, 2010).
 Not only does the system need to be backed up, but the method in which the
system is backed up needs to be assessed frequently to ensure that a back up
is taking place (Buppert, 2010).
 It is necessary to ensure that the network storage or hard drive is efficient in
terms of space and function (Buppert, 2010)
 Common back up programs include Legato and Net-backup software
(Rosenfeld, 2006).
 A cheaper, yet slower, option is hierarchical storage management software
(Rosenfeld, 2006).

Storage
 “The key driver leading to the need for healthcare
institutions to pay attention to storage and archival
resources is the dramatic growth in healthcare digital
information” (Rosenfeld, 2006)
 A cost efficient choice for storage management are
enterprisewide storage architectures.
 This architecture “…expedite[s] management of storage
resources, enhance[s] the ability to share application
data with other systems, and facilitate[s] automated
data backup and redundancy/continuity” (Rosenfeld,
2006)

EMR/EHR
Access
Implement password protected log-ins.
Automatic log out if no activity after 2
minutes.
Have designated staff to handle breaches
in security.
Have staff change their password every 6
months to ensure only employees have access
to sensitive records.
(Buppert, 2010)

HIPAA Considerations
 The HIPAA rule book is 1,500 pages long. Although this is a
massive amount of information, “…it is a well-thought-out, clear
set of rules about the accepted use of protected health
information” (McDonald, 2009).
 HIPAA requires all organizations using EMR/EHR to maintain
an audit trail.
 Other rules implemented by HIPAA regarding the EMR/EHR
took effect April 14, 2003.
 These rules are to help maintain each and every patients
privacy.


Protection of Files
 It is important to protect the privacy of sensitive patient information.
 With EMR/EHR comes the increased opportunity for security
breaches and viruses.
 Because of this, there needs to be increased security and awareness
when charts are pulled up on the computer.
 Built in automatic shut off and password protected screen savers
are a must have.
 Antivirus and malware programs also need to be installed on all
computers to ensure that privacy is maintained
 (Fetter, 2009)

Protection of Files (cont…)
 Due to the frequent occurrence of power surges, there is a chance for
disruptions in computer systems and network damage.
 This risk can cause a loss of patient information and aggravated staff
members.
 Uninterruptible power supplies (UPS) can be installed to prevent this from
occurring.
 A great option to use because it is generator friendly and removes the
problems associated with generator frequency synchronization problems.
(Reisz, et al., 2010)

Education
 Anyone who will be operating or charting in the EMR/EHR needs to
be properly educated on the proper way of doing so.
 IT workers who are familiar with the program and all that it entails
are great resources to the facility and it employees.
 An important aspect of EMR/EHR education is developing a plan that
will enhance computer literacy and competency of the staff.
 It is “…critical to assess, develop, and maintain staff competency to
ensure quality of care in all nursing areas” (Miller & Arquiza, 1999).

Education
Strategies
 Select members from each unit to be
trained in a way that they would be able
to train others- “Super users”
 Structure classes based on position/level
(i.e. Nurses, doctors, CNA would be in
three different classes)
 Conduct annual competency checks to
evaluate if more training is needed.
 Have employees perform self assessments
and compare with comments made by
“super-users”
(Miller & Arquiza, 1999)

Education Strategies (cont…)
 Depending on whether weekly or monthly training
sessions are needed, there needs to be an adequate
number of IT personnel available to “…answer questions
and give impromptu training on [various units], and
receive feedback on…problems in return” (Transitioning
to, 2006).
 Organizational planning and shared resources combined
with a well thought out mission, vision, and yearly
objectives can help advance knowledge and competency
(Fetter, 2009).
 Provide refreshments and support to facilitate
participation.

Principles to Improve Effectiveness
 Assess training needs
 Don’t rush training time
 Have a low student-to-instructor ratio
 Allow staff to practice their new knowledge in the
classroom before use on real charts.
(Fetter, 2009)

Principles (cont…)
 Have paper versions of screen shots available to aid in
learning how to navigate through the EMR/EHR.
 Allow extra practice time
 Have extra trainers available to answer individual
questions.
 Technical support needs to be available for each unit.
(Fetter, 2009)

 Taking into consideration all aspects of
implementing a CIS is a daunting task. Genesis, the
joint initiative task force from St. Johns, has been
responsible for the research and implementation of
EPIC at St. Johns.
 The total installation cost, Mercy-wide, has been
approximately $500,000,000.
 The following presentation discusses where the costs
were incurred.
Micki Struckhoff, RN – VP Systems Integration, St. Johns Springfield.

What Is A Computer Network?
Simply stated, a computer network “is two or more
computers connected so that they can communicate
with each other and share information, software,
peripheral devices, and/or processing power.” The
most common of which is called a LAN (local area
network) and a WAN (wide area network).
highered.mcgraw-
hill.com/sites/0072464011/student_view0/chapter6/glossary.html

Hardware and Software
Hardware & software for a computer network
involves several components. Keep in mind, when a
large network is installed, the hardware & software
needs can increase significantly.
An upgrade to existing computer networks typically
accompanies the addition of a CIS package.

Components
Hardware
Robust computer
workstation
Network Cables
Router with firewall
Servers & Backups
Repeater (if signal
attenuation an issue)
Peripheral Equipment
Fiber optic connection to
internet
Software
Compatible OS (operating
system & license)
CIS Software & license for
each server (usually based
on size of network
involved)
Internet access
Software firewall
Antivirus

Classic Network
Bandwidth &
Hardware Map
The picture on the left is a great depiction of what a typical wide area networks
bandwidth looks like without hardware. The right is a very basic map of a LAN.

Support Personnel
Relevant to the discussion is the number of support
technicians available and their associated salaries.
According to indeed.com, the average salary for a
computer technician in Springfield, MO is $33,000 per
year. Depending on the size of network, this cost
could multiply very quickly. The network manager
will average $66,000.

Support Personnel Continued
 As is the case with EPIC, there are groups of IT
Technicians within the IT Department that strictly
support the CIS, according to Micki Struckhoff, RN.
 Anyone supporting the software must be certified
through EpicCare, the company that supplies St.
Johns’ CIS software.
Micki Struckhoff, RN. – VP Systems Integration for St. Johns
Springfield.

Multiple redundancies are required for this
type of market. Several ISPs are involved in
making this system as failsafe as possible to
achieve maximum stability.

Workstations
Workstations are the PCs that everyone does their
work.
St. John’s needed to upgrade each PC that the
hospital had to support the new software.

Part of the purchase of any CIS will be to train
those utilizing the system. With EPIC,
Certified Trainers were sent to Wisconsin for
training by the company, EpicCare. As it was
during the CIS implementation at St. John’s,
those who would help the remainder of the
system to become trained were the
“Credential Trainers” for the next site for
training, which included retired teachers.

Implementation
Prior to implementing a CIS, a committee known as
Genesis at St. John’s, gathered information from all
aspects from the hospital end-users. This committee
represented a cross-section of all areas of the system.
The needs from the end-user was translated into what
the software was going to accomplish for our
healthcare system. Going “live” would be done in
phases as to eliminate potential unforeseen issues.

Implementation
Other aspects needing to be considered is the
“transitional time and problems associated with
switching over to a new clinical software.”
http://informatics.umdnj.edu/clinical/information_systems.htm

Challenge To Implementation
Mercy wanted to standardize all areas to reduce the
cost of building software. Most common challenge
was to standardize all order sets collaboratively across
all regions.
Micki Struckhoff, RN – VP Systems Integration, St. Johns Springfield

Updates for the software are twice per
year. This year will be a full system
upgrade in December. Those wishing to
improve their skills have the opportunity
to work in a computer lab setting prior to
utilizing the upgraded software.

Summary
While the costs associated with this CIS were
considerable, a massive upgrade to the network
backbone was the costliest portion. Thousands of due
diligence and man hours went into the
implementation of the CIS to ensure the most stable,
reliable and user-friendly software would run
seamlessly in our health care system.

References
Al Mallah, A., Guelpa, P., Marsh, S & van Rooij, T., (2010). Integrating genomic-based clinical decision support into electronic
health records. Personalized Medicine. 7(2), 163-170.
Barey, E.B.,(2009). The Electronic Health Record and Clinical Informatics. In McGonigle, D., & Mastrian, K.(Eds.), Nursing
Informatics and the Foundation of Knowledge(pp.219-237). Boston: Jones and Bartlett Publishers.
Buppert, C. (2010, January 13). Medscape. Retrieved October 1, 2010, from Authors and Disclosures:
http://www.medscape.com/viewarticle/714812
Clinical Decision Support Systems. (2003). Retrieved October 6, 2010, from http://www.informatics-review.com/decision-
support/index.html
Fetter, M. (2009). Improving information technology competencies: implications for psychiatric mental health nursing. Issues in
Mental Health Nursing, 30(1), 3-13. Retrieved from CINAHL Plus with Full Text database.

References Continued
Indeed.com. Salaries for computer technicians in Springfield, MO. Retrieved
October 23, 2010. http://www.indeed.com/salary?
q1=Computer+Technician&l1=springfield%2C+mo
Institute of Medicine. (2003). Key capabilities of an electronic health
system: Letter report. Washington, DC: National Academics Press.
Informatics Institute: University of Medicine & Dentistry of New Jersey .
Retrieved October 20, 2010
http://informatics.umdnj.edu/clinical/information_systems.htm

McDonald, C. (2009). Protecting patients in health information exchange: A defense of the HIPAA privacy rule. Health
Affairs , 447-449.
McGonigle, D. & Mastrian, K. (2009). Nursing Informatics: and the foundation of knowledge ( pp. 193). Massachusetts:
Jones and Bartlett Publishers, LLC.
McGraw-Hill Online Learning Center. Retrieved October, 21, 2010. http://highered.mcgraw-
hill.com/sites/0072464011/student_view0/chapter6/glossary.html
Medscape. (2010, September 10). Retrieved October 1, 2010, from OJIN: The Online Journal of Issues in Nursing:
http://www.medscape.com/viewarticle/723608
Miller, E., & Arquiza, E. (1999). Improving computer skills to support hospital restructing. Journal of Nursing Care
Quality, 13(5), 44-56. Retrieved from CINAHL Plus with Full Text database.

Reisz, T., Denny, J., Nguyen, D., Braun, D., Merkel, R., Kuhn, P., et al. (2010).
2010: change & progress: our panel of experts offers readers their take on
what to look for in healthcare technology in the year ahead. Health
Management Technology, 31(1), 12. Retrieved from CINAHL Plus with Full
Text database.
Rosenfeld, K. (2006). What is application-attached storage costing your facility?
As electronic healthcare databases grow, traditional backup systems may
become inadequate. Is information lifecycle management the future of data
storage? Health Management Technology, 27(8), 22-25. Retrieved from
CINAHL Plus with Full Text database.

Struckhoff, Micki RN – VP Systems Integration, St. John’s Springfield.
Personal interview October 25, 2010.
Ten commandments for implementing clinical information systems
Proc (Bayl Univ Med Cent). 2004 July; 17(3): 265–269. Retrieved October 23, 2010
www.ncbi.nlm.nih.gov/pmc/articles/PMC1200662/
Transitioning to electronic medical records: the move to electronic records presents
opportunities and challenges for physicians. (2006). AMIA Annu Symp Proc , 629-633.
University of California, Irvine, Donald Bren School of Information and Computer Sciences.
Retrieved October 22, 2010. http://www.ics.uci.edu/.../Tech-EC/EC-EB/index.html
The design and implementation of a computerized patient record at the Ohio State University
health system-a success story. (n.d.)
Retrieved from http://www.himss.org/content/files/davies_2001_osuhs.pdf

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