Clinical information technology
Some of the concepts in this report are based on work performed by the author and others at Catholic Healthcare West (CHW), a 48-hospital system based in California, Arizona, and Nevada. The challenge was to craft a strategy for moving forward on the issue of clinical information systems.
To meet this challenge, the multidisciplinary team developed an innovative auditing and planning process. This process was used to develop clinician-driven standards for inpatient clinical information system functionalities, measure the level of technology use in each hospital against system standards, and provide tools to help hospital executives prioritize clinical system investments across all CHW hospitals.1
Clear, complete descriptions identified the clinical functionalities to be included in an integrated information system and the order in which they should be introduced to ensure optimal utilization of the various system components. The underlying premise was that the central focus of clinical systems planning must be the diverse workflow needs of clinicians and that their in-depth involvement is critical to success.
Because of an extremely diverse group of stakeholders, the team first defined 55 functionalities needed for caregivers to function efficiently in the acute-care setting. These were defined and reviewed by the physician Medical Informatics Information Officer (MIIO), nursing leadership, physician informaticists, and a variety of information technology (IT) department leaders. For each of the 55 items, the team defined the technology capabilities required, the likely users, the rationale for its implementation, barriers typically experienced, and any other functionalities that would need to be implemented before the functionality under discussion could be put in place.
Assessing existing functionalities
Once prioritization was accomplished, a team of 3 people, including 2 nurses and the medical informatics physician, visited 43 CHW hospitals. Speaking with the doctors and nurses taking care of patients in the wards, they used a list of all functionalities to ascertain whether or not they were using technology to assist them in patient care.
Striking gaps were found in even the most basic functionalities. Even for simple forms of data review, the reality for many hands-on caregivers is that they are still living in a paper world. Given the ever-increasing dependency of decision making on laboratory data, shortened lengths of stay, and increased patient volumes and acuities, the continuing reliance on efficient distribution of paper has become more and more absurd.
With respect to capturing even the most basic POC information on a computerized system, the audit showed that much less was happening than many had assumed. For example, only 21% of CHW hospitals had vital signs and I&O information available in the computer for clinician use. Computerized medication charting was found in only 1 of the 48 hospitals. Recent straw polls conducted during presentations to diverse groups have validated that these numbers reflect national trends. Even in many otherwise sophisticated hospitals and academic medical centers, such POC information is found on a clipboard that is often unavailable at the time decisions are being made.
Medication safety technology
The need to support clinicians in medication use at the POC can be recognized both intuitively and from the evidence. A 1995 study by Bates et al3 indicated that medication errors resulting in preventable adverse drug events (ADEs) or potential adverse drug events (PADEs) occurred most often during ordering (56%) and administration (34%). However, before administration, pharmacists caught 6% of the ordering errors, and nurses intercepted an additional 42%. Nurses also intercepted 33% of all transcription and dispensing errors. However, 0% of drug administration errors were intercepted. In a study by Leape et al,4 51% of the nonintercepted potential ADEs and PADEs occurred during administration, making safety at the POC one of the greatest areas for potential improvement in the medication use process.