1. business and industrial
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Improving the Quality and Safety of Care
through Implementation of an Integrating
Clinical Informatics System
Nicholas E. Davies Award Application
Cincinnati Children's Hospital Medical Center
3333 Burnet Avenue
Cincinnati, Ohio 45229-3039
May 15, 2003
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Improving the Quality and Safety of Care through
Implementation of an Integrating Clinical Informatics System
Cincinnati Children's Hospital Medical Center
3333 Burnet Avenue
Cincinnati, Ohio 45229-3039
Brian Jacobs, MD
COE Project Director
Phone: (513) 636-4259
Fax: (513) 636-4267
E-Mail: [email protected]
Terri Price RN, BSN
Director, Patient Services
Phone: (513) 636-8050
Fax: (513) 636-7504
Email: [email protected]
Gayle Lykowski RN, MBA
COE Project Manager
Phone: (513) 636-2281
Fax: (513) 636-7504
E-Mail: [email protected]
Marianne Speight
Vice President, Information Services
Phone: (513) 636-4846
Fax: (513) 636-7504
Email: [email protected]
Daniela Mahoney RN, BSN
ICIS Sr. Project Manager
Healthcare Innovative Solutions, Inc.
Phone: (330) 948-7018
Fax: (801) 640-8887
Email: [email protected]
Neil Johnson MD
Medical Director, Information Services
Phone: (513) 636-7912
Fax: (513) 636-7504
Email: [email protected]
Marty Goodfriend RN, BSN
Manager, Application Training & Support
Phone: (513) 636-7400
Fax: (513) 636-7504
Email: [email protected]
MariJo Rugh MT ASCP, BA
Community Physician Liaison
Phone: (513) 636-1980
Fax: (513) 636-2511
Email:[email protected]
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Cincinnati Children’s Hospital Medical Center
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Introduction
Cincinnati Children's Hospital Medical Center has achieved rapid implementation of a clinical informatics system that provides
our physicians, nurses and allied health professional staff with advanced, pediatric-specific clinical decision support to meet the
unique needs of safely caring for children. We believe Cincinnati Children’s is the first health care system to combine
technological innovation with an industry-standard process improvement approach in addressing strategic institutional goals.
Described as the Integrating Clinical Informatics System (ICIS), the components of this leading–edge electronic platform
include Browser Technology based systems, computerized clinical order entry (COE), clinical documentation, electronic
medication and intravenous charting (Med/IV Charting), rules engine, and lifetime electronic clinical record (LCR).
While Cincinnati Children’s Hospital Medical Center has had informatics support in finance, patient management and specific
clinical areas for many years, it was not until the year 2000 that the institution began the journey to integrate informatics systems
technology directly into the workflow and clinical decision-making processes of physicians and nurses. The INVISION system
from Siemens Medical Solutions Health Services Corporation was chosen as the electronic platform to move Cincinnati
Children’s into the 21st century. The success in implementing ICIS was highly dependent on combining this technological solution
with a Six Sigma-based quality improvement approach. The principles espoused in the Six Sigma DMAIC model (Define,
Measure, Analyze, Improve and Control) were instrumental in bringing innovation to ICIS in a short 18 month planning, building
and implementation cycle.
In competing for the 2003 Nicholas E. Davies Award, the presentation below will address the Management, Functionality,
Technology and Value associated with this unique and successful health care transformation which has taken place at Cincinnati
Children’s Hospital Medical Center.
Management
System Planning
Describing the Organization
Cincinnati Children's Hospital Medical Center (CCHMC) is a 324 bed tertiary care freestanding children's hospital serving a
primary area with over 550,000 children in the southern Ohio, northern Kentucky, eastern Indiana, western West Virginia region
and secondary referral areas from 42 states and 31 countries. In addition to the main campus, there are 15 off site clinics
(Figure 1).
1.
College Hill
2.
Anderson
3.
Children's Health Care
4.
Drake Center
5.
Eastgate
6.
Fairfield
7.
Harrison
8.
Hopple Street Center
9.
Kentucky
10.
Mason
11.
Middletown
12.
Redwood Center
13.
St. Elizabeth
14.
West Chester
15.
Rockdale School Based Health Center (RSBHC)
Figure 1. Map of the Cincinnati metropolitan area indicating locations of the main campus and all satellite facilities.
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As an institution nationally recognized for excellence in diagnosing and treating complex pediatric diseases, CCHMC is one of
seven health-care organizations and the only pediatric center to receive the Pursuing Perfection Grant from the Robert Wood
Johnson Foundation in 2001. Children cared for at CCHMC are served by multiple centers of excellence, highlighted by the solid
organ transplant center, the heart center, the blood and marrow transplant center, the regional center for newborn intensive care,
the aerodigestive center, and many others.
The Children's Hospital Research Foundation, founded in 1931, is a nationally recognized pediatric research institution.
Research Foundation scientists have been responsible for such break-through discoveries as the oral polio vaccine, the first
practical heart-lung machine that made open-heart surgery possible, and discovery of key ingredients of surfactant used
throughout the world to save the lives of thousands of infants.
Nationally, among comparable pediatric institutions, CCHMC ranks second in number of surgical procedures, second in number
of outpatient clinic visits, fourth in number of emergency visits and fourth in number of inpatient admissions. Additional
institutional demographics are delineated in Table 1.
Table 1: Staffing, training and patient encounter demographics in fiscal year 2002 at CCHMC.
Staffing
2002 Hospital Statistics
♦
♦
1,045 Physicians
1,750 Nursing staff & thousands of allied health
professionals
♦ In 2002, CCHMC trained:
• 226 undergraduate medical students
• 293 residents
• 230 fellows
• 894 nurses
• 150 allied health professionals
♦
696,104 patient encounters consisting of:
•
•
•
•
577,310 outpatient visits
86,774 Emergency Department visits (including
level 1 trauma patients)
20,303 inpatient admissions
11,717 Home Care visits.
Vision and Strategic Objectives
The vision of CCHMC is to be the leader in improving child health. The three cornerstones to this vision are to dramatically
improve the delivery of care, to greatly increase the impact of our research and to implement new models of education for
pediatric professionals, patients, families and the public.
In support of this institutional vision, the ICIS Leadership Teams established the following strategic objectives:
1. Optimizing patient safety
2. Optimizing consistency in care
3. Improving clinician and patient care efficiency
4. Maximizing regulatory compliance
5. Enhancing provider, patient and family satisfaction
6. Providing cost-effective care
7. Improving the education of staff and trainees
8. Enhancing research productivity and
9. Strengthening performance improvement activities
These strategic objectives took precedence in the planning, design and implementation of ICIS at CCHMC. The Davies Award
application that follows will illustrate in a comprehensive way, how CCHMC has focused on these objectives and realized
significant gains in a short period of time by combining innovative technology with established process improvement and project
management techniques.
Leadership, Governance and the Push Forward
In the late 1990s, national and internal imperatives for processes that would support patient safety and evidence-based best
practices were on the minds of the CEO and board of directors. At the same time the CCHMC Board of Directors was coming to
its conclusions, Information Services began preparing the organization for the impending millennium and the Medication Safety
Committee established the need for a physician computerized order entry system. Concurrently, the implementation of an
enterprise Picture Archiving and Communication System (PACS) began. These efforts culminated in the appointment of Dr. Neil
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Johnson, Associate Professor of Radiology, as Medical Director of Information Services and Dr. Brian Jacobs, Associate
Professor of Pediatrics as the Clinical Order Entry Project Director. Dr. Johnson was leading the implementation of the PACS
system at CCHMC. He was a strong proponent of information system technology and its potential to affect clinical practices. Dr.
Jacobs was Chair of the Pharmacy and Therapeutics Committee and the Prescribing Task Force of the Medication Safety
Committee and was a natural fit to lead the Clinical Order Entry Project.
The Board of Directors drove strategic planning which focused on developing an organizational culture in which patient safety
was the number one priority. Information technology was regarded as a process improvement tool, not as an end in itself. It is
important to note CCHMC’s position with respect to information technology initiatives prior to the decision in 1999 to build ICIS
as it provides a better understanding of the distance CCHMC has traveled.
In 1995 CCHMC was running legacy systems for patient accounting and patient management from Shared Medical Systems
(now Siemens). These systems supported functions such as charge capture and billing. Islands of automation existed within
clinical departments to support the laboratory, radiology and pharmacy. There was little integration and no central information
technology strategy to prepare the organization for the 21st century. In 1995, CCHMC developed a strategic plan with the help of
a consulting firm that resulted in the creation of a CIO position and in 1996 began to establish the capital budget for a new
systems infrastructure.
In the ensuing years between 1996 and 1999 the Information Services Department grew from approximately 25 to almost 100
employees. Additionally, clinical experience and knowledge within the Information Services Department has grown. Today
CCHMC prefers that each of its clinical systems analysts have a clinical background. There are currently 8 clinicians working as
analysts in the Information Services Department. Patient Services (nursing) has also assembled a team of 7 clinicians that focus
on clinical informatics project implementations and education. CCHMC uses a multidisciplinary and shared ownership approach
to project governance. Physicians, nurses, other clinicians, information technology experts and members from finance, medical
records and legal services all participate in the design and implementation phases of clinical informatics projects.
Needs Assessment
In 1998, CCHMC participated in the Child Health Accountability Initiative on medication errors in which data collected by a
pediatric multi-site consortium identified opportunities for improvement and reduction in medication errors related to prescribing
practices. At CCHMC all medication orders in a single patient care unit were collected for a two-week period in February 1999
and reviewed by a multidisciplinary team, including medicine, nursing and pharmacy. The results of the study indicated that there
was a significant incidence of errors. In addition, the data suggested that 7% of all errors contained significant potential for
patient adverse events, such that 50% of the errors would result in increased monitoring, 31% would alter vital signs, 13% would
result in temporary harm and 6% would result in permanent harm.
Publication of the 1999 Institute of Medicine’s Report, To Err is Human: Building a Safer Health System has galvanized both the
political and consumer pressure on healthcare providers to ensure patient safety. Medication errors have been the focus of
many published studies with error rates noted to be as frequent as one in every 100 admissions. These errors have been noted
to represent as many as 20% of all adverse events (Bates DW, et al. JAMA 1995;274:29-34). In 1999, the Gartner Group
reported the results of a multi-site study in which 23% of medication orders contained errors, with incomplete orders accounting
for about 83% of these errors.
Responsive to both intrinsic and extrinsic influences, CCHMC embarked upon several strategic approaches focusing on the
reduction of medical errors, improving the quality of care delivery and increasing the clinical workflow efficiency. The strategic
initiatives leveraged an organizational culture in which patient safety is the number one priority.
Clinical Order Entry (COE) has been heralded by many experts as a strategy to have significant impact upon the safety of the
medication ordering process (Bates DW, et al. JAMIA 1999;6:313-21). Acknowledged benefits of COE include: eliminating the
issues of illegibility and incomplete orders thus reducing the potential for error; providing decision support to the prescriber at the
point of service; enabling orders to be entered from remote sites of the hospital; automating order sets and clinical pathways to
increase the care delivery consistency amongst diagnostic groups; and integrating with other currently utilized information
systems. Based on this information, the CCHMC Medication Safety Committee strongly urged the organization to pursue this
endeavor.
Additionally, CCHMC recognized the importance of a fully integrated informatics platform, not limited to a single application for
order entry, but rather an integration of all clinical applications. It was felt that integrating the clinical applications would enhance
patient care by optimizing clinical workflow of all care providers, given that clinical data is readily accessible at the point of care.
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System Acquisition
With patient safety as the driving force, the next progressive step of ICIS was the development of a comprehensive COE and
Clinical Documentation system. The needs of a pediatric medical center presented unique challenges. An order entry and
documentation application would require a level of sophistication that far-exceeded “off the shelf” applications. CCHMC had a
considerable investment in its existing INVISION legacy system and the IS staff had a significant understanding of the software
platform. The Information Services Department also felt that the INVISION system, enhanced by additional products and
integration, would provide the flexibility to create the desired functionality that supports pediatric needs (i.e., weight based dose
checking). The advanced clinical applications added to the legacy system that make up the ICIS are Clinical Documentation,
Lifetime Clinical Record, Enterprise Access Directory, Rules Engine, Med/IV Charting and Clinician Order Entry all using the
browser technology system building tools OAS Gold. All applications within the ICIS are accessible using a browser technology
solution (Net Access).
While other components of CCHMC's comprehensive information system contribute to a computer-based patient record system,
this Davies Award application focuses on those components that comprise ICIS because it is those components that are used by
physicians, nurses and other care providers in their direct, daily interaction with patients. Additional discussion regarding other
systems related to ICIS such as PACS, the CCHMC Discharge Summary System, the Discovery System (a repository of clinical
and research data) and various patient portals will be included in this application as they were, and continue to be, instrumental
in helping CCHMC achieve it’s stated vision.
Business Case
The fundamental mission of CCHMC is to be the fundamental leader in child health by transforming its healthcare delivery
process. As a result, CCHMC measures its return on investment in terms of improvements in the quality, safety of patient care
delivery and in the satisfaction of its employees, patients and families. Most of the strategic objectives mentioned earlier are not
amenable to simple, one-dimensional technical solutions. Successful remedies often require analysis and improvement in both
the underlying process combined with a sound technical approach. This methodology, based on best practice principles for total
quality management, has been successfully utilized at CCHMC in recent years in the deployment of several clinical informatics
systems. In recognizing the above, no information technology capital investments are made at CCHMC without first undergoing
a detailed process improvement analysis showing a direct link to one of the strategic objectives along with associated metrics for
evaluating success. The combined technologic and process improvement methodologies used in addressing institutional
strategic objectives are illustrated below in Figure 2.
Multidimensional
Technological Approach
Completed:
- New Data Center
- Mainframe Upgrade
- Strengthen Network Backbone
- Build a Wireless Environment
- Upgrade Servers, PC's, Printers
- Deployment of Mobile Devices
- Notification of Orders via Pagers
- Integration with Existing Platforms
- PACS
- Web-based Discharge Summary
- Clinical Order Entry
- Clinical Documentation
- Electronic MAR
- Web-based Portal to Clinical
Applications and Patient Data
- Lifetime Clinical Repository
Strategies Related to:
Optimizing Patient Safety&
Consistency of Care
Improve Clinician and Patient Care
Efficiency
Maximizing Regulatory Compliance
Providing Cost-effective Care
STRATEGIES
ICIS
Strategies Related to:
Enhancing Provider, Patient and
Family Satisfaction
Improving the Education of Staff and
Trainees
Enhancing Research Productivity
Strengthening Performance
Improvement Activities
Process
In Progress:
- Authentication via Biometric
Devices
- Deployment of an Enterprise
Single-Sign-On Solution
Realized Increased Levels in:
Patient Safety & Consistency of Care
Clinician Efficiency in Providing Care
Development of Pediatric Application
Features
OUTCOMES
Realized Increased Levels in:
Compliance with External Regulatory
Agencies Requirements & CCHMC
Policies
Increased Patient/Family and
Clinician Satisfaction
Multidimensional Process
Optimization Approach
- Creation of a Clinical Effectiveness
Department
- Creation of a Medication Safety
Committee
- Receiving the Pursuing Perfection
Grant (Robert Wood Johnson
Foundation)
- Creation of PCAPI - Bridging the
Technology and Process
- Creation of the ICIS Education
Team
- Creation of the ICIS Support Team
(on site 24X7)
- Redesign of Patient Registration
- Improve Clinical Workflow
- Redesign on Order Management
and Communication
Figure 2: The combined ICIS technologic and Six Sigma-based process improvement approach utilized at CCHMC in
successfully addressing institutional strategic initiatives. This planning methodology demonstrates how the
organizational strategies were achieved through the merging of technology and process reengineering
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The methodologies illustrated in this figure have become the fundamental drivers utilized by the ICIS implementation teams and
the standard by which institutional specific strategic objectives have been engaged in order to reach the desired outcomes. It
was recognized early in the project-planning phase, that successful implementation of ICIS would require substantial
reengineering. ICIS and the multidimensional process redesign initiatives received total support from CCHMC medical and
administrative leadership.
Global benefits expected from ICIS implementation included enhanced national reputation and improved recruitment and
retention of physicians, nurses, and allied health care professionals. More specific expectations in institutional benefit included
those related to the strategic objectives of the organization. The Value section of this Davies Award application further discusses
the metrics used to evaluate the projects' successes in each of these areas. ICIS, as well as the health care transformational
changes, are consistently assessed in relationship to the strategic objectives set by the organization.
Costs
The funds expended in designing, planning, implementing and supporting ICIS are described In Table 2. These costs include
server and software costs, implementation of a wireless infrastructure, fixed and wireless devices, implementation fees and
consulting fees. Internal resources are not included in the costs. Resource allocation for the ICIS project is further represented
in Table 3.
Table 2: CCHMC ICIS expenditures for the last 3 fiscal years
Description
Servers/Software/Interfaces
End User Devices – Fixed
End User Devices- Wireless
Consulting/Implementation
Fees/Education/Training
Total
FY 2000
$125,511
0
0
FY2001
$253,,452
$12,350
0
FY2002
$268,017
$202,500
$576,414
$169,200
$958,143
$2,770,381
$294,711
$1,223,945
$3,817,312
The total ICIS capital expenditures of approximately $5.3 million over the last 3 fiscal years represents approximately 15% of the
$35.3 million total Information Services capital expenses for this same time frame, and represent 2.2% of the $1,571 million
CCHMC total operating expenses for this period. The specific personnel resources devoted to the project are represented in
Table 2.
Project Risk Management
The greatest risk to the ICIS project was user acceptance of the system. In addition to the governance structure already
discussed, CCHMC took these 4 steps to ensure the project's success:
1.
2.
3.
4.
Multidisciplinary ICIS users were invited to join one of two ICIS design teams. These teams met on a weekly basis to
review and approve system design standards. The COE Design Team was tasked with review of the electronic order entry
component and was made-up primarily of physicians. The divisions represented by these physicians received
compensatory pay for the time invested in participation on this team. A minimum of 85% attendance was mandatory to
receive compensation. The Clinical Documentation Design Team was primarily composed of nursing personnel. This team
was responsible for the design approval of the Clinical Documentation platform. Each of these teams had shared
membership and included ancillary health care professionals (respiratory therapists, pharmacists, dietitians, health unit
coordinators, etc.) Specific resources were invited as necessary - for example, allergy physicians attended the design team
meetings related to the allergy data collection screens in both COE and Clinical Documentation.
CCHMC hired a consulting firm, Healthcare Innovative Solutions, to provide project management and implementation
services. The firm was staffed with experienced clinicians and analysts with Siemens product experience as well as a
consultant with Six Sigma Green Belt certification.
A significant public relations campaign began 18 months prior to the first unit implementation. The campaign made use of
presentations at standing physician and nursing meetings, Division Head and Departmental meetings, hospital Board of
Director meetings, hospital Grand Rounds, local and regional newspaper articles and television segments. The central
thrust of the public relations campaign centered around educating users on the merits of ICIS, providing a compelling
rationale for voluntary involvement with the system. The training and education components of the public relations
campaign are discussed in more detail in Communication, Education and Support below.
The pilot units for implementing ICIS were carefully selected based on a risk analysis that occurred early in the process.
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Table 3: Resource allocation of employees specific to the ICIS project in percentage of full time equivalents.
ICIS Leadership
Team Members
COE, Med/IV Charting, Rules, LCR
Team Members
Clinical Documentation
Team Members
Training and Support
CCHMC Internal Staff
•
MD – Clinical Project
Director - 30 %
•
MD – Medical Director of
IS – 10%
•
IS Application Integration
Director – 10%
•
IS Vice President – 5%
•
COE Project Manager
•
CD Project Manager
•
ICIS Project Manager
•
Financial Director
•
RN Physician Liaison
•
Associate Director
Pharmacy
•
MD Clinical Director of
Laboratory
•
Operations AVP
CCHMC Internal Staff
•
RN Analyst – MD/Nurse Orders – 90%
•
2 RN Analysts – Order Sets Building and
Management – 90%
•
Analyst – Rules Development and Order Sets
Management – 50%/50%
•
Analyst – Ancillary Orders – 90%
•
2 LCR (1 RN) Analysts - 80%
•
RN Analyst – MD Liaison – 90%
•
Pharmacist – 30%
•
Interface Analyst – 10%
•
RN Analyst Pharmacy Orders – 90%
•
RN Analyst COE Project Manager 90%
CCHMC Internal Staff
•
3 RN Analysts – 90%
•
RT Analyst/ Educator
(50%/50%)
•
Analyst Educator
(50%/50%)
•
Analyst Educator –
100%
•
RN Director Clinical
Documentation
Project Manager 75%
CCHMC Internal Staff
•
2 Analysts Educators
– 100%
•
2 Analysts (see
Clinical
Documentation
section) 50%
•
Super Users from All
Units
•
24X7 Clinical Support
Staff – 100%
Consultants
Consultants
•
Consultant – 100%
•
3 Consultants Pharmacy Orders – 100%
•
3 Consultants Ancillary Orders – 100%
RN Consultant ICIS Project Manager – 100%
COE Design Team (12 MD’s, 1 APN, 2 RN’s, RT
Clinical Documentation
and Various Ad Hoc Members)
Design Team ( 14 Nurses
from all Major Areas, RT’s,
& other Ad Hoc Ancillary
Members)
Implementation
Background
For 15 years prior to implementation of ICIS, nurses and health unit coordinators were the primary users of computer systems.
Physician lab orders were transcribed into the computer system, diets were ordered from nutrition services, patient care charges
were placed in the computer system and patient classification was entered on a daily basis. Physician interaction with clinical
systems had been limited to the retrieval of patient laboratory results. Early in the 1990’s Information Services began to move
toward integrating disparate systems with the implementation of a central repository for laboratory and radiology results.
CCHMC placed the development of a robust information technology infrastructure in the 1995 strategic plan. Information must
be easily available to clinicians for patient care, education and research. CCHMC also created a CIO position and recruited an
information management team that could transform the way information was made available to the organization. The several
years that followed saw a dramatic increase in the development of the Information Services Department and an accompanying
increase in network infrastructure to support the vigorous development of clinical systems.
The medical community saw rapid deployment of an internally developed web-based Discharge Summary System (DSS), PACS
and a web-based results reporting system in 2000. Results reporting and PACS were considered “quick wins” for CCHMC, as
both were rapid implementations that vastly improved the availability of key clinical information in a user-friendly manner.
PACS at CCHMC
As mentioned above, in March, 2000, CCHMC completed the implementation of an enterprise-wide PACS, including
simultaneous implementation of Computed Radiography. This was accomplished over an 18 month period. The PACS project
was the first clinician-driven implementation of an information system at CCHMC. PACS project leadership sought to maximize
the use of electronic systems by partnering with IS to design and implement PACS.
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CCHMC is now fully “filmless” as all radiological examinations in all modalities (Computed Tomography, Magnetic Resonance
Imaging, Ultrasound, Nuclear Medicine and fluoroscopy) are acquired, stored, retrieved and viewed digitally, excluding scoliosis
films for the Orthopaedic clinic. All associated exam information and reports are sent to PACS and linked to each exam. Each
year, 180,000 exams are sent into PACS from the base hospital, 6 remote outpatient facilities, a remote Positron Emission
Tomography unit and other outside institutions.
PACS is utilized exclusively throughout the entire enterprise including the Operating Room, Emergency Department and a large
Orthopaedic practice. Over 3000 radiologists, technologists, referring physicians, and nurses use PACS for image and report
review on a regular basis. In addition, community physicians access their patients’ images and reports from private offices via a
secure remote connection. A CD jukebox system is used for distribution of exams outside CHMC and for conference purposes.
Remote connections have been created to several outside institutions for clinical purposes. Studies are sent from the University
of Cincinnati Neonatal Intensive Care Unit, Shriner’s Hospital for Children and Children’s Medical Center in Dayton, Ohio for
remote reading and/or review by clinical physicians.
Transition to New Processes
The implementation of ICIS required a multi-faceted approach including workflow analysis, improvements in underlying
processes and a sound, user-friendly design approach. The ICIS Leadership Team was challenged with providing an optimal
solution to meet the unique care needs of children. Detailed analysis of clinician workflow, with its associated process variations
and inefficiencies in care delivery, identified the need for ICIS to provide a level of complexity that was not available in the
proprietary software.
ICIS design and implementation required the creation of the COE Design Team, Clinical Documentation Design Team and the
Interdisciplinary Information Technology Committee. The first of these teams was created in October 2000. The primary focus
of these teams was to provide clinical input necessary to optimize the design of ICIS while ensuring the integration of ICIS into
the clinical workflow. Existing enterprise committee structures were also utilized, to achieve the proper balance of enterprise
standardization, while maintaining unique divisional requirements where necessary. Additionally, the implementation required
coordinated efforts by the following teams and task forces:
Live Planning Task Force
Downtime Minimization Task Force
Wireless Infrastructure Team
Device Task Force
Biometric/Single Sign-on Team
Volume/Stress Testing Task Force
ICIS Education Team
Support Team - Bluecoats
Leveraging off of an organizational culture in which patient safety and quality improvement were accepted as core values,
strategies for a successful implementation were enacted. In May of 2001, an interdisciplinary task force came together to
facilitate clinical documentation performance improvement. This initiative included RN representatives from all care delivery units
along with ancillary care providers from Respiratory Therapy, Nutrition, Social Service, Child Life, Home Care, Laboratory,
Speech, Transport, Occupational and Physical Therapy. A gap analysis between the current state of care delivery and optimal
care delivery was critical in determining the best approach for an organizational redesign of the care delivery process.
The outcome of the group's work was the creation of the Patient Care and Access Process Initiatives (PCAPI). Realizing the
impact of the implementation of ICIS on clinician workflow and the transition in process that would be required to achieve the
desired future state of health care delivery, the Executive Board of CCHMC reviewed and supported the PCAPI initiative. The
PCAPI initiative was led by the Associate Vice President of Patient Services and the MD Chief of Staff. It was comprised of
representatives from Nursing, Medicine, Patient Management, Patient Services, Information Services, Registration, Utilization
Review, Scheduling, Finance and Materials Management. PCAPI worked with ICIS project team leaders, Pursuing Perfection
teams and existing enterprise committee structures to help ensure a successful redesign.
The PCAPI teams, worked with physicians, nurses and ICIS project leaders, outlined principles of change with the goal of
standardizing process, improving patient flow, maximizing revenue capture and ultimately improving patient and family
satisfaction. The Performance Improvement exercise also provided the necessary map of clinician workflow and data stores for
ICIS design and build.
Analysis of these workflow maps, data stores and decision points enabled the ICIS Clinical
Documentation team to define data critical in the support COE. Furthermore, it provided references that contributed to the
elimination of various forms used in the documentation process. It is important to note that the ICIS project teams worked
closely with Health Information Management (HIM) and Risk Management in addressing the accessibility challenges and legal
requirements surrounding the electronic medical record.
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The process restructuring and ICIS implementation was an enterprise initiative that was supported at every level within the
organization. While participation on these teams was primarily voluntary, incentives and recognition for the significant time
commitment was available including physician compensation to associated divisions and departments for project involvement,
lunches, gifts and certificates of recognition. In addition, indirect compensation was realized, as committee participation and
involvement in enterprise quality improvement initiatives, was noted to be important in supporting/justifying clinical advancement.
Implementation Planning
Prior to the implementation in any given patient care unit, the dominant patient populations were evaluated for the purpose of
assuring that order sets were available within ICIS. Having order sets available facilitated the transition to electronic order entry.
These order sets were designed to significantly improve physician efficiency in contrast to ordering each item of patient care
individually. The use of approved order sets contributed to the standardization of care of like patient conditions.
As key patient care areas were approaching ICIS implementation, clinician advocates from these respective units performed
usability testing of ICIS. Through this exercise several valuable lessons were learned. Two examples follow: 1) It was identified
early in the implementation planning stages that the critical care unit documentation requirements could not be met by the data
entry fields and displays available within ICIS. The time it took to perform the frequent documentation of various clinical data,
such as vital signs was also unacceptable. Therefore, the extent of the implementation of Clinical Documentation within the
critical care areas was limited to Med/IV Charting and admission history. As a result of these findings CCHMC began pursuing a
critical care documentation system. The GE Centricity system was selected and is currently in the implementation phase. The
critical care flowsheet charting using the new system is scheduled to go live in all the critical care units in early 2004. 2) Usability
testing of COE led to the creation of convenience order sets. The Regional Center for Newborn Intensive Care (RCNIC)
primarily uses approximately 30 different medications. Those medications were all placed into a convenience order set within
COE to allow the most efficient ordering process for the clinician. Practical actions such as the ones listed above have
contributed to greater ICIS user acceptance and satisfaction.
Several weeks of live implementation planning occurred before the introduction of ICIS in any patient care area. Live planning
involved meeting with key members of the clinical team from the units scheduled for roll-out, and a cross-section of Information
Services personnel. These meetings were key to gaining ICIS ownership among the clinicians, assisted in the identification of
changes in processes to be affected by ICIS, and provided a level of comfort in allowing clinicians to be prepared about what to
expect from the system. The details of these meetings will be described within the Operations section.
Implementation Timeline
One of the most remarkable aspects of the ICIS project was the rapidity with which it was implemented throughout the institution.
The timeline for ICIS implementation is indicated below in Figure 3. After house-wide implementation of the web-based portal in
August 2000, COE, Clinical Documentation and Med/IV charting analysis and system design began in October of 2000.
Radiology Lite
One of the first problems identified in the analysis phase was very low compliance in legible completion of the written order
requisition for radiology exams. Typically, a Health Unit Coordinator partially completed the requisition and there was seldom a
corresponding written physician order. To gain additional insight to the physician’s workflow and improve compliance with
physician orders for radiology exams, a radiology order entry module was rolled out in February 2001 in the ICU/CICU units and
then fully deployed house-wide three months later. This order entry module (aka Radiology Lite) represented the anticipated look
and feel of the complete COE system. It remained the primary method for obtaining inpatient radiology examinations while
building of the remaining inpatient order pathways continued. Through this limited implementation the following 6 objectives
were realized:
1.
2.
3.
4.
5.
6.
Introduced ordering clinicians to ICIS with the incorporation of this new model into their workflow
Improved the turn-around-time for stat, portable radiographs (see Value section)
Provided the Radiology Department with complete, legible orders with clinical indication for the study along with primary and
secondary clinician contact information
Promoted system acceptance among the physicians
Validated the ICIS/COE system design for the analysts involved in the COE development
Confirmed the need to closely assess the impact of electronic order entry on processes for the order writer, service provider
and bedside care giver
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Approximately 5 months after the deployment of the radiology order entry module, the roll-out approach for full ICIS
implementation was created with 5 goals in mind:
1.
2.
3.
4.
5.
Pilot the application in both a general care setting and an intensive care setting prior to a comprehensive inpatient rollout
Minimize the time that the hospital had two processes for inpatients– electronic and paper
Provide a wireless infrastructure and wireless devices to support the workflow of the caregivers and the physicians
Provide ample user support to readily address training needs and process issues
Provide generous technical support to address application issues in a timely manner
Pilot Unit Selection and Subsequent Hospital Roll-Out
Two pilot units were then selected based upon 5 factors: First, these units were set up for wireless devices. Second, there was
more than adequate staffing on these units. Third, the unit culture and director supported ICIS enthusiastically. Fourth, there
were relatively self-contained patient populations that did not frequently transfer to or from other patient care units other than the
intensive care unit. Finally, nearly every specialty service was represented on these units. These two units were successfully
piloted in April 2002. An intensive care unit (The Regional Center for Newborn Intensive Care) followed this successful pilot in
June 2002. This unit was selected as it was self-contained with minimal transferring of babies to and from other areas.
The initial timeline specified that there would be a pilot in April 2002 and completion of the roll out by July 2002. The analysis of
the caregivers’ workflow revealed point of care documentation and the incorporation of ICIS on physician rounds would require
the use of wireless devices. A move from the oldest portion of the hospital to a new patient care tower was scheduled for
September 2002. No investment would be to place a wireless infrastructure in the old hospital building. Therefore, it was
determined that the remainder of the hospital would implement ICIS after the move to the new patient care tower in September
2002. Patient care units were then implemented one floor at a time, every 4 weeks, to allow for adequate support and training
time. Units that transferred patients between each other were identified, and the implementations of those units were scheduled
to closely follow each other. By December 2002, ICIS was implemented on thirteen inpatient care units. The implementation
success is likely attributable to shared ownership and partnership between clinical and information technology teams, thorough
analysis focused on workflow process improvement and meticulous project management practices.
Phase II, which will include additional Clinical Documentation components (see the ICIS Future Plans section) is on schedule for
implementation by November 2003. Hematology/Oncology is a combined outpatient and inpatient area and is currently slated for
ICIS implementation in the summer of 2003. During this implementation, CCHMC will be piloting the outpatient use of ICIS, as
the continuity of care management of oncology patients often requires the seamless flow of patients between the outpatient and
inpatient treatment areas.
ICIS Timeline
ICIS Phase I
ICIS Project Planning
ICIS
Q2/00♦♦♦ Q3/00
Q4/00
Q1/01
ClinD
oc
Hem/BMT/
RCNIC
Live
Live Onc
Pilot
Live Hosp.
Rad. Lite
Live
Live
System
Q2/01
Design
Q3/01
ICIS Phase II
Build/Test
Train & Live
Q4/01
Q1/02
Q2/02
ICIS - Phase I
Hospital Roll-Out
Q3/02
Q4/02
System Build/Test
Q1/03
Q2/03
Q3/03
CD Live
Q4/03
ICIS - Phase II
COE- Inpatient Units
Med/IV Charting
Rules Engine – COE
Clinical Documentation:
o
Vital Signs, Intake & Output, Heights/Weights,
o
Allergies, Admission Assessment, Admission and Shift Pain Assessment,
Shift IV/CVC Assessment,
o
Nursing Worklists
Lifetime Clinical Record
COE– Optimization
o
Hem/Onc/BMT (Inpatient/Outpatient), Dialysis,
Sleep Studies, Research Patients, Card. Cath
Rules Engine – CPOE, Clinical Documentation
Clinical Documentation:
o
Clinical Documentation/Multidisciplinary
o
Shift Assessment, Discharge Assessment
o
Progress Notes
o
Patient Education
Figure 3: ICIS timeline
Communication, Education and Support
Communication, education and support are essential components in the successful implementation of clinical systems.
Contributing factors to the successful implementation were: leveraging opportunities to create awareness about the ICIS
benefits, developing user specific content delivered through multiple modalities and supporting the assimilation of new
knowledge through an intense 24 X 7 support structure. This approach provided the foundation by which the ICIS Education
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Team developed education and support strategies. The ICIS Education team was created with the goal of developing strategies
for educating and training the end users prior to the implementation. The ICIS Education Team used three specific strategies
with great success:
1.
2.
3.
A public relations campaign initiated approximately 18 months prior to the ICIS implementation. The goal of the
campaign was to infiltrate and saturate the organization with information highlighting the benefits afforded by ICIS
Role-based training was structured to user-specific content, yet offered the flexibility to combine various modular training
contents to meet unique user educational needs. This strategy minimized staffing disruptions and maximized learning
Just-in-time training was used throughout the development of training schedules and coordinated with the staged
implementation plan for patient care areas. Training included unit-specific processes identified by Live Planning Teams that
were analyzing the integration of ICIS use into workflow
The traditional Information Services’ help desk is open Monday through Friday for normal business hours. The ICIS
implementation has had significant impact on all aspects of patient care delivery and has necessitated the expansion of the
existing, traditional Help Desk structure to assure user efficiency and satisfaction. Given the expansive scope of the project and
the criticality of a quick response to answering clinician questions, additional entry-level staff were recruited and trained to
provide on-site ICIS user support. This group of support staff are known as Blue Coats and are instrumental in providing first
level support to the clinicians with the ICIS applications.
Users access support through the Help Desk automated call distribution application by selecting an option specific to ICIS. After
selecting the appropriate option, the call is routed to a voice messaging system instructing the user to leave a brief message
about their specific issue. The Blue Coats strive to provide a 15-minute response to the user who leaves a voice message.
Users also have the option of calling the Blue Coat support staff directly through a shared support pager for more critical matters.
Since support staff is on-site, direct interaction with users is available as needed. If complex issues are identified, the Blue Coats
will contact the ICIS analyst on-call who provides the second level of support.
The Blue Coats were instrumental in gaining compliance with the surgeons in placing inpatient post-operative orders in ICIS from
the surgical suite. During the first six months of the introduction of ICIS, a Blue Coat was located full-time in the OR. The Blue
Coat evaluated the daily surgery schedule for potential inpatients and the presence of a community surgeon who had limited
exposure to ICIS. The Blue Coat anticipated the need for order-writing assistance and appeared in the OR suite to provide sideby-side support to the surgeons and ensured that all devices were operational.
The ICIS analysts rely heavily on Blue Coats to communicate the ongoing functionality updates to the users and to provide realtime focused training when and where necessary. Blue Coats round to each nursing unit at least once per shift. The goal is to
provide proactive support in identifying issues for which users may not contact the Help Desk, address any device questions or
address simple problems. All issues identified on rounds as well as those called to the Help Desk are logged into a database for
further analysis and intervention by the project teams.
Change Management
Many of the core functions of the ICIS had to be developed to reflect the needs of children and the unique workflow of clinicians
caring for these patients. A rigorous change control process had to be implemented early in the design phase to successfully
manage the high volume of system changes and ensure that the communication between the project team and users was
maintained. During the implementation phase serious consideration was given to the fact that in all areas there was an existing
order entry system used primarily by the Health Unit Coordinators. Getting the ICIS to coexist with the existing environment took
creativity and great attention to details. Separating the navigation of the system from the typical IBM based screen emulator to
the new Web based user interface and pathways was achieved by consolidating some on the old function in a re-mapped format
onto the new ICIS navigator. Constant communication with the various departments and users had to be maintained to ensure
their workflow was not affected by these changes.
To ensure quick response time to user needs during the implementation phases, the project leaders met with key management
and unit staff and agreed on the communication process during the live event and thereafter. Daily triage meetings with the unit
staff and physicians were scheduled for the duration of the on-site support. These meetings provided a great forum for
communication between the two teams. All new changes of the system were documented and brought back to the unit for
distribution and staff education. If the changes affected other areas that used the ICIS, they were communicated to the
appropriate unit representatives.
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The Feedback button available on every screen of the ICIS provides the end-users with an easy, user-friendly tool to
communicate their non-emergent needs or recommendations for enhancements. The feedback button prompts the user to
indicate the level of severity of the concern, the type of problem and the questions or suggestions they may have. ICIS analysts
review the feedback and respond within 24 hours for non-critical issues. The input received from this feedback process has
resulted in system enhancements and built of new functionality. The feedback button has also been helpful in identifying key
users who need special attention and those who can be recruited for membership on the project design teams. The volume of
feedback was typically high immediately following an implementation and decreased by 80-90% in the subsequent weeks. It was
and still remains the goal of the team to always contact the user as soon as possible (24 hours) to both acknowledge the
feedback and communicate the plan to address the concern. Additional contact is made when the concern has been completely
addressed.
As the ICIS has become widely used throughout the institution and now touches virtually every department, a more formal
change control process has been implemented. Changes within the system have potential to impact other electronic systems or
processes throughout the institution. A Change Control Management Group evaluates system changes that involve moderate to
significant user impact after presentation to the design teams. Members of this group are representatives from the ICIS project
and education teams, a patient management analyst, an operations analyst, a process facilitator from PCAPI and ad hoc
members of various departments. Considerations for approval of a change or enhancement include current personnel resource
demands, budget impact, and timelines for other planned changes in the systems. Complex requests for change are routed
through the ICIS Leadership Team for approval. Any change that involves significant cost, resource allocation or resource
definition issues are then escalated to the appropriate groups for validation and approval. In Figure 4, the change control
process used to support the design and construction of ICIS is outlined. This process has been instrumental in helping ICIS
Project Team managers maintain control over the project, ensure that major milestones are met, and that the project stays on
budget and on time. A testimonial to the effectiveness of the change control process is that there have been no
postponed unit implementations since the project has begun.
Figure 4: ICIS
Implementation
Change Control
Process.
C hange
D is p o s itio n
11
U s e r G ro u p
A n a lys is R e la te d P ro c e s s
B u ild in g R e la te d P ro c e s s /O th e r
3
C hange R equest
10
1
C hange
M anagem ent
Log
No
18
P ro je c t M a n a g e r
(P M )
2
Y es
14
12
4
6
15
Y es
5
A n a lys is
F e a s ib le ?
Y es
8
No
9
No
7
D e ve lo p m e n t
Team
C O E P ro je c t
L e a d e rs h ip T e a m
(L T )
16
Y es
19
Y es
20
22
B u ild in g
F e a s ib ility?
13
17
C hange
R equest
R e je c te d
Yes
24
26
B u ild in g B e g in s
C lin ic a l A d vis o ry
G ro u p (C A G )
21
C hange
Request
R e je c te d
Y es
23
C a b in e t
AN AL Y S IS R E V IE W P R O C E S S
1 . C h a n g e R e q u e s t S u b m itte d
2. P M Logs Request
3 . C la rific a tio n F e e d b a c k O b ta in e d
4 . A n a lys is F e a s ib ility A s s e s s e d
5 . P M A p p ro ve s A n a lys is a n d A s s ig n s to D e v. T e a m
6 . D e v. T e a m C o m m u n ic a te s R e s u lts
7 . P M N e e d s A p p ro va l fro m L T
8 . L T A p p ro ve s A n a lys is a n d C o m m u n ic a te s to P M
9 . L T R e je c ts A n a lys is a n d C o m m u n ic a te s to P M
1 0 . P M C o m p le te s D is p o s itio n
1 1 . P M N o tifie s U s e r o f O u tc o m e
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No
25
C hange
Request
R e je c te d
B U IL D IN G R E V IE W P R O C E S S
1 2 . P M P re s e n ts A n a lys is R e s u lts to L T
1 3 . L T D e te rm in e s B u ild in g F e a s ib ility
1 4 . B u ild in g A p p ro ve d a n d C o m m u n ic a te d to P M
1 5 . P M A s s ig n s to D e ve lo p m e n t T e a m
1 6 . B u ild in g B e g in s
1 7 . B u ild in g R e je c te d
1 8 . L T D e c is io n C o m m u n ic a te d to P M (1 0 , 1 1 )
1 9 . L T A p p ro ve s b u t E s c a la te s R e q u e s t to C A G
2 0 . C A G A p p ro ve s a n d In fo rm s P M (1 5 , 1 6 , 1 0 , 1 1 )
2 1 . C A G R e je c ts R e q u e s t
2 2 . C A G In fo rm s P M (1 0 , 1 1 )
2 3 . C A G A p p ro ve s b u t E s c a la te s to C a b in e t
2 4 . C a b in e t A p p ro ve s a n d In fo rm s P M (1 5 , 1 6 , 1 0 , 1 1 )
2 5 . C a b in e t R e je c ts R e q u e s t
2 6 . C a b in e t In fo rm s P m (1 0 , 1 1 )
Cincinnati Children’s Hospital Medical Center
Davies Award – Application
Operations
Data Management
A critical step in planning the ICIS design was and remains the analysis of current processes, data flow, communication and
usage. It was through the Clinical Documentation Performance Improvement analysis effort that many inconsistencies were
noted between CCHMC policy-defined charting standards and actual documentation practices. This initiative revealed that the
implementation of ICIS would have significant impact on the way in which data was managed from the point of entry, to storage
and retrieval.
HIM and ICIS team members reviewed the existing processes for data storage as well as the medical record components. It was
evident that what was required included a forms analysis for needed revisions, creation of new templates for documentation in a
downtime event, and an analysis of the components which would need to remain on paper during ICIS implementation. This
analysis led to an effort to consolidate and standardize the order sets process within the organization. To accomplish this
complex task a new HIM Forms Committee was created. This Committee was charged with consolidating and streamlining the
use of order sets within the organization. To date, Forms Committee continues to be responsible for all review and approval of
new forms and order sets. Currently, there are 212 order sets approved and built into ICIS. These approved order sets are
also posted to an Intranet site, (the Intranet Order Set Repository), so that they can be printed for use in the event of ICIS
downtime.
Throughout the implementation of the COE and Clinical Documentation computer screens, predefined values were made
available in the form of drop down selections. This ensured that key standards were followed and the information collected could
be retrieved, reported upon and easily analyzed. Using the organization’s approved abbreviations list along with pre-defined
data categories, each data field was analyzed and classified. The classification was based on three categories: clinical,
regulatory/legal and reimbursement. These activities contributed to improved communication amongst the care provider and
various departments and increased staff efficiency, with an associated decrease in clarification phone calls.
With ICIS implementation, written orders are no longer acceptable and many of the forms used in the nursing documentation
process have been removed. Also, to ensure that electronic data integrity is maintained, all data collected during a planned or
unplanned downtime event is back-loaded into the system. The downtime forms used for collection of data are also part of the
legal medical chart and can be referenced should there be a need for auditing of the electronic data.
System Access/Confidentiality
Access to the system is restricted based on role-based unique user identifications and passwords. Prior to issuing system
access information, employees must read and sign a confidentiality agreement that includes clear statements of disciplinary
action up to and including termination for violations of the policy. Passwords must be reset after 120 days. As a result of the
ICIS project, CCHMC reengineered the security and access process and has established a central security administrator for all
users of information technology. Security, privacy and confidentiality are maintained consistent with Health Insurance Portability
Accountability Act (HIPAA) regulations and CCHMC security policies. ICIS utilizes user specific sign-on, password protection
and electronic signature for order entry assuring that only designated staff will have access to order entry and documentation
functionality. To maximize security the COE system requires validation of the user password at the time the orders are sent for
processing. The outcomes realized by the new process include:
1.
2.
3.
4.
Increased availability and utilization of applications by streamlining the request process
Improved user satisfaction with the issuance of the same user sign-on ID for multiple systems
Effective meeting of HIPAA and CCHMC security requirements
Timely access to patient information to enhance patient care
Impact on Operations
COE affects all aspects of a hospital’s business: clinical quality, regulatory compliance, and financial management. Since the
physicians orders initiate services that account for over 80% of health care charges it was important to ensure that these
processes are improved and not disrupted by the ICIS implementation.
Early in its planning stages, the ICIS Project Management and Leadership Teams recognized that the implementation of such a
complex system would require careful consideration in regards to minimizing negative impact on patient care and clinician
workflow. Furthermore, the team decided that to ensure greater user acceptance and confidence the Implementation and
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Clinical Support Teams would need to be available 24X7 during each unit implementation. Based on these assumptions, six
months prior to the planned live event the organization began recruiting staff for the Blue Coats. These individuals were primarily
nursing students who were oriented to the units and trained in the features of the ICIS and related practice processes.
Initially, the implementation of ICIS was planned in a phased approach so that the impacts on operations were well controlled
and disruptions minimized. Due to the ICIS complexity the team began implementation planning months prior to the targeted live
date. The implementation planning process was well structured and required direct clinician user involvement as well as
management and supporting staff participation. Standard meetings were scheduled 6-8 weeks prior to each planned patient
care unit implementation date. The ICIS project leads, representatives from the ICIS Education Team, unit management and
staff attended and identified any new ICIS processes that varied from the existing practices. Through this methodology, new
practices were identified and then communicated back to the clinical users and ICIS Support and Education Teams.
The processes that were most significantly affected by the implementation of ICIS were those related to patient flow through the
hospital. The attention to detail in regards to patient flow issue was a key success factor – particularly in early unit
implementations given the presence of multiple care providers along with the small number of live ICIS units. Patient flow issues
required the development of new processes for both the ICIS and non-ICIS units to which the patient may be transferring to or
from. These processes focused on learning where to find the electronic data, how to read the new printed forms, who has the
responsibility to write transfer orders and how the information is to be communicated between various clinicians. Figure 5 shows
a sample of the new patient flow processes summary made available to providers in the RCNIC. This and similar tools were
used to provide end-user education as well as to maintain consistency in the support communication. Many process-related
helpful hints were posted on both fixed workstations and wireless devices to help the staff remember what to do in certain
situations.
Figure 5: A
representative sample
of a patient flow
process summary tool
that was utilized in the
Regional Center for
Newborn Intensive Care
(RCNIC) at CCHMC.
The steps that were
required in COE and
Clinical Documentation
as they related to a
patient transferring
through various locations
within the hospital are
delineated.
Initial Implementation Approach
Another major consideration was the implementation approach. For the two pilot units, it was decided that, based on the live
date, only newly admitted patients would be placed in ICIS. This was primarily due to the high degree of patient turnover in
these areas. To differentiate between the ICIS patients and the ones who remained on paper the charts and patient names were
flagged with orange stickers. By the second week of implementation in these 2 units, the long-term patients were back loaded
and the units were considered fully live on ICIS. This approach had a range of positive and negative impacts on both the clinical
and ICIS team. Some of the negative impacts related to the nurses’ workflow. Several nurses experienced difficulty in managing
patients at the same time in both the electronic and paper environment. Since this was a new experience for everyone, the
physicians had difficulty discerning between the two environments, therefore, they wrote orders on paper when they should have
entered them in COE (and vice versa).
Changing the Implementation Approach
Using the lesson’s learned during the implementation of the pilot units and in speaking with the clinical users, the ICIS team
changed the live implementation strategy. For subsequent unit implementations, on the day prior to going live, the ICIS team
and selected unit staff back loaded all of the active patient orders into the system. The unit remained on paper until the following
morning at 0600 when the ICIS Implementation Team performed a last check and entered any new orders. From that point
forward, the orders were placed in COE and the appropriate clinical documentation and medication administration data was
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placed in ICIS. All the live implementation events were communicated throughout the organization and especially to other
departments such as the pharmacy and laboratory. Strict back loading guidelines were identified and a system of checks and
balances were initiated. Although there were some difficulties along the way, the implementation process was designed such
that operational impacts were minimal and quickly rectified.
The pharmacy department was one of the areas significantly impacted by the deployment of ICIS. The gains immediately
recognized were related to the clarity and completeness of the physician’s orders, the decrease in number of phone calls to
clinicians, and the dramatically decreased medication turn-around time (see the Value section for elaboration). Due to the fact
that an interface between ICIS and the pharmacy system does not exist, large volumes of printed orders were produced not only
at the time an order was entered, but also when orders were revised, held and resumed. All the stat orders printed on a
separate printer to ensure faster turn-around time; nonetheless, the pharmacy staff was initially inundated with paper. To correct
the problem, the ICIS Pharmacy Analyst created a program that would queue all the active orders session summary prints of
routine medication orders and automatically batch print them every 15 minutes. This change greatly improved the user
satisfaction and efficiency in the Pharmacy Department with no significant impact on the turn-around-time on medication delivery
process.
As a pediatric organization, every aspect of the implementation had to be analyzed in a great detail to ensure system
compatibility with children and their families. Portable devices had the potential to intimidate or scare small children. Loose
electrical cords and non-stable carts could be dangerous to these patients. The staff used liberties in naming the devices with
amusing names and placing appropriate decorations on the portable carts to decrease patient anxiety. The nursing staff spent
time explaining to parents and family members the nature and benefits of the project to assure them that they would continue to
get great care.
With the deployment of ICIS throughout the organization several inefficient processes related to the patient’s admission, transfer
and discharge were identified. For example, orders needed to be placed electronically post-operatively while in PACU prior to
patient placement in a definitive room. This caused the ordering physician to use the medical record number search feature to
find the patient. There were instances where the wrong patient case was selected and COE orders entered that caused
disruptions in the continuity of care. Working together with the PCAPI team, a major re-engineering process was initiated to
address these inefficiencies. This led to the creation of temporary (virtual) beds where for each unit (including OR) there were an
equivalent number of temporary beds created. This facilitated a process of placing all scheduled admissions in beds to minimize
the chance of orders being place on wrong cases. To further support these new processes, the ICIS team placed various
system logic and blocks in the system that would not allow the orders to be entered by the clinician if the patient had not yet been
placed in a bed.
Other significant process changes were related to the ordering process for over-flow and pre-admit psychiatry patients. The
existing process did not support the ICIS model that was based on order entry primarily by physicians. For this patient
population there was great involvement from the RN triage nurse who initiated many of the orders via verbal orders. This led to
the creation of an inactive order entry pathway that would allow the physicians to enter the care orders in advance and at the
appropriate time, the RN would activate the orders.
The impact on processes discussed in this section are only a fraction of the multiple changes that needed to be enacted to
support patient care prior to, during and after the ICIS deployment. The ICIS team confirmed what pioneers in the industry have
been saying about COE implementations: “Indeed, physician order entry is more than a technology – it is a clinical process
facilitated by technology. This distinction is critical to appreciating the fundamental challenge to CPOE implementation. CPOE
requires significant clinical process redesign, which in turn requires extraordinary commitment by physicians, other clinicians,
and executive leadership. Although many of the same principles apply to any large-scale clinical change project, they are critical
to CPOE, which some have viewed as the Holy Grail of clinical systems” (Sittig, DF, et al. JAMA 1994;1:108-123).
Successful Management of the EHR Effort - Partnership and Ownership
The ICIS implementation has been extremely successful to date. In early 1999 when the organization acknowledged the need
for physician order entry many leaders assumed the project was an Information Services Department-driven project. By early
2000, leaders in the organization were frustrated and did not feel Information Services had made any progress towards the
implementation of additional clinical systems or an electronic medical record. Assignment of a physician as the COE Project
Director was the catalyst needed to form the necessary partnership and structure that exists today. A clinician-driven project
leadership team and clinician-driven design teams will continue to direct the evolution of the ICIS.
As mentioned, appropriate assumptions of ownership of the various aspects of the ICIS were essential for a successful
implementation. A sense of ownership by the staff on the nursing units was instrumental in the successful conversion from the
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previous paper-based approach to the ICIS. Those units who took responsibility for problem solving associated with the
implementation have been those who have found the greatest satisfaction and seen the most benefits from the ICIS. Live
planning sessions with a unit that involved key managers and staff leaders from the patient care area were a good predictor of
support that would be needed to ensure success at the time of the implementation and to sustain the project in that area.
Another important management fundamental was the use of a planning methodology focused on process improvement as the
driver for information technology decisions. All design discussions began with understanding clinician workflow and processes.
These discussions facilitated both a well-designed product and shared ownership of the system.
An important lesson was learned regarding the challenge of employing the services of super-users from each nursing area to
assist during the transition to an electronic record. While it was helpful to have some very well trained super-users, the project
team was unable to rely on these resources to support their peers during the live event. . Due to the nursing staffing shortages
that existed at CCHMC, it was unrealistic to expect that super-users would be able to be removed from their patient care duties
to support other clinicians. The project managers quickly recognized that Project Team members would need to be the primary
support staff during an implementation.
With the introduction of ICIS, there have been several unanticipated events that took place (Table 4). Many of these events
uncovered significant process improvement opportunities. The appropriate design team evaluated and intervened in each of
these events.
Table 4: Summary of process improvement opportunities arising after ICIS implementation.
Unanticipated Consequences
Verbal orders entered under the incorrect physician.
Although the ICIS has led to a significant decrease in the
number of verbal orders, there have been cases where
the nurse attributed the order to the wrong physician
Excessive COE clinical alerts. Too many alerts were
being generated by normal practice, especially in
intensive care units where multiple sedation agents,
vasoactive medicines, antibiotics or other potential
conflicts are common usage. Too many alerts led to
desensitization to warning alerts
Unanticipated Expiration of Medications. The CCHMC
policy for limiting treatment duration of certain drugs was
engineered into the system in the form of default
expirations. The ordering party may accept the default in
haste. The physician would find out after the fact that the
medication was no longer being administered due to
expiration of the order
Process Improvement Solution
In the isolated cases when verbal orders are accepted, the nurse
is asked to confirm if the correct physician was selected from the
list of physician names
Rather than simply remove all generic and therapeutic duplicate
checks, alerts were evaluated for helpfulness and those that were
deemed a nuisance were removed from the system. The allergy
checking and dose range checking both remain. Certain absolute
maximum doses have been added for very high-risk drugs
Several system features were built into the system to alert
clinicians to orders approaching expiration. These orders are
indicated on the active order display; the last dose of a medication
is labeled as such by the pharmacy; and the nurse administering
the medication gets an alert as the last dose of the medication is
charted on the Medication/IV Charting
As is common with the introduction of electronic systems, bad practices or broken processes are often uncovered. The goal of
the thorough workflow analysis during implementation planning is to minimize the occurrence of surprises once the system has
been implemented. Despite CCHMC’s efforts at methodical analysis of processes, several imperfect systems were discovered
after implementation. The design teams and PCAPI took the lead in investigating these practices and worked towards their
resolution. These are depicted in Table 5 below.
Table 5: Summary of process and practice problems identified after ICIS implementation.
Broken Process/Imperfect Practice
Delayed placement of patient registration into the
system. Delays in getting the patient account set up in
the clinical system resulted in delays in order placement
and the ability to document care
Placement of the order “Home meds per routine”. In
the manual world, some clinicians would write the above
Process Improvement Solutions
The admitting and registration process underwent a complete
performance improvement initiative to anticipate the arrival of
scheduled admissions and place them in a temporary unit until the
actual patient arrival. This allowed preliminary orders to be placed
on the patient before their arrival
The resolution of this issue is not an information system fix, but it
uncovered the practice. Physicians are making an increased
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Broken Process/Imperfect Practice
order when they did not have direct contact with the
family. The expectation was that the bedside caregiver
would assess the home medications and pass that
information on to the physician at a later time or write
them as verbal orders. This was particularly common
with surgeons who were writing post-operative orders
while in the operating room
Order writing undertaken primarily by a single
individual on a specialty service. One of the specialty
services has a very high turnover of surgery cases. An
electronic order entry system does not provide efficiency
at the front-end of order writing. Therefore, the time
consumed by the placement of inpatient orders by a
single individual affected his/her involvement in hands-on
surgical experience
Misuse of verbal orders by particular services or in
particular situations. Compliance with CCHMC policy
on verbal orders was difficult to measure in the paper
world
Process Improvement Solutions
effort to evaluate home medications during the clinic visits prior to
surgery, and Same Day Surgery staff is now more detailed in the
documentation of home meds after interviewing the parents preoperatively
Data was provided to the service on the number of minutes that
each surgeon spent on the system per day. Using this data, the
division was able to justify the addition of a nurse practitioner to
assist in inpatient care and order management
Verbal order management is carefully reported on a regular basis
to monitor the number of verbal orders and the types of verbal
orders.
Feedback to the clinicians who give and take
inappropriate verbal orders has resulted in improved compliance
with policy
Functionality
Description of ICIS
The COE application includes all inpatient care orders approved procedure and diagnosis-based pediatric-specific order-sets.
With patient safety as the main driving force behind the project, standard decision support tools were employed, such as drug
allergy, duplicate orders, therapeutic drug duplicate and drug/drug interaction checking. Additional pediatric specific decision
support tools were designed and implemented in various ICIS pathways.
The Clinical Documentation application includes vital signs, heights, weights, allergies, physical and admission history, intake
and output records, IV and Central Venous Catheter assessments and pain assessments. Nurse-to-nurse communication orders
allow nurses to select orders that are based on the developmental age of the patient (i.e., infant, toddler, school-age, adolescent,
and adult). A nursing worklist option allows for generation of a document for use in guiding care delivery. It contains patient
demographic information and all care orders. Admission history and pain assessment tools allow clinician to tailor
documentation to the developmental age of the patient.
The integration of COE and Clinical Documentation results in the generation of the Med/IV Charting platform, (the electronic
medication administration record), directly linking the ordering, dispensing and administration processing in the medicationmanagement cycle. Previous internal and published data indicated that transcription errors represented 15% of all medication
errors at CCHMC. As discussed further in the Value section, transcription was completely eliminated as a source of error
through Med/IV Charting that is populated in real-time through the COE medication order entry pathway.
Functionality included in ICIS was determined with the strategic objectives in mind: safety, consistency, efficiency, compliance,
user, patient and family satisfaction, and care based on research and performance improvement activities. The approach taken
to meet each of these objectives can be found in Table 6.
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Table 6: Desired strategic objectives and the approach taken for their accomplishment.
Desired Outcome
Approach
Optimizing Patient Safety and Consistency in Care
Assure Complete Legible Orders and Legible Documentation
Providing Identifiable Physician Contact Information
Decreasing Use of Verbal Orders
Elimination of Transcription Errors
Minimize Risk of Mis-dosing Medications
Standardization of Care for Common Diagnoses
Access to Most Up-to-Date Clinical Resources
Improved Pharmacy Order Management
Elimination of illegible, incomplete orders through the implementation of
COE; all departments are trained on the viewing of patient orders and
documentation
Every order is automatically populated with the pager number of the ordering
physician or nurse practitioner
Physicians have access to patient data and ability to write orders from any
remote locations; the workflow is supported by the use of portable, wireless
devices
Concurrent implementation of electronic MAR with COE eliminated
transcription errors
Dose range checking: includes patients of all ages, including those less than
30 days of age. The reference formulary dB comprises top 97% of
medications used at CCHMC including all high risk medications alerting the
clinicians if certain ranges are exceeded; absolute values are defined for
predefined drug categories; all weight fields contain edits that calculate if the
patient is between 3-97 percentile for age on the growth chart to alert
clinician to possible error in entering dosing weights
Creation of over 220 pediatric specific order sets (number increasing weekly)
and inclusion of evidence-based guidelines for common diagnoses
Links to online resources which are consistently updated so that decision
support resources are the most current, such as CCHMC’s formulary,
Children’s Oncology Group, Micromedix, Clinical Effectiveness Guidelines,
Policies, etc.
Alerts to staff on orders approaching expiration, both in the ordering
pathways and in the medication documentation pathways; the clinician is
notified 24 hours in advance of drugs approaching expiration allowing timely
reviewing of orders; alerts on the charting of expired or discontinued
medications
Clinician Efficiency
Eliminate the Inefficiencies Associated with Admitting the Patient New processes were defined to pre-register patients and place them in a
into the Computer System in a Timely Manner
temporary bed assignment in the computer to allow for standard pre-admit
orders and post-operative orders to be placed prior to patient arrival; this new
reengineered process supports the most effective management of patient’s
flow eliminating delays in care initiation
Elimination of Redundant Documentation
Concurrent implementation of clinical documentation; single entry
communicates data such as allergies or weights to all appropriate clinicians;
admission history from other admission within last 180 days pulls forward to
allow for updates rather than complete re-entry of data
Accessibility of Patient Data from Any Location
With the concurrent implementation of Clinical Documentation and COE on a
common platform, patient-specific data is available from any PC within
CCHMC; community MD's also have access to displays of patient data from
their community offices resulting in time savings from 30 minutes to 2
hours/day due to elimination of phone calls, avoiding hospital trips when
patients were discharged, etc.
Accessibility of Reference Data
Direct links to the specific medication in the formulary from the ordering
screen, to specific policies related to the specific order (i.e., restraint policy,
med administration policies, etc.)
Minimize Need for Order Clarification
Patient pertinent information associated with the order is required at the point
of order entry, such as clinical information for radiological procedures,
significant clinical history, required indications for use of non-formulary meds,
MD consults, etc.
Shift the Initiation of Care to Earlier in the Day
Use of wireless devices during rounds supports the order-writing at bedside
in real-time
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Desired Outcome
Approach
Improve Efficiency of Care Givers - Direct Communication of Automatic paging of respiratory orders to covering therapist; automatic
Orders
paging for stat, portable x-rays; setting new visual triggers for new order in
the clinical documentation pathways; new policies implemented to support
the checking of the electronic orders (i.e., nursing must verify the system for
new orders at a minimum every two hours)
Minimize Time Required for the Management of Patient Data
Intake and output automatically calculates the cumulative totals and fluid
balance; creation of computer-generated work-lists used in shift to shift report
and workflow management throughout the day
Improve Ease of Chart Audits and Data Collection for Process Create various reports to monitor system efficiency and staff compliance with
Improvements Activities, Clinical Effectiveness Monitoring and the Clinical Documentation (i.e., monitoring of alerts usefulness, order
System Effectiveness
utilization by hour/day, device utilization tracking, time spent on order writing
per clinician, dose range checking triggering and clinician response,
association of clinician fatigue post calls and order writing, pain assessment
and reassessment compliance, etc.)
Maximizing Regulatory Compliance
Improve Compliance with Signing Verbal Orders
Timely Documentation of Patient Data
Eliminate Inappropriate Use of Verbal Orders on Narcotics
Eliminate Generic Logons and Sharing of ID's
Physician census displays include a counter of number of unsigned orders;
verbal orders update the patient list for the physicians who gave the orders
and remain active on the list until the orders are co-signed by the ordering
physician or other authorized clinicians
Alerts and reminders trigger at the point the patient is selected to inform the
nursing staff of the pain assessment and re-assessment post intervention
and completion of admission history if not initiated of completed within 24
hours of admission date/time; edits to assure correct recording of weights;
automatic charging for Durable Medical Equipment upon IV assessment and
enteral pumps based on tube feeding orders
Piloting the placement of narcotic orders from home with the Pain
Management team; weekly monitoring of verbal orders for narcotics via
system reports; staff education to increase awareness regarding hospital
policies
New security policies were defined, holding users accountable for the
security of their logons and passwords; defined a new centralized process for
obtaining system access; currently in process of assessing the technical
requirements for installing biometric devices for authentication as part of a
single sign-on enterprise solution
Clinician and Patient/Family Satisfaction
User Friendly and Highly Accessible Methods for Communication Every screen in the system provides a link for the user to provide instant
Between the ICIS End-Users and the Technical and Leadership (non-urgent) feedback, recommendation and suggestions for system or
Team
process changes to the implementation and leadership team through e-mail;
the e-mail is monitored 24X7 by the ICIS support team and second level of
support (technical staff, project director and project managers)
Eliminate Patient and Family Frustration Related to Redundant Eliminated the need to ask family the same questions repeatedly, as data is
Questions by Various Care providers Seeking the Same readily stored in the lifetime clinical repository and available real-time to all
Clinical/Historical Information
authorized care-providers
Pediatric-Specific Initiatives
Standardization of Patient Care through Use of Clinically Approved Over 220 pediatric-specific ordersets span across diagnoses and care of
Order Sets
patients of all developmental ages; currently developing 142 additional
orders sets to support the Blood Marrow Transplant and
Hematology/Oncology unit
Weight-based Dosing
Created CCHMC-specific weight-based dosing alerts to include premature
infants through adulthood
Age-weight Checks
Alert to clinician when recorded weight falls outside the 3 - 97 percentile on
the growth curve based on age in months to cover all age groups; minimizes
risk that weight is documented in pounds rather than kilograms
Ordering Related to Developmental Age of Patient
Nurse-to-nurse communication orders allow nurse to select orders that are
based on the developmental age of the patient (i.e., infant, toddler, schoolage, adolescent, adult)
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Desired Outcome
Documentation Related to Developmental Age of Patient
Optimized Nutrition Orders
Access to Pediatric Reference Sources
Approach
Admission history, pain assessment and the nurse to nurse care orders are
tools that allow clinician to tailor documentation to developmental age of the
patient
Nutrition orders are inclusive of diets for patients of all ages, from premature
formulas to adult selections
When ordering a medication, link directly to that CCHMC formulary page for
that specific medication; links to Health Topics (patient/family education
pamphlets)
One safety feature worth highlighting is the dose range checking capabilities of the system. Due to the lack of availability
of commercial dose reference data for children (particularly neonates), CCHMC had spent years of research and compiled an
internal reference database that includes the most often ordered inpatient drugs from birth to adulthood (18 years of age). These
great efforts paved the road for the development of the Dose Range Checker since the reference data was now readily available.
Working with physicians and clinical pharmacists, the team analyzed the areas where the medication errors were produced in the
manual environment. Based on the information collected the specifications of the Dose Range Checker were defined and
included the following characteristics/requirements:
9.
Minimum/maximum allowable single dose
Minimum/maximum allowable daily frequency
10.
Total daily dose
11.
Never to exceed single dose
Never to exceed total daily dose
Checks against give route (for certain medications
dose references were different based on the routes)
7. Patient age
8. Indication code (diagnosis).
For antineoplastic
medications reference data is unique to the treatment
protocol selected using diagnosis, (ICD9 codes)
and/or the protocol code name
An example of a Dose Range Checker in action is shown in Figure 5.
1.
2.
3.
4.
5.
6.
Checks the medication ranges in multi-ingredient IV
fluids
Taper dose medications
Checks for the PRN medications. If the frequency
entered is a range (Q4-6 hours) the check is
performed on the highest frequency that could
potentially be administered and advises the clinician
not to exceed the recommended dose.
The
recommendation is stored with the order and
displayed in red on the electronic MAR.
Figure 5: A dose range checker alert that is triggered after a physician enters an excessive dose of furosemide. The circled
text provides useful information to the
clinician to allow the revision of the
medication order.
Since dose calculations for children
are primarily weight-driven, a dosing
weight that is used primarily for
medication dose calculation and a
scale weight that reflects the actual
measured weight of the patient is
entered.
Additional logic was
designed to alert the clinician if there
was a > 5% variation between the two
weights.
To ensure the efficiency of the Dose
Range Checker was achieved, the
ICIS team obtained user feedback
and produced reports tracking their responses to the alerts generated. The user feedback indicated that in particular situations
when the patient’s age or weight was close to the next range available, the clinician would prefer to use the doses in that
particular age/weight group. They felt the alerts generated for these patients were too strict and oftentimes not applicable. To
address the issue the COE Design Team and pharmacists agreed to allow a ± 5% margin for the calculated doses.
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Once the Dose Range Checker build was completed a meticulous quality assurance testing plan was defined and followed. The
Dose Range Checker was populated with the reference data for the 470 most toxic (or frequent) medications ordered at
CCHMC. The Dose Range Checker required three levels of quality assurance testing: analyst, pharmacist and physicians. It
was estimated that once the first two quality assurance levels were completed it would take a physician an average of 15
minutes to test each drug for all the appropriate ranges, ages and give routes. To provide accurate calculations, patients with the
appropriate ages (day 1 to 18 years) were admitted in the system. To reflect the specifics of the test scripts, the date of birth for
these patients was modified each time prior to the test sessions. Additional time to address problems was also considered and
built into the quality assurance testing timeline.
Using the Six Sigma controlled plans as reference the analyst developed medication specific test scripts that would encompass
all of the Dose Range Checker specifications. The quality assurance process spanned a period of two months. Medical/surgical
residents were employed to perform the validation and to speed the process. Following a system orientation and specific Dose
Range Checker education, the physicians attended two-hour testing sessions to complete the task. The analyst was actively
involved in these sessions and was able to address and correct any immediate problems. If more significant changes needed to
be made, the quality assurance cycle for those particular drugs was initiated from the beginning. At the end of each medication
validation, the clinicians signed off the individual quality assurance testing forms and the medication was activated into the
production environment.
Every medication ordered in COE alerts the clinicians at the point of ordering if the Dose Range Checker data is not available for
the drug selected. For medications that require dose calculations based on body surface area, (i.e. cyclophosphamide), the
clinician receives a Dose Range Checker error alert if the height of the patient is missing indicating that this data is required to
complete the check. The Dose Range Checker status is displayed and printed with each order. The system tracks up to three
Dose Range Checker episodes per order and stores the information for each attempt. Example: If the physician is alerted that
the maximum daily dose is exceeded, the specific alert is stored with the order. When there are no errors in the dose
calculations the Dose Range Checker performs the check and stores a notation with the order that “DRC Passed”.
Approach to Ongoing Management of the Paper Record
The applications included in phase I of Clinical Documentation were based on data necessary to support the physician in the
order writing process, as well as data that could be grouped to both support the nurses workflow and eliminate complete paper
forms. The concurrent implementation of COE and Clinical Documentation resulted in the elimination of twelve paper forms. In
order to condense remaining data being collected manually, two forms were developed to maintain consistency in data collected
and to better support the clinician workflow. Three downtime forms were created – these covered new admissions during a
downtime, and shift-to-shift assessments in the acute care setting and critical care.
Careful analysis and planning for data management early in the design phase proved beneficial. The Phase I applications
implemented with ICIS beginning in April of 2002 represented 55% of acute care documentation and 11% of critical care
documentation. Estimated cost savings since April of 2002 on paper forms no longer needed with ICIS exceeds $40,000..
The HIM forms committee worked with ICIS team members and Legal Services to establish criteria for electronic data storage in
the Lifetime Clinical Repository (LCR), to oversee printing requirements and to direct the ICIS team in the process required for
maintaining a complete patient medical record.
LCR is being populated with all ICIS patient information. Eventually LCR will serve as both the clinical and legal medical
repository for patients at CCHMC. While this process is evolving it was decided to print all the electronic data captured in ICIS
upon patient’s discharge, therefore maintaining a complete paper chart. A dedicated printer was placed in HIM to generate the
Final Discharge Reports. These reports queue in a dedicated document group and, through manual intervention by HIM staff, the
reports are released during the night shift. This printing approach supports the workflow of HIM staff and ensures reports are not
misplaced. The HIM forms committee approved all electronically generated documents that would comprise the Final Discharge
Report. These documents included a comprehensive order summary, complete medication administration record, admission
history, vital signs, intake and output and assessment summaries.
Physicians and Other Caregivers as Contributors
Involving clinicians in the design and modification of ICIS was a key strategy closely associated with successful implementation
of clinical systems. Design, modification and enhancement priorities were primarily the decisions of the multidisciplinary
Physician and Nursing Design Teams. These teams focus on improving clinical processes, assuring user efficiency and
maximizing productivity, while optimizing patient safety. Since implementation, 100% of all inpatient orders are placed in ICIS
by the attending and resident staff with verbal orders placed by other licensed professionals. Documentation of patient data is
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entered into ICIS on all units except the hematology/ oncology unit and is consistent with the pre-defined scope of the ICIC
project.
There have been a multitude of users who have utilized ICIS since its inception. The numbers and types of clinical roles include:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
173 Attending MDs
314 Residents
31 Advanced Practice Nurses
731 Registered Nurses
13 Pharmacists
10 Nutritionists
4 OT/PT Therapists
79 Respiratory Therapists
21 Patient Care Attendants
8 Health Unit Coordinators
8 Home Health Staff
5 Social Workers
189 Student nurses
84 Radiology technicians
Specific Processes Targeted for Improvements in Quality, Efficiency, and Reliability
It has been estimated that the implementation of ICIS was accomplished with approximately 20% technology innovation and 80%
process re-engineering. The birth of PCAPI was a strategic step for redesigning processes related to patient care. It included
registration, information and financial data collection, clinical intervention, delivery of care, environment and support functions.
This initiative was instituted in order to support the automation of the patient record and to support the movement of patients and
staff from the old hospital to the new clinical building.
The PCAPI Clinical Intervention Team brought paper charting to the bedside. This transition paved the way for point of care
documentation via fixed and mobile devices with the implementation of ICIS. Bringing charting to the bedside not only proved
beneficial from an efficiency factor but also served to improve patient and parent satisfaction. The PCAPI Clinical Intervention
Team instituted patient/parent charting. The development of forms for patient/parent documentation empowers the patients and
their parents in the care delivery process. Patient/Parent documentation, where optional, is favorable to and has been primarily
used by patients and/or parents of chronically ill children. A goal with ICIS in the future is to allow for electronic capture of the
patient/parent documentation.
The PCAPI Registration, Information and Financial Data Collection Team focused their efforts on processes that support
functionality as it related to patient flow. Physicians, nurses and clinical staff are in the business of health care delivery. The
challenge of this PCAPI team was to ensure patients are bedded in the system for proper communication of location to ancillary
services, for improved efficiency in the order writing process, to facilitate patient flow, to assure prompt patient placement, and to
include the nurses in the rounding process. As mentioned in an earlier section, bedding the patients to support the workflow of
the surgeon and to enable the communication of patient location to ancillary services was accomplished via the development of a
virtual unit in the ICIS system. The admitting department manages the placement of patients that will be admitted postoperatively for 23-hour observation or longer on night shift before the patient’s surgery. Admitting places the patient in the virtual
bed corresponding to the destination unit for that patient. The surgeon can proceed with electronic ordering for these patients
and the ancillary services such as pharmacy can dispense medications quickly to the destination unit for that patient.
A new position called the Patient Care Facilitator (PCF) was created to manage the patient flow on the unit and facilitate care
delivery. There is one PCF on each unit on each shift. As the physicians round on their patients, they are encouraged to write
their care orders as they go. The PCF rounds with the physicians and discusses progression to discharge. This process has
resulted in discharge orders being written earlier in the day. In turn, this has resulted in discharges occurring earlier in the day.
This result is discussed further in the Value section. The PCF also manages such processes as obtaining needed supplies and
appropriate beds for patient admissions and for implementing downtime procedures as needed. A direct result of this process
change is the ability to efficiently receive and manage new admissions. It is now rare that a patient is in an outpatient area
waiting for an inpatient bed. This demonstrates how establishing this role was instrumental in the success of managing the
patient flow for the ICIS patients.
Information Access
Since ICIS is a web-based system, information is available from any device within the institution, whether it is in the outpatient
clinics, inpatient units or one of the 15 satellite clinics. All applications within the ICIS are accessed via single-sign on with
context sharing of patient information. CCHMC encourages clinicians to place orders from anywhere within the institution when
patient conditions change in order to minimize the need for verbal orders. In addition, a combination of fixed and mobile devices
has been deployed to meet user needs. Information accessible to authorized users includes:
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•
Documentation and demographics such as allergies (food, drug, and product), intake and output, pain assessment, vital
signs, weights, heights, head circumference, the medication administration record, admission history and physical
information, intravenous/central venous catheter/ peripherally inserted central catheter assessments and tracking,
demographic information, patient location, team affiliation, attending physician.
•
Results information such as laboratory results, pathology results, operative reports, cardiac catheterization results,
pulmonary function test results, radiology results and online discharge summary.
All of the information is seamlessly integrated through a single click in the Navigator bar. Most results can be viewed in tabular
form or graphical trends. Various users have different levels of access. Physicians and nurses can view the entire above, health
unit coordinators can view data output only.
The mobile devices are utilized on physician rounds to facilitate the placement of orders as the need is identified, resulting in a
shift in orders being placed earlier in the day. The Value section below describes specific improvements in this area. Clinical
documentation at the point of care is also facilitated by the use of mobile carts and pen tablets. There is a 1:1 ratio of devices to
care provider in the critical care units and 1:2 ratio elsewhere.
Remote access of data has been encouraged since the implementation of the web-based results portal in January of 2001.
Community physicians have been granted extranet access to this web-based portal, and training of the community physicians
has been a focus of the physician representatives over the last year. Approximately 97% of the pediatric community has been
trained on the use of the extranet access to their patient data. To provide convenient access, the Medical Staff Central portal
was developed to provide the community physicians with access to valuable hospital resources via the Web (Figure 6). They
can view patient results and COE orders as well as the organization’s clinical guidelines. Clinicians can update their pertinent
information by clicking the “Update Contact Info” tab. This generates an email to the appropriate resource that will update the
enterprise doctor master. Also, they have access to view and print to all referral forms as PDF formats and view the pediatric
staff resident assignments. There are great efforts in place to expand the access and functionality of this portal to best support
the practice of community physicians. Other resources available include PubMed, American Academy of Pediatrics, Center for
Disease Control, etc.
Figure 6. Medical Staff Central –CCHMC developed
web-based portal geared to community physicians
and medical staff. This portal is accessible via the
CCHMC intranet and extranet and provides access
to valuable CCHMC resources including ICIS.
CCHMC has not implemented the entry of orders
from community offices during the initial phase of
implementation.
As the support structure is
developed to provide adequate technical assistance
to community resources, community physicians will
be given the ability to place orders within the ICIS on
their inpatient population.
CCHMC has begun working with the University
Hospital of Cincinnati to allow access to the ICIS for
those physicians who cross-cover in specialty
disciplines. CCHMC is also beginning to explore
remote access via a virtual private network for selected physicians who do not have in-house coverage in off-hours. This
advancement will minimize the use verbal orders .
There is a multitude of online informational resources available to users from the web-based navigator and imbedded within the
documentation and ordering pathways. These resources include internal links to items such as the:
1. Clinical Lab Index, which contains information on specimen collection requirements and turn around times
2. CCHMC formulary with dosing and indication information
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3.
4.
5.
Links to order-specific policies and procedures, such as digoxin and KCl administration policies, are on the ordering screen
for these orders
Restraint policies, pain management policy, isolation guidelines and neonatal visitation guidelines
Pediatric assessment standards
The clinician does not have to search out these policies or even leave the order function since they are available on the ordering
page for the specific associated order. Every medication order has a link directly to the associated formulary page that is specific
to the CCHMC formulary. In Clinical Documentation policies, standards and guidelines are built into the applications. Point of
care access guides care practice requirements and makes care delivery more efficient. CCHMC has developed Health Topics
that contain educational material written by CCHMC nurses and physicians. Use is intended for CCHMC patients and families
and reflects practices within CCHMC. These can easily be accessed from ICIS when the nurse is teaching families about
procedures, home care and disease states. Figure 7 shows a screen shot of a digoxin order function within ICIS and the ability
to click and go directly to the digoxin entry in the formulary or the digoxin policy.
Figure 7: Order Window Accessing
Formulary Information. Context specific
medication information is maintained and
links to the corresponding medication
name in the formulary.
External links to items such as Pub Med,
Micromedex, and the CCHMC Pratt Library
are also available for ease of use while in the
web-based portal. The variety of resources
available encourage users to access data at
the point that it is needed in caring for
patients and assures that users are
accessing the most up-to-date reference
material.
Through a common user interface an authorized clinician can view patient results from multiple sources, orders, documentation,
and demographic data. A user may also enter documentation or orders and generate worklists and patient reports in hard copy.
Physicians have the ability to enter their pager numbers into a database that can be linked to an order, so that the physician
contact number is automatically associated with each order. Advanced Practice Nurses (APN) can create a collaborating
physician list that is available to them when ordering a medication outside of the APN license.
Additional patient data can be found through links to PACS, Discharge Summary System and the state immunization registry.
Links to these systems do require an additional sign-on and lacks the sharing of patient context at this time. CCHMC is exploring
options for a single sign-on solution that will also allow context sharing between disparate systems.
Decision Support
Order/Clinical Practice Standardization
Two initiatives, key to the early success of the ICIS, included the development of Order Sets for patient care and the
development of pediatric pain assessment pathways.
Order Sets and Best Practice Guidelines: Prior to ICIS implementation a comprehensive search revealed 470 pre-printed
orders throughout the institution for the care of a variety of diseases, diagnoses and procedures. These pre-printed orders were
often redundant (6 acute asthma order sets), contained outdated medications or medication errors, lacked an origination date
and/or an owner, and were devoid of information as to the source of the orders. It was recognized early on that a more
organized approach would be necessary in order to utilize the powerful feature of order sets into the ICIS. Six organizational
steps were taken in this new approach:
1.
A forms committee was created. The purpose of this committee was to solicit and receive proposed order sets which
would then undergo multidisciplinary evaluation for content and format. Order sets are submitted from a variety of sources
from the most formal (i.e. Sixteen Health Policy and Clinical Effectiveness evidence-based practice guidelines) to smaller
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2.
3.
4.
5.
6.
divisional-level order sets (i.e. the PICU cortisol stimulation test order set). When approved by the Forms Committee, the
order set is assigned an owner (usually the Division who put it together), and an approval date
An intranet order set repository was created to house the order sets by category
Order sets were built into the system
A process was created between the pharmacist and the owner of the order set to make sure it accurately reflects original
content and meets the service's workflow. Each owner is asked to decide line-by-line whether the order should be
automatically included (requiring no additional thought/work on the part of the clinician), or excluded and requiring clinician
input
A formal sign off process by the order set owner is required prior to activating the order set in the live system
Convenience sets have also been created and placed in the ICIS for less comprehensive orders commonly used by a
smaller service (i.e. the Otolaryngology medication order set containing age specific orders for acetaminophen
promethazine and amoxicillin)
To date, 181 Order Sets (27 of which are best practice guidelines) and 48 convenience sets have been developed and placed in
ICIS. Order sets are organized by department (Surgery, Medicine, Anesthesiology, etc.) and by division (General Pediatrics,
Endocrinology, Cardiology). Order sets which may be used by more than one division are included in more than one location
(i.e. Asthma Order Sets appear in Pulmonary, General Pediatrics, and Allergy). Individual physician order sets are not permitted
in the ICIS as the institution is focused on evidence or consensus-based consistent approaches to care.
Pediatric Pain Assessment: This need was based on the following factors:
1.
2.
3.
4.
5.
6.
Five different pain scale tools are utilized to assess pediatric pain at CCHMC (Figure 8)
There was lack of consistency in providing pain management education to patients and/or parents upon admission
The pain scale determination is based on patient developmental level, coherence and parent preference
Numerical pain scores are highly variable between each pain scale tool
Patient pain assessment occurring a minimum of once every shift was inconsistent
CCHMC received a Type I recommendation from the Joint Commission for the Accreditation of Health Care Organizations
for lack of consistent documentation for reassessment of pain following the implementation of pain interventions.
Figure 8: Shift to shift pain assessment indicating the various scales used based on patient’s development age. Pain
score is automatically calculated.
Shift-to-shift pain assessments were not originally in scope for the Clinical Documentation application development. However, in
planning for ICIS, it was realized that automation of pain assessment would provide the standardization and data repository
needed and ultimately improve pain assessment practices. Therefore a shift-to-shift pain assessment application was designed
and built for use in the acute care areas that would be implementing ICIS.
Clinical Documentation was designed and built to support the initiation of pain management education and assessment upon
admission. In the Comfort category of the Admission History the screen lists the questions that prompt the nurse to select a pain
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scale tool for use in collaboration with the patient/parent and also prompts the nurse to educate the patient/family on pain
management. The Comfort screen links to the Pain Management policy on the CCHMC Intranet as a decision support tool. To
ensure that the initial pain assessment is completed upon admission, the Physical Assessment pathway includes a link to the
Pain Assessment function. Upon selection of pain assessment in the system the nurse is presented with the same pain scale
used upon admission. This ensures continuity in pain scale use and scoring and also reduces the chance that pain scales are
selected haphazardly. Dependent on the pain scale tool that was selected, the pain assessment parameters are presented and
chosen by the nurse based on the patient assessment. This standardizes the assessment process. Once all parameters have
been selected, the system automatically calculates the appropriate pain score. The nurse is required to indicate which, if any,
interventions were implemented to improve comfort. When interventions have been implemented the subsequent pain
assessment is documented as a reassessment.
Since the implementation of ICIS followed a Phased approach throughout 2002, benefit measurements of the evolution of the
pain assessment pathway in Clinical Documentation are focused on the two early pilot units.
Standardization and automation of this process combined with further nurse education has improved areas identified as
previously deficient in the manual pain assessment documentation process. Timely reassessment of pain following the
implementation of pain interventions remains a challenge. As a result, a Pain Reassessment Rule was designed and
implemented in May of 2003. This Rule prompts the nurse to reassess for pain after pain interventions have been documented.
The Clinical Documentation team is currently evaluating the effectiveness of this novel rule.
Concurrent Clinical Decision Support
The ICIS leadership team, Pharmacy, Therapeutics Committee and Patient Safety Committee decided prior to ICIS
implementation that decision support tools must support the safety and efficiency of patient care while having minimal impact on
clinician efficiency. Five principles were established:
1.
2.
3.
4.
5.
Decision support tools would be placed into ICIS with the following prioritization: a) patient safety, b) patient care efficiency,
c) patient care consistency, d) clinician efficiency, e) user satisfaction, f) regulatory compliance, and g) cost effectiveness
Ideas for decision support tools would be solicited from clinicians throughout the organization
Decision support tools would need to be approved by the COE and Clinical Documentation Design Teams prior to
implementation
No decision support tool would be implemented without an associated active monitoring program examining effectiveness
A task force would be created to examine the results of the monitoring program and suggest decision support tool
modifications to the Multidisciplinary Design Teams. A major principle adopted by this task force was to minimize nuisance
alerts to a target level no greater than 35%
In order to accomplish the monitoring, all alert messages are periodically tagged with two statements requiring user attention at
the time of order entry. The statements are:
ο
This alert was helpful
ο
and
This alert was not helpful
This user query is left in place for 2 weeks and then turned off. Users must click one of these radio buttons. The analysis of
these alerts includes the details of the order (date, time, medication, patient, unit, clinician), the clinician response to the
statement; and whether the alert altered prescribing practices (i.e. did the order get revised as a result of the alert, or was the
alert overridden). Alerts that are found not to be helpful and which do not alter prescribing practices are determined to be
nuisance alerts. A multidisciplinary Alert Task Force meets on a regular basis to analyze this data and make recommendations
to the ICIS Design Teams regarding modifications necessary in the alerting system. There are a number of alerts generated
within ICIS. These alerts make up a significant proportion of clinical decision support referred to as knowledge-based prompting.
In Table 7, the various forms of knowledge-based prompting in ICIS are further described.
Table 7: Knowledge-based prompting.
Alerts
Medication Dose Range
Absolute blocks for medication dosing
Age-weight checker
Generic duplicate
Rules
IV to PO
Pain assessment & reassessment
Potassium
Aminoglycoside
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Alerts
Therapeutic duplicate
Scale weight vs. dosing weight variations
Medication-allergy check
Medication Interaction
Verbal order physician selection check
Charting on expired medications
Charting last med dose
Scale wt not recorded with 24 hrs of admission
Adjusted Ideal Body Weight for obese patients
Rules
DNR – duplicate order alert
Knowledge Access
An important focus of decision support is that it be present at the clinician's fingertips and does not interrupt the clinician ordering
process. These decision support tools are set up to allow the clinician with questions about an order to pause, click into the
resource, discover the information they are seeking, and proceed with the ordering process. Decision support tools have already
been discussed to some extent in the Information Access section. Decision support tools include Internet-based and intranetbased resources, system help and information screens. These tools are further elaborated upon in Table 8.
Table 8: Decision Support Tools.
Category
Internet Based Resources
Intranet-based Resources
System Help and Information
Screens
Verbal Orders
Decision Support Tool
Formulary - Pediatric Lexi-Drugs Online
Pub Med Internet medical literature search engine
MicroMedex medication reference
Children's Oncology Group web site
CCHMC policies
Evidence-based medicine guidelines and pathways
CCHMC Online – the Children’s Hospital Intranet reference site
Patient information sheets (Health Topics) for families and patients
Comprehensive laboratory index
Isolation procedures reference
Direct policy links (chemotherapy, controlled substances, digoxin,
potassium, restraint, pain management)
Nutrition guidelines
Orders approaching expiration alert
Unsigned verbal orders alerting system
Extending the Continuum of Care to the Family
CCHMC is committed to engaging the patient and patient's family in the care delivery process. The Pursuing Perfection Grant Raising the Bar for Health Care Delivery has identified the delivery of perfect care for patients and families with diabetes, cystic
fibrosis and juvenile rheumatoid arthritis as a major priority. Key to achieving optimal outcomes is the creation of a
patient/family/caregiver team that engages in supportive, informative interactions in which the family and the patient are central
to decision-making. Providing information critical to decision-making available in a simple patient friendly format is essential to
this approach. In a significant effort to provide this support, CCHMC has developed and tested a proof-of concept version of the
pediatric chronic care patient portal, focusing on two populations: liver transplant and cystic fibrosis patients. This work has
included the difficult task of planning, developing, and testing interfaces to many back-end legacy systems, as well as the
consolidated display of this information. The first trial with actual cystic fibrosis families began in May 2003.
In its current state, the patient and family portal consolidates and makes available the following types of information:
•
•
•
Patient height, weight and body mass index over time (produced on standardized growth charts)
Results of approximately forty kinds of laboratory study results and cultures
Run-charting of specific medication doses
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•
•
•
Pulmonary function test results
Records of inpatient and outpatient visits
A tool that will enable secure communication between families and caregivers
Aggregated Data Analysis and Reporting
Since implementation of the ICIS, a wealth of information has been made available for performance improvement activities.
Information that is now readily available includes order entry statistics to permit assessment of resource utilization and the impact
of performance improvement activities. Knowing the volume of orders entered has allowed optimal timing of elective system
maintenance, scheduling of pharmacy employees, and patient care discharge and planning practice improvement. Compliance
with regulatory and policy requirements can now be readily assessed. For example, a simple weekly query now provides
information regarding the number of verbal orders, the percentage of verbal orders which are not signed, and specific information
about non-compliant providers. This data has been widely utilized by HIM. Queries have also been helpful in documenting
utilization of clinical evidence based order sets. Existing hospital committees who have utilized ICIS reports for their routine
activities include Risk Management, Patient Safety, Pharmacy and Therapeutics, Medication Safety, Performance Improvement
and others.
Orders entered into the ICIS also populate the CCHMC Discovery System - designed to facilitate clinical-genomic research by
synthesizing supercomputer hardware and custom software. Discovery is discussed in more detail in the Data Sharing with Other
Organizations section later in this application.
Finally, ICIS links seamlessly to Ohio's Statewide Immunization Information System. This system saves clinicians time by
retrieving immunization records in less than a minute, 24 hours a day, and by reducing physician paperwork. In addition, this
system analyzes the patient's immunization record and compares doses received to doses that are due according to the
recommendations of the American Academy of Pediatrics. Overall, this system has increased immunization rates and quality of
care provided.
Data aggregation across an entire chronic care population, such as cystic fibrosis, is accomplished by the use of a disease
specific patient registry database that is tuned for use in research and process improvement. This registry database is part of a
larger database structure that also includes registries for other patient populations, such as diabetes and juvenile rheumatoid
arthritis. This data can be viewed through a number of standard reports, and can also be accessed in an ad hoc manner using
data-mining tools. A significant number of chronic care front-page measures for our Pursuing Perfection initiative are derived
from these databases. At the moment, the maintenance of these patient registries requires significant manual data-entry, but
CCHMC is already developing the data transfer technology to bring to these databases the same primary source data that is
accessed by the patient portals. The combination of the patient portals and the registry databases give CCHMC comprehensive
access to this information, due to specialized front-ends and a more flexible form.
Workflow and Communications
Successful implementation of computerized systems must meet the workflow requirements of the users. Prior to ICIS
implementation, much work was performed to accurately analyze the clinician workflow in order to design and build system
applications that would support clinician practice. One of the most challenging aspects of this build was to replicate and/or
incorporate many of the communication processes that occurred naturally in the workflow of the clinician. The dilemma of how to
build systems that would gain efficiency and not interrupt continuity previously achieved in the manual documentation workflow,
dictated the need for notification and communication system features. One of the major concerns of users during the planning
stages of ICIS was how will clinicians be notified of new orders. When orders were written on paper the chart was flagged and
placed in a rack at the main nurse unit desk. Unit personnel monitored and took act upon these orders in a timely manner. In
ICIS orders can be entered from anywhere. Though verbal communication from physician to nurse regarding new and revised
orders is still strongly encouraged, several features have been imbedded in the pathways to facilitate communication and
maximize efficiencies through ICIS.
The nurses and the physicians added several features to the system to facilitate order management. New orders are indicated
on the unit census list with a ‘Y’ next to those patients with recent orders. On the active order display, new orders display in a
blue font. The clinician performs a function that acknowledges the new orders and the order color subsequently changes to a
black font. The changing of the font provides a quick visual cue to the clinician of new orders and indicates to the order-writer
whether the order has been acknowledged by the bedside clinician. An end of shift function was designed so the nurse or
respiratory therapist can acknowledge that all orders for the shift were seen. This acknowledgement displays in red on the active
order display and easily identifies where the line of responsibility for order review begins and ends from shift to shift. Physicians
are alerted to patients who have orders that require countersignature as a result of a verbal order or by nature of the order that it
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requires two physician signatures. This A column on the physician's personal patient census indicates this. Also, facilitating
therapeutic communication, all orders that are going to expire within 24 hours will appear at the top of the patient’s order display
under a banner indicating they are approaching expiration. This promotes continuity in the therapeutic regimen for the patient by
providing advance notice of the need for renewal evaluation. In the event that the physician did not see an order pending
expiration, the nurse is prompted when charting the last dose of a medication to consult the physician for potential renewal.
CCHMC is combining the electronic entry of orders with pager notification to enhance the communication of respiratory orders
and radiology orders. Orders for STAT portable radiographic studies are sent directly to a pager carried by the radiology
technician. The communication is within moments of the completion of the order and has eliminated the need for phone calls or
faxes to the radiology department. This has translated into a significant decrease in the turnaround time for the availability of
STAT radiographs. In the pediatric intensive care and cardiac intensive care units respiratory orders are also sent to the pager
of the patient’s respiratory therapist, resulting in real-time electronic communication of orders to respiratory therapy. Based on
the successes of these limited uses of pager notification, CCHMC is currently planning the expansion of this technology to other
units and ancillary care providers.
Repetitive data entry is commonplace in the manual world of documentation. Before the implementation of ICIS, allergies were
documented on 11 different forms, and the documentation of weights was redundant as well. The elimination of this redundant
input and storage of patient information was one of the primary goals of the Clinical Documentation ICIS team. In ICIS the
allergies and weights are documented in one location and are displayed as needed in ICIS. Admission histories are stored and
retrieved when a patient repeats a hospitalization within a six-month period. Nurses have gained significant efficiency in being
able to validate patient history rather than repeat it with every admission. Parents of chronically ill children that frequent
CCHMC, have expressed satisfaction in no longer needing to repeat complex historical data for each subsequent admission.
Data collected in the admission history can be collected and displayed in ICIS. This enables the physician and nurse to have
important information at the point that care decisions are being made. For example, the nurse collects the form of medication
preferred (liquid, chewable, tablet, etc.) in the admission history. This data is displayed on the non-injectable medication order
screen for the physician so the proper preferred form is ordered. Pain scale preference and comfort items such as blanket or
pacifier are collected in the admission history. Within the pain assessment function, the patient’s preferred comfort scale and
comfort items are displayed. Patient status is reported to ancillary departments through documentation. If a patient fails the
nutrition screening during the admission history process, the system automatically sends a failed screening notice to the Nutrition
Therapy office for follow-up. Likewise, nursing indicates the progress of the patient’s diet, facilitating the communication of the
appropriate diet to nutrition therapy eliminating the need for frequent phone calls.
Additional efficiencies include the ability of ICIS to perform calculations and conversions. The Intake and Output application
calculates the intake and output as it is documented and has eliminated the need to manually calculate shift and 24-hour totals.
With the implementation of ICIS, CCHMC standardized the temperature scales across nursing units to Celsius. A button which
converts Celsius to Fahrenheit was placed on the vital sign screen. The nurse can document the temperature in Celsius, select
the Fahrenheit button and display the temperature in Fahrenheit. This can be communicated to the patient or parent who is at the
bedside as the temperature is being documented.
Data Sharing with Other Organizations
One of the byproducts of automating information management is the ability to share data with other organizations. For instance,
the cystic fibrosis registry database is used as the source for the data that is sent to the Cystic Fibrosis Foundation (CFF). The
ICIS team has developed specialized data export scripts to generate the annual CFF registry submission. In collaboration with
the CFF, CCHMC will soon develop new software to largely eliminate the data entry step and export data from the cystic fibrosis
portal to the CFF registry database.
One of CCHMC’s most important research systems is the Discovery System (Figure 9) developed by the Division of Pediatric
Informatics. The Discovery System is a repository of clinical and genomic data and is a system that opens a new frontier in
pediatric research and care. By integrating clinical and genomic data, it not only makes information retrieval easier but also
breaks down boundaries that traditionally have separated health care professionals from molecular scientists. In the past, clinical
and basic science investigators have followed separate paths, in part because of different goals but also because combining
clinical and genomic data has been an arduous, manual task. Discovery overcomes this obstacle by providing a secure,
automated gateway to patient demographics, treatment and outcome histories, biological specimen data, laboratory reports, and
even financial records.
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Figure 9: The CCHMC Discovery
System. Each hour, the Discovery System
collects clinical and research data from more
than 20 legacy systems throughout CCHMC.
Once acquired, the data is transferred into a
centralized repository where it is reformatted
to ensure security and confidentiality.
Clinical and basic science investigators use
customized software to pull data out of the
repository and analyze it in previously
unimaginable ways.
Other Operational and Strategic Activities
Administrative
True to the CCHMC vision of being the leader in improving child health through care delivery, research and education, CCHMC
adopted a variety of operational and strategic activities. In addition to the nearly $5 million dollar commitment over 3 years to
design and implement ICIS, CCHMC’s efforts in clinical effectiveness and establishing evidenced-based guidelines placed
CCHMC in an optimal position for application and receipt of the Robert Wood Johnson Foundation Pursuing Perfection grant.
Cincinnati Children’s Hospital was the only pediatric institution to be awarded the distinguished Pursuing Perfection grant. The
objective of the grant mirrors the vision of CCHMC in the comprehensive improvement of child health.
Both ICIS and the Robert Wood Johnson Foundation Pursuing Perfection grant optimized the opportunity for operational
realization of the CCHMC vision. Working congruently, the two initiatives complemented each other in approach and in outcome
as the Pursuing Perfection and Clinical Effectiveness teams developed evidenced-based Guidelines for treatment of common
diagnoses and ICIS automated these guidelines in COE order sets. The result was standardized care delivery based on best
practices and outcomes. Automation of the care orders provides the mechanism for quick changes as evidence of best practice
evolve over time. Automation ensures that the guidelines in use for care delivery are standardized across caregivers and
departments.
ICIS provided the needed information to query for effectiveness in care delivery. Quality management and assurance via data
reporting provide the needed data feedback to continually improve process and systems. The ability to replace manual chart
reviews for data collection on items such as the number of cardiology consult orders written in the past 6 months has major
practice and financial implications. Queries of clinical information captured in ICIS have proved efficient in monitoring data for
many purposes. Query of number of physician orders written per hour each day, provides the needed data for determining the
best time clinically for scheduled system maintenance and/or scheduled downtime. Real time query of clinical data, such as
patients with daily weight orders that were not weighed during the day, provides clinical directors and unit performance
improvement staff, feedback to correct any data documentation deficiencies within 24 hours. Other examples of system queries
include: daily reports of discharged patients with orders requiring co-signature; daily follow-up reports listing patients in which an
allergy history was unobtainable upon admission; weekly report listing of who gave and received verbal orders; and monthly
reports that monitor pain assessment compliance.
Financial management and fiscal viability are equally important in order to achieve comprehensive success in the stated vision.
Addressing financial management, the extraction of clinical data is also utilized to maximize revenue capture.
In previous practice, nurses were required to complete a charge capture form each shift to allow for manual entry of documented
charges by a data manager. The usage of durable medical equipment utilized during care delivery was documented. Accuracy
of the manual documentation of equipment usage was questionable. Since the usage was to be documented on a separate
form, the data documented was not always consistent or complete. Realizing that the most efficient way to capture patient
charges is at the point of documenting clinical data, the ICIS Clinical Documentation team customized a charge capture pathway
for these equipment charges.
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By policy, nurses document intravenous site checks every hour. At 0600, 1400 and 2200 as the nurse is documenting the
intravenous site check, a screen is automatically presented to select the equipment used for that shift by the patient. Each day
at 2200, the patient is automatically charged for the documented cumulative equipment usage in the past 24 hours. In the event
that a nurse does not document a site check at 2200 to trigger the daily charging, a report is generated nightly listing these
patients and their equipment usage based on the 0600 and/or 1400 data entered. The charges are entered manually by a data
manager. Enteral feeding pumps are charged daily via COE for each patient that has an active order for enteral feeding and
where a rate and/or run in duration are specified. By automating these charges it was estimated that equipment charge capture
has improved by 8.5 % .
ICIS Clinical Documentation and financial management integration has proven to be a powerful tool for point of care revenue
capture. As Clinical Documentation is expanded, the goal is to continue to support charge capture where possible. This will
maximize efficiency and revenue capture by eliminating the manual charge capture form completed by each nurse. The
functional integration of ICIS and financial management goes beyond charge and revenue capture. Administrative accountability
for the success of ICIS is best exemplified in the allocation of 4.2 FTE’s to provide Blue Coat end user support for ICIS.
Patient Safety
Medical errors are responsible for preventable patient injury. The majority of medical errors originate during the medical
prescribing process. Several investigators have concluded that the prescribing stage should be the predominant target area for
error reduction interventions. Though there are few studies that have investigated strategies aimed at the prevention of medical
errors in children, successful approaches to medical error reduction in adults include standardizing care orders through the use
of clinical pathways and pre-printed orders, computerized physician order entry, and decision support. Though much of the
research data is forthcoming, implementation of the ICIS has had a positive impact on patient safety in children. Much of the
improvement in patient safety is due to complete, unambiguous, legible care orders. In addition, standardized, easily obtainable
order sets and computerized clinical decision support has resulted in the reduction of reported medical errors and has had a
positive impact on patient safety. Indeed, COE with clinical decision support has been the main patient safety thrust aimed at
reducing prescribing errors at CCHMC. Specific achievements in improving patient safety will be further highlighted in the Value
section of this application.
Research
Computerized order entry and clinical documentation programs are expanding rapidly throughout institutions in the United
States. There is a paucity of data available to justify the enormous time and financial investment required for these programs to
be successful. This is particularly true in children, where specialized programming is required to meet the special requirements
in this population. In 2002, a multidisciplinary research group consisting of physicians, nurses, pharmacists, respiratory
therapists and information services experts was created at CCHMC - the Clinical Informatics Outcomes Research Group
(CIORG). The primary aim of the group is to examine the impact of computerized order entry and clinical documentation on
patient safety, clinician efficiency, user satisfaction, regulatory compliance and cost effectiveness. The enthusiastic and
motivated individuals within the group have designed and implemented many research projects within each of these 5 areas.
The group has made considerable progress thus far, and selected outcomes are described in the Value section of the
application. The CIORG has made considerable use of the inherent ability to query the ICIS as described in the Aggregated
Data Analysis and Reporting paragraph of the Decision Support Section above. Data derived from the CIORG projects are
utilized internally for performance improvement, presented at local and national meetings, and prepared for publication in peerreviewed journals.
In addition to the formal research efforts by the CIORG, data from the ICIS are used to support clinician education, cost
effectiveness efforts and epidemiologic data collection efforts. Clinicians are routinely educated through the ordering and
documentation process with informational help links to policies, intranet-based resources, evidence-based guidelines, and
informational pop-up windows. Rules such as the IV to PO conversion rule have been implemented to guide clinicians in
effective cost-cutting and safety maneuvers for their patients. Measurements of compliance with pain reassessment following
pain interventions justified the implementation of the pain rule. To ensure improved compliance, benefit measurements and
system modifications in the pain assessment application remain ongoing. Hospital groups such as the Infection Control
Committee and Central Venous Catheter Committee have effectively utilized ICIS data to facilitate tracking of infections and
catheter complications. The Discovery System, discussed in detail above, is also a key research tool used by CCHMC.
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User Satisfaction, Productivity, and Effectiveness
User Satisfaction
User satisfaction is defined not by the extent to which ICIS is utilized, but rather by the degree to which ICIS primary goals of
patient safety and efficiencies are realized and influenced by the end users. User satisfaction is assessed by three primary
methods:
1.
2.
3.
User feedback button: User feedback is prioritized according to "break-fixes", re-design, or future enhancements
Post-implementation support calls: Calls are received, logged and triaged by the support staff resulting in immediate
resolution or further escalation to the appropriate project team
Formal user satisfaction surveys: Survey distribution will take place in May 2003 to measure user satisfaction 1-year
post implementation and they will measure staff perception of ICIS on patient safety, care delivery and staff efficiencies
User satisfaction was analyzed and quantified with respect to system alerts after placing a data collection tool within the ordering
pathways. A multidisciplinary Alerts Task Force of critical care clinical staff and ICIS project staff analyzed the data collected in a
two-week period focusing on the value of medication system alerts. User feedback on medication alerts activated in ICIS
resulted in the discovery that 73% of alerts were felt by users to be not helpful (nuisance alerts). The Task Force was able to
significantly reduce the number of nuisance alerts presented in the ordering pathways. Further data collection and analysis is
scheduled post-alert reduction to measure overall improvement of the helpful: nuisance ratio.
Realizing that usability drives user satisfaction, the admission history application in Clinical Documentation was completely
rebuilt. The admission history application in Clinical Documentation was originally constructed to support 4 different patient
populations. There was an admission history for the neonate, pediatric inpatient, pediatric observation patient and the adult
patient. Built electronically as separate modules, data collected in one would not pull forward if the patient came back to
CCHMC for a different type of stay. The nurses expressed dissatisfaction with this functionality. This resulted in the 4 admission
history modules being technically rebuilt to support the need for data availability for review, revision and validation across patient
visits regardless of length of stay. A typical Clinical Documentation screen is noted in Figure 10.
Figure 10: An example of
a Clinical Documentation
input screen for patient
nutritional information.
The Clinical Documentation
Design Team was essential
in providing feedback into
the design of such screens.
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Technology
Scope and Design of the EHR System
System Description
To align with the vision of the organization, the ICIS design and infrastructure had to support integration with various peripheral
systems. It was recognized that modern technologies had to be deployed and a robust internal infrastructure had to be built.
While the focus of this application has been on the ICIS, it is important to recognize how the other informatics platforms and
electronic resources fit into the overall scheme. The Discovery System for example, is a peripheral component to the actual ICIS
system but nonetheless critical to achieving CCHMC’s vision. Figure 11 provides a pictorial view of the how the major systems
at CCHMC relate to and integrate with ICIS.
Figure 11: ICIS Integration with Existing Electronic Platforms at CCHMC.
Intranet
Other
Cactus
Finance Developed
Apps
Decision
Support
Data Warehouse
PHIS
HBOC
OHA
Discovery
Microbiology
Medical Search Notes
NACHRI
Administrative
Support
Payor Upload
Patient Concerns
Patient Refunds
Census
Outpatient Registry
Donor2
OP Stats
ERAS
United Way
Divisional/
Departmental
Oncology
Hemophilia (Dr. Gruppo)
BMT
Liver Split
ADSC
CORE Disease Mgmt
PICU
Dawn AC
Patient
Financials
Policies and
Procedures
CCHMC Formulary
CCHMC Employee
Directory
Report.Web
Cacti
Siemens NetAccess
Micromedix
Safety College
Project Management
Order Sets
CE Guidelines
Siemens Unity - PA
Siemens Signature
HDS
HDX
CSC Papers
LAN 23
NHS - Anesthesia
General Financials
Siemens Unity - GL, AP,
Fixed Assets.General Acctg
ESI Materials Management
ESI Purchasing
ICIS Components:
Clinical Order Entry
Clinical Documentation
Med/IV Charting
Rules Engine
Lifetime Clinical Record
Interface Engine
Resource
Management
PeopleSoft - Human
Resources
Matrix
Debitek
Bed Tracking
Ansos
Tempus - Enterprise
Scheduling
ESI - OR Scheduling
ESI - PL Wizard
Room Scheduling
Clinical Management
Cerner Classic - Laboratory
Cerner Millenium Pathology
Siemens - Radiology
GE - PACS
Emstat - Emergency Dept.
Mdiware - Pharmacy
Pyxis - Automated Med.
Delta - Home Health
Nursing
MBI - Home Health Rx
Chartlinks - OT/PT/Speech
MUSE - Cardiology
MARS - Cardiology
CardioAccess - Cardiology
SoftMed - HIM
HSS - HIM Encoding
Lanier - Dictation
Discharge Summary
Critical Care
Clinic Notes
CVC tracking
System Infrastructure
The ICIS client server production environment is built on two servers, running on two clustered servers each server being an HP
LT6000r with 6 CPU (700MHz each), 8 GB RAM. The hard drives are: 2x9.1 GB Internal in Raid 1 and 4x9.1 GB for a shared
cluster. The operating system for each server is Microsoft Windows 2000 Advanced Server. To minimize impact on the
production system, a test and development environment was built on separate servers. The mainframe is an IBM model RA6,
88 MIPS size using OS390 R2.10. It stores approximately 1 Tera Byte of data and processes an estimated of
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500,000 transactions per day. It provides connectivity to 4,500 devices on main campus and off site locations (i.e. Fairfield,
Anderson, Florence, EastGate, Harrison, Hopple, Vernon Place, Bethesda). It supports the Siemens based applications such as
INVISION, LCR/CVE, COR and it interfaces with other support systems such as: Laboratory (Cerner), Radiology (Siemens),
Pharmacy (WORx), Siemens Financials (Unity, Signature). The ICIS web based modules - OAS\Gold access requires an applet
be downloaded over the network. The user selects a link from the web page and a java applet program is downloaded. The
first time the user signs into OAS\Gold the CAB file is downloaded Once downloaded, the CAB file is stored in the browser's
cache memory, which is stored on the PC hard drive. The next time the user logs in the browser verifies to see if the version of
applet has changed. If the version has changed, an updated version is downloaded on the workstation and is cached. The
browser passes control to the OAS\Gold applet, which in turn creates a TCP/IP socket request to the OAS\Gold server that
launched it. The communication software on the OAS\Gold server accepts the request and in turn establishes a connection to
the CICS via the TN3270 service on the mainframe.
The Net Access portal was architected by the vendor for fast, easy, and intuitive access to data residing in INVISION and LCR.
When a user clicks on a link on the screen, the request is passed to the Net Access web server; the code on the Net Access
server formats a specific data query for the INVISION system and/or directly to DB2 for EAD/LCR data. When the data is
returned from the mainframe it is merged with pre-built templates on the Net Access server and then returned to the browser as
a standard HTML web page.
The ICIS web servers provide web-based services for the workstations using vendor’s proprietary code. The code extracts
selected data from INVISION and EAD/LCR. The Web Servers merge the information with HTML templates and returns the
HTML information to the browser on the workstation for display. Microsoft Internet Information Server (IIS) software was
installed along with Security Certificate to enable SSL 128-bit encryption between the web server and web browser. The
Microsoft SNA client was installed for communication to the SNA Gateway. The Servers utilize the Windows 2000 Server
operating system with TCP/IP as the network protocol. An appropriate 10/100MB high performance network interface cards were
required for connecting this workstation to the LAN. The ICIS Servers run Platform Services (Plats) software. The Global
Session Manager (GSM), a component of Plats, supports a single logon and provides the coordination of two or more
applications into a seamless workflow.
An application server was required for Rules Engine only and is where the business logic for Rules Engine runs. The application
server was configured with a mapped network drive to the file server where the rules are stored. Rules (with Net Access &
OAS/Gold) are triggered within the CICS on the mainframe. The Interactive Data Exchange (IDX) mechanism processes and
sends the data in HL7 format to the servers for processing. The server operates on the Intel hardware platform and utilizes the
Windows 2000 operating system and TCP/IP as the networking protocol. Rules can be triggered on the mainframe, workstation,
or server depending on the workflow and desired place to prompt clinicians with the predefined alerts and reminders.
Integration Engine - OPENLink™ is an Interface Engine that runs as a client-server solution using an Intel-based PC server and
requires Microsoft Windows 2000 as the primary OS. OPENLink™ uses completely mirrored (identical) servers, using Microsoft
2000 Server Advanced Edition OS, to provide fault tolerance through server redundancy. Both servers are connected by a
dedicated network connection that maintains a "heartbeat" signal. Under normal operating conditions both servers are actively
processing interface traffic. Both servers will exchange the heartbeat signal over the dedicated network connection indicating that
they are "alive". When a server fails, the remaining active server senses the loss of its heartbeat signal. The remaining server
then begins to process all of the interface traffic. The mirrored configuration of the servers allows service to continue with only a
minor interruption of interface processing.
Once the server is returned to service, processing can be manually reset for normal operation as described above. The servers
are clustered using Microsoft Cluster Server software available as a built-in feature of Windows 2000 Server Advanced Addition.
Microsoft Cluster Server provides the tools to switch resources (disk drives, TCP/IP addresses, network file shares, etc.) from a
failed server to the surviving server. OPENLink™ servers use SCSI disk drives in a RAID level 1 (mirrored drives) configuration
for their system disks to provide fault tolerance and improve performance. The shared data disks are also configured using RAID
technology to provide further fault tolerance and improve data storage and retrieval performance.
CCHMC's current networking infrastructure is running Layer 3 switches, with redundant switch fabrics, redundant pathing, and
N+1 power. The current backbone has redundant switches at the CORE running over a 4-GIG trunked line, 4-GIG lines running
from the CORE to each distribution closet (MDF). From the MDF there are 2-GIG redundant paths to the IDF, supplying 10/100
mb connectivity to the desktop. Server connections are 10/100/1000 depending on requirements.
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CCHMC's physical server infrastructure is comprised of HP/Compaq rack-mounted server hardware. Currently there are 170+
Windows 2000/NT servers and 50+ Novell 4.11/5.1/6 servers. Windows 2000 is the primary platform for application servers.
Novell NetWare 6 is the primary platform for file and print services. Critical applications/services are placed on clustered
hardware to provide high-availability. The ICIS applications are accessed via thin-client MS Windows-based desktops and
laptops. CCHMC's logical directory infrastructure includes Windows 2000 Active Directory and Novell eDirectory 8.6. The
existing e-mail platform is GroupWise 6. The IS provides web-access, POP/IMAP, and mail relaying services in addition to the
traditional GroupWise client to the enterprise. Figure 12 diagrams the networking architecture specific to the ICIS project.
Wired and wireless
devices running I.E.
Browser Technology to
access Invision
Wireless Device
with GANYMEADE
Wireless
Access Point
Wireless Sniffer
http/s
Floor Switch
PRINTWAY Server
for IP Printing
FLUKE
Monitor
for wireless AP
and wired
switches
IP
NETIQ for
server
monitoring
http/s
http/s
Sniffer from MDF to
SNA server
Workstation
with GANYMEADE
http/s
NETIQ for
server
monitoring
IP
http/s
MDF
Sniffer from device
to MDF
http/s
Router
IP
IP
OAS Gold1
IP
Netoasstage
Mainframe
CVE
Net Access
D/C Switch
DLC
IP
T/R
Token-ring
IP
SNA/DB2
http/s
IP
Support Workstation
Figure 12: CCHMC ICIS Network Diagram.
Integration
The system is integrated by 19 ADT interfaces, 7 financial interfaces, 4 Orders interfaces, 13 results’ interfaces to repositories (5
LCR) and research databases. All are written in accordance with HL7 interface standards. Seven non-HL7 interfaces are
supported primarily for financial applications. .
Data Modeling
To seamlessly facilitate the data capture, storage and retrieval amongst all systems, the ICIS team worked with various
departments to facilitate and implement data definition standards. These standards were essential to ensure that any new terms
added to any of the interfaced peripheral systems was defined and stored in the Lifetime Clinical Record. Data modeling was a
major building block in the implementation of ICIS. While allowing the flexibility to accept patient information as free text, it is
also needed to represent and store quantifiable data. The Lifetime Clinical Record represents the central repository for patient’s
clinical and demographic data. Using the Common Vocabulary Engine, inherent to the application, thousands of terms were
defined and stored. This supported the creation of synonyms that allow the users to search for the information needed using
different medical terminology. Also, data definition standards were created and used as drop-down selections in both COE and
Clinical Documentation. It is estimated that approximately 98% of the COE data and 90% of the Clinical Documentation fields
are predefined. In the build of the system, CCHMC’s approved abbreviations list was primarily used. Another effort to ensure
that data stored meets the organizational standards was in the creation of order sets. Predefined clinical information
requirements and medication administration instructions are built upfront with the order set, ensuring the continuity and integrity
of data stored with the order is maintained.
Security and Data Integrity
Security/Confidentiality and HIPAA Compliance
CCHMC policies and procedures for protecting patient privacy are compliant with HIPAA regulations. CCHMC has had a longstanding confidentiality policy. However, HIPAA privacy regulations have resulted in some significant changes. A patient
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directory was created that informs CCHMC personnel about the level of information the patient or immediate family has
authorized. When the patient and family arrives, they are asked what relatives and friends are allowed to know and at what
level: 1) that the patient is admitted, and 2) the location of the patient. Unit census shows the answers to these questions. All
inquiries about patient condition are directed to the family. CCHMC has documented patient privacy rights for patients and their
families. Currently audit logs identify users that have looked at identifiable patient information and at what type of information
they have looked.
Disciplinary action up to, and including, termination is stated in the security and confidentiality policy that employees are required
to sign. Additionally, employees have to sign a form confirming what type of access is needed for the specific job function they
have been hired to perform. This is used for auditing purposes when patient family members suspect information abuse.
Data Quality and Integrity
Data quality and integrity are maintained through four main processes:
1.
2.
3.
4.
Order sets include pre-defined comments and additional instructions that the user might normally key so that they are all
consistent. The end user can change the comments if appropriate for care
Most data is defined in structured format. COE data elements are 98% structured, Clinical Documentation allows for some
more flexibility, with 90% of the fields in structured format
Verbal orders are only accepted under extreme conditions and are strictly monitored
All charting is performed by exception
Data Archiving and Storage
For the mainframe environment CCHMC performs a full system pack backup weekly and full application backups weekly. Tapes
are stored off-site. Tapes are rotated weekly, keeping the latest in the vault and a week-old backup in the Data Center. The
application backup procedures are designed and managed by the vendor.
Data Standards
The ICIS design team began to design standards into the system from the earliest planning stages, including positioning and
color-coding. All mandatory fields, for example, are color-coded in yellow. CCHMC has a published list of available
abbreviations as the primary reference for items that are built into the system. All clinical documentation vocabulary has been
standardized across all units at CCHMC.
PCAPI assisted in the standardization of the inconsistent practice of body temperature documentation. In February of 2002
CCHMC switched to documenting all body temperatures in Celsius. This standardized the units of measure to metric for all
numeric data collected. The environmental and support teams of PCAPI led this process in collaboration with Clinical
Engineering, Educational Services and the Clinical Documentation team. A campaign was launched that resulted in the
conversion of digital and paper thermometers to Celsius. The campaign also resulted in the generation of an online conversion
table within the vital signs application and hard copy conversion tables that can be attached to name tag holders, the digital
thermometers and mirrors in the patient rooms. These conversion tables are necessary in communicating body temperature to
the patients and parents who primarily relate only to the Fahrenheit unit of measure for body temperature.
Performance
Availability
A primary concern with computer-based systems is slow performance and a perceived lack of availability of the system. CCHMC
looked carefully at minimizing scheduled downtimes for necessary file maintenance and consolidation of the application of
system updates. As the reliance on computerization increases, this is a critical consideration that contributes directly to user
attitude towards the system. CCHMC identified critical business processes and evaluated the volume of usage over the entire
institution in determining the optimal time for scheduled downtime. This has become a very strict standard under which all
parties must adhere. Scheduled downtimes are communicated to the user community in order to prepare them for this
inconvenience and alteration in workflow.
The IT department monitors devices connected to the network on a consistent, ongoing basis. On average, the ICIS is available
over 99.9% of the time, including PCs and servers.
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Response Time
Stress testing across the network was undertaken prior to the implementation of ICIS at key points along the implementation
timeline. It was recognized that this implementation would appreciably affect the volume of transactions through the network and
mainframe storage. This resulted in an evaluation of the sizing of the mainframe and an assessment of how performance could
be optimized. This approach across the infrastructure has assisted in providing users with the most optimum response time.
Ongoing monitoring of response time in several key functions is tracked multiple times per day. This response time data is
trended and assessed parallel with CPU utilization. As delays in response time are identified, monitoring of transactions across
all aspects of the network is assessed to determine where performance can be improved.
Continuity Planning
CCHMC has been prompted to re-examine the unscheduled downtime communication flow after a prolonged unscheduled
downtime that resulted because of a network virus. A well-defined process for unscheduled downtime notification has since
replaced a more cumbersome notification process. The ICIS education team also determined that a competency on downtime
procedures was needed to assure that every user is familiar with this process to streamline the transition between the electronic
and manual world.
There are now three components in place to manage downtime:
1.
2.
3.
A detailed narrative is included in user training and posted at each unit to direct user action when an outage occurs. This is
a 10-page book that details how to maintain the continuity of patient care when there is a scheduled or unscheduled outage.
The book includes the calendar for scheduled outages
A clinician checklist that is used for each patient to help ensure all procedures have been followed
A flow chart is used by on-call analysts and Super Users to assists them in identifying what troubleshooting should be done
as a first level of support and who to notify
Service Level Agreements
For each user feedback that is non-emergent the ICIS team is committed to reply via e-mail or phone within 24 to 48 hours,
depending on if it is a weekday or weekend. Around the clock pager support is available and the turnaround time is 15 minutes.
For all new order sets the ICIS Team is committed to a turnaround time of seven business days.
Upgrades and Enhancements
ICIS applications are continually undergoing upgrades and enhancements through the application of vendor updates and
customization, as the business needs demand. Vendor updates are carefully evaluated and tested prior to implementation to
assure that they provide value-added features to the system. Customizations of pathways that are in production are thoroughly
scrutinized and evaluated by representatives of the user community to determine the need for the change and the
implementation plan for the customization.
One example of a pathway that has been enhanced is the Allergy pathway. The pre-implementation ICIS allergy system
application was based on vendor provided data fields for allergy data capture and storage. It was determined that in order to
provide the highest level of patient safety, the standard was raised for allergy data capture. The collaborative effort between the
COE Design Team, the Clinical Documentation Design Team, the Food Allergy Task Force and Risk Management took place to
redesign an allergy pathway that would include an online audit of all allergy additions, modifications and or deletions. Realizing
that food and product allergies can invoke reactions as serious as medications, the pathway was redesigned to require the
assessment of all three categories.
Ongoing evaluation of system functionality and receipt of user feedback results in frequent system enhancements. CCHMC
regards communication of application changes as critical to keeping the users informed about improvements and their potential
impact on processes and functionality.
CCHMC is constantly evaluating technology improvements that will allow for additional efficiency in user workflow and
improvement in system performance and reliability. CCHMC’s infrastructure has built in additional redundancy to assure
reliability as clustering solutions became available. CCHMC is evaluating biometric and an enterprise-wide single sign-on
solution to improve the access and security processes between disparate systems. Included in this evaluation is consideration of
a context sharing solution that will allow the visual integration of disparate systems.
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Value
Success in Meeting Expectations of the Project Goals and Business Case
CCHMC has been successful in meeting the expectations of the ICIS project goals. The business justification was the belief that
focusing on process improvement as the driver for technological change coupled with Six Sigma quality management techniques
in system design and project management would result in rapid innovation of the information systems. The ICIS project has
been instrumental in helping CCHMC realize their vision of dramatically improving patient care, greatly increasing the impact of
our research and implementing new models of education for pediatric professionals, patients, families and the public.
In this application, it should be apparent that CCHMC has implemented an advanced provider-driven system including Clinical
Documentation and COE within an 18-month time frame. The industry standard for implementing such a system is roughly three
years. The success is likely attributable to a principle strategy of putting ownership of the system in the hands of the
clinicians. Physicians led the project effort; physicians, nurses and other clinicians drove the design processes; and the
corporate culture of empowering all clinicians to embrace the system based on its merit all were key success factors.
The Clinical Informatics Outcomes Research Group, has been tasked with examining the impact of ICIS through targeted
hypothesis-driven research projects in each strategic objective area. These projects are discussed with quantifiable evidence of
their success in the next section, Success in Achieving Desired Change in Targeted Processes. From a business case
standpoint, there have been many important positive process improvement outcomes, and these are described further in Table
9.
Table 9: Process Improvement Outcomes – Business Case.
Strategic Objectives
Optimizing Patient Safety
Process Improvement Outcome
Complete, unambiguous, legible orders
Reduced clinician and service provider pages and phone
calls to clarify orders
• Reduced turn around time for critical medications and
radiographic studies
• Reduced medication errors
• Reduction in percentage of mislabeled laboratory
specimens
Improved consistency of care due to widespread use of order
sets and best practice guidelines
• Improved patient registration process
• Reduced documentation (i.e., allergies)
• Eliminated Intake and Output calculation times
• Reduced medication turn around time
• Reduced time to take and receive results for stat
radiographs
• Reduced resource consumption in process improvement
efforts
• Earlier enactment of patient care orders through use of the
computer on rounds
• Improved Internet and Intranet-based informational
resources
• Complete and accurate patient information on orders and
reduced clarification calls
• Reduced verbal orders.
• Reduced verbal orders for controlled substances.
• Improved security in patient information.
• Improved compliance with pain assessment.
• Improved electronic communication of employee issues,
concerns and suggestions
•
•
Optimizing Consistency in Care
Improving Clinician and Patient Care Efficiency
Maximizing Regulatory Compliance
Enhancing Provider, Patient and Family Satisfaction
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Strategic Objectives
Process Improvement Outcome
Community physician access to ICIS and improved
satisfaction
Improved durable medical equipment charge capture by 8.5%.
This is due to automated charge capture that is integrated into
the clinical documentation workflow
Rapid and complete access to electronic results, reference
resources and teaching material and enhancement of the care
delivery process
Improved aggregate data analysis of clinical data collected
through the ICIS. Currently, the system is queried on a regular
basis as a powerful source of information to assist with safety
initiatives, performance improvement, demographic analysis,
workload analysis, utilization review and academic research, to
name just a few areas. Data can now be acquired in a more
complete and accurate way in a fraction of the time required prior
to the implementation of ICIS. The charts and graphs in the next
section, illustrating quantifiable process improvements, were
easily generated using simple queries into the system
•
Providing Cost Effective Care
Improving the Education of Staff and Trainees
Enhancing Research Productivity and Strengthening
Performance Improvement Activities
Success in Achieving Desired Change in Targeted Processes
With the success of the ICIS implementation, the institution began to see significant immediate benefits in most of the targeted
areas indicated above. One clear marker of system acceptance is related to an assessment of orders entered into COE by
physicians and nurse practitioners. The number of orders generated with each new unit implementation increased dramatically
over the 9-month implementation period (Figure 13). In addition, significant variation exists by day of the week in regards to the
number of orders entered into COE (Figure 14).
70000
Pharmacy
Non-Pharmacy
Total Orders
Figure 13:
Number of
monthly orders entered
into COE in the ICIS
between April 2002 and
December 2002.
Total Orders
60000
50000
40000
30000
20000
10000
0
r
Ap
-0
2
y
Ma
-0
2
Ju
n-
02
Ju
2
l- 0
gAu
02
p
Se
Month
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-0
2
Oc
t-0
2
No
v-0
2
De
2
c-0
Cincinnati Children’s Hospital Medical Center
Davies Award – Application
3500
TOTALS Pharmacy
TOTALS Non-Pharmacy
ALL ORD
3000
Order Number
Figure 14: Variation in number of
patient care orders by day of week.
Overall, approximately 3000 orders
are entered each day. Pharmacy
orders represent 1/3, while nonpharmacy orders represent 2/3 of the
total orders. Weekends have 50%
fewer orders generated than
weekdays.
2500
2000
1500
1000
500
0
1
Optimizing Patient Safety
2
3
4
5
6
7
1=Mon, 2=Tue, 3=Wed, 4=Thu, 5=Fri, 6=Sat, 7=Sun
In recent years, CCHMC has viewed patient safety as the foundation of quality. Institutional organizations such as Medication
Safety Committee, Patient Safety Committee and Risk Management had noted recognizable deficiencies in the area of patient
safety and these deficiencies were often interrelated with inconsistency of care between providers. Though not unique to this
institution, problems with illegible, incomplete, and ambiguous written care orders were commonplace:
1.
2.
3.
4.
Many written orders had no identifiable physician contact information
Verbal orders represented 22% of all care orders and often were a source of medical errors
Transcription of written orders to the medication administration record represented 15% of adverse drug events or potential
adverse drug events.
Incorrect medication dosing related to lack of drug information or miscalculation resulted in several serious errors each year
The CCHMC Formulary contains 3,770 medications. Of these, 470 have been designated as "high alert" medications because
of their narrow therapeutic window or because of their widespread use. Prior to COE implementation, age-adjusted dose range
checking limits were established for all 470 of these high alert medications to include minimum and maximum single dose,
maximum total daily dose, minimum and maximum frequency. The dose range checker data was derived from internal data
utilized for over 20 years. After implementing the data set into the test system, the dose range checker for each age range and
medication was validated by a system analyst and a pharmacist and received final verification and sign off by a responsible
physician. Once the verification process was complete, the data was transferred into the live system.
As a result of the ICIS implementation, clinicians now generate complete, unambiguous, legible orders that include clinician
contact name and pager number on all orders. This rapid and enormous transformation has reduced clinician and service
provider pages and phone calls to clarify orders, and has been associated with a reduction in the delay in turn around time for
critical medications and radiographic studies. Furthermore, there has been a noteworthy trend in the number of reported
medication errors within the institution. Medication error reports are received, categorized and entered into a prospective
database within the Risk Management Department at CCHMC. There has been a remarkable decrease in both overall
medication error reports as well as medication transcription error reports after ICIS implementation. Though it is difficult to
attribute these global improvements solely to the ICIS, the results noted with medication transcription errors are likely to be
directly attributable to this implementation, as transcription has been virtually eliminated throughout CCHMC.
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The graph below in Figure 15 represents the total number of medication error incident reports by month beginning in April 2002
when the ICIS was implemented on the first patient care unit. The light blue line indicates all reported medication errors
(ordering, transcribing, dispensing and administration) and the dark blue line represents transcription-related incident reports. As
can be seen, medication errors have steadily decreased to the point where they are nearly eliminated for transcribed reports and
are reduced by about 50%
160
for all reports.
All Reports
140
Transcription
T-Heme
Figure 15: Medication
error rate by incident
reports
# Events
120
100
80
60
40
20
Fe
b
n
Ja
ec
3-
D
ov
N
ct
O
p
Se
ug
Ju
l
n
ay
Ju
A
2-
M
A
pr
0
M onth of Year
Another concerning issue within the institution centered on mislabeled laboratory specimens. This problem, though infrequent,
was associated with missing and inappropriately placed laboratory results that occasionally effected patients. The percentage of
mislabeled laboratory specimens since ICIS implementation has reached a significantly low threshold within CCHMC (Figure
16). This surprising result is likely attributable to the seamless way in which legible and complete laboratory requisition
information and specimen labels are automatically generated within the patient care units.
Mislabeled specimens - Mean and 2 S.D.s
0.16
COE
0.14
0.12
Percent
Figure
16:
Change
in
Mislabeled Lab Specimens
over
a
5-year
period
culminating in the last 10month period after ICIS
implementation. Two criteria for
statistical indication of "special
cause variation" were fulfilled by
the end of December '02, namely
a "shift" (eight consecutive points
on one side of the mean) and the
1 SD rule (4 out of 5 consecutive
points beyond 1 SD). Both of
these continue to be true with the
inclusion of the January '03 data
(the last point on the graph).
0.1
0.08
0.06
0.04
0.02
0
0
10
20
30
40
50
60
Months, 7/98 - 1/03
Evidence of the system's value is apparent in the Institute of Safe Medication Practices annual survey. The ISMP conducts an
annual National Medication Safety self-assessment report utilizing responses to 20 core characteristics that ISMP considers
important for a safe medication system. A comparison of the CCHMC aggregate results from 2002 surveys demonstrated
significant improvement in the core characteristics when compared to 2000. In addition, as indicated in Figure 17, CCHMC
exceeded the performance in most core characteristics in comparison to other children's hospitals. We attribute this
performance level to ICIS.
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C
19
C
17
CHMC 2002
C
15
C
11
C
9
C
7
C
5
C
3
2002
C
13
100
90
80
70
60
50
40
30
20
10
0
C
1
Figure 17: Institute of Safe
Medication Practice Survey
Results. Average CCHMC
Core Characteristics Scores
in Comparison to other
Children's Hospitals.
Average Scores
Davies Award – Application
Core Characteristics
Optimizing Consistency in
Care
At CCHMC, care orders for common diagnoses such as status asthmaticus, bronchiolitis, gastroenteritis and dehydration,
pneumonia, appendicitis and others lacked consistency prior to implementation of the ICIS. Variations in the care of one
common disease, bronchiolitis, was assessed to run in the 50 to 60 % range depending on the year of study. These findings
existed despite the availability of evidence-based guidelines, pathways, and order sets through the Clinical Effectiveness
Department. Though these treatment guidelines were available, many were inaccessible prior to ICIS implementation.
Furthermore, decision support resources such as the hospital formulary, published literature, and hospital policies were often
outdated, inaccurate, and inaccessible.
Subsequent to ICIS implementation, there has been a significant improvement in consistency of care for those diseases and
diagnoses for which order sets are available. For example, a recent audit of 181 patients admitted with the diagnosis of
bronchiolitis revealed that 127 (70%) of these patients received care through a COE generated bronchiolitis order set - a 20%
improvement over the periods prior to ICIS implementation.
With the implementation of ICIS, over 220 pediatric-specific order sets and convenience order sets are now readily available for
use within the ordering pathways within COE. Links to Clinical Effectiveness guidelines and pathways, the hospital formulary,
CCHMC policies, and internet resources such as PubMed are now just a mouse click away form the ordering pathway in COE.
Improving Clinician and Patient Care Efficiency
Inefficiencies in the patient registration process prior to ICIS implementation was associated with delays in patient admission and
initiation of care - a source of frustration for both patients, families and care providers. Redundant documentation was more
often the rule rather than the exception. For example, a workflow analysis noted that patient allergies were being documented
on nine different written forms prior to ICIS implementation. Patient specific data necessary for care, such as laboratory results,
radiographic study results, pathology results, specialized test results, vital signs, intake and output, and allergy information
required retrieval from a variety of electronic and non-electronic platforms in multiple locations. Clinicians, pharmacists,
radiology staff, and consultants spent a considerable portion of their day clarifying care orders over the phone.
Medication turn around time for stat orders averaged 61 minutes, and it was noted that it took the radiology technicians 22
minutes on average to arrive after a request for a stat radiograph. Patient data management including totaling of intake and
output over shifts and creating nursing task lists during change of shift had become a time-consuming process. Furthermore,
management and communication of care orders was labor intensive including hand transcription of orders, faxing of orders and
phone calls to transmit orders. Finally, resource consumption utilized in process improvement efforts was high as a result of
intensive clinical data collection efforts and manual chart audits.
Since implementation of ICIS, efficiency of care has significantly improved through more rapid notification of orders. The time
required for STAT radiology exam results and respiratory therapy care has been markedly reduced through the use of rapid
pager notification of orders (Figure 18).
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1000
Pre COE
Post COE
100
# Minutes
Figure 18: Time Required to
Complete each Stage of a STAT
radiology study. Pre- COE
represents the mean time required for
each stage in 27 studies. Post COE
represents the mean time required for
each stage in 20 studies.
Stage 1= time from order to technician
arrival
2=time from clinician arrival to
obtaining radiograph
3=time to image available for viewing
4=time to verbal radiologist report
5=time to preliminary written report
6=time to final written report
*
*
*
*
10
1
1
2
3
4
5
6
Processing Stage
Care orders are now entered and carried out earlier in the day, facilitating change in therapeutic plans, transfer and discharge in
a more timely fashion. The impact of encouraging care teams to bring COE into the patient care rounding process is noted in
Figure 19. Ordering times have shifted steadily to the left of the graph indicating the earlier start times.
TOTALS 4/21-4/27
April-September 3rd Week Cumulative Orders
TOTALS 5/20-5/25
TOTALS 6/16-6/22
TOTALS 7/14-7/20
600
Totals 8/11-8/17
550
TOTALS 9/15-9/21
500
450
400
Order Number
Figure 19: Time
of day that
orders
are
entered.
Encouraging
clinicians to take
the computers on
rounds resulted in
a “left shift” in the
peak time of
entering orders to
an earlier time in
the day.
350
300
250
200
150
100
50
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
Order Hour
Internet and Intranet-based informational resources are now readily linkable through the ICIS to clinicians, providing state-of-theart pediatric-specific information. Another important measure of improved patient care efficiency is the turnaround time for
medications. In Figure 20, there was a notable improvement in turn-around times at various stages of the medication ordering
process between 2000 and 2003. Improvements range from an 18 - 85% decrease in time depending on the medication cycle
stage.
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Cincinnati Children’s Hospital Medical Center
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120
110
2003
2000
100
90
52%
80
70
20%
17%
Minutes 60
50
21%
40
70%
30
20
10
18%
85%
49%
0
rit
d
ve
ei
ec
R
x-
ve
ie
ec
ed
er
iv
el
ed
it
un
it
un
R
'd
ec
R
nt
-E
d
ec
R
x-
D
dve
ei
ec
rit
W
R
R
W
R
ft
Le
el
ec
-R
r
te
En
dve
ei
ec
rit
t-D
En
R
W
Figure 20: Decrease in
Medication Turn
Around Times from
2000-2003. The time
required in each stage of
the medication
administration cycle is
indicated before and after
ICIS implementation.
Overall medication turnaround time was reduced
by 52%, as indicated by
the last set of bars on the
right.
d
t
ni
U
Finally, an important measure of both efficiency and safety is represented by the accuracy and completeness of patient
information on requisition forms for important laboratory, radiologic and consultative studies. The performance of these studies
and the interpretation of the results are significantly affected by the accuracy, legibility and completeness of this information. A
study performed in radiology before and after implementation of the ICIS noted significant improvement in the above requisition
information, resulting in improved satisfaction, more accurate interpretations, and diminished clinician clarification calls.
Maximizing Regulatory Compliance:
On average, 40% of verbal orders remained permanently unsigned prior to ICIS implementation. Significant personnel costs
were associated with monitoring and managing this issue. Documentation of patient data (such as pain assessment, intervention
and reassessment) was not performed in a timely manner in order to meet both internal and external regulatory compliance
requirements. Inappropriate (non-emergent) use of verbal orders for controlled substances was commonplace despite
regulations prohibiting such practices. Required patient care orders such as admit, discharge, and consult orders were often
absent from the written medical record in random audits. Finally, there were significant lapses in security related to access to
electronic information systems (i.e. sharing of user passwords and use of generic passwords).
Compliance in local policies governing verbal orders and unsigned verbal orders has dramatically improved since implementing
the ICIS. The ability to query the date, time, location, and provider giving and receiving the verbal order for controlled
substances has been significantly improved.
Since January 2003, the combination of system query and an intervention program has resulted in a 24% reduction in verbal
orders for controlled substances. The intervention program consists of a regular weekly ICIS query that indicates all clinicians
who have unsigned verbal orders for three or more days. These individuals are contacted by email and informed of the concerns
by the Health Information Management Department. In Figure 21, the impact of implementation of the ICIS and associated
intervention program on the percentage of total patient care orders as verbal orders, and percentage of verbal orders which were
not signed by the physician after three or more days is noted.
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60%
Figure 21:
Change in
Verbal and Unsigned
Verbal
Orders
since
implementation of the
ICIS.
There have been
significant reductions in
both the percent of total
orders that are given as
verbal orders as well as the
percent of unsigned verbal
orders.
Paper
% Verbal
% Unsigned
50%
COE
40%
30%
20%
10%
08 '02
/3
1/
09 02
/2
8/
11 02
/0
2/
11 02
/2
3/
12 02
/1
4/
01 02
/0
4/
01 03
/
02 25/0
/1
5/ 3
03 200
3
/0
8/
03 200
3
/2
9/
20
03
'0
2
Ju
ly
Ap
r
Ja
n
'0
2
0%
Date
Compliance with Pain Assessment has been another area of marked improvement since the ICIS implementation. In two
quarters since implementation of the Clinical Documentation application in the ICIS, there has been an observed 40%
improvement in the initial documentation of pain assessment (Figure 22). Initial pain assessment is now close to 100%.
110
A7
100
Percent
Figure 22: Initial Pain
Assessment Compliance
A7N and B5W represent two
patient care units.
B5W
90
80
70
60
Efforts to better manage patient pain
50
and comply with pain documentation
3 r d Q tr 2 0 0 2
4 th Q tr 2 0 0 2
1 s t Q tr 2
standards resulted in the initiation of a
Pain Task Force. It was difficult in the
manual process to see improvements in the performance measurements for pain. The scores for documentation of initial pain
assessment upon admission from month to month were inconsistent. The two pilot went live on the electronic pain assessment
module in the 2nd quarter of 2002. Steady improvements have been noted on both of these units beginning in the 3rd quarter of
2002 as reflected in Figure 22.
Enhancing Provider and Patient and Family Satisfaction
In the radiology user satisfaction survey, ordering clinicians (n=81), radiology technicians (n=24), and radiologists (n=24) were
noted to have greater satisfaction with the quality and quantity of patient information provided on the radiology requisition and in
the response time to performing a radiologic study.
Radiologists and ordering clinicians indicated greater satisfaction with the time to deliver and receive a verbal study report.
Radiology technicians noted greater daily efficiency through the use of the COE pager notification process. Compliance with
signed radiology orders and revenue capture was much improved after ICIS implementation. Improved user satisfaction is also
evidenced by the widespread acceptance of the ICIS, overall clinician enthusiasm, and participation in ideas for system
enhancement. Formal validated user satisfaction surveys have been developed and will be administered after all units have
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been implemented for a 12-month period. There are many variables impacting clinician satisfaction with the implementations of
clinical information systems. The CIORG sought to understand the degree by which is user satisfaction is correlated to
recognizing the benefits of ICIS on patient safety, workflow and clinician efficiency. Figure 23 displays preliminary results from
user satisfaction survey.
Score
Figure 23: Preliminary user
5
satisfaction survey results
Doctors Non-Physicians
performed approximately one
4
year after ICIS implementation.
Physicians (n=41) and Nonphysicians (n=41), (nurses and
3
respiratory therapists) were
asked to complete a 5 question
2
survey with the following
questions: 1) ICIS is easy to
navigate; 2) ICIS decreases
1
errors in health care; 3) ICIS
focuses on improving clinical
processes while maintaining or
0
improving productivity; 4) ICIS
1
2
3
4
5
optimizes clinical workflow; 5)
ICIS improves the quality of
Question #
care. Users were asked to
score their response to each question. A score of 1=strongly disagree; 2=disagree; 3=neutral; 4=agree; 5=strongly agree. Each
bar represents the mean score for each question. As indicated in Figure 23, responses to the survey were generally positive in
the neutral to strongly agree range. There were no significant differences between physicians and non-physicians.
Figure 24 shows the results of the user satisfaction survey conducted amongst 20 respiratory therapists.
100
90
80
70
60
*
*
Yes
No
Q6
Q8
*
50
40
30
20
10
0
Q1
Q2
Q3
Q4
Q5
Question #
Figure 24: User Satisfaction
Survey results from CCHMC
Respiratory
Therapists.
All
respiratory therapists in the critical
care units were asked to complete
an anonymous user satisfaction
survey.
Sixteen (80%) of the
therapists returned the 8 question
survey.
Significantly improved
satisfaction was noted in 4 of the 8
questions referencing patient safety,
workflow efficiency and order turnaround time, with trends noted in 3
additional questions.
Approximately 75% of community physicians admitting children to CCHMC have extranet access to ICIS from their offices in the
region. Access at this point is limited to the ability to view information only as appropriate security is not yet in place to allow
order entry from these locations. During two time periods in 2002, community physicians were asked to complete a user
satisfaction survey regarding their use of the ICIS. The results are noted in Figure 25.
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Always
Rarely
Sometimes
Never
Always
Rarely
Sometimes
Never
Figure 25: User Satisfaction Survey,
Community Physicians. During two periods in
the year of ICIS implementation, (preimplementation n=73, and post-implementation
n=123), community physicians were asked the
question "How often do you use the ICIS to obtain
laboratory and radiographic testing results on the
patients for which you provide care?" The survey
demonstrated a significant increase in the
utilization of this informatics platform from these
remote locations over this short time period.
ICIS Future Plans
The second phase of ICIS includes the expansion of COE and Clinical Documentation systems to the Hematology-Oncology
units. Due to the extremely complex medical needs of these patients and the multifaceted processes followed when caring for
these children, the ICIS team had to build new features and functions to support these clinicians.
Following the same implementation methodology described in the content of this application, phase two of ICIS began with a
detailed analysis of Hematology-Oncology units. The analysis included evaluation of the clinician’s workflow, order writing and
documentation practices, antineoplastic medication order verification process and patient flow. The disease nature of these
children often requires multiple follow-up hospital visits for recurrent treatments. Also, the treatment protocol of the oncology
patients could extend from months up to three years. Based on this information the team decided early on that the scope of ICIS
had to be extended to encompass the outpatient areas.
Once again, less efficient processes were revealed especially as they relate to the patient’s flow through the different areas.
Because certain active data is stored at the patient account level, changes had to be made in the system and current processes
to ensure the continuity of electronic data is maintained. The greatest concern expressed by the clinicians was the safety of
ordering antineoplastic drugs in ICIS. Due to the high toxicity of these drugs, various levels of verification and blocks had to be
built. The clinical team decided that these drugs should only be entered into the system in an inactive state, and only once they
are verified by the appropriate, authorized clinicians were they to be activated. Another complex build of the system was related
to timed orders (time 0). These orders are to be acted on only if certain medical conditions are met and they must follow a very
rigorous sequence (i.e., start drug “x” if urine gravity reached “y” level). Since the nurse is the primary clinician who will initiate
time 0, the linked, timed orders are maintained in a less than an active status until the nurse enters the appropriate time. This
action schedules the orders according to the sequence indicated by the protocol.
To address the unique concerns of the physicians, a dose calculator was built allowing them to use protocol specific dose ranges
and calculations. Figure 26 shows the dose calculator used for ordering a multi-ingredient intrathecal medications.
The Hematology-Oncology implementation will be phased in beginning July 2003. The oncology patient population will be
converted to ICIS at the end of the implementation. This will allow for completion of all order set builds (142) related to Cancer
Oncology Group protocols and will ensure the users gain greater system acceptance.
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Figure 26: Dose Calculator.
Supports dose calculations using
various formulas. Patient and
medication reference data is prepopulated form the order set. All
calculations are stored with the
order and are accessible for
viewing.
Other targeted projects for
phase two include the ICIS
interface
to
pharmacy,
expansion of ICIS to research
patients, cardiac cath, outpatient
dialysis and sleep study patients.
The team has a list of
enhancements that will be
provided to the users as well as
a new TPN module.
The Clinical Documentation Team is currently completing a detailed analysis of the shift to shift assessments, discharge
planning, plan of care, progress notes and education record. The preliminary findings reveal a great need to integrate the
documentation data across all disciplines. Other findings indicate that the data is not captured in a standard format and there is
great variation and redundancy on how it gets documented. The ICIS team is currently working with the senior management of
the organization and JCAHO auditors to evaluate the required standards and obtain concurrence on streamlining the clinical
documentation process.
The multidisciplinary approach taken for phase two will result in significant changes in the documentation practices across
disciplines. Anticipating the outcomes of this initiative, the team is confident that through merging the process and technology,
patient care will be enhanced, and patient and family satisfaction will increase. This reengineering process will also contribute to
meeting the regulatory standards as well as increase staff efficiency. To demonstrate the success of this initiative the team is
currently obtaining baseline data that will be compared with post automation data in the future. The targeted implementation
date for the phase two of Clinical Documentation is November 2003.
User Testimonials
This application would not be complete without mention of user comments regarding their impressions of ICIS.
From the Doctors
“ICIS has been a godsend for my office staff and patient families. It has resulted in increased efficiencies for the office staff and
physicians, decreased patient anxiety and provides rapid turn around of information. Clinical information is legible, organized
and much more accessible. In the old days we used to tell a family we would call them in a couple of days with the results of an
MRI completed on their child. Today we can look it up in NetAccess and call them back within a few hours. For my patients that
have been admitted to CCHMC, I can review orders and medication dosages for accuracy. This was time consuming and almost
impossible before COE.”
“NetAccess allows me to know what’s going on with my inpatients before I ever leave the house in the morning. I feel so much
more aware of what’s going on with my patients.”
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From The Nurses
“A note to the team…You are appreciated!!!! Your dedication is an example of the highest level of professional practice.”
“It has changed the way I work, I finish my charting at the bedside. No looking for papers or notes, I walk away form the bed and
I am finished.”
“I feel more confident that the orders are accurate, I can read them easily. I am not guessing at the doses and where the
decimal point is!”
“I can not wait for the next part to be done. Will it be ready tomorrow?”
“The Clinical Information systems have had a huge impact on my care delivery. Before COE and Clinical Documentation I always
had to stay after my shift to chart. Now, by real time charting I have only had to stay after my shift twice in the past year and both
times it was because I had a patient in crisis not because I had to finish my charting.”
“The MAR is available at the bedside and I refer to it when giving my meds, I do not rely on notes jotted down hours ago. I know
that it is up to the minute information and accurate.”
“All the documentation is clear and easily read. Some of the nurse's have very messy handwriting and with some of these drugs
spelled only slightly different from each other, it is easy to make an error. I am confident that the name is correct and when it
matches my pharmacy label and I know I have the correct med.”
“I am always concerned about patient safety. This system is very accurate and easy to read. No guess work! I don't have to
worry about orders being missed, delay in treatment or other less than optimal outcomes. We all want to do the very best for our
patient's and their families.”
From a Parent
“As a parent of two children, both having cystic fibrosis, I want the best health care delivery system possible. Since I "play with"
computers all day as a database manager, successfully used computer-based health records is my quest. Data mining and
validation is paramount in any data source, and since that is what I do best, I can show others what I know, ultimately offering the
best health care available.”
“Cincinnati Children's Hospital has taken a huge step in 'patient centeredness' allowing parents to become team members in
developing better health care. They are not just testing out the water by putting their toes in, they have jumped in feet first. This
brave initiative has provided me a way to share my knowledge and expertise to help improve health care for my children and all
children in the Cincinnati area.”
Acknowledgments:
The authors of this Davies Award application would like to thank the doctors, nurses and allied health professionals at CCHMC
whose enthusiasm, motivation and dedication played a significant role in the success of ICIS. The authors would also like to
acknowledge Charlene Underwood and Don Rucker MD from Siemens Corporation for their review and contribution to this work.
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