Next Generation Clinical Systems: Is It Time to Jump? Elaine Remmlinger Principal and National Service Director Kurt Salmon Associates New York, NY Stacy Melvin Consultant

CIS Development No longitudinal history—information was retained for the current episode only and purged at final billing leaving little in the way of an easily accessible historical patient record. Character-based screens—the user interface was unfriendly and oriented to data entry, not clinical functionality. Point to point interfaces—there were few interfaces other then laboratory and possibly radiology. Interfaces were custom developed for each situation and required significant maintenance. No clinical depth—for the most part, systems were really not clinically oriented at all. The focus was on charge capture with orders, order status, charges, limited results, and little clinical information. Not physician oriented—physicians did not use these systems, except in selected academic medical centers that required residents to perform order entry. No alerts or reminders—clinical decision support was largely non-existent; few systems had the ability to check for duplicates.

Impetus for next generation systems Major technology breakthroughs and medical science innovation. The Internet, which enables providers and patients to instantly connect to volumes of information, including reference materials and test results, has provided opportunities to alter the processes involved in providing health care significantly. The Institute of Medicine Reports that focus on the use of clinical information systems and the CPR to reduce preventable adverse events; improve coordination and communication in the treatment of chronic illnesses; and improve the overall effectiveness, timeliness, efficiency, and quality of care. Leapfrog Group Initiatives, which recognize and reward health care providers for major advances in protecting patients from preventable medical errors and has put forth the use of Computer Physician Order Entry (CPOE) as one of its benchmarks. Development of coalitions with representation from agencies with responsibility for licensure and oversight interested in patient safety and CPOE Adoption of patient safety program mandate by JCAHO Passage of state legislation mandating “patient safety programs” that may include CPOE and advanced clinical information systems beginning (e.g., CA) Consumerism, which hinges on the expectations of an informed public with increased expectations regarding patient safety, availability of information, ease of access, and outcomes.

The Future Vision

The Next Generation Fully replace the paper-based chart Contain patient-centric health status information over time Integrate multi-media information from multiple sources Facilitate timely, accurate, and comprehensive communication of clinical information throughout the continuum of care Meet clinical, legal, and administrative requirements Provide ready access to clinical knowledge bases and decision support tools Enhance the quality, productivity, and efficiency of the organization Reduce medical errors through the use of clinical decision support and Computer Physician Order Entry Ensure confidentiality and integrity of patient information Appear seamless and user-friendly to end-users.

See Appendix for additional slides explaining the model. CDO - clinical delivery organization CPOE - Computerized provider order entry CDSS - Clinical decision support systems IM COUNCIL Dec 8, 2008

Vendor marektplace Historically, CIS products focused on the inpatient environment and ambulatory function was not integrated with these inpatient systems. Vendor consolidations continue, but products are still not integrated. Larger “core” clinical information systems often do not provide adequate functionality for specific departments (e.g., Emergency Department, cardiac services, oncology, etc.) Mature, outdated legacy products continue to be supported, giving many health care organizations less incentive to move to newer platforms The proliferation of e-Health products with many dot.com failures leaves vendors and providers unsure of what direction to take even though the functionality available through e-Health is desirable.

Focus on caregiver utilization

Potential Benefits and Advanced Clinical Information Systems

Barriers Financial: acquisition, implementation and maintenance costs Cultural – resistance to change Product status – no one fits all

Potential CIS strategies

The organizational impact of implementing any system must also be considered: What changes in workflow will be required? How should the facility be designed to optimize workflow (e.g., device placement) and encourage use of clinical information systems? What policy and procedure changes will result? What is the Total Cost of Ownership of alternative strategies? What are the potential benefits? How do alternative strategies impact relationships with affiliates? What are the resource requirements for implementation/conversion by strategy?

Due Dilligence

Drivers for the future Paperless Clinical Environment Filmless: Picture Archive and Communication System (PACS) Patient Access to Information Client Services Integration: Direct patient access via the Internet and other sources to scheduling Telehealth: Specialty care available to rural or remote areas and homebound individuals