Dependable Systems For Quality Care CHAPTER 15 Dependable Systems For Quality Care

OBJECTIVES: 1. To explain the relationship between dependability and health care quality. 2. To identify and explain five guidelines for building dependable systems. 3. To present an informal assessment of the healthcare industry with respect to these guidelines.

INTRODUCTION: The healthcare industry is undergoing a dramatic transformation . This transformation is driven by several factors: Skyrocketing cost of healthcare delivery Exposure of patient safety problems Aging “baby-boom” population

SOME TECHNOLOGIES IMPORTANT IN TRANSFORMING CARE DELIVERY: EHR Electronic, outcomes based decision support Wireless communication Tablet PCs, Personal Data Assistants Continuous Speech Recognition Clinical Knowledge bases CPOE Electronic Prescribing RFID tagging Enterprise Application Integration (EAI) Robotics

The International Council Of Nurses (ICN) Code of Ethics for Nurses affirms that the nurse “holds in confidence personal information” and “ensures that the use of technology is compatible with safety, dignity and rights of the people”. As IT assumes a greater role in healthcare decision making and in the provision of care, the nurse must rely on IT to help protect the patients information and safety.

System Reliability Service availability Confidentiality Data integrity DEPENDABILITY- measure of the extent o which a system can justifiably be relied on to deliver the services expected from it. It comprises the ff. six attributes: System Reliability Service availability Confidentiality Data integrity Responsiveness Safety

WHEN THINGS GO WRONG

WHEN THINGS GO WRONG: February 2003, issue of CIO - “one of the worst healthcare IT crisis in the history”. Catastrophic failure in the network infrastructure that supported CareGroup, one of the most prestigious healthcare organization in the US which resulted in the 4 hr closure of the emergency room, complete shutdown of network and network services were not fully recovered until 6 days of the onset of the disaster.

August 200, the Blaster and SoBig worm attacks invaded hospitals around the world. The bottom line is that systems, networks and software applications are highly complex, and the only safe assumption is that failures will occur. Thus, dependability is an essential factor in planning and operations. WHEN THINGS GO WRONG

GUIDELINES FOR DEPENDABLE SYSTEMS

GUIDELINES FOR DEPENDABLE SYSTEMS All computers are vulnerable to both human created threats (malicious code attacks and software bugs) and natural threats (hardware aging and earthquakes). Tolerant Systems- more practical approach to attaining dependability. It is a system that anticipate problems, detect faults, software glitches, and intrusions.

5 fundamental guidelines that can increase dependability of the healthcare systems: GUIDELINE 1: ARCHITECT FOR DEPENDABILITY A fundamental principle of system architecture is that an enterprise system architecture should be developed from bottom up so that no critical component is dependent on a component less trustworthy than itself. The simplest the design and integration strategy will be the easiest to understand, to maintain, and to recover in case of failure or disaster.

GUIDELINE 2: ANTICIPATE FAILURES Minimizing complexity is more easily said than done. MOORE’S LAW – the speed of the processors id doubling every 18 months, while the cost of the computing power is halving within the same time period. As computers are getting faster, systems are getting more and more complex and design flaws are becoming an increasingly catastrophic problem. Anticipation of failures at the infrastructure level, features that are transparent to software applications should be implemented to detect faults, to fail over to redundant components when faults are detected and to recover from failures before they become catastrophic.

GUIDELINE 3: ANTICIPATE SUCCESS The systems planning process should anticipate business success. Modeling of use case scenarios will enable the system designer to visualize the data flows, system loading, and network impact resulting from business growth and success.

GUIDELINE 4: HIRE METICULOUS MANAGERS Managing and keeping complex networks and integrated systems available and responsive requires meticulous overseers Good system administrators meticulously monitor and manage systems and network performance using out-of-band tools that do not themselves affect performance. They use middleware to manage the workload across the network They take emergency planning very seriously and procedures for managing emergencies and recovering from disasters.

GUIDELINE 5: DON’T BE ADVENTUROUS For dependability, one should use only proven methods, tools, technologies and products that have been in production, under conditions and a scale similar to the intended environment. The enterprise with a requirement for dependable systems should not be the first (or second) to adapt a new technology.

Assessing the health care industry

ASSESSING THE HEALTHCARE INDUSTRY Provides an informal assessment of how well healthcare provider organizations follow the guidelines. Conveys observation of the healthcare industry as a whole and the opinions of a passionate advocate of dependable systems for healthcare. Healthcare Architectures The HIPAA prescribes administratives, physical and technical safeguards for protecting the confidentiality and the availability of critical system services: Security management Assigned security responsibility Information access management Security awareness and training Security incident procedures Contingency planning Evaluation Business associate contracts

ANTICIPATING FAILURES The architectural complexity increases the opportunities for failures to occur. Medical applications that are hosted on PCs and PDAs have a greater likelihood of failures than applications hosted on server machines that are physically protected. Computers are increasingly being used in safety critical clinical applications and without careful and appropriate attention to software safety, we can reasonably expect that failure will contribute to the loss of human life.

ANTICIPATING SUCCESS Healthcare organizations definitely expect their software applications, computer systems and networks to work. Providers assume their systems will work well as any other medical equipment despite the fact that many of the software applications they use are running on the same kind of PCs that have failed them at home.

IT Management Many provider organizations truly do not recognize the criticality of IT to their business success. These organizations have hired IT managers who appreciates the important role of IT in a health care environment and who recognize the need for dependable systems that could anticipate and recover from failures.

ADVENTUROUS TECHNOLOGIES IN HEALTHCARE The 5th guideline “don’t be too adventurous” is more difficult to assess for healthcare. For dependable IT, the healthcare practitioner’s skepticism is a good thing. Newness and change are anathema to stability. Well planned and carefully executed changes over time are desired and expected, healthcare organizations should not be overly eager to adopt new technologies for life-critical systems.

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