Evaluation Of Clinical Information System Implementation In The ICU

Overview of Clinical Information Systems

Question:

Evaluate whether implementing Clinical Information System (CIS) in the Intensive Care Unit (ICU) enhances the workflows of healthcare workers and improve the quality of care provided to critically ill patients. 

Clinical Information System or CIS is the computerized system that stores, double checks and organizes the medical information. Paper charts are replaced by the CIS system as it serves to keep together several information electronically, which includes prescriptions, health history, dictation and doctor’s notes. CIS has significantly helped in improving patient care as it contains several safety features, which reduces the probability of errors significantly. CIS is equally private and secure as it permits only the caregivers who are qualified to access the patient records, as compared to the conventional paper charts (Moher et al., 2015). There are several advantages of the implementation of CIS in healthcare as in case of any emergency, the physician can have immediate access to the entire medical history of the patient. When a patient makes an office visit, the physician can go through his medical records and place the test orders directly from the system. Immediate access is to the test results for the doctors is another advantage and adding to the list, the doctor can send the prescription to the pharmacy directly, that helps the patient on an easy collection of medicines (Mador & Shaw, 2009).

Apart from the above clinical advantages of CIS, it has a very important role to play in the Intensive Care Units (ICU) for improving the patient outcome. It enhances the workflow of the healthcare workers and improves the quality of care provided to the critically ill patients. It is a common belief that in the 21^st century, the healthcare system will require the intensive application of the CIS in the ICU for managing and acquiring data, data transformation for availing information and dissemination of information for using it to improving patient care. It is more important and evident to use CIS in the ICU than at any other arena of healthcare, as it involves complex decision-making processes. Critical illness dynamic requires physiological data that are time stamped and are integrated with the clinical context. Processing of this data takes place through a wide array of nonlinear and linear analytical tools (De Georgia et al., 2015). Advanced data analytics can take place only through the CIS and it helps the physicians to make informed and timely decisions for improving the outcomes of the patients. Therefore, integrated informatics for critical care architecture is essentially required for the integration, synchronization, acquisition, storage and integration of all the patient data into a searchable and single database that is waveforms and numeric. This helps to process the data for extracting features that are clinically relevant from the original raw data for translating them into information that is actionable. Technological advancements are working to bring all these features together (Haynes et al., 2010).

The present systematic review deals with the evaluation of the implementation of CIS in the ICU and determines whether it improves the patient outcome by enhancing the workflow of the healthcare workers and improves the quality of care provided to the critically ill patients. The review will investigate the impact of the implementation of CIS in ICU on the different activities of the nurses in ICU like documentation time, direct patient care and quality of care. The findings from the various literature will be thoroughly analyzed by the researcher and the outcome will be represented statistically, followed by an extensive discussion of the findings and the actual impact of the clinical information system. Various studies have been conducted on this aspect by different authors, however, no single study have been found that could address the complete implementation of the CIS in ICU and its impact on the nursing activities of documentation time, direct patient care and quality of care. This article aims to fill this gap and will develop a clear understanding of the findings of the investigation by systematically reviewing peer-reviewed articles.

Advantages of CIS in Healthcare

Figure 1: Health Information System Forming the Clinical Information System

The aim of this systematic review is to evaluate whether implementing CIS in the ICU enhances the workflows of healthcare workers and improve the quality of care provided to critically ill patients.

1.1.2 Objectives of the Study

The objectives of this systemic review are as follows:

• Reviewing the available literature describing health information systems, with a particular focus on CIS in the ICU and the evaluation of such systems.
• The impact of using CIS on documentation time, direct patient care and quality of care.

Introduction of computers to the hospitals took place in 1970 when they started to develop Electronic Medical Records (EMR)  that included POMR (Patient Oriented Medical Record) introduced at the University of Vermont. University of Utah introduced HELP (Health Evaluation through Logical Processing) and the Duke University introduced TMR (The Medical Record). Harvard introduced the COSTAR (Computer Stored Ambulatory Record) and was programmed by the Massachusetts General Hospital Utility Multi-Programming System. For the outpatient and inpatient settings, RMRS (Regenstrief Medical Record System) of Indiana was the first of its type (Nadelson & Nadelson, 2014). Not all these EMRs were associated with the intense ICU environment based on the real time data.

Weil and Shubin have been credited for the introduction of computers in the ICU in the year 1966 with the purpose of automatic collection of the vital signs from the monitor place on the bedside. It proceeded to the development of CARE (Clinical Assessment, Research and Education System) that was a clinical decision support system developed for aiding in the treatment of the surgical patients, who are critically ill (Amarasingham et al., 2009). The system helped in the continuous monitoring of the metabolic ad physiologic functions of the patients who were critically ill and managed the electrolytes and fluid data with the respiratory and cardiac functions.

Hewlett-Packard introduced the PDMS (Patient Data Management System) but it failed to excel in the ICU because of its complex menu, old user interface and was incredibly slow. In the year 1980, blood pressure and heart rate were automatically monitored and its advancement was marked by the data representation in the graphical displays. 1990 introduced internet access to the ICUs that increased and improved the clinical functionality significantly. Web based software supported the cumulative patient data by presenting and recording the patient data continuously by providing links to the nursing documentation, physician notes, imaging and laboratory data from the EMRs and representing them collectively as CIS (Darbyshire, 2004). In the year 2003, GE introduced the Centricity system for the critical care patients and in 2007, Philips introduced its ICIP (IntelliVue Clinical Information Portfolio). This was the first of its kind CIS that was introduced in the ICU for the critical patients. Centricity Critical Care (CCC) by GE automatically collected data from the ventilators and monitors and displayed it in the spreadsheets of the typical paper type ICU charts. Data collection took place from the medical devices through their interfaces that are connected by the UID (Unity Interface Device) network. ICIP by Philips supported manual and automatic documentations of the physiologic data that had the time resolutions of five minutes (Van Der Meijden et al., 2003). It was supported by a relational database that helped to achieve the essential clinical information like text notes, lab results, patient demographics and medications.

Role of CIS in ICU for Improving Patient Outcome

From the above inventions, it can be seen that different technological advancements at different times have helped the healthcare professionals to improve the patient care by getting better information of the patient. Detailed information of the patient, through either EMRs or CIS, helped the doctors and surgeons significantly to avoid errors and reduce the time of treatment and that would eventually contribute towards the improved patient outcome. Automation of the processes drastically changed the concept of documentation (Häyrinen, Saranto & Nykänen, 2008). Records were no longer missing and were kept confidential more effectively than the conventional systems that significantly reduced the documentation time. It had a direct effect on the quality of care as proper and rapid interpretation and representation of data helped in providing the correct intervention to the patient, without any attempt of experimentation (Bosman, 2009). Direct patient care also improved with technological advancement as patients in ICU are in the condition of critical illness. Therefore, their treatment, patient education, counseling and medication are all important factors for the doctors and the nurses and digitalizing them effectively was of help, especially in case of shift change and worsening of the conditions.

Figure 2: Components of CIS

Figure 3: The Systematic Review Design

The above flow diagram describes the design of the present systematic review and the pattern that will be followed by the researcher in answering the research questions. Following the sections of abstract and introduction, the researcher will develop the research questions in the review questions chapter which will be followed by the review method identification. Thereafter, the results will be derived from the study and they will be discussed thoroughly in the discussion part. Next, a conclusion will be drawn to the study followed by the limitations of the study with future recommendations. The researcher will follow the ethical considerations while conducting this study and will avoid the conflicts of interest. This study pattern will finally provide with a justifiable systematic review of the research topic.

The section of literature review includes the knowledge and substantive findings of the methodological and theoretical contributions to any particular topic. The literature review part in this study will discuss the previous comparative studies that the various researchers have carried out to demonstrate the application of CIS in the ICU. The researcher in this section will analyze the topic of application of CIS in the ICU and this is not a part of the actual systematic review. This is only a prologue of the actual systematic review that the researcher has carried out in order to exhibit the various research works that have been carried out on the research topic by various researchers.

Plenderleith (2013) carried out a research work regarding the application of CIS in the ICU and found that it helps to manage data in large numbers that are generated daily in the ICU. Appropriate linkage to the systems like monitoring, laboratory helps to simplify the acquisition and data accuracy is increased that are sent to the patient records. Once the data enters the CIS, they are observed from different viewpoints without repeated entries for improving the patient care. The feature of decision support in CIS provides it a versatile dimension. Data concentration at one point simplifies the process of audit, improves the quality and helps to obtain the information from the management more easily as compared to the conventional paper notes. In the ICU, on an average, 1100 data items are acquired everyday for each patient. These data includes data for physiological measurements and intervention records for continuation notes and drug administration. For the conventional system of data recording based on papers, manual entry of data used to take place on multiple paper sheets that included duplicate entry of information. This process often led to poor legibility mistakes and transcription errors. Cross-referencing of data does not happen and they are poorly filed. The patients take the notes away after they leave the ICU and therefore, for performing quality improvement audits, huge collection of paper becomes mandatory. Viewing the information from different aspects is essential in ICU. When data is entered in the system, different contexts can be applied to its presentation. For example, ventilator parameters are observed on the specific screen for ventilator and the data subset is found on a summary screen (Fraenkel, Cowie & Daley, 2003). Existing data is incorporated automatically in a different context even if they are from a separate assessment. This feature is helpful in the collection of the information for scoring systems and augmented care pathway. Routine calculations that include production totals of fluid balance, physiological variables and drug prescribing that is weight based are automatically performed. The patient charts are filed after collection in a standardized and accessible format without spreading it as multiple note sets (Ammenwerth et al., 2003). The reviewing of the entire event becomes simplified like summary of the duration of the ventilation of the patients. The collection becomes simultaneous unlike through the conventional way of collecting the forms. Reviewing compliance and performing audit for the care bundles becomes simple as the data becomes easily available. The most innovative invention for the CIS is the decision support that analyzes the data pattern and helps to trigger suggestions (Wang & Liao, 2008). This includes the suggestion for considering ventilator bundle if the patient is on a ventilator and is intubated. Suggestion for considering sepsis in case if the patient is having a tachycardia, pyrexia and increased count of white cell. For drug prescriptions, dose checking can be advised if gentamicin is prescribed for a patient who has a raised creatinine level (Heeks, 2006). Although this feature is applied for generation of prescriptions, but it is well expanded in other aspects as well like a symptomatic indication for acute lung injury. All these factors do not contribute to the wellbeing of the patient directly, but they act together to provide outputs that are significantly positive and improves the patient outcome (Ammenwerth et al., 2004). 

Objectives of the Study

Donati et al. (2008) opined that although CIS have been implemented in many ICUs for a long time, little evidence has been derived about their impact in the staff perceptions and quality of care of the patients. Therefore, the authors compared the time required by CIS and manual patient charting on paper for evaluation of the perception of the staff members while working in an ICU. Useful information can be obtained remotely and from bedside by CIS in an ICU. CIS is constructed on an architecture that based on client-server interface with workstations placed on the bedside for each patient. The physiologic variables are interpreted by electronic charting that provides information to different bedside devices through various interfaces. The sophisticated forms of the CIS include doctor order entry, electronic medical record and radiographic image displaying by PACS (Picture Archiving and Communication Systems). Laboratory and monitoring interfaces are used for automatic collection of data by CIS. All the relevant information of the patient are stored in the database of the CIS like current medication, drug history, specific information, laboratory results and drug interaction warnings. The study design was based on the evaluation of the benefits of using CIS in the ICU on the basis of reduced data time. From the study, it was found that it took 274 minutes for each patient every week for manually recording vital signs, calculating scores, blood gas analysis, chart therapy, fluid balances and laboratory data. However, after the introduction of CIS, the time for the same activities was reduced to 21 minutes every week for each patient. There was a marked difference between the activities examined before and after the introduction of CIS. It was found that prior to installation of CIS, the time spent by the nurses for charting was 17.4% and the time spent for gathering patient data was 6.7%. After the installation, the charting time was decreased by 10% and the data gathering time was reduced by 4%. A significant amount of time was saved after the implementation of CIS as manual charting was no more required and the saved time is utilized in patient care. When the demand for nursing time in the ICU increases, priority is given to patient care and results in delayed documentation. More the illness of the patient, more is the generated data in the ICU and the potential benefits of CIS becomes more as considerable is saved in charting and gathering (Haux, 2006). During the study, the data collection periods and the staff members like consultants, nurses and physicians were similar to avoid any bias in the results. The only variable in the study was the patients as they were constantly changed throughout the study. From the study, it was also seen that there was significant time loss with the use of computer as well. Since computers are being intensively in daily lives, therefore, adaptation to the CIS system was easy and rapid for the staff members for accessing patient data. The health professionals easily extracted massive amount of ICU data and considerable time was saved as the applied software system was significantly flexible and allowed sufficient customization to the nurses and physicians as per their requirements (Samaras & Horst, 2005). Downtimes were effectively handled to avoid any data loss. Increased time for patient care resulted in improved patient outcomes and better patient compliance.

Introduction of Computers to Hospitals

According to Saleem et al. (2015), there are facilitators and barriers to the use of CIS in the ICUs and record keeping for anesthesia. The authors evaluated the use of CIS for the care and recovery settings of post anesthesia and operating rooms.  The study was carried out at three medical centers. The administrative staff and clinicians at the workstations placed at bedside, nursing stations, operating rooms and in the physician’s rooms use the applications. It facilitates the creation of the assessments, electronic data records and multiple procedures for medical devices. For achieving the objective of the study, an ethnographic study was carried out by the authors where the participants were the end users of CIS and ARK (Anesthesia Record Keeping). Optimization of the ARK and CIS systems was hindered by the software challenges, poor usability, integration issues, hardware challenges, lack of coordination, training concerns and inadequate technical support. These barriers were multifaceted with related sub-barriers and were described along with the participants’ quotes. Qualitative field observations were used for the analysis of data, they were represented at a level that could be integrated through the cases for showing the behavior pattern and the themes associated with the implementation of the ARK and CIS systems. The barriers presented in the research are addressed by collaboration and cooperation with the vendors and relevant changes have to be made in the system for including them in the ICU documentation. The most important ability is the integration of ARK and CIS with the other applications and meeting the customizations requirements, software challenges and better data display organizations (Kushniruk & Patel, 2004). Hardware challenges can also be sorted out by external technical support and with the collaboration and cooperation of the vendors. The study identified several barriers to the implementation of the CIS in the healthcare systems and there probable outcomes and solutions have also been derived, with proper recommendations. The methods of human factor engineering are used for applying an approach that is user centered to the requirements specifications, system integration, implementation of the application and application evaluation. Although the benefits of the application of the CIS have been discussed in several other studies, this research proved to discuss the barriers of the system. However, the barriers can be overcome by proper measures and CIS can be utilized to deliver better patient outcome and increased satisfaction and support for the healthcare professionals, working in ICU (Petter, DeLone & McLean, 2008).

Gómez Tello et al. (2011) carried out a research work for determining the functional and technical standards with the application of CIS in the ICU. CIS is a useful tool for management of patient data in the ICU. It is very important to describe the minimum suitable specifications for making the tool helpful and operative. The results of the process of healthcare are improved by the CIS as it optimizes the quality and safety and collaborates to improve the patient management process. The objective of the study was to prepare a document with the recommendable operating and technical requirements for CIS. The study was carried out in a hospital in Spain and designated a team of software and clinical experts to attain the objective of the study. For the study, ten participants were employed by the engineers and managers from five different Spanish companies manufacturing CIS. There were two phases in the project where the first phase involved checklist completion for establishing the present situation of the application of CIS and the second phase was result discussion by a team of experts. From the study, it was determined that according to the nursing perspectives, incorporation of the essential resources in the system is necessary for carrying out the necessary activities of patient care. CIS must have the tools for care planning with subsequent generation of its activity reports. The advantage of CIS was easier and better to access by the users helped to take decisions that are based on the integrated and consistent information on the prime indicators. The identification of the trends and occult relations for the data developed the management and clinical hypothesis. The requirements from CIS were to achieve a set of characteristics that is useful in ICU settings (Wu & Wang, 2006). For this, four different sections were designed like functional, technical, management and data safety. All these sections were met satisfactorily by the CIS and its utilization in the ICU as per the requirements was successfully established. The study concluded with the saying that CIS is a very versatile and useful tool for using in the ICU and it can be customized as per the client requirements.

Synthesizing the research articles, it can be said that all the researchers aimed at a common aspect that ICU significantly helps in the daily activities of the nurses in the ICU and other departments in a hospital. The researchers from the various studies stated that compared to the traditional methods of data keeping, CIS had been very for maintaining the records as a huge amount of data is generated from the ICU every day. Proper maintenance of this data is essential for effective treatment and it takes a long time for maintaining such a huge data. Nurses devote a large portion of time in documentation and therefore, the quality of patient care decreases due to reduced duration of direct patient care.  However, in most of the studies, implementation of CIS had a positive impact on patient care as the load of documentation was reduced and the nurses could devote more time to direct patient care. This invariably increased the quality of patient care and therefore, the findings from the articles from this section of literature review were aligned with the topic of the present research and the selection of the articles proved to be fruitful in finding the significance of the research topic, as a prologue. 

References

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Amarasingham, R., Plantinga, L., Diener-West, M., Gaskin, D. J., & Powe, N. R. (2009). Clinical information technologies and inpatient outcomes: a multiple hospital study. Archives of internal medicine, 169(2), 108-114.

Amarasingham, R., Pronovost, P. J., Diener-West, M., Goeschel, C., Dorman, T., Thiemann, D. R., & Powe, N. R. (2007). Measuring clinical information technology in the ICU setting: application in a quality improvement collaborative. Journal of the American Medical Informatics Association, 14(3), 288-294.

Ammenwerth, E., Brender, J., Nykänen, P., Prokosch, H. U., Rigby, M., & Talmon, J. (2004). Visions and strategies to improve evaluation of health information systems: Reflections and lessons based on the HIS-EVAL workshop in Innsbruck. International journal of medical informatics, 73(6), 479-491.

Ammenwerth, E., Gräber, S., Herrmann, G., Bürkle, T., & König, J. (2003). Evaluation of health information systems—problems and challenges.International journal of medical informatics, 71(2), 125-135.

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