1. Current and Emerging Use of Clinical Information Systems
Chapter 5

2. Outline Clinical Information Systems Definition and Functions
Electronic health record/Electronic medical record
Computerized provider order entry
Medication Administration
Telehealth and Telemedicine
Definition and Functions
Current Use of Systems
Factors Influencing Adoption
Value of Systems
Barriers to Diffusion

3. EMR Adoption in Hospitals

4. Adoption of EHR
Meaningful Use of Electronic Health Records, April 2011 through May 2012.

10. Electronic Medical Record
MRI Five Levels of Computerization
Level 1: Automated Medical Record
Level 2: Computerized Medical Record System
Level 3: Electronic Medical Record
Level 4: Electronic Patient Record
Level 5: Electronic Health Record

11. Five Levels of Computerization (Figure 5.1)

13. Value of EMR Improved quality, outcomes and safety
Computerized reminders and alerts
Improved compliance with practice guidelines
Reduction in medical errors
Improved efficiency, productivity, and cost reduction

14. Value of EMR continued Improved service and satisfaction
Patient satisfaction
User satisfaction
Less stress
Improved job satisfaction
Quality of documentation

15. Other major types of CIS
Computerized provider order entry (CPOE)
Medication administration using barcoding
Telemedicine
Telehealth—for our purposes, we will focus on online communication (e.g. ) between patients and providers

16. CPOE
Computerized Provider Order Entry, at its most basic level, is a computer application that accepts physicians orders electronically, replacing handwritten or verbal orders and prescriptions. Most CPOE systems provide physicians with decision-support capabilities at the point of ordering.

17. What is CPOE?
Electronic entry of physician orders and instructions for treatment
Order entry at point-of-care or off site
Communication over a network to medical staff
Integration of various departments (radiology, laboratory, etc..)
A trend that is being implemented and used in hospitals and facilities in increasing numbers today. It is the process of entering orders and treatment instructions by the physician for patients under their care. It can be done in the hospital or facility in which the patient is admitted but also provides the ability for MD’s to enter orders off site in places such as their home. It links the various departments of the hospital when orders are entered, such as triggering the lab about lab work that was ordered and radiology departments on tests ordered and schedule times. In a sense the department responsible for filling or carrying out the order that was entered is informed via the computer network.
(Wikipedia, 2010)

18. What is CPOE, continued Replacer of hand-written orders
Immediate alerting of allergies or contraindications at point of entry
Real-time clinical decision support
Supports access to patient data
CPOE eliminates the need for hand-written orders. As an order is entered in to the system, allergies or possible contraindications for the patient are immediately alerted to the physician before final submission. The real-time support also provides duplicate therapy warnings, alternate dosage and/or alternate medication suggestions. Allows the physician access to patient data and assessment information potentially needed for the decision making.
(Open Clinical, 2006)

19. CPOE Hardware Desktop Computer Laptop Computer on Wheels
PDA (Personal Digital Assistant)
PALM Pilot
CPOE software can be placed and utilized on many different types of hardware. Typically placed on desktop computers for use. It can also be utilized mobilely on laptops and PDA’s or PALM handheld computers.

20. CPOE Software Provider Order System
Multiple manufacturers
Cerner
McKesson
Eclipsys
Siemens
Quadramed
HMS
Meditech
May be coupled with Clinical Decision Support Systems (CDSS)
Many companies manufacture types of Computer Provider Order Entry systems. Most CPOE systems are combined with Clinical Decision Support Systems that reduce errors and decrease costs.
(MedicExchange, 2010)

21. Cerner CPOE Offers single solution to automate workflow Capabilities:
Enter orders
Check orders
Document
Communicate
Evaluate patient status
(Cerner Corporation, 2010)

22. Cerner CPOE, continued Benefits with Cerner: Improve patient safety
Save time
Save money
Enhance communication
Reduce errors
Easy-to-use
(Cerner Corporation, 2010)

23. CPOE Usability Evaluated with indicators: Ease of use Ease of learning
Satisfaction
Efficiency of use
Error tolerance
Fit of system to task
(McGonigle, D. & Mastrian, K., 2009)

24. CPOE Usability, continued
Most often implemented in large academic medical centers
25-27% of U.S. hospitals over 200 beds using CPOE
11.3% of U.S. hospitals actively using CPOE (physicians entering >50% of orders)
Currently 291 hospitals that use CPOE at the 100% level
Most CPOE sites also using barcode scanning
(Hess, J., 2010)

25. CPOE System Ensures standardized and complete orders
Increases patient safety by reducing errors
Automates workflow
Supports ready access to patient data and assessment
Improves efficiency by integrating multiple departments
Provides order sets for easier use
(Open Clinical, 2006)

26. CPOE Advantages Direct entry of orders into EMR
Replaces handwritten orders
Cross reference for potential drug- interactions or allergies
Reduces wait times for patients
Improves compliance with best practices
Ready access to patient data
CPOE has more documented advantages than disadvantages. CPOE allows for many positive results not only for the staff that utilize it but patients as well.
(Open Clinical, 2006)

27. Advantages, continued Improves patient safety
Potential to improve efficiency
Cost saving benefits by:
Reducing number of duplicate tests
Reducing errors
(Open Clinical, 2006)

28. CPOE Disadvantages Cost User resistance
Personalization for individual hospitals
Potential for integration issues with other systems
Disruption of workflow with employee training
CPOE is expensive to implement and maintain.
(Open Clinical, 2006)

29. Informatics Competencies
Basic knowledge of computer usage
Three levels of competencies:
Technical
Utility
Leadership

30. Informatics Competencies, continued
Technical:
Web
Expert data systems
Nursing and Hospital information systems
Multimedia
Telecommunication devices
(Kaminski, 2009)

31. Competencies, continued
Utility:
Process of using computers and other technology
Leadership:
Ethical issues with using computers
Management issues with using computers
(Kaminski, 2009)

33. Barriers to CPOE use Physician entry an issue
Takes longer to place order; many systems are ‘cumbersome’, take too many steps
Incentives may not be aligned with use
Lack of confidence in system reliability
Insufficient training
Mandating use – should you?

34. Medication administration
Use of barcoding becoming more widespread
Aids in correctly identifying patient, drug, dose, etc.
HIMSS implementation guide—good resource
More widely accepted
Has been used successfully by many health care organizations
Again, has potential to aid in making sure the right meds, get to the right patient, at the right dose…

35. Fitting Pieces Together (Figure 5.9)

36. Barriers to Adoption Financial (acquisition and support)
Organizational or Behavioral (user acceptance)
Technical (need for standards, integration)

37. Strategies for Overcoming Barriers
What strategies are being employed to help overcome—
Financial barriers?
Behavioral barriers?
Technical barriers?

38. Summary
Examined 5 different clinical information systems—their current use, status, and value
Discussed the three major barriers to adoption of these systems—financial, behavioral and technical and strategies to overcome them