IMPLEMENTING and UPGRADING CLINICAL INFORMATION SYSTEM What is Clinical Information System? It is designed to support clinical nursing practice.

. The skills required to deliver direct patient care necessities the ability to coordinate patient care involving multiple disciplines and departments. A CIS assists clinicians with data necessary for decision-making and problem solving. The components of a CIS must interact in much coordinated fashion. A CIS must serve the organization and the patient in much the same way an efficient health care delivery system. MAJOR CIS REQUIREMENTS for NURSING CARE Administer a nursing care department Assist the management of nursing practice Assist nursing education Support nursing research The implementation of clinical information is a process introducing an application or information system to an organization, ensuring full benefit and potential of the system. The ability to manage change often marks the difference between success and failure of implementing a change initiative and moving an organization(Ritter and Glaser, 1994)

each phase generally result in system failure in one or more following areas: CIS does not meet the stated goal of the project There is a failure to gain end-user acceptance. Expenditure exceed budget. Anticipated benefits are unrealized. The PLANNING PHASE Begins once an organization has determined that an existing need or problem may be filled or solved by the development or implementation of a CIS or application. Establishing committee framework to research and make recommendations for the project is an important first step. CIS Committee Structure and Project Staff Nursing administrators involvement is the paramount to success of the project Assigning appropriate resources, whether financial or personnel, is a critical success factor. Transition management is a series of deliberate, planned interventions undertaken to assure successful adaptation/assimilation of a desired outcome into an organization. A three-tiered committee approach is recommended to accomplish the design, implementation or upgrading of a complete CIS: Steering committee Project team Departmental teams CIS Steering Committee This committee generally includes representatives from the following areas: Hospital administration/hospital finance Nursing administration Medical staff Information system department at the director or manager level Major ancillary departments(laboratory, radiology, pharmacy, dietary, medical

Eight Phases of Implementation Planning System Analysis System Design/System Selection Development Testing Training Implementation Evaluation Attempting to implement or upgrade a system without accomplishing the task associated with

records/patient registration, patient accounting) Health information management(medical records) Legal affairs Outside consultants(as needed) Other appointed members(as needed)

motivational skills DEPARTMENTAL TEAMS The charge of the departmental teams is to: to thoroughly understand the departments information needs. to gain a full understanding of the softwares features and functions to merge the new systems capabilities with the departments operations to assist in the system testing effort to participate in developing and conducting end-user education to provide a high level of support during the in initial activation period of the new system. PLANNING During this phase, the information requirements necessary to solve the problem or accomplished the goal are assessed. In the American Society for Testing Materials (ASTM) standards, the planning phase is referred to as the project definition. Commercial software developers and consultants rank this phase as the most critical factor in the selection of a system Excellent planning is time consuming and seemingly costly. The process can take up to 2 years to design and develop or to select and implement a new system. The planning phase involves the following steps: Definition of the problem and/or stated goal Feasibility of the study Documentation and negotiation of project scope Allocation of resources Definition of the Problem Precisely is essential and often not readily apparent not until the information requirements are precisely define real characteristics be revealed.

The CIS steering committee: Provides oversight guidance to the selection and integration of a new CIS into organization. May need to meet frequently during early planning phase and implementation phase, less frequent during middle stages. Project Team Led by an appointed project manager and includes a designated team leader for each of the major departments affected by system selection, implementation, or upgrade proposes. OBJECTIVES of the Project Team Understand the technology and technology restrictions, if any Understand the impact of interdepartmental decisions Make decisions at the interdepartmental level for the overall good of the CIS within the organization Become the key resource for their application A stated goal for the selection, implementation, or upgrading of a CIS is to improve patient care. The project teams ability to evaluate multiple departments information desires in light of the capabilities of the proposed system is important to the overall success of the project. The project manager is responsible for managing all aspects of the project. It includes software application software development, hardware, and networks. The project manager must have: good communication facilitation organizational

 When updating or expanding the CIS, the project definition includes the identification of equipment currently available, its age, the degree of amortization, and the need for hardware or operating system software upgrades prior to undertaking an upgrade project Feasibility Study Preliminary analysis to determine if the proposed problem can be solved by the implementation of a CI or component application. Helps to identify the information needs, objectives, and scope of the project. Helps the CIS steering committee understand the real problem by analyzing multiple parameters and by presenting possible solutions. The feasibility study seeks to answer the following questions: What is the real problem to be solved and/or stated to be met? Where does the project fit into the overall strategic plan of the organization? What specific outcomes are expected from the project? What are the measurable criteria for determining project success from the above outcomes? What research and assumptions support the implementation project? What are the known limitations and risks to the project? What is the timing of the remaining phases of the project? Who will be committed to implementing the project? What are the estimated costs in both dollars and personnel time? What is the justification for the project, including the relationship between costs and benefits? A feasibility study includes the following topic areas: Statement of the objectives Environmental assessment

Determination of information needs Determination of scope Development of a project timeline Recommendations

Documentation and Negotiation of a Project Scope Agreement Drafted by the project team and submitted to projects steering committee for acceptance. It includes: Scope of the project Application level management requirements Proposed activation strategy for implementing the CIS or application Technical management and personnel who will maintain the equipment Allocation of Resources Last step in planning phase Determining what resources are required to successfully complete the project scope agreement. Points to be considered when planning for resources Present staffing workload Human resources(number of personnel, experience and abilities and percentage of dedicated time to the project) Present cost of operation Relationship of implementation events with nonproject events Anticipated training costs Space availability Current and anticipated equipment requirements for the project team

System Analysis Phase fact finding phase where all the data requirements related to the problem defined in the project scope agreement are collected and analyzed to gain a sound understanding of the current system, how it is used and what is needed from the new system.

 Process analysis is foundational to the actual system design since it examines the objectives and project scope in terms of the end user requirements, the flow of information in daily operation and the processing of required data elements. Through the analysis effort, the individual data elements, interfaces and decision points of the project are identified. The importance of this phase should not be under estimated. Design changes during this phase often add minimal costs to the project As the project progresses to the development and implementation phase, the cost of programmatic or design changes increases dramatically. The system analysis phase consists of the following five steps: Data collection Data analysis Data review Benefits identification System proposal development -it sets forth the problems and goals and the requirements for the new systems overall design. It outlines the standards, documentation, and procedures for management control of the project and it defines the information required, the necessary resource, anticipated benefits, a detailed work plan, and projected costs for the new system. It furnishes the committee recommendations concerning proposed CIS. Data Collection -the collection of data reflecting the existing problem or goal is the first step in the system analysis phase. Two important documents are created as a result of data collection: The first is the creation of a workflow document for each major goal or problem to be resolved by the implementation of the new software or system The second is a functional design document outlining how the new system will resolve the identified goals/problem Data Analysis it is the analysis of the collected data and it provides the data for development

of an overview of the nursing problem and/or stated goal defined in the project scope agreement. Data Review the third step in analysis phase is to review the data collected in the feasibility study, the workflow documents, and the functional specification and provide recommendations to the project steering committee for the new system. Benefits identification The overall anticipated benefits from the system are documented in the fourth step in the system analysis process. The proposed benefits statements become the criteria for measuring the success of the project. System Proposal Development it sets forth the problems and goals and the requirements for the new systems overall design. It outlines the standards, documentation, and procedures for management control of the project and it defines the information required, the necessary resources, anticipated benefits, a detailed work plan, and projected costs for the new system. It furnishes the committee recommendations concerning proposed CIS. The System Design phase The design details of the system and the detailed plans for implementing the system are developed for both functional and technical components of the system. There are three major steps in the system design phase: Functional specifications Technical specifications Implementation planning Functional specifications -uses the functional design document developed in the system analysis phase of a CIS and builds on the design by formulating a description of all system inputs, outputs and processing logic required to complete the scope of the project. It further refines

what the proposed system will encompass and provides framework for its operation Data manipulation and output -the departmental teams and users determine what the actual data will look like in its output form and gain consensus from departmental teams for the proposed design. Technical specifications-technical personnel work closely with the project and departmental teams to ensure the technical components of the proposed system work in concert with technology and end user needs to assist in the development of the implementation plan. There are four major areas: Hardware (select hardware) Application software (develop software) Interface systems (transmit data) Conversions (conversion of data from legacy system to new system) Implementation planning- the last step in the system design phase is to establish a detailed implementation plan. This plan coordinates all tasks necessary to complete the development of new software, implement a new system, sand/or upgrade a current system Whether the project is software development or the implementation or upgrading of a system, the implementation work plan details the following: Personnel Timeframes Costs and Budgets Facilities and equipment required Development or implementation tasks Human-computer interactions Operational considerations system test plan These areas are detailed in an implementation work plan encompassing 14 steps: 1. Project Planning/Administration 2. Hardware & Software Delivery 3. Application Administration 4. Application Verification

5. Team Leader Training 6. Conversion & Interface Planning 7. Building Database (files & tables) 8. Policies and Procedures 9. Peripheral Device identification 10. Functional Test 11. Integrated Test 12. End User Training 13. Live Operations 14. Post Implementation Evaluation If the project steering committee decides to develop its own system programs, the project staff must proceed with the development phase of the system, which includes the following: Select Hardware Develop Software Test System Document System TESTING PHASE The system, whether newly developed or commercially available, must be tested to ensure that all data are processed correctly and the outputs are generated. Testing verifies that the computer programs are written correctly and ensures that when implemented in the production environment, the system will function as planned. Systems are tested to determine if the programming protocols are used correctly and if programs execute correctly. Alpha testing accomplished by testing group within development organization; focuses on entire application or system. Beta testing occurs at the first client site. When commercially available software is being implemented, three levels of testing are recommended. The first level is often called a function test. During this round of testing, the departmental teams and verify the database, ensuring that correct data have been entered into the files and table. The expected departmental reports are reviewed to assure correctness and accuracy. Multiple interaction of functional test often occurs until the department team is

confident about the system profile and setup. The final round of testing occurs during end-user training. As more users interact with the new system, previous unfound problem may surface. Evaluation of the severity of the newly discovered problems and the corrective action required is an ongoing process during implementation DOCUMENT SYSTEM The preparation of documents to describe the system for all users is an ongoing activity, with the development of the documentation occurring as the various system phases and steps are completed. Documentation should begin with the final system proposal. Several manuals can be used that provide guides to the system components and outline how the entire system has been programmed or defined. USERS MANUAL Highlights how to use the system and describes what outputs the system can produce REFERENCE MANUAL Used by the project team members to understand how the system works. It describes what data are input, how the databases process the data, and the mechanisms used to generate outputs OPERATORS MAINTENANCE MANUAL Enables operators to keep the system up and running by providing the functional and technical specifications needed for the system. Manuals should be written in sufficient detail such that the system users and operators understand how the system was developed, how it operates, and how it can be maintained, updated, and repaired. TRAINING PHASE It is essential to train the end users on how to use the system properly

A CIS will function only as well as its users understand its operations and the operation streamline the work TWO LEVELS OF TRAINING: 1. The project team and selected members of the departmental team receive training from the developer or vendor. This training details the database, processing logic and outputs of all the systems features and functions. 2. End-user training, takes place once the departmental and project teams have finished profiling the system to meet the functional testing has been completed. This training stresses how the user will complete his or her workflow using the new system. Training on the new system should occur no more than 6 weeks. When the training occurs for more than 6 weeks before the activation of the new system, additional refresher training is often required by the end-users. Training of the nursing department usually requires the development of a separate training plan. The large number of nursing staff members to be trained necessitates a significant amount of advanced planning Training is the most effective when handson, interactive instruction is provided. Training guides or manuals explains the system; however, retention of information is increased if the learners are able to interact with the new system in a manner stimulating their workflow with the new system Computer-assisted instructions (CAI) -a teaching process that uses a computer in the presentation of instructional materials, often in a way that requires the student to interact with it. Also called computer-assisted learning. in a special training room or on the units can be used to provide hands-on experience.

 End-user training offered 2 perspectives: a general overview of the system explains how the user will interact with the system to his or her daily work. While a users/training manual is developed for the training sessions, most end-users express the desire to have a pocket size reminder (cheat sheet) outlining the key functions of the new system. Establishing a training lab as well as providing access to the training environment from the departments and nursing units prior to the activation of the new system provides end users the opportunity to practice at times convenient to their work requirements and reinforces the training. IMPLEMENTATION PHASE Organizes all the steps into a detailed plan describing the series of events required to begin using the system or application in the production or live environment and details the necessary computer and software maintenance operations required to keep the systems running. This phase ensures that once the system is installed in the live environment, the systems and the delivery of the healthcare in the organization will run smoothly. The go live work plan includes a detailed description of the preparation steps required for all facets of the system, the timing requirements to accomplish the tasks, the defining elements indicating the completion of the critical task and the party responsible for determining if the criteria to progress in the plan have been met. Detailed in this plan: The activation of interfaces The timing of the final conversion of the data (if any) into the new system And the activation activities for each of the nursing units and departments.

Four activation approaches are possible: Parallel Pilot Phased-in Big bang theory Parallel approach- the new system runs parallel with the existing system until users can adjust. Pilot approach- a few departments or units try out the new system to see how it works and then help other units or departments to use it. Phased-in approach- the system is implemented by one unit or department at a time. Big bang approach- a cut-over date and time are established for the organization, the old system is stopped, and all units/departments begin processing on the newly installed system. A command center is established to coordinate all issues, concerns and go live health desk functions. Team members and trainers often serve as resources to the end users on a 24-hour basis for a period of time post implementation. Sometimes called super users, these team members are available in the departments and on the nursing units to proactively assist user during the first on the 1-2 weeks of productive use of the new system or application. The coordination of all activities requires a cohesive team effort. THE EVALUATION PHASE The evaluation phase describes and assesses, in detail, the new systems performance. The evaluation process summarizes the entire system, identifying the both the strengths and weaknesses of the implementation process. To evaluate an implemented hospital information system, many principles are important for CISs. One authority suggests

evaluating duplication of efforts and data entry, fragmentation, misplaced work, complexity, bottlenecks, review/approval process, error reporting (or the amount of reworking of content), movement, wait time, delays, setup, low importance outputs, and unimportant outputs. This evaluation component becomes a continuous phase in total quality management. Other approaches to evaluating the functional performance of a system exist. Investigating such functions as administrative control, medical/nursing orders, charting and documentation, and retrieval and management reports are used to assess system benefits. Each of these areas is evaluated through time observations, work sampling, operational audits, and surveys.