Practical Guide to Clinical Computing Systems

Design, Operations, and Infrastructure

Thomas Payne

• Publisher: Academic Press
• Year: 2014
• ISBN:
  9780127999197
• Edition: 2
• Topic: Computer Science
• Subtopic: Bioinformatics
• Index: Computer Science

Although informatics trainees and practitioners who assume operational computing roles in their organization may have reasonably advanced understanding of theoretical informatics, many are unfamiliar with the practical topics - such as downtime procedures, interface engines, user support, JCAHO compliance, and budgets - which will become the mainstay of their working lives.

Practical Guide to Clinical Computing Systems 2nd edition helps prepare these individuals for the electronic age of health care delivery. It is also designed for those who migrate into clinical computing operations roles from within their health care organization. A new group of people interested in this book are those preparing for Clinical Informatics board certification in the US.

The work provides particular differentiation from the popular first edition in four areas:

• 40% more content detailing the many practical aspects of clinical informatics.
• Addresses the specific needs of the Clinical Informatics board certification course – for which it is presently recommended by the ABPM
• Focus on new tech paradigms including cloud computing and concurrency – for this rapidly changing field.

• Focuses on the practical aspects of operating clinical computing systems in medical centers rather than abstruse theory
• Provides deepened and broadened authorship with a global panel of contributors providing new wisdom and new perspectives - reflecting inclusion of the first edition on the clinical informatics study guide materials
• Presents a practical treatment of workday but often unfamiliar issues – downtime procedures, interface engines, user support, JCAHO compliance, and budgets

Chapter 1

Introduction and Overview of Clinical Computing Systems within a Medical Center

Thomas H. Payne Medical Director, Information Technology Services, UW Medicine
Associate Professor, Department of Medicine; Adjunct Associate Professor
Department of Biomedical Informatics and Medical Education and Department of Health Services, University of Washington, Seattle, WA USA

Abstract

Clinical computing systems—defined computing systems used in direct patient care—are commonplace in healthcare organizations and growing dramatically in importance. Clinical laboratories and hospital business offices were the first to adopt computing systems within hospitals, but today electronic medical record systems (EMRs) and computerized practitioner order entry (CPOE) are being installed in many medical centers globally and are integrally tied to clinical care. Most medical centers could not run efficiently without their clinical computing systems. The purpose of this book is to help readers learn about the design, operations, governance, regulation, staffing, and other practical aspects essential to successfully operating clinical computing systems within in a healthcare organization.

Keywords

electronic medical record

computerized practitioner order entry

picture archiving and communication systems

clinical computing systems

errors

IT problems

Contents

1. The healthcare setting 2

2. Rising dependence on clinical computing systems 3

3. The importance of computing operations and support 3

4. Importance of monitoring performance 5

5. Real-world problems and their implications 6

6. Introducing clinical computing systems can introduce errors 7

7. We need greater emphasis on safe operations of clinical computing systems 8

References 8

Clinical computing systems—defined computing systems used in direct patient care—are commonplace in healthcare organizations and growing dramatically in importance. Clinical laboratories and hospital business offices were the first to adopt computing systems within hospitals, but today electronic medical record systems (EMRs) and computerized practitioner order entry (CPOE) are being installed in many medical centers globally and are integrally tied to clinical care. Most medical centers could not run efficiently without their clinical computing systems.

It’s challenging to install clinical computing systems such as electronic medical record systems, but it is arguably even more difficult to keep them continuously available, 24 hours every day of the year, even at 2am on New Year’s Day. Operating these systems over the long term requires planning for expansion, replacing hardware, hiring and training staff, promptly helping clinicians with application questions, avoiding and correcting network outages, upgrading hardware and software, creating new interfaces between systems, and myriad other tasks that are often unnoticed by clinicians who use them. Yet these tasks must be accomplished to continue to accrue advantages from sophisticated clinical computing systems in which organizations have invested so much.

The informatics literature focuses a great deal of attention on implementing clinical computing systems, and managing the change this entails. This is not surprising, since the transition from paper to electronic systems is usually more difficult than expected. Much less attention has been devoted to the critical tasks involved in keeping systems continuously running and available to their users. This requires understanding of long-term issues—the marathon of continuous, reliable operation rather than the sprint of implementation.

Successfully operating clinical computing systems is easier if you learn the fundamentals of how they work, even if you recruit and hire people who know more about the fundamentals than you do. All those involved in the long-term operation of clinical computing systems may benefit from this fundamental background. That is the purpose of this book: to help readers learn about the design, operations, governance, regulation, staffing, and other practical aspects essential to successfully operating clinical computing systems within in a healthcare organization.

1 The healthcare setting

Healthcare is delivered in many settings, but in this book we will concentrate on medical centers and large clinics. Both of these settings have higher volumes and pace than was true 20 years ago. For example, Harborview Medical Center and the University of Washington Medical Center in Seattle, Washington, where many of this book’s authors are based, are filled beyond their designed capacity many days each year. Harborview’s average occupancy in 2006 was 97%. Emergency room volumes are rising, with 50–70 of the 300 patients seen at Harborview Medical Center daily ill enough to warrant immediate admission. The number of intensive care unit beds is rising at both Harborview and UW Medical Cerner, because of increasing need to care for critically ill patients. The pressure of hospitals filled to capacity leads to more patients being treated in clinics or the emergency room, and as a consequence clinics treat more complicated medical problems than in the past. The pressure of high patient volumes along with pressures to constrain healthcare costs and to improve quality and efficiency have led many organizations to turn to approaches used successfully in other sectors of society, including process improvement techniques and adoption of information technology.

2 Rising dependence on clinical computing systems

The volume of information clinicians use in day-to-day care has risen over the last 50 years. Imaging studies such as chest films are increasingly acquired, stored, and displayed in digital form. Computerized tomography and magnetic resonance imaging studies have always been acquired digitally. As the number and resolution of these patient images has risen, picture archiving and communication systems (PACS) are commonly used instead of folders containing acetate X-ray films. Paper records are commonly scanned and displayed on workstations. Physicians, nurses, and others are increasingly entering notes and orders electronically and viewing medical records using EMRs. Laboratories and pharmacies have long used computing systems to manage their departments. Critical care units capture enormous volumes of patient information such as vascular pressures, mechanical ventilator data, heart monitoring data, and other information from bedside devices. Often these data are gathered, summarized, and displayed for clinicians using computing systems. Because of pressures from patient volumes, acuity, and reimbursement rules, there are strong incentives to manage and act on clinical information rapidly and efficiently; clinical computing systems help make this possible. As a consequence, many hospital leaders feel that fundamental hospital operations depend on reliable availability of clinical computing systems. It simply would not be possible to deliver care to as many patients or to efficiently manage a medical center if paper systems alone were used on wards, intensive care units, and support departments.

In many countries including the United States, reimbursement for care and budgets are more commonly tied to performance and to the health of populations of patients. Understanding the health status of large numbers of people and the quality of the care they receive requires automation. Assuming risk for delivering that care makes better understanding of health status and utilization patterns that clinical computing systems can provide. And to meet the promise of a learning healthcare system, we must understand which measures we take to preserve and regain health are effective, and which are not. Again, automation of the process of care is essential.

3 The importance of computing operations and support

Because of this dependence, clinical informatics has an increasingly important practical side. This has been true for decades, but clinical computing operations have become even more critical as paper-based patient care processes are automated. CPOE, electronic documentation, bar coded administration of medication, PACS systems, results review, remote access, ICU systems, and others have increased clinicians’ dependence on reliable, fast access to clinical computing systems. Phrases such as “five 9s,” long familiar to the telecommunications industry, are now heard in hospitals to signify standards for availability far above 99.9% of the time, which would leave clinicians without their systems 0.1% of the time, or 43 minutes each month.

It is important to develop or select, configure, and install clinical computing systems successfully, but to the degree that clinicians grow to depend on them, continuous availability becomes more important. The need for reliable clinical computing systems continues long after the excitement of the initial installation has come and gone. The bar is continuously being raised, and once raised, it is not lowered without disruption, risk, and upset clinicians. Hospitals and clinics have rising volumes and pressure for increased productivity, which computing systems can help.

Backup systems must be present to protect against unplanned system downtime. But backup systems are no substitute for system reliability, because moving to and from backup systems carries risk. To the degree that systems are more reliable, paper backup systems may become unfamiliar to medical center staff. The transition to and from paper backup systems can create harm. For example, when downtime affects entry of orders, orders that were in the process of being entered when downtime occurred are not received by the filling department. The clinician may delay entering more orders because of uncertainty over whether the electronic CPOE system will soon be brought back online. If the assessment is that the downtime will last longer than the organizational threshold to move to paper ordering, then the clinician may decide to re-enter orders on paper and continue doing so until the announcement that the CPOE system is again available for order entry. Orders that had been entered on paper may then be “back entered” so that the electronic order list is again complete. During the transition from electronic to paper, and then from paper to electronic orders, order transmission is delayed, and there is a risk that orders will either be missed or entered twice, either of which could be hazardous to patients. Though procedures are usually in place to reduce risk of these hazards, if 10,000 orders are entered each day in the organization (seven orders each minute) and there are three hour-long unscheduled downtimes a year, the likelihood of error-free communication of all 1260 orders entered during these downtimes is low.

Causes for system outages are highly variable. For the last 12 years, I have logged emails I receive describing clinical computing system problems that have affected University of Washington clinical areas, and though my log is incomplete, there are over 3000 entries. Causes include construction mishaps severing cables between our hospitals, technical staff entering commands into the wrong terminal session on a workstation, air conditioning system failures, users mistakenly plugging two ends of a network cable into adjacent wall ports, denial of service attacks launched from virus-infected servers on our hospital wards, planned downtime for switch to daylight savings time, and many others. The healthcare system has much to learn from the aviation industry’s safety advances. Jumbo jet flights are safe because of a combination of standards, simplified engine design (turbine rather than piston engines), rigorously followed checklists and policies, redundancy, careful system monitoring, and many other advances learned from meticulous investigation when things go wrong. Medical center clinical computing systems can be made to be safer and more reliable by using the same approaches, yet we are only beginning to do so.

With each new clinical computing application or upgrade, complexity rises, and the infrastructure on which these systems rest carries a higher burden. When one studies these systems and learns from those who keep them running how complex they are, it leaves one with a sense of amazement that they run as well as they do. This is coupled with an impress...

Table of contents

• Cover image
• Title page
• Table of Contents
• Dedication
• Copyright
• Contributors
• Preface to the Second Edition
• Preface to the First Edition
• Chapter 1: Introduction and Overview of Clinical Computing Systems within a Medical Center
• Chapter 2: Architecture of Clinical Computing Systems
• Chapter 3: Creating and Supporting Interfaces
• Chapter 4: Infrastructure
• Chapter 5: Security
• Chapter 6: From Project to Operations: Planning to Avoid Problems
• Chapter 7: Implementation and Transition to Operations
• Chapter 8: Troubleshooting: What Can Go Wrong and How to Fix It
• Chapter 9: Working with the User Community
• Chapter 10: Health Information Management and the EMR
• Chapter 11: Legal Issues in Medical Records/Health Information Management
• Chapter 12: Working with Organizational Leadership
• Chapter 13: Careers in Biomedical Informatics and Clinical Computing
• Index