1. Badger, Kathy

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After years of struggling to have clinical processes even considered for automation, we are now at the forefront of an informatics revolution-with the clinical information system (CIS) as an important topic. Indeed, in many institutions, the CIS is driving information services strategic plans, budgeted allocations, and resource consumption. Yet, CIS development has been slow and costly.


Rapid health care industry changes make the development of CIS difficult. Whereas trends toward managed care and increased ambulatory services are clear, the detail upon which to build a sound clinical informatics plan is not as apparent. For instance, precisely which outcomes should be captured in a CIS is still a topic of debate. In addition, as the marketplace shifts its focus toward the CIS arena, new systems and new functionality will clutter the field and make choices about CIS more complex for nurse executives and nurse information specialists. Unfortunately, nursing is still in its infancy in developing the knowledge and skills required to select, customize, and fully utilize the technological advances of the information age. The following future CIS attributes should help guide nurse executives and nurse information specialists in their CIS decisions.


The Clinical Information System of the Future

Whereas the number of acute care beds may be dwindling overall, the acuity of the patient population in those beds is increasing. The CIS of the future must handle more acute care monitoring as well as documenting critical bedside procedures. Systems are being developed to decrease the incidence of redundant data entry by automatically collecting information from bedside patient care equipment and providing easy methods to copy valid parameters from previously documented assessments. Charting methods that have proven efficient in manual form, such as charting by exception and PIE (Plan, Intervene, Evaluate), are being adapted into automated systems. Data entry and display devices are becoming smaller and more portable, increasing their adaptability to point-of-care use.


As the patient population in acute care settings changes, the care delivery process also must change. Less costly means of caring for the acute patient population are being created, resulting in changes in the skill mix of patient care providers. Vendors are aware that CIS flexibility in supporting an evolving model of care delivery may determine a company's viability in the marketplace. Increasingly, documentation modules in the CIS are becoming more multidisciplinary in nature, and data are being presented to all caregivers in an integrated fashion.


Organizing and Managing Care

Clinicians will need to be presented with a variety of tools to organize their workload. System functionality already has moved from one simple, nondifferentiated task list to integrated task lists sorted by each level or type of caregiver involved in providing services. Simple system reminder messages have evolved into patient activity schedules and "to do" displays for the caregiver that include not only direct patient care functions but also indirect and support activities as well. End-of-shift report information is being "flagged" in some systems based on pre-set criteria and then collated and presented to the oncoming group of caregivers. This ensures that salient information is communicated without tying up both shifts of caregivers for inordinate amounts of time. Although not yet widely available, the emergence of tools integrating patient care tasks across multiple patients should be commonplace in the next-generation CIS.


An increase in ambulatory care combined with the fluidity of patient movement across the care spectrum will result in the demand for a CIS that processes and moves data seamlessly between settings, treatment modalities, and geographical boundaries. A sophisticated documentation and analysis system is crucial for tracking patient progress, monitoring deviation from a predetermined clinical pathway, and managing patient outcomes throughout an entire clinical course. Clinical information systems are just beginning to incorporate clinical pathway functionality, primarily for use with inpatient populations. This functionality will expand as the manual use of these tools becomes more prevalent.


Quality of Clinical Decisions

Clinical decision-making will be made on at least two important levels, individual and aggregate patient data. First, individual patient clinical decisions must be driven by comprehensive, accurate, and timely data collection and analysis. Clinicians must have data available to them when needed. Also, because individual clinicians may cognitively process data differently, multiple presentation options must be provided. In this way, the clinicians' ability to consider all salient parameters during treatment decisions will be enhanced.


Several CIS have expanded data display options to include a variety of graphs and textual formats. Some systems are using full-body line drawing to depict the location, size, and other attributes of wounds, lesions, and clinically significant surface abnormalities. Technology can allow the display of diagnostic quality radiographic images and the ability to store pictures, for example, charting the healing progress of a wound; however, the technology is used infrequently at point of care currently because of expense and space considerations. In the future, these images will need to be integrated into CIS patient records. Similarly, the use of sound in clinical systems has been limited to storing dictated notes or issuing alert signals. In future CIS, the use of sound technology will be expanded to support the recording of clinical sounds, such as breath sounds or cardiac murmurs, with playback on demand. Clinicians could then compare these attributes and determine patient progress.


Aggregate patient data forms the second needed level. Aggregate patient data has impact on clinical business management and decisions faced by institutions. Therefore, the efficacy of clinical processes in the entire institution must be examined critically. This critical examination can be accomplished only with appropriate data collection and analysis techniques within supporting CIS. Until now, much of the effort to collect and analyze aggregate information for patient outcomes has focused on physician practice. The institution that remains competitive in the future will be the one able to determine the best practices across all clinical disciplines. Additionally, contributions toward patient outcomes will need to be correlated to particular multidisciplinary groups and their changes in practice. Clinical information systems of the future must provide these aggregated data.


Clinical decision-making also will be aided by access to a variety of general and context-specific information and knowledge sources. Many institutions and CIS vendors are exploring access to professional literature, the Internet, and other sources of expert information and advice.



A combination of factors affecting the health care delivery system will impact the tools used by clinicians to deliver and document care. These factors include: a changing patient population, new therapies and technologies, and an increased emphasis on the effectiveness and efficiency of clinical services. To support these trends, future CIS must have both quantity and quality of data and information, and also the flexibility to migrate to newer care delivery and documentation methods.


As the specialty of nursing informatics has gained credibility, experienced clinicians have become more vocal in expressing the needs of the nursing profession. With vendors' keen interest in expanding CIS functionality, nurses should not hesitate to take the lead in defining patient care automation needs, exploring opportunities to use existing technologies in new ways, and staying abreast of emerging applications in clinical information systems.