CareNet and UPMC- St. Margaretâ€™s Emergency Department 1

CareNet and UPMC- St. Margaret’s Emergency Department 1

The Process of Adopting and Implementing an Electronic Health Record: One Emergency

Department’s Experience with CareNet

Nancy Gorsha, Ellen Mering, and Audra Ziegenfuss

University of Pittsburgh, School of Nursing

Introduction to Nursing Informatics (NURSP 2075)

Dr. Deborah Lewis, EdD, CRNP, MPH

December 6, 2004


Abstract

The University of Pittsburgh Medical Center (UPMC) St. Margaret’s Hospital (SMH) has

recently implemented a computer information system (CIS) using Cerner Corporation software

application products. SMH was chosen to pilot the implementation of CareNet, a software

application designed for record keeping in acute care settings. The Emergency Department (ED)

has a unique patient flow and unique priorities compared to the rest of the hospital, and CareNet

facilitates documentation by automating the ED’s workflow. Consequently the ED has

encountered its own set of implementation issues that are gradually being resolved through a

variety of strategies developed by SMH’s eRecord team. Nurses are involved in each part of

CareNet’s life cycle. Their involvement has a direct impact on user satisfaction and success of

the CIS. Both the end-users and information system can be considered integrated parts of a

whole, both capable of influencing change in the other.


Table of contents

Abstract……………………………………………………………………………………….2

Introduction…………………………………………………………………………………................5

Organizational Information

Organization of the Information Management Department……………………………..6

Accreditation………………………………………………………………………………….10

Evolution of the Information System………………………………………………………10

Motivations and Objectives…………………………………………………………….......14

Future Plans……………………………………………………………………………….…16

Adapting to the Change/Stage of Life Cycle…………………………………………..…18

Information System Design and Development

End-Users…………………………………………………………………………………….21

Selection of Vendor………………………………………………………………………….21

System Architecture……………………………………………………………………..….22

HL7 Standards……………………………………………………………………………....23

If the System Fails………………………………………………………………………..…23

Security…………………………………………………………………………………..…..24

The Internet: Information to Health Care Users and Ensuring Quality…………....25

Information System Applications

Organization…………………………………………………………………………………26

Utilization……………………………………………………………………………….…. 34

Support and Satisfaction………………………………………………………….….……42


Analysis

Socio-technical Perspective………………………………………………………………48

How the Information System Influences the Organization……………………………50

How the Organization Influences the Information System……………………………54

Conclusion……………………………………………………………………………………………56

References……………………………………………………………………………………………58


It is October 5, 2004. In a meeting room on the ground floor of the University of

Pittsburgh Medical Center St. Margaret’s Hospital, a multidisciplinary team of health care

providers have gathered to assess problems in the Emergency Department (ED) which have

arisen from the September 11th

go-live of SMH’s new computer information system (CIS) less

than a month before. A nurse, a physician and a department secretary each represent their

colleagues in the ED. Several administrators overseeing the project are also in attendance. One

by one the problems are considered. A physician expresses frustration at the length of time it

takes to input orders with the new system. “It may be only an extra 30 seconds,” he comments,

“but it adds up” (J. Nicholas, personal communication, October 5, 2004). A discussion follows

about physician order sets and the importance of making sure that physicians understand their

usefulness as early in the process as possible. A nurse reports on the inconvenience of chasing

after the computers on wheels (COW) (A. Culleiton, personal communication, October 5, 2004).

She is reminded that computers will not be installed in each room in the ED until SMH’s new

ED opens in 2005. For now the nurses must understand and endure. With each problem the

question arises, does something need to be changed or is this just part of the process of adjusting

to the new technology? As the physician facilitating the meeting puts it, “This is the house we

live in now. We may just need to get used to it. It’s not going away” (J. Diamond, personal

communication, October 5, 2004).

The discussion in this room is just one of many discussions in a process that has led to the

institution of a pilot CIS system at SMH. The CIS that has recently been installed at SMH will

serve as a model that will eventually be implemented in most of the other hospitals in the UPMC

health system. In fact, there is a good likelihood that other regional hospitals not part of UPMC

will eventually share information with UPMC’s information system. SMH’s go-live is the result


of four intensive years of work on a project which has required complex organizational structure,

extensive design and development and has led to the implementation of a variety of software

applications, specifically CareNet, in use in SMH’s emergency department.

Organizational Information

Organization of the Information Management Department

UPMC St. Margaret’s information management department is called the Information

Systems Department (ISD). The organizational chart shown in Figure 1 shows how this

department fits into the organizational structure at SMH.

Figure 1. SMH Organizational Chart

Chief Information Officer (CIO) Donna McCormick reports to David Martin, the president and

Chief Executive Officer of SMH. The information management department is organized into

three functional responsibilities. These responsibilities include management and maintenance of

the telecommunications network, management and maintenance of information systems at SMH

and oversight of SMH’s eRecord project.

The eRecord project that Donna McCormick leads at SMH, is a part of a UPMC wide

initiative to create a paperless medical record that will eventually be accessible to all UPMC


hospitals and affiliated physicians. In 2004 UPMC changed the name of this initiative from

Electronic Health Record Project to eRecord. Documents created before 2004 use the earlier

name.

The UPMC information system is divided into two zones that use the eRecord, a

community zone and a core zone. The core zone is comprised of academic centers such as

UPMC Presbyterian and Montefiore hospitals. The community zone includes nonacademic

hospitals within the UPMC health system.

The eRecord project team at SMH has its own organizational structure which is

illustrated in Figure 2 (see following page) Figure 2 shows the overall organization of the

eRecord project within UPMC as a whole and indicates how SMH’s eRecord project team fits

into this organization.

SMH’s team is one of several eRecord project teams within the UPMC system.

Since the software that is used at UPMC is developed by Cerner Corporation, CIO Donna

McCormick and a Cerner representative oversee the eRecord project at SMH. A project

management team reports directly to Donna McCormick. This team oversees separate groups

that focus on each of the different software applications that are in use at SMH, such as CareNet

and PharmNet. Two other teams are involved with training and creating reports. Donna

McCormick is a member of a cabinet that consists of SMH’s CEO, representative physicians and

other administrators who play a role in eRecord development. Three advisory committees report

directly to the CIO. These committees include an application and technology committee, a

physician advisory committee and what is called a champion committee. (See Figure 3, p. 9).


D. Drawbaugh, Chairman

eRecord Leadership

Committee

Dave Martin, CEO

UPMC SMH

Executive Sponsor

Donna McCormick,

CIO, UPMC SMH

eRecord

Project Lead

Dave Hunker

Application Project

Manager

Chuck Rudek

Technical Project

Manager

Kim Morea

Surginet

PCRR

Reports

CareNETClinical-

Documentation

Orders

Kevin Conway

Charge Services

Training Specialists

FirstNET/VERSUS

PharmNET

Clinical Reporting

Chris Zuk, LAN II

Adam Maloney LAN I

ISD Staff

Deb Wolf, Director

Clinical-Operational

Informatics

Chair, SMH Champions

Deb Wolf, Business & Metrics

J. Stogoski, Workflow Optimization

M. Josefowki, Communication

S. Evans, Education

N. Gorsha, Policies & Procedures

C. Girt, Physician Engagement

T. Wolfhope, Job Impact

I. Arndt, Stakeholder

P. Dzubinski, Financial Oversight

eRecord Organizational Chart

UPMC SMH

Figure 2. SMH eRecord Organization

___________________________________________________________________

Reprinted with permission of Donna McCormick, CIO, (2004).


Figure 3. eRecord Program Governance

__________________________________________________________________________________________

Reprinted with permission of Donna McCormick, CIO, (2004).

Champion’s chairperson, Debra Wolf, heads the champion’s committee. This committee

is designed to facilitate communication between the end users, eRecord project managers and

directors. Nine staff leaders, known as champions, monitor a variety of issues many of which

directly affect end users. For example, Nancy Gorsha is in charge of monitoring and trouble

shooting policy and procedure issues which arise from the implementation of the new CIS.

Other champions monitor such things as job impact, educational needs, physician’s issues and

workflow optimization. Debra Wolf, in addition to being the champion’s chairperson, monitors


business metrics. Among other duties this role includes evaluation of the benchmarks by which

the effectiveness of the CIS is gauged. All of the champions are in close contact with end-users.

The champion’s concept will be revisited as part of the discussion of nurses’ roles and the

management of CareNet.

Accreditation

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) accredits SMH.

The hospital is also required to comply with Pennsylvania Department of Health regulations. In

addition, in order to receive Medicare and Medicaid reimbursements, SMH must comply with

the regulations that guide reimbursement for these federal programs. Further, The Health

Insurance Portability and Accountability Act of 1996 (HIPPA) has developed national standards

for privacy and security of health data. SMH is required to comply with these standards.

Finally, the Clinical Laboratory Improvement Amendments (CLIA) certifies SMH’s lab. This is

a requirement in order for SMH to receive Medicare or Medicaid reimbursement.

Evolution of the Information System

Planning for the implementation of a CIS system at SMH began in March of 2003 but the

steps that led to SMH’s key role in the implementation of UPMC’s system began back in 1998.

In 1998, UPMC signed an agreement with Cerner Corporation, a health care software provider,

for what CIO, Donna McCormick described as “a handful of products” (personal communication

Oct. 26, 2004). These included; Power Chart Results Review, software designed for the

hospital clinical and diagnostic results, SurgiNet, software designed for the operating room,

PharmNet, software designed for the hospital pharmacy, CareNet, software designed fro acute

care management and FirstNet, software designed for the ED.


A small team was developed to implement these software packages and UPMC

Presbyterian Hospital was chosen to pilot the project. The idea was that a large hospital, already

at the cutting edge of technology would be better able to absorb the change that would be

involved in automating certain record keeping functions. The implementation did not proceed as

well as the planners hoped. Getting the software applications up and running was a struggle. In

fact, although First Net and SurgiNet are still in use at UPMC Presbyterian today, physician and

staff resistance made it impossible to successfully implement CareNet. Six years later, CareNet

is up and running at SMH but in 1998 it was an idea whose time had not yet come.

At this point, UPMC reconsidered its approach. The organization stopped thinking small

and began to build the big team which eventually selected SMH as an early adopter of the

software used in the eRecord project. Donna McCormick was brought on board in 2000. By this

time, UPMC had committed itself to what Donna McCormick refers to as the Enterprise Solution

(personal communication Oct. 26, 2004). In 2000, UPMC signed a 12 year contract with Cerner

Corporation to acquire access to the whole suite of healthcare software applications produced by

the company. In addition, UPMC acquired a deep discount of 80% on Cerner acquired software

developed by third parties (other companies with which Cerner has contractual agreements). For

example, if a third party associated with Cerner developed software that could scan documents

into the computer record, UPMC could acquire the software at a deeply reduced price.

In 2001, UPMC hired the health care consulting firm Cap Gemini Ernst & Young who

were paid approximately 20 million dollars, to help guide the process of adopting a CIS. This

18-month project led to the development of what is referred to as the “franchise model” (D.

McCormick, personal communication Oct. 26, 2004).


Development of the franchise model occurred in two stages. In the first stage the concept

model was developed. This was done through a serious of “rapid design sessions” (D.

McCormick, personal communication Oct. 26, 2004). These sessions lasted from one to three

days and involved large groups of health system clinical staff, selected to represent every role

within the UPMC health system. Fifteen to twenty design sessions were held and each session

was run by a facilitator and a record keeper who took notes on the content discussed in the

sessions. During the sessions, each job function that could be automated was broken into steps

and examined in detail. For example, a physician might walk through every step involved in

ordering a lab test. The goal was to design a model that accurately incorporated each step of all

the processes required by the health practitioners who used them. The goal was also to develop

a model that would drive best practice and standardize clinical procedure. If a health provider’s

description of a procedure did not match best practice then ideally the procedure would be

modified within the model to better support best practice.

Eventually, the conceptual model was formed. Meanwhile the Electronic Health Record

Team had evaluated which hospital might be suitable to pilot the new model. It was assumed

that the model would need adjustments; and that instituting the model would be a learning

experience, not just for the hospital that took on this task, but also for UPMC as a whole. UPMC

sought a medium size hospital whose leadership was interested and willing to take on this

challenge. Physician buy-in was considered essential. The team also sought a financially sound

hospital whose budget and assets could help support the process. SMH fulfilled all of these

requirements (D. McCormick, personal communication Oct. 26, 2004).

Besides choosing St, Margaret to pilot the new information system, team members

created paper versions of forms that looked like the screens that practitioners would be using


with the new computer system. When these new forms were created, members of the team

gathered up all the forms currently in use throughout the UPMC health system and replaced them

with the new forms. The purpose, of course, was to help ease the eventual transition to the

computer by getting health providers used to the new formats in advance. The new forms also

helped to standardize practice throughout the system. In some cases the new forms changed

practice. For example, the policy for nursing assessments changed from narrative documentation

to charting by exception (D. McCormick, personal communication Oct. 26, 2004).

SMH is not the only hospital that has recently implemented new software. In 2002,

UPMC Children’s Hospital of Pittsburgh implemented computerized provider order entry, a

component of CareNET. Children’s Hospital used the champion’s team system that SMH

subsequently adopted as a result of Children’s positive experience. (D. McCormick, personal

communication, September 17, 2004).

One of the first stages of SMH’s implementation of the new system was an investment of

$150,000 to remodel a part of one of the buildings at the hospital in order to create a training

room, offices and a meeting room for the team members who would be involved in the

implementation project. The team that moved into these rooms was made up of members of the

original eRecord team that had been involved with the central planning for the eRecord for all of

UPMC (D. McCormick, personal communication Oct. 26, 2004). Debra Wolf was brought in to

chair the Champion’s team. With Jackie Stogoski’s help, members of the Champion’s team were

gradually selected from SMH’s staff from among those who showed interest in various aspects

of the project (Debra Wolf, personal communication, November 2, 2004).


Motivations and Objectives

Debra Wolf commented that many of UPMC’s objectives and motivations for use of the

system were not formally identified by the organization before beginning the work of developing

the system. (Debra Wolf, personal communication, November 2, 2004). Nevertheless, the

reasons for developing the system were apparent to the team members involved in the

development of the system.

Several factors motivated the UPMC health system to engage in the huge project of

developing a CIS ambitious enough to include a plan to link most of the regions health care

records together in a single network. The Institute of Medicines groundbreaking report To Err is

Human (1999) had a big impact on medical institutions. This report called on regulators and

accreditors to develop higher standards of safety within health institutions. Much of the

systematic standardization called for would clearly require an automated system. It seemed

apparent that this report would influence government regulatory policies as well as JCAHO

accreditation guidelines.

In 1998, the LeapFrog Group was formed when a group of large employers came

together to discuss the best way to work together to use purchasing power to influence the

quality and affordability of healthcare (LeapFrog Group, n.d.). After the Institute of Medicine

issued its report in 1999 the LeapFrog Group increased its focus on safety. Leapfrog is

essentially a consumer advocacy group. As Donna McCormick notes, “Consumers drive change

in healthcare and are a force that healthcare systems cannot get away from” (D. McCormick,

personal communication, October 26, 2004).

Debra Wolf also noted other motivations for implementing a CIS system at UPMC.

(Debra Wolf, personal communication, November 2, 2004). First UPMC’s leaders predicted


that in the long run, the CIS would translate into more profit for the organization. This profit

would presumably come from greater efficiency, increased patient safety and an enhanced

reputation for being at the cutting edge. UPMC clearly hopes that this combination will continue

to give it the competitive edge in the region. “UPMC,” Debra Wolf notes, “wants to be on the

cutting edge when it comes to technology” (Debra Wolf, personal communication, November 2,

2004).

Besides the general motivations that prompted UPMC to embark on this project, SMH

has identified several specific benchmarks to use to gauge the success of the project.

(Electronic Health Record Benchmarking Committee Summary, 2003) Although the

benchmarks were not expressed as objectives, they indicate specific areas that SMH plans to

analyze in the post CIS implementation go-live environment. A rough summary of those

benchmarks that are currently relevant is included in Table 1.


Table 1

Values for Comparison Before and After Implementation

Operating Room Services Clinical Documentation Pharmacist/ Medication

Errors

Cost per service and per

procedure

% Patient pain education # of clarifications made by

pharmacist on medication

orders

Time needed to schedule

cases

% monitoring effects of

medication on patient

# Omission errors

Documentation compliance % pain assessment # Improper dose errors

# of cases % advanced directive

documentation

# Extra dose errors

# of OR minutes per 24

hour period

Costs of printing test results # Wrong drug errors

# of minutes per day for

inpatient OR and outpatient

OR

Utilization of standardized

nursing documents

#Unauthorized drug errors

Since the system has the capability of generating reports that are tailored to the questions

and concerns of the users, documentation and assessment of the identified benchmarks and other

concerns is an ongoing process. Because SMH’s CIS system has been up and running for less

than three months, not all of the analysis spelled out in the benchmark report has been

completed.

Future Plans

Both UPMC and SMH have plans for additional change in their use of information

technology in the next five years and beyond. SMH’s eRecord team will continue to educate its

stakeholders in the use of the newly implemented technology. CIO Donna McCormick notes

that ongoing feedback and problem solving meetings will continue to contribute to the

refinement and improvement of the existing applications. (D. McCormick, personal

communication, October 26, 2004). Furthermore, she expects that design session meetings will

continue to be held to help envision future changes in the system. SMH is also currently

building a new ED. When the new ED is completed in January of 2005, SMH will introduce


another Cerner soft ware package FirstNet that is specifically designed for use in an Emergency

Department (D. McCormick, personal communication, October 17, 2004).

In the broader picture, UPMC has introduced many of the same software packages in use

at SMH in several of its area hospitals including Presbyterian Hospital, Shadyside Hospital, the

Hillman Pittsburgh Cancer Institute and Bedford Hospital. In 2005 UPMC plans to bring

Passavant on line. In that same year, UPMC plans to institute what it calls the Health Economic

Architecture (HEA) (D. McCormick, personal communication, October 17, 2004). This term

refers to the capability of having all sites within the UPMC health system have access to all

patient eRecords within the system.

UPMC’s plans for future development of its information system go even beyond linking

institutions within the UPMC health system to patient records. UPMC plans ultimately to create

a system that will centralize medical information within the region. McCormick described the

plan as “like a utility service” for health providers outside of the UPMC network. (D.

McCormick, personal communication, October 26, 2004). Instead of smaller networks of health

providers building their own information system from scratch, they would have access to

UPMC’s system for a monthly fee.

The federal government has expressed interest in such an initiative. In late September of

2004, Dr. David Brailer, Information Technology Coordinator for the United States Department

of Health and Human Services, visited Pittsburgh to examine UPMC’s eRecord

accomplishments. According to the Pittsburgh Post Gazette, Dr. Brailer’s goal was to consider

whether UPMC’s initiatives might be used as a model for similar systems that might be

developed across the country (Snowbeck, C., 2004).


Adapting to the Change/ Stage of Life Cycle

SMH put a lot of effort and planning into preparing its staff for the changes that would

come with the new information system. In the early stages, a readiness assessment survey

(UPMC St. Margaret Electronic Health Record Readiness Assessment, 2003) was distributed to

all staff at SMH to evaluate attitudes toward technological change. An analysis of survey results,

including recommendations based on these results, was presented to Champion committee

members in October 2003 (St. Margaret Hospital EHR Project Readiness Assessment Summary,

Oct. 22, 2003). Revised and standardized forms that mirrored the screens that practitioners would

ultimately be using with the Cerner software were developed and put into use. The champion

system promoted ongoing communication with end users. All staff were required to participate in

training classes within at least two months of the go-live date. After implementation, follow up

trouble shooting sessions focusing on different user groups in the hospital or on specific issues

were held regularly.

Almost three months after going live, SMH is still in the process of adapting to the

change. Many minor glitches were worked out fairly early. For example, CareNet computer

provider order entry had a screen that was programmed to request the wrong dosage of a

medicine. Also, a few screens would not “pull through.” That is information from an order

entry screen would not appear on a summary screen (J. Nicholas, personal communication,

October 5, 2004). Physicians in the ED quickly learned the value of physician order sets, which

are standardized orders packages for frequent use situations. The packages can be modified as

needed. Extra steps were painfully noted in some of the ordering procedures and were

eliminated. Methods for communicating problems were also developed. For example, in the ER

a problem list is now kept on a clipboard by a central computer. Minor glitches produced their


share of grumbling and hair pulling but in general many small problems seem to have been dealt

with fairly efficiently through improved communication and regular problem solving sessions (J.

Nicholas, personal communication, October 5, 2004).

Many staff are still adapting, not so much to the particulars of the new technology but to

the overall change of working in a paperless environment. Some complain that their electronic

documentation takes longer than paper documentation. Team members argue that there is a

learning curve but that in the long run electronic documentation should allow more time for

patient contact. (D. Wolf, personal communication, November 2, 2004).

Meanwhile the new system is fine tuned and adjusted one problem at a time.

An electronic suggestion box is reviewed daily. For the first two months system support staff

called rounders visited units to respond to problems. These rounders reported back on any

patterns that the saw in users adapting to the new environment. Multidisciplinary trouble

shooting meetings still continue on a regular basis (D. Wolf, personal communication, November

2, 2004).

Having gone live less than three months ago, SMH is clearly at the initiation stage of the

organization-wide information life cycle. Douglas (2001) divides the implementation stage in 14

steps. Of these steps SMH is clearly in the final step or “post implementation evaluation”

(Douglas, M., p. 215). In terms of UPMC as a whole one might argue that UPMC is in the

expansion phase of developing an organization wide information system. SMH has played a key

role in this expansion. The refinements that occur from the implementation at SMH should help

for smoother implementations at other health care facilities within the UPMC system.

Aarts (2004) notes, “the introduction of information systems in health care practices is a

thoroughly social process in which both the technology and the practice are transformed” (Aarts,


p.208). Debra Wolf (D. Wolf, personal communication, November 2, 2004) emphatically agreed

with this statement. When asked to give specific examples of some of the ways in which

practice has been transformed, she made the point that the physicians are more accountable

under the new system. “There are so many details that physicians used to assume that nurses

would follow up on,” she observed. “Now they’re accountable for them. They have to

document everything. It’s changed the way that physicians think about orders” (D. Wolf,

personal communication, November 2, 2004).

Information System Design and Development

Selection of the Information System

UPMC went through two stages of its information system design and development. In

the first stage UPMC Presbyterian was selected as the hospital to pilot adaptation of new

software. At that stage UPMC’s information system department (ISD) was involved in system

design decisions. According to Maureen Bradley (M. Bradley, personal communication,

October 24, 2004), team leader in charge of testing, people who played a key role in the

implementation of this information system were ISD Director Sean O’Rourke, ISD Associate

Director Suzanne Paone, and ISD Client Services Manager Sandy DePellegrini.

In the second stage, the Enterprise agreement gave UPMC access to the complete range

of Cerner software. Donna McCormick (D. McCormick, personal communication, October 26,

2004) recalls that at this stage UPMC CIO Dan Drawbaugh, eRecord Executive Director Dan

Martich MD, ISD Director Sean O’Rourke, ISD Director Paul Sikora, Darinda Sutton, UPMC

Director of Nursing Informatics and Gail Wolf, UPMC Chief Nursing Officer, played key roles.

End-users were not involved in the selection process.


End-users

Although end-users were not involved in the selection of the software supplier, they were

intensely integrated into the development of the information system. This was evident in the

early use of rapid design sessions that drew on users from every role within the UPMC system in

order to study the detailed steps of every procedure that might be impacted by the new

information system. Once the project had moved to SMH, the early assessment of end-users

needs with the Electronic Health Record Readiness Assessment Survey and the champion

concept insured that end-users would continue to have significant input into the development of

the system. SMH CIO, Donna McCormick notes that nurses had input in the design of the new

system from the very start when paper forms were designed to reflect future Cerner screens (D.

McCormick, personal communication, October 26, 2004).

Selection of Vendor

UPMC’s system vendor is Cerner Corporation. Cerner was the chosen vendor for the new

software applications but there was a need for the Cerner applications to communicate with other

existing applications such as Sunquest, the lab application and IDXRad the radiology

application. According to McCormick, these ancillary systems have to “map a code to talk in

HL7” (D. McCormick, personal communication, October 26, 2004).

The decision to use Cerner was made in 2000. At that time the choice of possible

vendors was narrowed to Epic Systems and Cerner, both companies specialize in health care

information systems. The decision went to Cerner since this company had more of a focus on

inpatient care than Epic which had created more software for the out patient world of physician’s

offices (D. McCormick, personal communication, October 26, 2004).


System Architecture

McHugh (2001) notes that the term architecture “refers to how communication among the

various computers is accomplished” (McHugh, M. L., p. 64). Broadly speaking SMH can be

said to have a broadcast network architecture. In a broadcast network the same information is

transmitted “to all the computers in the network that are expected to respond to it” (McHugh, M.

L., p. 64). Broadcast networks contrast with point to point networks in which information is sent

to a specific computer.

Cerner describes the architecture of its systems as “three-tiered, distributed, client server

model” (Cerner Corporation, 2004). According to McHugh (2001, p. 64), a client-server model

“awaits and fulfills requests from client programs in the same or other computers.” The three

tiers of Cerner’s architecture are the client, the middleware and the database. The software

applications function at the client tier. The middleware connects the client to the database and

plays a role in transferring data in both directions between the client and the database. The

databases stores and organize both long term data that is used repeatedly and active data that is

entered by the system users (Cerner Corporation, 2004). UPMC has a local area network

(LAN); the computers are interconnected within the organization. Computers can be connected

in different ways. In other words, they can have different topologies. SMH has what is known as

a bus topology. In a bus topology all of the computers are connected “in parallel to each other”

(McHugh, M. L., p. 64). With a parallel connection, “if one computer fails, other computers can

still access the information” (McHugh, M. L., p. 64).

The UPMC system architecture consists of four very large computers called Regattas

(trade name). SMH system architecture currently resides on three of the four Regattas. Each

Regatta is comprised of nodes. Each node is dedicated to one aspect of the clinical information


process that is referred to as a domain. Each process/domain (DEV or development, TST or test,

MOK or mock, PRP or pre-production, and PRD or production) of the UPMC clinical

information system is shared between more than one Regatta. The sharing insures that, should

there be a failure in one of the nodes, the entire UPMC system would not be crippled. For

instance, when a new software application or new code (feature, function, fix of broken things) is

introduced into the UPMC Health System, the application/code is first introduced/tested in the

H2TST domain. If everything goes well, the system is switched over to/testes in the H2MOK

domain. Once success is achieved in H2MOK, the code/application is moved into the H2PRP

(pre-production) domain. The code/application moves from H2MOK to H2PRP twice before it

is transitioned into H2PRD domain (actual use in real time). The community zone currently

utilizes domains existing in nodes on three of the four UPMC Regattas. (D. McCormick,

personal communication, November 22, 2004).

HL7 Standards

According to Maureen Bradley, the CIS at SMH and its ancillary functions, comply with

Health Level Seven (HL7) standards (M. Bradley, personal communication, Oct. 24, 2004).

HL7 is an organization founded in 1987 whose mission is to provide international standards “for

the exchange, management and integration of data that support clinical patient care, and the

management and delivery of healthcare services”(HL7 in the 21st Century, 2000). The interface

standards that HL7 provides will be invaluable in implementing UPMC’s long term goals of

providing health care professionals throughout the region with access to patient records.

If the System Fails

If the system goes down in a paperless hospital environment the consequences could be

disastrous. Every health provider within the hospital is dependent on the system in order to


provide appropriate and timely care to his or her patient. Debra Wolf, Director of Clinical and

Operational Informatics, spelled out the contingency plans that St. Margaret has developed for

just such a scenario. (D. Wolf, personal communication, November 2, 2004). She explained that

three separate down time reports are run behind the scenes. A 36 hour summary report is created

which includes lab and test results, a report listing the current medications the patient is on with

the last dose given and a report listing the patient’s active orders. These reports are sent from the

network, at varying time intervals, to the hard drive of a non-network computer in the Nursing

Administration Office. If the network fails, the Nursing Administration office can access the

hard drive to produce a print copy of the information listed above.

SMH also schedules down time on a regular basis once a month for computer

maintenance. A schedule of planned downtime comes out annually. Most computer

maintenance issues can be taken care of during this planned downtime. SMH has a scheduled

down time policy for each of the different types of users on the system. For example, the

pharmacy can get a printed copy of the MAR during a scheduled down time. (D. Wolf, personal

communication, November 2, 2004).

Security

Security is an enormous priority in any health care CIS. As the Institute of Medicine

points out (Crossing the Quality Gap, 2001), “automated records can make it much easier for

hackers to assemble lists or find (or alter) information about individuals.” HIPPA privacy rules

have accented the importance of good security in CIS which store and transfer patient data.

Security breaches like the University of Minnesota glitch in which the identities of 410 deceased

kidney donors were accidentally revealed (Gross, 2002) have sent a clear warning to all

healthcare systems that information security cannot be taken casually. According to Maureen


Bradley (M. Bradley, personal communication, Oct 24, 2004) there is a standard Security Policy

for the Cerner system that is in compliance with ISD Security and HIPPA Standards and all

security issues, concerns and requests adhere to these policies.

UPMC and SMH have developed a security system that will both prevent users within the

system from gaining access to patient information that is not relevant to their practice and will

prevent hackers outside the system from gaining access to patient information. Debra Wolf

(D.Wolf, personal communication, November 2, 2004) explained that users within the system

leave an electronic fingerprint in the form of a login each time that user enters a patient medical

record. A history of clinician access to patient charts is randomly audited. A highly visible

patient, such as a celebrity might also have their medical records audited to make sure that only

authorized users have visited their charts.

Debra Wolf also claims that hacking into UPMC’s system would be a formidable task.

“UPMC’s firewall is incredible,” she noted. She added that before the current firewall was

installed a virus did successfully get into the network and “destroyed a lot of hardware” (D.

Wolf, personal communication, November 2, 2004).

Currently some users, mostly physicians, are able to access SMH’s CIS from outside the

hospital through a portal. Security codes are required for access through the portal and before

the user can log into the UPMC system every application in use on his or her computer must be

closed.

The Internet: Information to Health Care Users and Ensuring Quality

According to Maureen Bradley (M. Bradley, personal communication, Oct 24, 2004)

decisions about consumer health information on the internet come from several sources at SMH.


She lists health plan managers, the community relations department, corporate communications

and ISD as departments that participate in such decisions.

The internet is used to communicate information to healthcare customers on UPMC’s

webpage (University of Pittsburgh Medical Center, n.d.). This web page includes seven different

categories of information, “diseases & conditions,” “medicine cabinet,” “health tools,” “UPMC

Classes & Events,” “Health Sciences Library,” “Patient Education Materials” and “Schools of

the Health Sciences” (UPMC, n.d.) Health on Net Foundation (HON) has given UPMC a 97%

rating for the quality of its internet healthcare information (HON, n.d.).

Information System Applications

Organization

Enterprise Applications and Estimated Annual Clinical Information Systems Costs

There are numerous eRecord applications in clinical use within the larger University of

Pittsburgh Medical Center (UPMC) (see Table 2). These are part of UPMC’s agreement with

Cerner when they negotiated a figure encompassing an enterprise of applications rather than a

limited set. As a component of the UPMC Health System, SMH also has these systems

available. Although all of these applications have not currently been implemented at SMH, their

implementation is an option of the near future. CareNet Acute Care Management System, the

focus of this review, is a sub-component of PowerChart. PowerChart is the name for the

eRecord. Of the three applications that PowerChart offers (Enterprise Clinical Data Repository,

Enterprise Order Management, and Enterprise Documentation Management), CareNet is the

name of the documentation management application. A brief description of both PowerChart

and CareNet are given in Table 2, but a detailed description will follow in the discussion on the

application’s support of nursing practice.


Table 2

Clinical Applications Currently in Use in the UPMC Network

Application Description

Ambulatory Computerized Physician Order

Entry Medication (EasyScript)

EasyScript is used for medication ordering

within the eRecord. Drug interactions and

allergies are checked and automatic updates to

the patient’s eRecord made.

Clinical Documentation & Orders Entry

(CareNet)

CareNet integrates nursing and physician care

by automating documentation and orders.

Emergency Department (FirstNet) FirstNet is integrated into PowerChart and is a

patient tracking and triage system.

Health Economy Architecture (HEA) HEA integrates many computer environments

across the UPMC network and provides for

continuity of care including the aggregation of

clinical information.

HealthTrak- UPMC Patient Portal This web-based application allowing patients

to be pro-active in their health care decisions.

Outpatient Practice Management (PowerChart

Office)

Multifunctional use is the key to this outpatient

practice management system. Its scope

supports both clinical and business activities

occurring in private practice.

MedTrak- UPMC Physician Portal MedTrak links inpatient and outpatient realms

for continuity of care both within and outside

the UPMC network.

Pharmacy Management (PharmNet) This is part of eRecord and provides

medication order entry, intravenous fill lists,

and medication administration records.

Positive Patient Identification (PPID) Barcode technology ensures the five rights of

medication administration are being met.

Results Review (PowerChart) Multi-disciplinary face of eRecord providing

an interactive, graphical user interface.

Single Sign On (CCOW/ Sentillion) Only one login per session is needed for

eRecord users to maintain the same patient

between applications.

Specialty Laboratory Management System

(PathNet)

Clinical and management applications are

automated and integrated into eRecord. It also

automates the process of organ transplant

services across UPMC.

Structured Clinical Documentation

(PowerNote)

Care documentation and ordering are

combined and alleviates the repetition

physicians encounter during note taking.

Surgical Scheduling and Documentation

(SurgiNet)

SurgiNet provides electronic surgical case

scheduling, picklists, intra-operative

documentation, and automated charging. Note. Adapted from ERecord status report. (2004, September). Copy Editor, 2-4.


D. McCormick (personal communication, October 26, 2004), the Chief Information

Officer at UPMC- St. Margaret, discussed the costs involved in design and development,

implementation, and support of the electronic health records. As previously mentioned, SMH

was targeted for participation, since its financial status enabled support for the implementation.

Monetary costs involve three items of interest: cost of hardware and software, cost of education,

and intellectual resources (Simpson & McCormick, 2001). UPMC negotiated a twelve-year, $40

million dollar agreement with Cerner Corporation for the suite of software applications and

discounts on third party agreements. Of the $4.7 million dollars budgeted for SMH capital costs,

$1.5 million dollars was allotted toward the required hardware. In order to prepare SMH for the

upcoming information system, $250, 000 was allocated for implementation and support.

Education and intellectual resources fall under the capital annual budget for information science

(IS) services, and UPMC allowed for $50-60 million dollars toward these services for the entire

health system. Half of the initial IS figure was intended for implementation of the eRecord. For

the 2005 fiscal year, SMH has a budget of $1.5 million dollars in capital costs.

Relationship Between Administrative and Clinical Components

The clinical data input of CareNet provides the opportunity for administrative aggregate

analysis. The Institute of Medicine (2001, pp. 170-171) claims that “automated clinical and

administrative data enable …[assessments] of clinical outcomes…and care processes;

identification of best practice; and evaluation of effects of different methods of financing,

organizing, and delivering services.” Performance improvement measures provide a link between

the administrative and clinical components of CareNet. There are corporate benchmarks that the

UPMC Health System is targeting for performance improvement. These include community

acquired pneumonia, congestive heart failure, acute myocardial infarction, and central line


infection. Theoretically, the functions of CareNet should theoretically facilitate improvements in

these areas by enhancing patient care. Performance improvement targets specific to the

Emergency Department are (1) leaving the Emergency Department prior to or following being

seen by a physician, (2) inquiries concerning a patient’s financial information prior to triage, (3)

length of stay, (4) and the use of moderate sedation. CareNet, and other components of the

greater clinical information system, also help facilitate improvements in these areas by forcing

health care providers to assess and evaluate a number of different aspects of their delivery of

patient care.

SMH’s own set of benchmarks was discussed earlier. SMH has developed an initiative to

improve and standardize clinical documentation through benchmarking particular areas for

measurement prior to and following implementation of the electronic health record (Electronic

Health Record Benchmarking Committee, 2003). Two targeted areas are advance directive

documentation which was only 61% compliant in September, 2003 and the time to admit a

patient to a general medical-surgical unit. Benchmarking is a quality assurance tactic and

important in the delivery of quality health care (D. Wolf, personal communication, November 3,

2004). Reports are generated on the benchmarked items and reviewed for quality assurance and

performance improvement. Currently it is not simple to retrieve data on any new item of interest

or query an investigator might have. The reports have to be customized, planned and scheduled

and are a time-consuming effort.

In addition to benchmarking, administrative and clinical components meet at the billing

function. Cerner applications send Charge Description Master (CDM) codes to the UPMC

billing system (McKesson’s MediPac) which is the patient billing application (D.McCormick,

personal communication, November 8, 2004). This is an automated function of the Cerner


applications and cuts down on the time it takes for coding done by an employee devoted to that

function.

Finally, another source of interrelatedness of administrative and clinical components

takes place not within CareNet, but rather, outside the technology and in the meeting room. Both

administrators and clinicians, the end users of the administrative and clinical components, work

as a team to promote successful pre-implementation, implementation, and post-implementation

phases of the clinical information system. Relationships are formed among these

multidisciplinary groups of people. The success of the eRecord, comprised of CareNet and other

applications of the clinical information system, is the ultimate goal.

Nurses Roles in the Management of CareNet and other Applications

The success of the clinical information system is “increasingly dependent upon how well

the people and organizational issues are managed” (Lorenzi, Riley, Blyth, Southon, & Dixon,

1997, p. 79). Nurses are one group of primary end-users of the clinical applications, specifically

CareNet. Nurses do the majority of documentation and are held accountable for errors and

impediments to correct and accurate data recording. Therefore, it is logical that they should be

involved early in the process of adopting a new clinical information system. M. Berg (1999, p.

94) recognizes the need for a user-centered system and understands that being user-centered

involves more than “[graphical user interfaces], good communication or adequate training

programs.” Berg suggests that the end-users need to be the driving force behind design and

implementation and involved “early, thoroughly, and systematically” (Berg, 1999, p. 94).

Involving nurses in the process aids in the preparation and acceptance of the impact a

new system has on the organization. Organizational change will occur as a result of the

information system, but the information system must also change in response to the end-users


needs. Nurse management of the information system facilitates this process. Lorenzi et al.

(1997) use Field Theory to explain the need for nurse involvement in the change process. Field

theory is based on the need for involvement of the people within the change to motivate them to

make it a success. If there is no involvement there will be no motivation, and the change might

be seen as a threat. Nurse involvement might be considered a tactic with positive impacts such

as having more involved staff, a better understanding of the influence of the changes on the

organization, a better understanding of the changes, and an enhanced ability to cope with the

changes (Lorenzi et al., 1997).

One specific example of how nurses manage the clinical information system are the use

of champions and superusers. Champions and superusers are nurses and physicians who act as

liaisons between their professional groups using the applications and the administrators

mandating them. The champion role begins early in the design and development process and

evolves into the post-implementation phase. The restructuring phase occurring after

implementation also involves nurses, but not as champions. Nurses’ roles as champions and

restructuring entities will be the focus of the next two sections.

Champions. The role of champions in the management of clinical applications is the

foundation for an increased acceptance of change. Champions do not serve a passive role in

success of the information system. They are involved in the “aggressive seeking of inputs at the

earliest possible stages of the overall process. . . . with continuous feedback on the status of the

inputs and detailed explanations of why some inputs cannot be utilized or implemented”

(Lorenzi et al., 1997, p. 88). J. Ash (1997, p. 103) describes champions as those who take

creative ideas and “bring them to life.” According to Ash, their contribution may include

promoting the new idea, building support, dampening resistance, and facilitating implementation.


The champion structure (see Figure 4) is composed of nurses, administrators, and

physicians assigned specific roles. While acting within their roles, the champions act to create a

“smooth landing” for the end-users and facilitate communication between the project team and

the end-users. Champions allow the organization to influence the information system and the

information system to influence the organization.

Figure 4. St. Margaret Hospital’s Champion Structure.

___________________________________________________________________ Reprinted with permission from D. Wolf, Director of Nursing and Operational Informatics (2004).

Three topics of user involvement are discussed by Lorenzi et al. (1997). These include

cognitive, motivational, and situational topics. Nurses, and specifically champions, use each of


these topics in the management of the clinical applications. Cognitive functions involve the

actual knowledge of technology. One role of the champions is to ensure that the end-users are

receiving sufficient knowledge and support. Therefore, they are not only motivators as Lorenzi

et al. (1997) indicate, but they are also reinforcers. Knowledgeable champions act as positive

reinforcers by explaining the system and designing the training. Superusers are other individuals

involved in cognitive functions. They are nurses and physicians on each unit or floor considered

to be the point-of-contact if any application support is needed.

Champions also serve a motivational function to try to understand the end-users’

motivation for using or not using the technology. Motivation encompasses a person’s self-

efficacy, beliefs and expectations, and interest. Situational topics involve those inherent to the

organization itself. Champions seek to understand the environment on particular units or floors.

If the environment is well understood, influencing application acceptance might be approached

appropriately. That is, if a particular floor is more resistant to change than others, advocating for

the system might be approached differently than if the floor was open to change.

Restructuring. The role of champions is primarily for the design and development and

implementation phases of adopting a new clinical information system. However, their roles do

not cease once implementation has occurred. Inherent in the word change is the notion that it

does not seem to come to an end. Implementation is not so distinct from the evaluation phase

and nurses’ management of the applications continues. The support structure changes and the

champion structure is phased out, but nurses continue to manage the application by acting as

superusers and voicing requests for application adjustments to the IS department.


Utilization

Nurses Involvement in the Utilization of CareNet

The Emergency Department nurses utilize CareNet for their nursing documentation.

However, documentation has more to do with nursing data and support of nursing practice.

Nursing utilization involves more than just the functions within the application. Utilization also

involves acceptance and ownership of the application by the nurses. Nurses are involved in the

utilization by championing it and also by seeking ownership of it. If nurses do not feel as if they

own the application, they will not utilize it. Therefore, nurses need to be involved in seeking

ownership in order for it to be successfully utilized. Three themes emerge out of the concept of

nurse utilization—acceptance, ownership, and success.

Acceptance and ownership. As the primary users of CareNet, nurses must be willing to

accept the application in order for it to be successfully utilized. UPMC’s unsuccessful attempt to

implement CareNet is an example of a good system that was rejected by the end-users due to

their inability to “own” the system. There are numerous theories on acceptance and rejection of

various information systems, so the focus will be limited to ownership. Lorenzi et al. (1997)

create the idea of owning the problem and the solution and allowing technology to be an enabler

rather than a prohibitor. Lorenzi and Riley (as cited in Aarts et al., 2004, p. 209) expand on the

concept of ownership by describing how a “technically best” system can be brought to its knees

by people who do not feel ownership and resist implementation, whereas a “technically

mediocre” system may be extremely valued by its users.

If the Emergency Department nurses “perceive they own the problem and the solution,

they will work with the developers to make the system work” (Lorenzi et al., 1997, p. 94). If

CareNet is viewed as an enabler and empowerer for the Emergency Department nurses, they will


support its development and implementation. The Emergency Department nurses, as a collective

unit at SMH, have gained ownership of both the existing problems and the solutions CareNet is

able to offer.

How nurses come to own the problem and the solution lies in how useful they perceive

the technology to be. Ash (1997) suggests that users must see the need for change in order to

support a change. The benchmarked areas that the UPMC network and SMH have indicated are

areas that need to be changed. For example, if bringing multiple disciplines together and

expediting the receipt of lab values and images decreases the time a patient spends in the

Emergency Department, CareNet has provided a solution to the problem of lengthy Emergency

Department stays.

Successful utilization. Success is distinct from acceptance. A clinical information system

can be successful and not accepted or accepted and not successful. How success is defined is

central to whether or not it exists (Ammenwerth, Mansmann, Iller, & Eichstadter, 2003, Aarts,

Doorewaard, & Berg, 2004). Delone (as cited in Ammenworth et al., 2003, p. 82) gives six

categories of success. These include “comprising system quality, information quality,

information use, user satisfaction, individual impact, and organizational impact.” Although it is

early in the course of its implementation, CareNet appears to be accepted by the majority of

Emergency Department nurses and some physicians. If its success is viewed in terms of

individual and organizational impact, deficits in the nursing process are visualized more clearly

and able to be rectified. Rectifying potential problems is useful in that it provides a solution

before the problem has ever been created.


How Applications are Used to Capture Nursing Data and Support Nursing Practice

In November 24, 2003, CareNet was the only document management solution recognized

by the Nursing Information and Data Set Evaluation Center (NIDSEC) (American Nurses

Association, 2003). The NIDSEC cited CareNet for completeness, accuracy, use of appropriate

nomenclature, clinical content, clinical data repository, and good general system characteristics.

Beyond supporting nursing practice, information systems also hold the potential to advance

nursing knowledge (Graves & Corcoran, 1988). The application captures nursing data and

supports nursing practice in three ways—documentation, health care collaboration, and quality

assurance.

Documentation, health care collaboration, and the information gap. Although there are

different types of data, data specific to the nursing practice is considered patient-specific data

which is concerned with a particular patient and may be acquired from a variety of sources

(Henry, 1995). Data entry is facilitated by the use of a user-friendly graphical user interface

(GUI). There are a number of windows available for the nurse to capture patient data. Having

well-designed windows or screens discourages data entry errors (Nelson, 2001) because the

workflow of the Emergency Department nurse is replicated in the flow of windows presented to

him or her. In addition, the application is flexible enough to allow for the creation of specialty

documentation appropriate for a particular care area such as the Emergency Department.

Specialty documentation allows for what Feied, Smith, Handler, Gillam, & Pietrzak (2004,

p.121) refer to as a series of “rights” which include “the right information to the right clinician at

the right time, formatted in the right way to meet the information needs of the moment”.

Once the patient demographics are entered, the next available window might be vital

signs and pain assessment followed by a brief medical history including current medications. All


of the entered data may be used many times “by different users for different purposes” (Nelson,

2001). In fact, the Institute of Medicine (2003) recommends having result management to allow

all providers to access data quickly to increase patient safety and the effective care. This reuse

and additive effect of data reduces redundancy and results in a streamlined approach to

documentation. By accessing data from a single location each time, PowerChart, geography no

longer becomes an issue. Multiple healthcare providers, including nurses, can simultaneously

access patient data from various locations (Cerner Corporation, 1998). This promotes healthcare

collaboration by allowing speedy communication among a variety of disciplines.

If a patient has been to a community facility such as SMH, which is different from the

academic core facilities, a patient history will be available to the triage nurse as he or she enters

the patient demographics into the system. Having a patient history available when a patient

presents to the Emergency Department reduces the patient’s length of stay, a benchmark for all

UPMC Emergency Departments (Stiell, Forster, Stiell, & van Walraven, 2003). A lack of

available information, termed infopenia by Feied et al. (2004), results in a large amount of time

dedicated to locating documents and test results and recording the information that someone else

has more than likely already recorded. Nursing practice is supported by eliminating the need for

the nurse to shuffle through papers and spend lengthy periods of time communicating to other

members of the team in person or on the phone. This allows the nurse to have a total picture of

the patient in a short amount of time in order to assess and plan an intervention.

Quality assurance. Identifying deficits in healthcare and gaps in nursing is a secondary

function of CareNet, or any electronic documentation system. The identification of deficits aids

in the process of quality assurance and supports nursing practice by demonstrating where

improvements should be made and allowing for standards to be created based on information the


documentation provides. Hospitals ultimately compete with each other in the healthcare market

and the measures used to outrank one another are often based on the quality of care they provide

(Institute of Medicine, 2001). Henry (1995) suggests information on the quality and cost of

health care are needed for both internal quality management and external reporting to regulatory

agencies. Data that quality assurance assessments are based on might come from data entered by

a health care team member or data shared between various information systems (Henry, 1995).

One way CareNet promotes quality care is its elimination of errors related to poor handwriting.

Data that once might have been handwritten had the potential to be illegible and a source of

erroneous actions. If correct data is entered into an eRecord, erroneous actions directly linked to

illegible handwriting might be reduced thus increasing quality of care.

Analysis of data in the form of reports of benchmarked areas can help identify gaps. The

identification of gaps is essential to their elimination, and anticipation of gaps allows for

preparedness if they are encountered (Cook, Render, & Woods, 2000). If there is a deficit in

nursing practice, electronic documentation facilitates the auditing process in order to identify and

remedy those deficits. Nurses who were deficient prior to the implementation of CareNet will

most likely continue to be deficient after its implementation, but easier auditing of

documentation might increase the identification of nurses in need of additional support.

An example of improving an individual’s nursing practice is the case of a patient exposed

to rabies who entered SMH’s Emergency Department. The nurse responsible for her care needed

guidance from pharmacy as to an alternative route for administering the intramuscular rabies

vaccine due to the patient’s relatively small muscle mass. When the documentation was

retrieved to evaluate the situation, no skin assessment was made in the documentation. Since

skin assessment is a window available to the nurse, this should have guided her documentation


and practice. If a paper chart was used, it might have taken longer for the pharmacy to retrieve

and evaluate the patient documentation. Among the number of papers involved in Emergency

Department cases, skin assessment might have been overlooked and not targeted by the evaluator

either. CareNet allows those with queries about particular assessments to locate that

documentation quickly and be skeptical about whether the assessment was made if the window

lacks data. Nursing practice is again supported by making nurses aware of their deficits so they

may be more effective practitioners.

If the documentation was not made, it might be assumed the care was not given.

Neglecting to provide appropriate care drives litigation against health care organizations.

Electronic documentation is a component of quality assurance and anti-litigation tactics. One

way CareNet ensures this by supporting accountability. Although all information on paper charts

should have the appropriate initials with it, the omission of this information can be a challenge to

accountability. CareNet embeds a security measure wherein all data that is accessed, inputted, or

updated is tagged with the end-user’s identification. Appropriate identification results in the

correct individual being held accountable for a medical error. A provider might be more diligent

in what he or she documents in he or she knows they will always be directly linked to that data.

Standardized Languages in CareNet

The use of standardized languages is another way a healthcare organization can support

quality assurance. CareNet’s standardized language is limited to SNOMED, although it does use

an in-house UPMC-accepted language (M. Bradley, personal communication, October 2004).

The SNOMED standardized language is a joint effort between SNOMED International and the

United Kingdom’s National Health Service (NHS) (SNOMED International, n.d.). It is a

common language enabling consistent “capturing, sharing and aggregating [of] health data across


clinical specialties and sites of care” (SNOWMED International, n.d., p. 3). The use of

SNOMED enables accurate data recording, and it operates with various software applications

and other medical classifications such as ICD-9-CM, ICD-03, ICD-10, Laboratory LOINC and

OPCS-4. Having a common language helps to ensure the best health outcomes and to facilitate

the identification of disease trends.

SNOMED is a language primarily used by physicians. No standardized nursing language

is used. Without a standardized nursing language, it becomes difficult for nursing practice to

capture, store, analyze, and report on nursing-specific data (Zielstorff, 1998). CareNet would

benefit from a standardized nursing language that provides domain completeness, granularity,

parsimony, synonymy, non-ambiguity, non-redundancy, clinical utility, multiple axes, and a

combinatorial nature as suggested by Zielstorff (1998). The previously mentioned single entry,

multi-use data is a strong benefit to CareNet’s documentation. Standardized languages can

expedite storage and retrieval of patient-specific data, agency-specific data, and domain-specific

data (Henry, 1995).

Quality assurance and support of nursing practice also benefits from standardization. If

all the UPMC facilities used the same nursing language, gaps in practice might be even more

apparent leading to improvements of standards. If everyone is using the same language, similar

errors or similar effective practices are easier to identify and avoid or replicate. Graves and

Corcoran (1988) address the issue of a standardized nursing language when they discuss the need

for a nomenclature consistent with the discipline in order to facilitate data aggregation for the

purpose of guiding future practice. Telescoping further, Henry (1995) suggests the usefulness of

standardization in comparing organizations, communities, and regions. If all health care


facilities used the same standardized language even more gaps in practice and more evidence for

changes in standards might occur.

Automated Decision Support

Data refers to points of information about a variable (Graves & Corcoran, 1989). Data is

processed into information, and information is processed into knowledge (Graves & Corcoran,

1989; Henry, 1995). Knowledge, specifically nursing knowledge, is “simultaneously the laws

and relationships that exist between the elements that describe the phenomena of concern in

nursing . . . and the laws or rules that the nurse uses to combine the facts to make clinical nursing

decisions” (Graves & Corcoran, 1989, Knowledge section ¶1). McCargar, Johnson, &

Billingsley (2001) explain how knowledge base systems process knowledge into decisions. New

information is inferred to enhance decision-making.

PowerChart uses Cerner’s Discern Knowledge System to translate knowledge into

actions (Cerner Corporation, 1989). The Discern Knowledge System’s use in automated

decision support appears to be a function utilized by physicians more than nurses. The decision

support function of CareNet in SMH’s Emergency Department, however, is limited to food-drug

interactions and drug-drug interactions (D. Wolf, personal communication, November 3, 2004).

If an interaction is identified by the information system, an alert window appears to gain the

attention of the provider. It is important to note that although a system might indicate (through

decision support) an interaction, the nurse is the ultimate decision maker because it is the nurse

who collects data on signs and symptoms of adverse drug events.

Despite the Institute of Medicine’s (2003) recommendation that electronic health records

have decision support for the promotion of best clinical practice, screening, drug interactions,

and diagnoses and treatments, SMH did not approach their information system with the objective


of finding one with abundant decision support. One explanation why SMH has not adopted more

automated decision support applications is their reluctance to overlook the skills their employees

currently have and practice daily. Berg (1999) suggests that information technology is best at

aggregating and monitoring data and less so at making patient-specific judgments about that

data.

Support and Satisfaction

End-user Training and Technical Support

End-user training. Lorenzi & Riley (2000) discuss change management and personal

loss. One source of personal loss is the loss of an employee’s time and energy and its

reallocation to learning the new. Another source of loss is the loss of a “good feeling” related to

work. With a proper training phase, both of these losses are temporary.

Douglas, M. (2001) outlines various phases of the clinical information system process.

The phase Douglas positions prior to implementation is the training phase. Douglas outlines

objectives for the training phase. There are two levels of training. The first level involves the

training of the project team and select departmental members by the information system

developer or vendor. The second level involves the training of the end-users. All of the training

should occur no more than six weeks prior to and during the activation of the new system.

Douglas also suggests refresher courses and new employee training courses for the new system

as well. Training rooms are recommended with computer-assisted instruction so end-users have

hands-on simulation activities. Discipline-specific training is an additional recommendation

given by Lorenzi et al. (1997).

Prior to implementation, administration worked closely with the end-users of the

information system to assess the readiness of staff to adopt such a large scale change in their


organization. This was an action not addressed by Douglas, but one in which the Institute of

Medicine (2001) might conclude is a wise decision. The Institute of Medicine recognizes that

“the workforce is highly variable in terms of IT-related knowledge and experience and probably

also in terms of receptivity to learning or acquiring these skills” (p. 175). Two assessments were

made, a readiness assessment and a change acceptance assessment. The results indicated it was

prudent for SMH to move forward with the integration of a new information system.

Prior to the eRecord implementation, SMH did have training integrated into their plan.

Douglas’ suggestions can be identified in SMH’s training process. Both champions and

superusers were identified and both nurses and physicians were integrated into these roles. One

of the core facilities, UPMC- Presbyterian University Hospital, provided training staff to train

SMH’s champions. The champions trained the superusers, and the superusers trained the end-

users. In July, CareNet training was provided as an eight hour course for nurses. Physicians

received two 1.5 hour training courses. The eRecord system was activated in September, so the

July training time was appropriate according to Douglas’ (2001) six-week timeframe. The

training took place in a computer-training lab, also suggested by Douglas, housed in the

Electronic Health Record Office that was built specifically for the implementation of the

eRecord. A checklist was made to be sure training was complete, but a common complaint was

that there was no focus on specialty areas such as the Emergency Department. No discipline-

specific training was provided.

Technical support. As the information system moves from one phase to another so do the

training and technical support plans. Superusers, individuals identified from each unit or

department to act as support for that area, were scheduled during all shifts without patient

assignments during the first two weeks of system activation. Refresher courses occurring in


November were being implemented with the hopes that end-users have a greater capacity to

retain detailed information about the system than they were when they were first introduced.

Following Douglas’ (2001) suggestion, this is occurring post-implementation. The roles of

champions were primarily during the pre-implementation and early implementation phases.

Now that implementation is drawing to a close, restructuring is occurring and champions are

being replaced by traditional IS support as the information system is being maintained more than

implemented. At first unit directors were meeting daily to discuss issues with the information

system, and now they are emailing more rather than having formal meetings (D. Wolf, personal

communication, November 3, 2004). Interdisciplinary meetings will be occurring every two

months and then quarterly rather than daily.

During implementation, there were support individuals named rounders assigned to

particular floors to act as additional support when paged. The role of rounders is now less of a

physical presence and more of a phone presence. There is also an electronic box maintained by

the IS department in which a user can submit a heat ticket for a support request or a request to

change the application for a particular reason. The current chain of command when a user is in

need of support is the floor superuser first, rounder second, and obtaining and contacting

someone from the list of superusers third.

Before and After: Barriers to Implementation and User Satisfaction

Barriers to implementation. There were a number of barriers to implementing the

eRecord. Among these, the two largest barriers were a learning curve including a lack of

technical knowledge of most end-users and physician acceptance. Both of these were listed by

Bowles (as cited in McMcCargar, Johnson, & Billingsley, 2001) as individual and organizational

factors. Ammenworth et al. (2000) found similar barriers in their study which analyzed user


acceptance of a computer-based nursing documentation system. The barriers to nurses’

acceptance of the system were a low level of computer experience and acceptance of the nursing

process. SMH’s comprehensive training initiative to increase technical knowledge and available

technical support reduced the learning curve to an acceptable level, and implementation was

possible.

It is difficult to determine if these, or any, barriers arose out of a pre-existing

organizational environment resistant to change of any kind. Interactional theories suggest that

resistance is a product of interactions between users, the system, and the organization (Kaplan,

1997). A learning curve might be more individual, but physician acceptance has its roots in both

individual and organizational influences. Physician acceptance of the eRecord was low prior to

implementation. Reasons for physician resistance are numerous and have been studied.

Reluctance of physicians to change is a topic beyond the scope of a discussion on CareNet, but it

is prudent to review some reasons SMH’s Emergency Department physicians were reluctant to

change. One barrier to implementation physicians perceived was the schedule for training. They

were resistant to attend the two 1.5 hour training classes. Physicians also indicated dissatisfaction

with the lack of Emergency Department-specificity in physician order entry. Physicians

perceived the change as a process that slowed workflow.

User satisfaction. User satisfaction is part of the evaluation phase according to Douglas

(2001) and leads to system revisions. Evaluation is done on a microscopic level through

champions, superusers, and heat tickets. No formal evaluations are being conducted on the

benchmarked areas or user satisfaction until six months after implementation. The user

satisfaction part of the evaluation is how satisfied the users are with the system and how the

system improves patient care and operations. The readiness assessment and change acceptance


assessment were two tools to gauge the feasibility of implementing the new system. Now that it

has been implemented, the users’ satisfaction with the system must be assessed as well.

Lorenzi et al. (1997) suggest user satisfaction evaluations to take the form of surveys,

interviews, or observations in order to impact the organization positively by determining actual

versus expected system outcomes and obtaining information to improve future implementation

processes. SMH plans on using a satisfaction survey six months from the date of

implementation. The amount of feedback the champions have received was expected, and no

major issues detrimental to practice were found outside of a larger-than-expected learning curve

and acclimation period. Specific populations such as physicians and nurses had suggestions for

system improvements or identification of software bugs that they reported to the champions and

IS department for resolution.

Whether or not users are satisfied with a system influences that system’s success in the

institution. The concept of a successful information system was discussed with the nurses’

utilization of CareNet. Success is often measured by increased productivity. Kling (1999)

challenges the notion that computers increase productivity based on evidence that the statistics

don’t reflect this assumption. Kling, along with some economists, refer to the lack of

productivity increases as the productivity paradox. Users and organizations are often most

satisfied when productivity is increased, but it is not always easy to measure productivity.

Nursing practice might be considered a product offered by healthcare organizations, but nursing

practice is not an easily quantifiable product. Berg (1999) describes nursing practice as invisible

with no clear products. The Institute of Medicine (2001, p. 174) also concedes that the benefits

of information technology are difficult to quantify because “clinical transactions have only an

indirect effect on profitability.”


Kling (1999) offers an explanation for why certain organizational and individual practice

gains do not always translate into productivity. According to Kling, computers are more like

“productivity tools” which “improve the appearance of documents and presentations,…deepen

analysis, and …improve control” (The Productivity Paradox section ¶6). There are no standards

to measure all of the processing of data and information that nurses do on a daily basis. If it is

not measurable prior to a system implementation, measurement remains elusive following

implementation. Therefore, although documentation systems might improve quality of care and

reduce medical error, productivity gains are not necessarily observed or the objective.

Kling (1997) also postulates that organizations underestimate the skilled work involved

in extracting value from computerized systems. If users are not using the system to full capacity

and taking advantage of all its benefits, the users might not appreciate all the system has to offer.

User satisfaction might be increased if end-users were given the opportunity to utilize the system

to its potential. One of the objectives of the refresher courses being offered in November is to

help nurses realize the potential that exists in the details of the system now that they have an

understanding of its basic functions.

Analysis

The observation of CareNet at SMH provided an enhanced understanding of the field of

nursing informatics. Attending meetings, observing the information system in use, having a

hands-on opportunity with the information system in its intended setting, and having frank

discussions with the end-users about the system resulted in a global picture of CareNet’s life

cycle. The relationship between the information system and the organization became visible and

appeared to be in the forefront of every encounter at SMH. As such, the focus of a reflection on


how the observation has influenced a better understanding of nursing informatics is best

demonstrated via the Socio-technical perspective.

Socio-technical Perspective and Model

The eRecord has fulfilled every component of nursing informatics as defined by the

American Nurses Association (ANA). The ANA (n.d.) defines nursing informatics as

a specialty that integrates nursing science, computer science, and information science to

manage and communicate data, information, and knowledge in nursing practice. Nursing

informatics facilitates the integration of data, information, and knowledge to support

patients, nurses, and other providers in their decision-making in all roles and settings.

This support is accomplished through the use of information structures, information

processes, and information technology. (Nursing info section)

The eRecord, specifically CareNet, processes data, information, and knowledge to support

healthcare practice. What is most interesting are the effects the information system has on the

organization in order to fulfill these processes and the effects the organization has on the

information system to facilitate those processes being utilized.

The most appropriate term to describe the relationship between SMH and its information

system is “socio-technical.” According to Kling (1999), a socio-technical system is an

interdependent system comprised of people, hardware, software, techniques, support resources,

and information structures. Kling and Scacchi (as cited in Aarts et al., 2004) describe all the

components as forming a seamless web. Adopting a new information system is a social process

where both the technology and the organization are transformed (Aarts et al., 2004). The

information system and the organization are not two distinct parts coming together, but rather,

they are two interdependent parts that form the whole (Berg, 1999). Figure 5 demonstrates the


Ecology Structure Politics Culture

Psychology Human Resource

Intelligence Decision Making

Information System

Organization

Design & Development Implementation Evaluation

interconnectedness of SMH (the organization) and CareNet/ eRecord (the information system).

One is able to influence the other, and the means of influence are people as represented by the set

of arrows in Figure 5. Exactly what they influence is another topic of interest.

Figure 5. Representation of SMH’s Interconnectedness with its Information System.

________________________________________________ Note. Adapted from concepts taken from Lorenzi, N.M., Riley, R.T., Blyth, A.J.,

Southon, G., & Dixon, B. (1997). Antecedents of the people and organizations aspects

of medical informatics: Review of the literature. Journal of the American Medical

Informatics Association, 4(2), 79-93.

Using concepts adopting from Lorenzi et al. (1997), an information system is able to

influence changes in an organization’s

ecology (related to the competition of an organization in the healthcare market),

structure (control and accountability),

politics (of physicians, nurses, and administrators),

culture (customs, values, and assumptions of an organization),

psychology (how an organization mimics human behavior),


human resource (the people of an organization),

intelligence (assets of an organization),

and decision making (the basis of an organization).

To expand on Lorenzi et al.’s concepts, the organization is able to influence an information

system at any phase of its life cycle including its design and development, implementation, and

evaluation.

How the Information System Influences the Organization

Ecology

The ecology of a particular organization involves elements related to competition in the

healthcare market (Lorenzi et al., 1997). The organization has no measurable product; its

services are its only product, and they remain difficult to measure. Using information systems to

its benefit, an organization is able to attempt to hold a place in the healthcare market by

quantifying its quality of care using the information system. As a result, SMH is able to change

based on the knowledge obtained from aggregating data and processing it into information.

UPMC-St. Margaret is thus able to compete by adjusting itself to hold a place in the competitive

market of healthcare. Accordingly, informatics can be viewed as a driving force behind

consumer-driven healthcare.

Structure

An organization is structured on control and accountability (Lorenzi et al., 1997). An

organization seeks to control its practices by holding those who threaten them accountable.

When addressing organizational change in response to the introduction of an information system,

Kaplan (1997) mentions control within an organization as being a crucial element involved in

resistance. Administrators are able to maintain control by evaluating institutional data in the form


of reports generated from an information system. When errors are made, control is threatened.

Control is regained by identifying the errors and holding those causing them accountable.

Accountability is achieved by tagging all data entered with the end-user’s identity. Those held

accountable have the opportunity for performance improvement. Quality assurance practices are

then able to better nursing practice through the use of informatics. The information system is

able to drive an increased emphasis on accountability and facilitate organizational control.

Politics

All organizations have politics, healthcare institutions included. The politics occurring at

a healthcare facility involve nurses, physicians, and administrators. Lorenzi & Riley (2000)

concede that what might be considered system problems are actual internal policy problems.

Politics among the various professional groups are only accentuated by the adoption of a new

information system. Berg (1999, p. 88) refers to the “politically textured process of

organizational change.” Physicians bring in patients, and thus revenue, for a health care

institution and that provides them with a certain amount of control over administration.

However, administrators are the ultimate decision makers. Nurses, on the other hand, are

responsible for patient care and without them no healthcare institution would exist.

It was observed that politics played a larger role than perhaps it should have in adopting a

clinical information system. Each group had its own opinion and reasons for supporting or

resisting its implementation. The political tensions that existed prior to the introduction of the

information system were simply enhanced by the introduction of technology. Informatics has the

capacity to either disintegrate an already unstable political climate or help people move beyond

politics and toward a common goal.


Culture

Culture refers to those customs and values an organization holds (Lorenzi et al., 1997).

Because politics is often part of the culture of healthcare institutions, the changes information

systems have on culture are similar to those it has on politics. The culture at SMH is one of

teamwork where each player on the team has his or her own responsibilities in relation to the

patient he or she is taking care of. When an information system is introduced, reluctance to

accept it might be based on a clash between professional conventions and the system itself

(Kaplan, 1997).

Documentation, a once private affair, is now a team effort with the implementation of

eRecord. Each player reads, reviews, and updates documentation of the others. Multiple-user

access decreases redundancy, but it also fosters cooperation among colleagues and potential

criticism (Berg, 1999). Work practices become more visible, and this might have the effect of

straining interprofessional relationships. What was once a culture of teamwork has the potential

to become an environment of hostility when informatics is applied to documentation.

Psychology

During a meeting involving eRecord problems related to the Emergency Department, the

issue of physicians taking too long to enter patient care orders and the nurses’ subsequent refusal

to take verbal orders and enter them into the computer was raised. The physician’s response was

that if you have a dysfunctional family, you have a dysfunctional family -- an information system

will not be able to change that. Because organizations are made up of people they have their

own distinct behavior.

Again, the concept is similar to politics and culture. An information system will not

make a dysfunctional organization functional. That is beyond the scope of any information


system. What an information system can do is motivate changes in an organization by helping

that organization visualize where its deficits are. The issue of physicians refusing to take the

time to enter patient care orders and, instead, giving verbal orders has been brought to the

forefront with the increased emphasis on accountability and documentation. Therefore,

informatics can facilitate progress toward a more cooperative and less dysfunctional workgroup

by forcing issues to be raised that might otherwise not have been addressed.

Human Resource

“Without people, we don’t have an organization” (Lorenzi & Riley, 2000). Human

resource is the recognition that staff is the most valuable asset to any organization (Lorenzi et al.,

1997). This is realized by the reluctance of St. Margaret to implement more automated decision-

support applications. The information system simply cannot replace healthcare workers.

However, the system can drive organizational change by adapting the users in such a way as to

make the system work. The system cannot work without people, but people also need the

system. The work process must be redesigned to facilitate the function of the information system

(Lorenzi & Riley, 2000).

Intelligence and Decision Making

Intelligence is the core asset of a healthcare institution. With the use of information

systems, intelligence is not only more available to all those collaborating on a case but it is able

to be improved on and built. Information systems enable multiple health care providers to see

the same data about a patient and make clinical decisions in a quick and efficient manner. In

addition, with the aid of a standardized language, best practice and identification of errors are

promoted by aggregating data. Knowledge is thus built upon previous intelligence. Knowing


this, an organization can adapt their workflows and practices by knowing that the knowledge a

system generates is a benefit to them.

How the Organization Influences the Information System

Just as the information system was able to alter the organization, the organization is able

to alter the information system. Organizations do this by altering developers’ and

administrators’ approach to design and development, implementation, and evaluation.

Design and Development

In Lorenzi & Riley’s (2000) overview on change and change management, they comment

on the rate of change and the necessity to develop information systems to support changed

environments. Socio-technical approaches to system design take the end-users, and ultimately

the organization, into account. Insight into the work practices of the end-users is where design

and implementation should start, especially when designing for professionals (Berg, 1999).

UPMC directly influenced the development of SMH’s information system by hiring Cap Gemini,

a health care consultant firm, to provide guidance on development strategies.

Design is rooted in the organizational conditions according to Aarts et al. (2004).

Working through champions, superusers, and IS support, end-users are able to request alterations

in design to better fit their needs. A design the end-user is unable to use is not beneficial to the

organization. Information systems need to be developed “step by step” staying central to an

organization’s needs while allowing for changes in work practices and technology to “evolve

together” (Berg, 1999, p. 95). An example of end-user design modification is the Emergency

Department’s requests for additional room for documentation and a reordering of the triage

sections available in CareNet. Physicians also had requests for changes in the design of the


physician order entry application with regard to typographical errors, incorrectly built order sets,

and lengthy forms.

As a customer, a healthcare organization is able to request changes in the design of an

information system. Changes in design increase end-user satisfaction and a better utilization of

the information system.

Implementation

Part of the implementation of SMH’s information system involved the training and re-

training of the end-users. Champions were an asset during implementation, since they led

trouble-shooting meetings to discuss problems with the implementations. As a result of the

meetings, immediate changes in the implementation plan could be made.

Knowledge gained by the organization’s readiness and acceptance assessments guided

implementation as well. Knowing the large and diverse nature of the UPMC-network,

implementation was chosen to be activated only in certain facilities rather than the entire network

at once. The experiences of the hospitals undergoing implementation can be shared and

improved with other facilities planning to adopt the information system. The implementation

plan was adjusted to fit the needs of the organization. Similarly, financial resources guided

which hospitals were most equipped to handle the required manpower and support of

implementation.

Evaluation

When implementation ends and evaluation begins, users continue to “shape and craft the

information system to fit their particular requirements…often in a way unanticipated by

designers” (Aarts et al., 2004, p. 209). During an evaluation, an information system may be

considered a success or a failure based on how the system functions within the organization’s


needs and working patterns (Aarts et al., 2004). Evaluation should be guided by how well the

information system has met those needs. An evaluation should also be flexible enough to

address issues unpredicted prior to implementation. Issues raised by champions and end-users

are integrated into the evaluation process. In general, evaluations should consider

“relationships between system characteristics, individual characteristics, organizational

characteristics, and effects among them. Such approaches encourage evaluating an information

system’s impact upon an organization while evaluating organizational features’ impacts on the

system” (Kaplan, 1997, p. 95).

Because most implementations don’t have a specific end-point, evaluation is being done

on a constant basis as feedback is given by the end-users. As the system is affecting the end-

users, the end-users attempt to adjust by altering the system.

Conclusion

Observing SMH’s information system at work was a valuable experience and provided a

global perspective on how much time and work is dedicated to designing, implementing, and

evaluating a new information system. Sitting in on meetings gave a bird’s eye view of the

benefits and obstacles encountered when trying to apply new technology on a massive scale. An

information system’s life cycle unfolds as a sort of narrative in which every detail being

contemplated and assessed.

CareNet’s ability to streamline the documentation process for the Emergency Department

nurses provided many benefits including illustrating the need for organizational change. As the

organization adjusted itself for the technology, the technology was also adjusted to fit the

organization. Needs were met by continually evaluating and making the necessary adaptations.


The information system helps initiate discussion about topics which otherwise would not

have been addressed. More than ever before, the human element behind the processes automated

by the information system can be analyzed and critiqued. The technology serves as a mirror

which reflects the organization back to itself where all the deficits are able to be re-examined.

Based on the present experience, the future looks promising at SMH. It has been

demonstrated that no major change to a large organization is entirely smooth and some

unexpected events will occur. However, the organization has been able to quickly adapt and

address these events. Serving as a model of hope for other large-scale information system

adoptions, SMH has been recognized.


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