Achieving Standardization Through CIS Implementation
Standardization is based on the premise that when you know the right thing to
do, you should do it that way all the time. It applies to the way terms are defined,
the linking of consistent treatments to specific conditions, and the way information
is stored, accessed, and presented to clinicians.
What's in a word? If we were explaining the achievements of our industrialized society, "standardization" would figure prominently as an enabling principle. Standardization is a virtue without which our modern, technological civilization could not exist. Yet, when applied to health care, standardization is not always viewed as a desirable characteristic. We tend to think of it as the opposite of thinking creatively, an excuse to avoid exercising individual judgment. Even physicians often apply this pejorative connotation when considering the prospect of standardizing clinical practices. In reality, standardizing clinical processes and practices delivers important benefits to physicians, patients, and health care providers. The magnitude of these benefits is motivating health care organizations to rethink their historical reluctance to institute standardized practices. Standardization can be regarded by clinicians as their ally in providing patient care informed by leading practices, not as recipes for delivering "cookbook medicine." Partly for this reason, the concept of standardization is often referred to as "reducing practice variations."
How Much Standardization Is Enough?
Health care organizations realize that the delivery of quality patient care requires that clinicians have the freedom to exercise their professional judgments. As an organization implements a clinical information system (CIS), it must work to strike the right balance: sufficient standardization for the CIS to deliver its expected benefits, but sufficient flexibility so that physicians can tailor treatment to support legitimate local and case-specific variations. As Figure 1 shows, to achieve the right balance, organizations should consider where standardization is necessary to achieve targeted goals, and where individualization is acceptable to support adoption and legitimate local variations.
Figure 1: Achieving the Right Balance in Standardization
If You Know the Right Thing to Do, Why Not Do It That Way All the Time?
Standardizing clinical practices is based upon the premise that there are "evidence-based" treatments for many patient conditions. This is not to say that diagnosing a condition is simple, or that the treatments, though standardized, don't require skill to perform. For this reason, health care providers are implementing advanced clinical information systems as part of their overall clinical transformation initiative. They are seeking to improve the quality of patient care, reduce the cost of providing that care, and increase their market share within a competitive industry.
In a CIS implementation, standardization requires consistency in three key areas or levels:
- Content: Decide, for each condition, the right thing to do.
- Process: Standardize the right actions into processes, so that the right things are done consistently.
- Technical standards: Automate the right processes with applications that operate from consistently handled integrated information.
Content: How to Say It
"Language is the mother of thought, not its handmaiden." — Karl Kraus, Austrian satirist, 1874-1936
Standardizing content begins by standardizing words and definitions. Using the proper language and terminology means consistently and unambiguously calling the same thing by the same name. "Respiration rate" might mean the same as "breathing rate" to most clinicians, but for the purposes of standardization, one term must be agreed upon. Consistent definitions, rules, descriptions of treatments, intervention techniques, and responses to care ensure that information and treatment orders are properly interpreted. There must be no confusion about the meaning of any information contained in a patient record. For example, a nurse documenting how a patient is responding to pain medication will use the CIS, which provides a standard method for documenting the response, such as clicking on a computer screen in a particular location on a pain scale. This makes clinical documentation simple, consistent, comparable, and accessible for future reference. It lets all of us know that when a given value for pain is documented, we all share the same frame of reference.
Standardization of terms and definitions makes it easier to conduct accurate and in-depth analysis of clinical data, and minimizes future modifications of applications. The CIS will make use of previously established nomenclature and coding standards for procedures and products, such as SNOMED. Documentation language and treatment definitions are made consistent across all departments of the hospital, and even across multiple hospitals in an organization.
From the physician's point of view, consistency means using standard order sets for admitting a patient to the hospital. These order sets are clearly defined during the implementation process, so that leading practices and evidence-based medicine principles are embedded within the CIS. Although a CIS can facilitate the use of leading practices in common situations, the physician always has the option to customize treatment for a particular situation and/or patient.
The CIS encourages the use of leading practices by making the selection of common order sets and accepted treatments very easy. Physicians may have to work a little harder, "drilling down" or "tiering" through sequences of screens containing menus of less-common choices, to vary from locally-adopted leading practices. However, common choices that reflect preference yet are not influenced by evidence-based outcomes or costs can be easily accessed.
Process: How to Do It
Closely linked to defining consistent content is establishing and codifying consistent processes and practices. Process consistency means that clinical processes have common workflows, consistent sequencing of defined tasks, and interventions that use technology to reinforce leading practices in delivering patient care. Administration of medications, for example, is a common process in which a CIS delivers substantial benefits. The medication cart is brought to the patient's bedside. The patient is identified appropriately, and the patient's identity is confirmed by scanning a bar code affixed to the patient. The nurse documenting the administration of the drug identifies herself by scanning her individual bar code. Scanning the bar code on the medication confirms that it's the right medication at the right dose. The pharmacy application then checks back with the CIS to verify that this is the correct time for administering the medication, based on the physician's computerized order sets.
The administration of medication is but one example of the benefits of building standardized processes and interactions into the CIS. Such common protocols, for which leading practices are well-known, must be optimized to take advantage of enabling technologies, and then automated so that the desired processes, practices, and behaviors are institutionalized and reinforced throughout the hospital or hospital system. If automation occurs in isolation, without rethinking and redesigning the clinical processes the technology supports, the organization misses an opportunity to gain quality, safety, and cost benefits as well as competitive advantage. There's little benefit to automating or institutionalizing inefficient clinical processes. The objective of standardization at this process level is to improve patient safety and quality of care, to increase workflow efficiency, and to reduce variations in delivery of patient care.
Technical Standards: How Applications Handle Information
Consistency is also required in the technical standards that prescribe how patient information is stored, shared, retrieved, and displayed by the applications that comprise the CIS. Applications need to meet common system standards so that patient information is seamlessly available to clinical and business applications throughout the CIS. Applications make use of profiles and tables that contain required data elements. These elements need to be named consistently from one application to another. In this way, applications can link to patient data wherever they reside within the CIS. Consistency in technical standards also minimizes the effort required for application maintenance. Once the right standards have been established for the CIS, it is easy to add functionality to applications or to expand access to the system throughout the clinical enterprise and beyond.
Standardization also applies to the way clinicians and others interact with the computer system. Screens need to be consistent in design, menu structure, and the ways in which choices are presented. As the clinician advances from one screen to the next, specific items of information should stay in the same place. The way in which error messages come up and the way messages are phrased should always be the same.
The level of standardization that can be achieved is dependent on the system's computing model. Highly centralized systems, with a centralized data repository, support the highest level of standardization. More distributed computing models, such as separate hospitals with individual clinical information systems linked together into a health system network, accommodate a lesser degree of standardization.
Nevertheless, careful attention to standardization of content, process, and application technical standards makes it possible to implement a clinical information system in one hospital within a multi-hospital system, then to import the CIS in succession to each of the other hospitals in the system. This greatly accelerates the process of implementing a CIS across a chain of hospitals, so the organization receives benefits sooner. A franchised CIS reinforces standard policies and practices throughout a healthcare system, yet is flexible enough to permit tailoring of applications to accommodate local variations in service offerings or treatment methods. Over time, less effort and resources are required to maintain a clinical information system that is standardized across multiple hospitals, than to maintain multiple systems implemented independently in each hospital of the chain.
Standardization: The Reason for a CIS
Standardization is the reason for implementing a clinical information system. Standardizing leading clinical practices within an integrated CIS is the means by which quality and safety of patient care are improved, efficiencies realized, and costs reduced. Clinical transformation is the process of setting the standards for success.
