Critically evaluate the role of a Clinical Information System (CIS) in intensive care

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College Answer

CIS refers to a computerized system for managing the clinical record often within geographically designated areas within the hospital such as ICU, ED or OR.

Potential benefits of CIS include:

a)  Recording of bedside observations – automated, minimal transcription errors

b)  Legible record

c)  Electronic record of drug prescription

d)  Access to additional clinical information at the bedside – pathology, XRays

e)  Access to decision support systems – online databases, clinical pathways,algorithms

f)   Medicolegal – archiving, good audit trail

g)  Ease of collection of data for research.

Limitations of CIS

a)  Financial cost

b)  Rapidly changing nature of technology

c)  Lack of computer literacy amongst clinicians and the need for training prior to commencing work in the ICU

d)  No evidence that CIS decreases workloads or save expenditure on salaries e)  Data archiving and storage is a problem.

f)   No evidence that implementation of CIS results in improved patient outcomes.

g)  Interface with other computer systems

h)  Legality of drug prescription

i)  Other clinician entry

Discussion

These are computerised databases which store and retrieve the ICU medical records. They may integrate diagnostic test review, test ordering, prescription/administration of drugs, and storage/retrieval of imaging studies. LITFL has an excellent summary.

Whatever the public opinion of these things, at the time of writing (mid 2014) the inevitable invasion of ICCIS is coming to NSW and there is nowhere to hide.

The answer below is essentially a direct copy and paste effort from the summary of administrative topics.

Rationale

  • The amount of data recorded for ICU patients increases every year (some say, by ~ 6% per year)
  • Effective use of this information relies on the clinician;s ability to easily retrieve and search it, so as to make informed decisions
  • The increasing amount of information takes a toll by diverting time from patient-oriented workload towards non-patient-oriented documentation and administrative tasks
  • The rationale behind the use of CIS is to render easier the process of documentation by automating some routine tasks, and by improving access to the growing patient record

Advantages

  • Increased legibility and improved searchability of records
  • Automation and increased accuracy of repetitive tasks eg. recording of observations and ventilator settiings
  • May integrate with pathology results database
  • Electronic record of prescriptions offers improved and security with electronic signatures and passoword-protected ordering
  • Searchable database for audit and research

Disadvantages

  • Expensive to install and maintain
  • Difficult to integrate with other existing electronic systems
  • Steep learning curve
  • Computer literacy among staff influences the degree to which the CIS changes workload patterns(many things previously easy may suddenly become more difficult)
  • May degrade the quality of handover and ICU ward rounds (consultants focus their attention on surfing the CIS rather than on what the staff are telling them)
  • There are concerns that electronically signed prescriptions are legally invalid
  • There are concerns regarding the security of passwords, and the potential of untraceable "doctoring" of the records

Evidence in support of CIS use

Evidence against the use of CIS

  • No improvement in mortality in early studies of clinical decision support features of CIS
  • Many nurses are strongly opposed to this technology, largely due to a perceivedlack of training and support
  • Meta-analysis of studies did not confirm an improvement in time spent on direct patient care.
  • Computer keyboards act as a reservoir of nosocomial pathogens

References

Hammond, Jeffrey, et al. "A qualitative comparison of paper flowsheets vs a computer-based clinical information system." CHEST Journal 99.1 (1991): 155-157.

 

Wong, David H., et al. "Changes in intensive care unit nurse task activity after installation of a third-generation intensive care unit information system." Critical care medicine 31.10 (2003): 2488-2494.

 

Marasovic, Caroline, et al. "Attitudes of Australian nurses toward the implementation of a clinical information system." Computers in Nursing 15.2 (1996): 91-98.

 

Mador, Rebecca L., and Nicola T. Shaw. "The impact of a Critical Care Information System (CCIS) on time spent charting and in direct patient care by staff in the ICU: a review of the literature." International journal of medical informatics 78.7 (2009): 435-445.

 

Levesque, Eric, et al. "The implementation of an Intensive Care Information System allows shortening the ICU length of stay." Journal of clinical monitoring and computing (2014): 1-7.

 

Levesque, Eric, et al. "The positive financial impact of using an Intensive Care Information System in a tertiary Intensive Care Unit." International journal of medical informatics 82.3 (2013): 177-184.

 

Lapinsky, Stephen E. "Computers in Intensive Care." The Organization of Critical Care. Springer New York, 2014. 53-69.

 

Ehteshami, Asghar, et al. "Intensive care information system impacts." Acta Informatica Medica 21.3 (2013): 185.

 

Amarasingham, Ruben, et al. "Clinical information technologies and inpatient outcomes: a multiple hospital study." Archives of Internal Medicine 169.2 (2009): 108-114.

 

Hunt, Dereck L., et al. "Effects of computer-based clinical decision support systems on physician performance and patient outcomes: a systematic review." Jama 280.15 (1998): 1339-1346.

 

Bures, Sergio, et al. "Computer keyboards and faucet handles as reservoirs of nosocomial pathogens in the intensive care unit." American journal of infection control 28.6 (2000): 465-471.