Question 15

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

• Even very early CIS versions led to a significant improvement in documentation
• In one study, nursing staff spend ~ 30% less time on documentation, and this time appears to redirected to patient-oriented tasks
• It seems to shorten ICU stay without influencing any other important outcomes
• It may improve ICU funding by decreasing coding errors (illness severity and procedures coding for the purposes of billing), and presenting a more accurate representation of the activity level.
• More recent studies of the impact of CIS have found in pooled analysis that CIS improve a large number of important clinical outcomes, perhaps reflecting that the systems of today are a vast improvement in comparison to the systems of yesteryear.
• In particular, there may be an improvement in mortality

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

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