Facilitate Implementation of New Computer Systems
May 1, 1997
Facilitate Implementation of New Computer Systems
Implementing a clinical information system can solve a host of problems, but it can also create problems if you’re not careful. "When implementing a system, Murphy’s law reignsif it can happen it will," says Todd Taylor, MD, FACEP emergency physician at Good Samaritan Regional Medical Center and Phoenix Children’s Hospital in Arizona. Here are tips from ED experts on making the implementation process as painless as possible.
• Encourage the staff to use existing systems. It’s a good idea to get staff comfortable with using computers well before the system is put in place. "If you’re out looking for a system, it’s never too soon to start encouraging people to be comfortable using a keyboard mouse," says Marsha Zimmerman, RN, MA, Clinical Systems Coordinator at Hennepin County Medical Center’s ED in Minneapolis.
Duke’s ED prepared staff in advance by encouraging them to use the hospital’s mainframe to access data and order supplies. "Our goal is to get everybody to use the computer for lookups and identify any people who are computer phobic or have problems so we can hand-hold them through it," says Kathleen G. Finch, RN, BSN, Nurse Manager at Duke University Medical Center and Health Systems, in Durham, NC.
At the time, nobody in the ED was using computers regularly except the clerks, she says. Staff gained some additional exposure to computers when an automated medication dispensing system was put on-line. "We wanted to get people to be comfortable using the computer for medications," says Finch. "It was a tremendous time savings. We manage over 400 drugs, so you can imagine the accounting and inventory we did on a daily basis, and now we do none of that."
Initially, staffers were reluctant to go through a computer to get medications. "The nurses were saying, If I need a drug real fast now, I just go and grab it, you mean now I’m going to have to wait for a computer?’" says Finch. "We proved to them that they’d only have to wait seven seconds, but that could be seven seconds too long, so we still have some emergency stock supply."
The lessons learned will help when the system is implemented. "We learned to keep it simple, we could not force anything down their throats," says Finch. "We had someone to walk them through it each time until they felt comfortable. In two or three days, we were able to pretty much get folks over the hump."
• Identify "super users" to train others. "Super users" of computers were identified at Duke University’s ED and charged with teaching the new system to the rest of the staff. "Those nurses have gone through hospital information system training, and they are in turn training the nurses," explains Finch. "We learned that your super users aren’t necessarily your computer gurus, they had to be nurturing and have good teaching skills."
Select people who can explain the sign-ons and applications in a clear simple way. "Then have those people available to walk each person through as the system comes on-line," says Finch.
• Keep instructions simple. "Prepare your super users by having them take a complex concept and simplify it," says Finch. "They need to explain how to sign on, how to get from screen to screen, and how do you sign off? Any other information is extraneous and is not necessary to teach initially, and I think you do a disservice to the staff if you do that."
• Be realistic about what the system can do. "We’ve been very careful not to raise the expectations of the staff. When vendors come in, they’re very pie in the sky, and all of a sudden that becomes the expectation," says Finch. "When reality hits, it’s very different."
It’s important to set specific goals that are reality-based. "We’ve told staff that the initial module of the system will be impacting triage, and discharge instructions will be the most beneficial outcome to you," says Finch.
• Keep goals short-term. "Don’t say six months from now, because they haven’t even seen the computer yet, just tell them what they need to know, including the super users," says Finch. If a teacher knows too much in advance, it could adversely affect their educational approach, she explains.
• Emphasize that a new computer system can’t replace an efficient staff. "You’ve got to make people realize that an information system isn’t going to make you something you’re notit’s like wearing a nice tuxedo, but you’re still the same guy underneath," says Moore. "An IS can help us present information in the best manner, but it’s not going to make us into a knowledgeable hardworking group of people in caring for patients, that’s our responsibility."
It’s a mistake to oversell a system to the staff. "Building expectations in hopes that it generates enthusiasm almost for sure dooms the project," says Cordell. "Instead of saying, This computer system will make your life easier while scratching your back and slicing your bread,’ we should be making realistic projections."
Cordell suggests relaying the following message to ED personnel: "This information system is going to be a big change. We know there will be bugs and problems we can’t foresee and need your help identifying problems. We’re going to phase it in over the next year and inservice everyone at each step of the process. We’re in this together to improve care, make our work processes better, and ultimately promote the viability of our department."
• Install the system in stages. "Choose a core group of people committed to the system to do beta testing," says Taylor. "Don’t just plop everybody on at once. It’s not realistic to send everybody to classes, and then say, Now push the button and make it work.’ In the ED, that just doesn’t work, because as soon as the system starts to slow you down you cut corners and don’t do it, because you have patients to take care of, and there is no down time."
The system at Hennepin was implemented over a four-year period. "We think the buy-in from staff was much better than if we had done too many stages or modules all at once," says Zimmerman.
It’s a good idea to do training in stages. "It’s such an enormous system that no one can grasp all the functionality at one time," says Zimmerman. "Focus on shortcuts that make life easier, with ongoing training. We try to empower the staff so they feel it’s their system and not just something that’s being imposed on them by somebody upstairs who doesn’t know what’s going on."
• Select a system that meets your specific needs. "The most important thing is to choose a system based on what you need, not what bells and whistles are available from any vendor," says Zimmerman. "Focus what you want, not what they’re hanging in front of you that sounds good."
• Have extra staff on hand during the implementation process. At Hennepin, staff who had been identified as advanced users helped to educate other staff members when the first module was implemented. "They were told not to get drawn into patient care and just walk around to troubleshoot and answer people’s questions, which greatly relieved the amount of concern and frustration," says Zimmerman.
• Address patient confidentiality issues. It’s important to make staff aware of the penalties for breaching patient privacy. "There’s always a balance between an incredibly secure system and one that’s so secure that clinicians can’t get in and out of it," says Zimmerman. "We stress patient data privacy by having staff sign agreements yearly and distributing updated information about it. They need to know there are repercussions if any of that is broken, and we really get down on people if they share their PIN numbers or anything like that."
• Place computers in areas which minimize disruption. It’s not uncommon for dozens of computers to be added with the implementation of a new system. Positioning of computer work stations can impact efficiency. "We watched how the staff worked and tried to position stations in places that make sense," says Finch. "We also have a firm commitment not to disrupt the integrity of triage. It has its own mission, and that must always be accomplished."
The position of computers can also impact the patient-health care provider relationship. "There is some frustration from staff because it seems no matter how we place our computers at the bedside, they’re not in a position where they maintain eye contact with patient," says Zimmerman. "Angling yourself so you’re looking at the patient feels awkward." Plans are underway to correct this design flaw, she notes.
Help staff adjust to computerized documentation. "Some people have a difficult time making the transition to following a certain template," says Zimmerman. "We’ve found that some staff members are used to doing free flow subjective documentation in narrative form, and the new screens are built on pick lists and choices and are somewhat preformatted. There is some frustration with that, and people say their notes have lost personality."
In retrospect, the transition could have been made smoother by making the nurses’ paper charts similar to the computerized format, she says. "We changed the documentation model for the physicians long before we put them on the computer. We broke their chart into sections, and used a lot more check boxes on paper," she adds. "We learned it was important to do that because we didn’t do it with the nurses and it created a lot more chaos and frustration in the department."
The advantages to the new documentation should be pointed out to staff. "Pick lists and templates ensure everyone is charting the same way," notes Zimmerman. "If you use a narrative note, it can be disorganized. You may wind up with the same information, but it’s not retrievable from the database. If we do chart audits, we can query the database and don’t need to rechart everything."
• Carefully consider the impact of staff role changes. Although a new computer system inevitably alters staff responsibilities to some extent, it’s important to consider the pros and cons of every role change. At Scottish Rite Children’s Hospital, in Atlanta, nurses were resistant when bedside ordering became part of their job. "Initially, we were going to have the nurse order from the room, but they said, I’m not a secretary, why should I be ordering labs, that’s somebody else’s job,’" says Joseph Simon, MD, former director of the hospital’s ED.
The idea was to prevent delays stemming from backed-up charts at the registrar’s desk, but the problem wasn’t eliminated because nurses were often busy with other tasks. "We traded one delay for another and ended up with unhappy staff, so we decided not to do the role change," says Simon. "Also, it makes sense to blur job descriptions a little bit these days, but you probably don’t want to take an $18/hour nurse and have her do a $8/ hour job."
• Maintain flow of communication among staff. Frequently, a computerized system has the unexpected adverse effect of interfering with normal communication patterns of staff. At Hennepin’s ED, the nursing staff became irritated when physicians began entering data directly into the computer system.
In addition, the system has the changed the way tests are ordered. "Previously, the doctors used to walk around looking for a nurse to give them the order, but now they can go to any computer workstation and generate an order," Zimmerman explains. "There was a concern that we weren’t communicating with each other as well, and the computer was being used as the middleman. It was a side issue we didn’t expect, that people stopped talking to each other a little bit."
"The physicians have a responsibility to make sure the nursing staff have an understanding of the plan for the patient, and the nurses need to ask if something seems different. But we see 90,000 patients a year, so the tendency was to just put it in the computer, whereas before you had to find somebody to talk to," says Zimmerman.
The lack of communication led to problems with orders. "We established checks and balances to make sure an order that’s been cancelled wasn’t in the process of getting done," she says.
A committee will look at communication issues affected by the system. "This is a teaching hospital, so the issue was brought up with the nursing staff, the faculty, and the residents," says Zimmerman. "We’re going to consider the changes in normal communication patterns now that we had an electronic device to do some of it for us. None of it is bad or good, just different."
• Act promptly on staff suggestions. Soliciting input from staff isn’t enough. Suggestions need to be acted on or discussed in a reasonable time period. "We’ve found that it’s imperative that there is good communication from the staff to the clinical systems coordinator, and changes need to be made in a timely fashion," says Zimmerman. "If they don’t, the staff doesn’t feel it does any good to make suggestions."
• Use surveys to gauge staff attitudes. Surveys can be a useful tool to assess staff attitudes about computers. Instead of waiting until a new computer system is in place to get staff used to the idea, surveys can be a proactive approach. "We signed a contract with ORCA, but we haven’t installed the hardware yet so we have some breathing room to make people comfortable," says Finch.
That breathing room was used to survey every ED staff member who didn’t use computers, including physicians, nurses, and physician’s assistants, about their attitude towards computers. "We wanted to see how many people really felt that having computers in this environment would actually help them, and how many felt it would impose more work," says Finch.
Most people responded that they were unsure if computers would help or hurt ED efficiency, but 13% admitted they believed more work would be involved. Graphs were created which broke down the ED clinical staff by gender and title.
The survey served to open up dialogue about the new system, giving managers a chance to assuage concerns. "You look at the survey where folks have their greatest fear and address it as realistically as you can to calm them down," says Finch. "We wanted to get an idea of how big a challenge we have ahead of us, so we thought we’d get an idea of their misconceptions and misgivings about computers. It also served the purpose of allowing them to vent a little bit."
One concern voiced by clinical staff was that the system would interfere with triage. "We explained that, Yes, you may be taking time to input the data at triage, but you’ll never have to write that piece of information again.’It will flow through all the screens and always be available. So once entered, it’s available for all, never a second entry required," says Finch.
Above all, it’s crucial to keep staff informed from the get-goand keep your finger on staff attitudes. "You need to keep people informed about how things are progressing," says Finch. "By keeping us in touch with staff attitudes, the survey helped us to emphasize certain things, such as how it would save time."
The survey asked ED clinical staff if they strongly agreed, agreed, were uncertain, disagreed, or strongly disagreed with the following 20 statements:
1. A computer increases costs by increasing the clinical staff’s workload.
2. Computers decrease communication between providers and hospital departments.
3. Computers will allow the clinical staff more time for the professional tasks.
4. Part of the increase in costs of health care is because of computers.
5. The time spent using a computer is out of pro portion to the benefits.
6. Computers represent a violation of patient privacy.
7. Only one person at a time can use a computer terminal; therefore, staff efficiency is inhibited.
8. Computerization of data collection offers a remarkable opportunity to improve patient care.
9. Computers contain too much personal data to be used in an area such as the ED.
10. Computers cause the clinical staff to give less time to quality patient care.
11. If I had my way, I would never have to use computers.
12. Computers should only be used by the clerical staff.
13. Computers make my job easier.
14. Paperwork for the clinical staff could be reduced greatly by the use of computers.
15. Orientation for new employees will take longer because of computers and, therefore, unneces sarily delay work.
16. Clinical data in patient charting does not lend itself to computers.
17. Computers save steps and allow the staff to become more efficient.
18. The more computers in an institution, the less number of jobs for employees.
19. Increased computer usage will allow more time to be given to patient care.
20. Because of computers, we could face more lawsuits.
Before the system is implemented, a second survey will be conducted to determine the clinical staff’s proficiency with computers. "We’ll ask people if they’ve ever used a computer, if they use the Internet, computer programs, to get an idea of how sophisticated the group is," says Finch.
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