FUNCTIONS AND ADVANTAGES OF CIS

CIS seek to deliver several key benefits (Table 9.1).²³ These include the automation of repetitive manual tasks, improved accuracy through reductions in human error, attributable records simultaneously available from multiple points of care and integration with other bedside equipment and information systems. The built-in error checking and knowledge-based systems should also provide a safer and higher-quality clinical process. The CIS electronically capture the data and make this information potentially available to a multitude of systems. This obviates the need for repetitive manual data entry or transcription, while making the data accessible for a range of purposes which may include clinical, business and research reporting.

Table 9.1 Clinical information systems (CIS) benefits

The ICU is already a technology-rich environment, where bedside devices process and provide data elements in electronic format. Similarly, many clinical measurements are available on monitors, ventilators and pumps. Traditionally, these electronically derived values are transcribed on to observation charts and paper-based clinical records, as are repetitive clinical observations and arithmetic calculations which are often performed manually or with the aid of a calculator. The voluminous observation charts present a challenge for both storage and access, and transcription errors and arithmetic errors are prolific in these paper systems.

The CIS automates the process of electronic data collection from monitors, ventilators, infusion pumps, dialysis/filtration equipment, cardiac assist devices and other bedside devices and provides a real-time spreadsheet with arithmetic accuracy. Incorporation of clinical documentation and progress notes provides a legible and attributable record of events.

The patient record can then be accessed from geographically distant workstations in the ICU, the hospital, and even from other more remote sites. As long as the system is running, the record is easy to locate and always available.

A major contribution of CIS to clinical safety and quality is through the provision of an electronic prescribing and administration record for drugs and fluids. Errors in prescription and administration are a leading cause of adverse events with associated morbidity.^18,24 CIS provide both legibility and varying levels of decision support which may include defining usual dosages and administration routes, suggesting dose modification in the setting of organ failures, or preventing prescribing in cases of known allergy or likely drug interaction.²⁵

ARCHITECTURE AND COMPONENTS OF CIS

BASIC CIS ARCHITECTURE

All CIS share certain basic components consisting of workstations, a network and central servers (Figure 9.1). The user interface is presented at the workstation, which is usually at each bedside but may also be in nearby central and administrative areas, such as the nurses’ station, or more distant in the offices of clinical or administrative staff. Workstations commonly consist of relatively standard personal computer (PC) hardware being desk-, pendant or trolley-mounted, but may include laptops or personal digital assistants (PDAs) with wireless systems where technical challenges related to speed and reliabiltiy of data transmission can be overcome.

Figure 9.1 Clinical information systems architecture. LAN, local area network; WAN, wide area network; ADT, admission/discharge/transfer; CVHD, continuous venovenous haemodialysis.

Most CIS allow other applications, such as PACS, word processing or e-mail, to be run on the same PC, but this is potentially a rich source of system conflicts and requires careful administration.

Workstations are linked to each other and a centralised set of servers through a network of communication cables. Hubs, switches and routers control network traffic. A dedicated network, either actual or virtual, enhances system performance but it is important to ensure built-in redundancy in network loops and power sources to minimise potential interruptions from physical disruption or component failure.

The configuration of computer servers varies widely but it is common to have ‘paired’ or ‘mirrored’ servers, which duplicate their partner’s function. This provides protection from hardware failure, minimising system down time, and provides some degree of data protection. Servers have a finite capacity to process data from multiple workstations and other peripheral connections, and so larger systems may require multiple server pairs.

CIS usually require a separate workstation or server to manage the interfaces with other systems. These include hospital demographics (ADT systems for admission/discharge/transfer), pathology laboratory, pharmacy, radiology and hospital finance. Interfacing requires a software platform known as an interface engine. Additional software identifies the relevant data and directs and processes these data to the correct field in the appropriate format. Due to the huge variety of current and legacy systems, this process almost always requires custom-written code and programming, representing one of the major risks and expenses of systems integration.¹³

Bedside monitoring systems usually include a central station or server that can be linked with the CIS servers to transfer their downloaded information back to the bedside. Transferring data from other bedside devices is usually achieved by a cable connection from the device to a bedside concentrator in the patient bay. The connection requires an electronic decoder, specific to the manufacturer and model of the device. The concentrator must then communicate with the central servers via a subsidiary server that provides the software translator to complete the interface. A selection of established interfaces to commonly utilised equipment exists but often additional customised interfaces must be written.