Post on 12-Sep-2021
CareNet and UPMC- St. Margaret’s Emergency Department 1
The Process of Adopting and Implementing an Electronic Health Record: One Emergency
Department’s Experience with CareNet
Nancy Gorsha, Ellen Mering, and Audra Ziegenfuss
University of Pittsburgh, School of Nursing
Introduction to Nursing Informatics (NURSP 2075)
Dr. Deborah Lewis, EdD, CRNP, MPH
December 6, 2004
CareNet and UPMC- St. Margaret’s Emergency Department 2
Abstract
The University of Pittsburgh Medical Center (UPMC) St. Margaret’s Hospital (SMH) has
recently implemented a computer information system (CIS) using Cerner Corporation software
application products. SMH was chosen to pilot the implementation of CareNet, a software
application designed for record keeping in acute care settings. The Emergency Department (ED)
has a unique patient flow and unique priorities compared to the rest of the hospital, and CareNet
facilitates documentation by automating the ED’s workflow. Consequently the ED has
encountered its own set of implementation issues that are gradually being resolved through a
variety of strategies developed by SMH’s eRecord team. Nurses are involved in each part of
CareNet’s life cycle. Their involvement has a direct impact on user satisfaction and success of
the CIS. Both the end-users and information system can be considered integrated parts of a
whole, both capable of influencing change in the other.
CareNet and UPMC- St. Margaret’s Emergency Department 3
Table of contents
Abstract……………………………………………………………………………………….2
Introduction…………………………………………………………………………………................5
Organizational Information
Organization of the Information Management Department……………………………..6
Accreditation………………………………………………………………………………….10
Evolution of the Information System………………………………………………………10
Motivations and Objectives…………………………………………………………….......14
Future Plans……………………………………………………………………………….…16
Adapting to the Change/Stage of Life Cycle…………………………………………..…18
Information System Design and Development
End-Users…………………………………………………………………………………….21
Selection of Vendor………………………………………………………………………….21
System Architecture……………………………………………………………………..….22
HL7 Standards……………………………………………………………………………....23
If the System Fails………………………………………………………………………..…23
Security…………………………………………………………………………………..…..24
The Internet: Information to Health Care Users and Ensuring Quality…………....25
Information System Applications
Organization…………………………………………………………………………………26
Utilization……………………………………………………………………………….…. 34
Support and Satisfaction………………………………………………………….….……42
CareNet and UPMC- St. Margaret’s Emergency Department 4
Analysis
Socio-technical Perspective………………………………………………………………48
How the Information System Influences the Organization……………………………50
How the Organization Influences the Information System……………………………54
Conclusion……………………………………………………………………………………………56
References……………………………………………………………………………………………58
CareNet and UPMC- St. Margaret’s Emergency Department 5
It is October 5, 2004. In a meeting room on the ground floor of the University of
Pittsburgh Medical Center St. Margaret’s Hospital, a multidisciplinary team of health care
providers have gathered to assess problems in the Emergency Department (ED) which have
arisen from the September 11th
go-live of SMH’s new computer information system (CIS) less
than a month before. A nurse, a physician and a department secretary each represent their
colleagues in the ED. Several administrators overseeing the project are also in attendance. One
by one the problems are considered. A physician expresses frustration at the length of time it
takes to input orders with the new system. “It may be only an extra 30 seconds,” he comments,
“but it adds up” (J. Nicholas, personal communication, October 5, 2004). A discussion follows
about physician order sets and the importance of making sure that physicians understand their
usefulness as early in the process as possible. A nurse reports on the inconvenience of chasing
after the computers on wheels (COW) (A. Culleiton, personal communication, October 5, 2004).
She is reminded that computers will not be installed in each room in the ED until SMH’s new
ED opens in 2005. For now the nurses must understand and endure. With each problem the
question arises, does something need to be changed or is this just part of the process of adjusting
to the new technology? As the physician facilitating the meeting puts it, “This is the house we
live in now. We may just need to get used to it. It’s not going away” (J. Diamond, personal
communication, October 5, 2004).
The discussion in this room is just one of many discussions in a process that has led to the
institution of a pilot CIS system at SMH. The CIS that has recently been installed at SMH will
serve as a model that will eventually be implemented in most of the other hospitals in the UPMC
health system. In fact, there is a good likelihood that other regional hospitals not part of UPMC
will eventually share information with UPMC’s information system. SMH’s go-live is the result
CareNet and UPMC- St. Margaret’s Emergency Department 6
of four intensive years of work on a project which has required complex organizational structure,
extensive design and development and has led to the implementation of a variety of software
applications, specifically CareNet, in use in SMH’s emergency department.
Organizational Information
Organization of the Information Management Department
UPMC St. Margaret’s information management department is called the Information
Systems Department (ISD). The organizational chart shown in Figure 1 shows how this
department fits into the organizational structure at SMH.
Figure 1. SMH Organizational Chart
Chief Information Officer (CIO) Donna McCormick reports to David Martin, the president and
Chief Executive Officer of SMH. The information management department is organized into
three functional responsibilities. These responsibilities include management and maintenance of
the telecommunications network, management and maintenance of information systems at SMH
and oversight of SMH’s eRecord project.
The eRecord project that Donna McCormick leads at SMH, is a part of a UPMC wide
initiative to create a paperless medical record that will eventually be accessible to all UPMC
CareNet and UPMC- St. Margaret’s Emergency Department 7
hospitals and affiliated physicians. In 2004 UPMC changed the name of this initiative from
Electronic Health Record Project to eRecord. Documents created before 2004 use the earlier
name.
The UPMC information system is divided into two zones that use the eRecord, a
community zone and a core zone. The core zone is comprised of academic centers such as
UPMC Presbyterian and Montefiore hospitals. The community zone includes nonacademic
hospitals within the UPMC health system.
The eRecord project team at SMH has its own organizational structure which is
illustrated in Figure 2 (see following page) Figure 2 shows the overall organization of the
eRecord project within UPMC as a whole and indicates how SMH’s eRecord project team fits
into this organization.
SMH’s team is one of several eRecord project teams within the UPMC system.
Since the software that is used at UPMC is developed by Cerner Corporation, CIO Donna
McCormick and a Cerner representative oversee the eRecord project at SMH. A project
management team reports directly to Donna McCormick. This team oversees separate groups
that focus on each of the different software applications that are in use at SMH, such as CareNet
and PharmNet. Two other teams are involved with training and creating reports. Donna
McCormick is a member of a cabinet that consists of SMH’s CEO, representative physicians and
other administrators who play a role in eRecord development. Three advisory committees report
directly to the CIO. These committees include an application and technology committee, a
physician advisory committee and what is called a champion committee. (See Figure 3, p. 9).
CareNet and UPMC- St. Margaret’s Emergency Department 8
D. Drawbaugh, Chairman
eRecord Leadership
Committee
Dave Martin, CEO
UPMC SMH
Executive Sponsor
Donna McCormick,
CIO, UPMC SMH
eRecord
Project Lead
Dave Hunker
Application Project
Manager
Chuck Rudek
Technical Project
Manager
Kim Morea
Surginet
PCRR
Reports
CareNETClinical-
Documentation
Orders
Kevin Conway
Charge Services
Training Specialists
FirstNET/VERSUS
PharmNET
Clinical Reporting
Chris Zuk, LAN II
Adam Maloney LAN I
ISD Staff
Deb Wolf, Director
Clinical-Operational
Informatics
Chair, SMH Champions
Deb Wolf, Business & Metrics
J. Stogoski, Workflow Optimization
M. Josefowki, Communication
S. Evans, Education
N. Gorsha, Policies & Procedures
C. Girt, Physician Engagement
T. Wolfhope, Job Impact
I. Arndt, Stakeholder
P. Dzubinski, Financial Oversight
eRecord Organizational Chart
UPMC SMH
Figure 2. SMH eRecord Organization
___________________________________________________________________
Reprinted with permission of Donna McCormick, CIO, (2004).
CareNet and UPMC- St. Margaret’s Emergency Department 9
Figure 3. eRecord Program Governance
__________________________________________________________________________________________
Reprinted with permission of Donna McCormick, CIO, (2004).
Champion’s chairperson, Debra Wolf, heads the champion’s committee. This committee
is designed to facilitate communication between the end users, eRecord project managers and
directors. Nine staff leaders, known as champions, monitor a variety of issues many of which
directly affect end users. For example, Nancy Gorsha is in charge of monitoring and trouble
shooting policy and procedure issues which arise from the implementation of the new CIS.
Other champions monitor such things as job impact, educational needs, physician’s issues and
workflow optimization. Debra Wolf, in addition to being the champion’s chairperson, monitors
CareNet and UPMC- St. Margaret’s Emergency Department 10
business metrics. Among other duties this role includes evaluation of the benchmarks by which
the effectiveness of the CIS is gauged. All of the champions are in close contact with end-users.
The champion’s concept will be revisited as part of the discussion of nurses’ roles and the
management of CareNet.
Accreditation
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) accredits SMH.
The hospital is also required to comply with Pennsylvania Department of Health regulations. In
addition, in order to receive Medicare and Medicaid reimbursements, SMH must comply with
the regulations that guide reimbursement for these federal programs. Further, The Health
Insurance Portability and Accountability Act of 1996 (HIPPA) has developed national standards
for privacy and security of health data. SMH is required to comply with these standards.
Finally, the Clinical Laboratory Improvement Amendments (CLIA) certifies SMH’s lab. This is
a requirement in order for SMH to receive Medicare or Medicaid reimbursement.
Evolution of the Information System
Planning for the implementation of a CIS system at SMH began in March of 2003 but the
steps that led to SMH’s key role in the implementation of UPMC’s system began back in 1998.
In 1998, UPMC signed an agreement with Cerner Corporation, a health care software provider,
for what CIO, Donna McCormick described as “a handful of products” (personal communication
Oct. 26, 2004). These included; Power Chart Results Review, software designed for the
hospital clinical and diagnostic results, SurgiNet, software designed for the operating room,
PharmNet, software designed for the hospital pharmacy, CareNet, software designed fro acute
care management and FirstNet, software designed for the ED.
CareNet and UPMC- St. Margaret’s Emergency Department 11
A small team was developed to implement these software packages and UPMC
Presbyterian Hospital was chosen to pilot the project. The idea was that a large hospital, already
at the cutting edge of technology would be better able to absorb the change that would be
involved in automating certain record keeping functions. The implementation did not proceed as
well as the planners hoped. Getting the software applications up and running was a struggle. In
fact, although First Net and SurgiNet are still in use at UPMC Presbyterian today, physician and
staff resistance made it impossible to successfully implement CareNet. Six years later, CareNet
is up and running at SMH but in 1998 it was an idea whose time had not yet come.
At this point, UPMC reconsidered its approach. The organization stopped thinking small
and began to build the big team which eventually selected SMH as an early adopter of the
software used in the eRecord project. Donna McCormick was brought on board in 2000. By this
time, UPMC had committed itself to what Donna McCormick refers to as the Enterprise Solution
(personal communication Oct. 26, 2004). In 2000, UPMC signed a 12 year contract with Cerner
Corporation to acquire access to the whole suite of healthcare software applications produced by
the company. In addition, UPMC acquired a deep discount of 80% on Cerner acquired software
developed by third parties (other companies with which Cerner has contractual agreements). For
example, if a third party associated with Cerner developed software that could scan documents
into the computer record, UPMC could acquire the software at a deeply reduced price.
In 2001, UPMC hired the health care consulting firm Cap Gemini Ernst & Young who
were paid approximately 20 million dollars, to help guide the process of adopting a CIS. This
18-month project led to the development of what is referred to as the “franchise model” (D.
McCormick, personal communication Oct. 26, 2004).
CareNet and UPMC- St. Margaret’s Emergency Department 12
Development of the franchise model occurred in two stages. In the first stage the concept
model was developed. This was done through a serious of “rapid design sessions” (D.
McCormick, personal communication Oct. 26, 2004). These sessions lasted from one to three
days and involved large groups of health system clinical staff, selected to represent every role
within the UPMC health system. Fifteen to twenty design sessions were held and each session
was run by a facilitator and a record keeper who took notes on the content discussed in the
sessions. During the sessions, each job function that could be automated was broken into steps
and examined in detail. For example, a physician might walk through every step involved in
ordering a lab test. The goal was to design a model that accurately incorporated each step of all
the processes required by the health practitioners who used them. The goal was also to develop
a model that would drive best practice and standardize clinical procedure. If a health provider’s
description of a procedure did not match best practice then ideally the procedure would be
modified within the model to better support best practice.
Eventually, the conceptual model was formed. Meanwhile the Electronic Health Record
Team had evaluated which hospital might be suitable to pilot the new model. It was assumed
that the model would need adjustments; and that instituting the model would be a learning
experience, not just for the hospital that took on this task, but also for UPMC as a whole. UPMC
sought a medium size hospital whose leadership was interested and willing to take on this
challenge. Physician buy-in was considered essential. The team also sought a financially sound
hospital whose budget and assets could help support the process. SMH fulfilled all of these
requirements (D. McCormick, personal communication Oct. 26, 2004).
Besides choosing St, Margaret to pilot the new information system, team members
created paper versions of forms that looked like the screens that practitioners would be using
CareNet and UPMC- St. Margaret’s Emergency Department 13
with the new computer system. When these new forms were created, members of the team
gathered up all the forms currently in use throughout the UPMC health system and replaced them
with the new forms. The purpose, of course, was to help ease the eventual transition to the
computer by getting health providers used to the new formats in advance. The new forms also
helped to standardize practice throughout the system. In some cases the new forms changed
practice. For example, the policy for nursing assessments changed from narrative documentation
to charting by exception (D. McCormick, personal communication Oct. 26, 2004).
SMH is not the only hospital that has recently implemented new software. In 2002,
UPMC Children’s Hospital of Pittsburgh implemented computerized provider order entry, a
component of CareNET. Children’s Hospital used the champion’s team system that SMH
subsequently adopted as a result of Children’s positive experience. (D. McCormick, personal
communication, September 17, 2004).
One of the first stages of SMH’s implementation of the new system was an investment of
$150,000 to remodel a part of one of the buildings at the hospital in order to create a training
room, offices and a meeting room for the team members who would be involved in the
implementation project. The team that moved into these rooms was made up of members of the
original eRecord team that had been involved with the central planning for the eRecord for all of
UPMC (D. McCormick, personal communication Oct. 26, 2004). Debra Wolf was brought in to
chair the Champion’s team. With Jackie Stogoski’s help, members of the Champion’s team were
gradually selected from SMH’s staff from among those who showed interest in various aspects
of the project (Debra Wolf, personal communication, November 2, 2004).
CareNet and UPMC- St. Margaret’s Emergency Department 14
Motivations and Objectives
Debra Wolf commented that many of UPMC’s objectives and motivations for use of the
system were not formally identified by the organization before beginning the work of developing
the system. (Debra Wolf, personal communication, November 2, 2004). Nevertheless, the
reasons for developing the system were apparent to the team members involved in the
development of the system.
Several factors motivated the UPMC health system to engage in the huge project of
developing a CIS ambitious enough to include a plan to link most of the regions health care
records together in a single network. The Institute of Medicines groundbreaking report To Err is
Human (1999) had a big impact on medical institutions. This report called on regulators and
accreditors to develop higher standards of safety within health institutions. Much of the
systematic standardization called for would clearly require an automated system. It seemed
apparent that this report would influence government regulatory policies as well as JCAHO
accreditation guidelines.
In 1998, the LeapFrog Group was formed when a group of large employers came
together to discuss the best way to work together to use purchasing power to influence the
quality and affordability of healthcare (LeapFrog Group, n.d.). After the Institute of Medicine
issued its report in 1999 the LeapFrog Group increased its focus on safety. Leapfrog is
essentially a consumer advocacy group. As Donna McCormick notes, “Consumers drive change
in healthcare and are a force that healthcare systems cannot get away from” (D. McCormick,
personal communication, October 26, 2004).
Debra Wolf also noted other motivations for implementing a CIS system at UPMC.
(Debra Wolf, personal communication, November 2, 2004). First UPMC’s leaders predicted
CareNet and UPMC- St. Margaret’s Emergency Department 15
that in the long run, the CIS would translate into more profit for the organization. This profit
would presumably come from greater efficiency, increased patient safety and an enhanced
reputation for being at the cutting edge. UPMC clearly hopes that this combination will continue
to give it the competitive edge in the region. “UPMC,” Debra Wolf notes, “wants to be on the
cutting edge when it comes to technology” (Debra Wolf, personal communication, November 2,
2004).
Besides the general motivations that prompted UPMC to embark on this project, SMH
has identified several specific benchmarks to use to gauge the success of the project.
(Electronic Health Record Benchmarking Committee Summary, 2003) Although the
benchmarks were not expressed as objectives, they indicate specific areas that SMH plans to
analyze in the post CIS implementation go-live environment. A rough summary of those
benchmarks that are currently relevant is included in Table 1.
CareNet and UPMC- St. Margaret’s Emergency Department 16
Table 1
Values for Comparison Before and After Implementation
Operating Room Services Clinical Documentation Pharmacist/ Medication
Errors
Cost per service and per
procedure
% Patient pain education # of clarifications made by
pharmacist on medication
orders
Time needed to schedule
cases
% monitoring effects of
medication on patient
# Omission errors
Documentation compliance % pain assessment # Improper dose errors
# of cases % advanced directive
documentation
# Extra dose errors
# of OR minutes per 24
hour period
Costs of printing test results # Wrong drug errors
# of minutes per day for
inpatient OR and outpatient
OR
Utilization of standardized
nursing documents
#Unauthorized drug errors
Since the system has the capability of generating reports that are tailored to the questions
and concerns of the users, documentation and assessment of the identified benchmarks and other
concerns is an ongoing process. Because SMH’s CIS system has been up and running for less
than three months, not all of the analysis spelled out in the benchmark report has been
completed.
Future Plans
Both UPMC and SMH have plans for additional change in their use of information
technology in the next five years and beyond. SMH’s eRecord team will continue to educate its
stakeholders in the use of the newly implemented technology. CIO Donna McCormick notes
that ongoing feedback and problem solving meetings will continue to contribute to the
refinement and improvement of the existing applications. (D. McCormick, personal
communication, October 26, 2004). Furthermore, she expects that design session meetings will
continue to be held to help envision future changes in the system. SMH is also currently
building a new ED. When the new ED is completed in January of 2005, SMH will introduce
CareNet and UPMC- St. Margaret’s Emergency Department 17
another Cerner soft ware package FirstNet that is specifically designed for use in an Emergency
Department (D. McCormick, personal communication, October 17, 2004).
In the broader picture, UPMC has introduced many of the same software packages in use
at SMH in several of its area hospitals including Presbyterian Hospital, Shadyside Hospital, the
Hillman Pittsburgh Cancer Institute and Bedford Hospital. In 2005 UPMC plans to bring
Passavant on line. In that same year, UPMC plans to institute what it calls the Health Economic
Architecture (HEA) (D. McCormick, personal communication, October 17, 2004). This term
refers to the capability of having all sites within the UPMC health system have access to all
patient eRecords within the system.
UPMC’s plans for future development of its information system go even beyond linking
institutions within the UPMC health system to patient records. UPMC plans ultimately to create
a system that will centralize medical information within the region. McCormick described the
plan as “like a utility service” for health providers outside of the UPMC network. (D.
McCormick, personal communication, October 26, 2004). Instead of smaller networks of health
providers building their own information system from scratch, they would have access to
UPMC’s system for a monthly fee.
The federal government has expressed interest in such an initiative. In late September of
2004, Dr. David Brailer, Information Technology Coordinator for the United States Department
of Health and Human Services, visited Pittsburgh to examine UPMC’s eRecord
accomplishments. According to the Pittsburgh Post Gazette, Dr. Brailer’s goal was to consider
whether UPMC’s initiatives might be used as a model for similar systems that might be
developed across the country (Snowbeck, C., 2004).
CareNet and UPMC- St. Margaret’s Emergency Department 18
Adapting to the Change/ Stage of Life Cycle
SMH put a lot of effort and planning into preparing its staff for the changes that would
come with the new information system. In the early stages, a readiness assessment survey
(UPMC St. Margaret Electronic Health Record Readiness Assessment, 2003) was distributed to
all staff at SMH to evaluate attitudes toward technological change. An analysis of survey results,
including recommendations based on these results, was presented to Champion committee
members in October 2003 (St. Margaret Hospital EHR Project Readiness Assessment Summary,
Oct. 22, 2003). Revised and standardized forms that mirrored the screens that practitioners would
ultimately be using with the Cerner software were developed and put into use. The champion
system promoted ongoing communication with end users. All staff were required to participate in
training classes within at least two months of the go-live date. After implementation, follow up
trouble shooting sessions focusing on different user groups in the hospital or on specific issues
were held regularly.
Almost three months after going live, SMH is still in the process of adapting to the
change. Many minor glitches were worked out fairly early. For example, CareNet computer
provider order entry had a screen that was programmed to request the wrong dosage of a
medicine. Also, a few screens would not “pull through.” That is information from an order
entry screen would not appear on a summary screen (J. Nicholas, personal communication,
October 5, 2004). Physicians in the ED quickly learned the value of physician order sets, which
are standardized orders packages for frequent use situations. The packages can be modified as
needed. Extra steps were painfully noted in some of the ordering procedures and were
eliminated. Methods for communicating problems were also developed. For example, in the ER
a problem list is now kept on a clipboard by a central computer. Minor glitches produced their
CareNet and UPMC- St. Margaret’s Emergency Department 19
share of grumbling and hair pulling but in general many small problems seem to have been dealt
with fairly efficiently through improved communication and regular problem solving sessions (J.
Nicholas, personal communication, October 5, 2004).
Many staff are still adapting, not so much to the particulars of the new technology but to
the overall change of working in a paperless environment. Some complain that their electronic
documentation takes longer than paper documentation. Team members argue that there is a
learning curve but that in the long run electronic documentation should allow more time for
patient contact. (D. Wolf, personal communication, November 2, 2004).
Meanwhile the new system is fine tuned and adjusted one problem at a time.
An electronic suggestion box is reviewed daily. For the first two months system support staff
called rounders visited units to respond to problems. These rounders reported back on any
patterns that the saw in users adapting to the new environment. Multidisciplinary trouble
shooting meetings still continue on a regular basis (D. Wolf, personal communication, November
2, 2004).
Having gone live less than three months ago, SMH is clearly at the initiation stage of the
organization-wide information life cycle. Douglas (2001) divides the implementation stage in 14
steps. Of these steps SMH is clearly in the final step or “post implementation evaluation”
(Douglas, M., p. 215). In terms of UPMC as a whole one might argue that UPMC is in the
expansion phase of developing an organization wide information system. SMH has played a key
role in this expansion. The refinements that occur from the implementation at SMH should help
for smoother implementations at other health care facilities within the UPMC system.
Aarts (2004) notes, “the introduction of information systems in health care practices is a
thoroughly social process in which both the technology and the practice are transformed” (Aarts,
CareNet and UPMC- St. Margaret’s Emergency Department 20
p.208). Debra Wolf (D. Wolf, personal communication, November 2, 2004) emphatically agreed
with this statement. When asked to give specific examples of some of the ways in which
practice has been transformed, she made the point that the physicians are more accountable
under the new system. “There are so many details that physicians used to assume that nurses
would follow up on,” she observed. “Now they’re accountable for them. They have to
document everything. It’s changed the way that physicians think about orders” (D. Wolf,
personal communication, November 2, 2004).
Information System Design and Development
Selection of the Information System
UPMC went through two stages of its information system design and development. In
the first stage UPMC Presbyterian was selected as the hospital to pilot adaptation of new
software. At that stage UPMC’s information system department (ISD) was involved in system
design decisions. According to Maureen Bradley (M. Bradley, personal communication,
October 24, 2004), team leader in charge of testing, people who played a key role in the
implementation of this information system were ISD Director Sean O’Rourke, ISD Associate
Director Suzanne Paone, and ISD Client Services Manager Sandy DePellegrini.
In the second stage, the Enterprise agreement gave UPMC access to the complete range
of Cerner software. Donna McCormick (D. McCormick, personal communication, October 26,
2004) recalls that at this stage UPMC CIO Dan Drawbaugh, eRecord Executive Director Dan
Martich MD, ISD Director Sean O’Rourke, ISD Director Paul Sikora, Darinda Sutton, UPMC
Director of Nursing Informatics and Gail Wolf, UPMC Chief Nursing Officer, played key roles.
End-users were not involved in the selection process.
CareNet and UPMC- St. Margaret’s Emergency Department 21
End-users
Although end-users were not involved in the selection of the software supplier, they were
intensely integrated into the development of the information system. This was evident in the
early use of rapid design sessions that drew on users from every role within the UPMC system in
order to study the detailed steps of every procedure that might be impacted by the new
information system. Once the project had moved to SMH, the early assessment of end-users
needs with the Electronic Health Record Readiness Assessment Survey and the champion
concept insured that end-users would continue to have significant input into the development of
the system. SMH CIO, Donna McCormick notes that nurses had input in the design of the new
system from the very start when paper forms were designed to reflect future Cerner screens (D.
McCormick, personal communication, October 26, 2004).
Selection of Vendor
UPMC’s system vendor is Cerner Corporation. Cerner was the chosen vendor for the new
software applications but there was a need for the Cerner applications to communicate with other
existing applications such as Sunquest, the lab application and IDXRad the radiology
application. According to McCormick, these ancillary systems have to “map a code to talk in
HL7” (D. McCormick, personal communication, October 26, 2004).
The decision to use Cerner was made in 2000. At that time the choice of possible
vendors was narrowed to Epic Systems and Cerner, both companies specialize in health care
information systems. The decision went to Cerner since this company had more of a focus on
inpatient care than Epic which had created more software for the out patient world of physician’s
offices (D. McCormick, personal communication, October 26, 2004).
CareNet and UPMC- St. Margaret’s Emergency Department 22
System Architecture
McHugh (2001) notes that the term architecture “refers to how communication among the
various computers is accomplished” (McHugh, M. L., p. 64). Broadly speaking SMH can be
said to have a broadcast network architecture. In a broadcast network the same information is
transmitted “to all the computers in the network that are expected to respond to it” (McHugh, M.
L., p. 64). Broadcast networks contrast with point to point networks in which information is sent
to a specific computer.
Cerner describes the architecture of its systems as “three-tiered, distributed, client server
model” (Cerner Corporation, 2004). According to McHugh (2001, p. 64), a client-server model
“awaits and fulfills requests from client programs in the same or other computers.” The three
tiers of Cerner’s architecture are the client, the middleware and the database. The software
applications function at the client tier. The middleware connects the client to the database and
plays a role in transferring data in both directions between the client and the database. The
databases stores and organize both long term data that is used repeatedly and active data that is
entered by the system users (Cerner Corporation, 2004). UPMC has a local area network
(LAN); the computers are interconnected within the organization. Computers can be connected
in different ways. In other words, they can have different topologies. SMH has what is known as
a bus topology. In a bus topology all of the computers are connected “in parallel to each other”
(McHugh, M. L., p. 64). With a parallel connection, “if one computer fails, other computers can
still access the information” (McHugh, M. L., p. 64).
The UPMC system architecture consists of four very large computers called Regattas
(trade name). SMH system architecture currently resides on three of the four Regattas. Each
Regatta is comprised of nodes. Each node is dedicated to one aspect of the clinical information
CareNet and UPMC- St. Margaret’s Emergency Department 23
process that is referred to as a domain. Each process/domain (DEV or development, TST or test,
MOK or mock, PRP or pre-production, and PRD or production) of the UPMC clinical
information system is shared between more than one Regatta. The sharing insures that, should
there be a failure in one of the nodes, the entire UPMC system would not be crippled. For
instance, when a new software application or new code (feature, function, fix of broken things) is
introduced into the UPMC Health System, the application/code is first introduced/tested in the
H2TST domain. If everything goes well, the system is switched over to/testes in the H2MOK
domain. Once success is achieved in H2MOK, the code/application is moved into the H2PRP
(pre-production) domain. The code/application moves from H2MOK to H2PRP twice before it
is transitioned into H2PRD domain (actual use in real time). The community zone currently
utilizes domains existing in nodes on three of the four UPMC Regattas. (D. McCormick,
personal communication, November 22, 2004).
HL7 Standards
According to Maureen Bradley, the CIS at SMH and its ancillary functions, comply with
Health Level Seven (HL7) standards (M. Bradley, personal communication, Oct. 24, 2004).
HL7 is an organization founded in 1987 whose mission is to provide international standards “for
the exchange, management and integration of data that support clinical patient care, and the
management and delivery of healthcare services”(HL7 in the 21st Century, 2000). The interface
standards that HL7 provides will be invaluable in implementing UPMC’s long term goals of
providing health care professionals throughout the region with access to patient records.
If the System Fails
If the system goes down in a paperless hospital environment the consequences could be
disastrous. Every health provider within the hospital is dependent on the system in order to
CareNet and UPMC- St. Margaret’s Emergency Department 24
provide appropriate and timely care to his or her patient. Debra Wolf, Director of Clinical and
Operational Informatics, spelled out the contingency plans that St. Margaret has developed for
just such a scenario. (D. Wolf, personal communication, November 2, 2004). She explained that
three separate down time reports are run behind the scenes. A 36 hour summary report is created
which includes lab and test results, a report listing the current medications the patient is on with
the last dose given and a report listing the patient’s active orders. These reports are sent from the
network, at varying time intervals, to the hard drive of a non-network computer in the Nursing
Administration Office. If the network fails, the Nursing Administration office can access the
hard drive to produce a print copy of the information listed above.
SMH also schedules down time on a regular basis once a month for computer
maintenance. A schedule of planned downtime comes out annually. Most computer
maintenance issues can be taken care of during this planned downtime. SMH has a scheduled
down time policy for each of the different types of users on the system. For example, the
pharmacy can get a printed copy of the MAR during a scheduled down time. (D. Wolf, personal
communication, November 2, 2004).
Security
Security is an enormous priority in any health care CIS. As the Institute of Medicine
points out (Crossing the Quality Gap, 2001), “automated records can make it much easier for
hackers to assemble lists or find (or alter) information about individuals.” HIPPA privacy rules
have accented the importance of good security in CIS which store and transfer patient data.
Security breaches like the University of Minnesota glitch in which the identities of 410 deceased
kidney donors were accidentally revealed (Gross, 2002) have sent a clear warning to all
healthcare systems that information security cannot be taken casually. According to Maureen
CareNet and UPMC- St. Margaret’s Emergency Department 25
Bradley (M. Bradley, personal communication, Oct 24, 2004) there is a standard Security Policy
for the Cerner system that is in compliance with ISD Security and HIPPA Standards and all
security issues, concerns and requests adhere to these policies.
UPMC and SMH have developed a security system that will both prevent users within the
system from gaining access to patient information that is not relevant to their practice and will
prevent hackers outside the system from gaining access to patient information. Debra Wolf
(D.Wolf, personal communication, November 2, 2004) explained that users within the system
leave an electronic fingerprint in the form of a login each time that user enters a patient medical
record. A history of clinician access to patient charts is randomly audited. A highly visible
patient, such as a celebrity might also have their medical records audited to make sure that only
authorized users have visited their charts.
Debra Wolf also claims that hacking into UPMC’s system would be a formidable task.
“UPMC’s firewall is incredible,” she noted. She added that before the current firewall was
installed a virus did successfully get into the network and “destroyed a lot of hardware” (D.
Wolf, personal communication, November 2, 2004).
Currently some users, mostly physicians, are able to access SMH’s CIS from outside the
hospital through a portal. Security codes are required for access through the portal and before
the user can log into the UPMC system every application in use on his or her computer must be
closed.
The Internet: Information to Health Care Users and Ensuring Quality
According to Maureen Bradley (M. Bradley, personal communication, Oct 24, 2004)
decisions about consumer health information on the internet come from several sources at SMH.
CareNet and UPMC- St. Margaret’s Emergency Department 26
She lists health plan managers, the community relations department, corporate communications
and ISD as departments that participate in such decisions.
The internet is used to communicate information to healthcare customers on UPMC’s
webpage (University of Pittsburgh Medical Center, n.d.). This web page includes seven different
categories of information, “diseases & conditions,” “medicine cabinet,” “health tools,” “UPMC
Classes & Events,” “Health Sciences Library,” “Patient Education Materials” and “Schools of
the Health Sciences” (UPMC, n.d.) Health on Net Foundation (HON) has given UPMC a 97%
rating for the quality of its internet healthcare information (HON, n.d.).
Information System Applications
Organization
Enterprise Applications and Estimated Annual Clinical Information Systems Costs
There are numerous eRecord applications in clinical use within the larger University of
Pittsburgh Medical Center (UPMC) (see Table 2). These are part of UPMC’s agreement with
Cerner when they negotiated a figure encompassing an enterprise of applications rather than a
limited set. As a component of the UPMC Health System, SMH also has these systems
available. Although all of these applications have not currently been implemented at SMH, their
implementation is an option of the near future. CareNet Acute Care Management System, the
focus of this review, is a sub-component of PowerChart. PowerChart is the name for the
eRecord. Of the three applications that PowerChart offers (Enterprise Clinical Data Repository,
Enterprise Order Management, and Enterprise Documentation Management), CareNet is the
name of the documentation management application. A brief description of both PowerChart
and CareNet are given in Table 2, but a detailed description will follow in the discussion on the
application’s support of nursing practice.
CareNet and UPMC- St. Margaret’s Emergency Department 27
Table 2
Clinical Applications Currently in Use in the UPMC Network
Application Description
Ambulatory Computerized Physician Order
Entry Medication (EasyScript)
EasyScript is used for medication ordering
within the eRecord. Drug interactions and
allergies are checked and automatic updates to
the patient’s eRecord made.
Clinical Documentation & Orders Entry
(CareNet)
CareNet integrates nursing and physician care
by automating documentation and orders.
Emergency Department (FirstNet) FirstNet is integrated into PowerChart and is a
patient tracking and triage system.
Health Economy Architecture (HEA) HEA integrates many computer environments
across the UPMC network and provides for
continuity of care including the aggregation of
clinical information.
HealthTrak- UPMC Patient Portal This web-based application allowing patients
to be pro-active in their health care decisions.
Outpatient Practice Management (PowerChart
Office)
Multifunctional use is the key to this outpatient
practice management system. Its scope
supports both clinical and business activities
occurring in private practice.
MedTrak- UPMC Physician Portal MedTrak links inpatient and outpatient realms
for continuity of care both within and outside
the UPMC network.
Pharmacy Management (PharmNet) This is part of eRecord and provides
medication order entry, intravenous fill lists,
and medication administration records.
Positive Patient Identification (PPID) Barcode technology ensures the five rights of
medication administration are being met.
Results Review (PowerChart) Multi-disciplinary face of eRecord providing
an interactive, graphical user interface.
Single Sign On (CCOW/ Sentillion) Only one login per session is needed for
eRecord users to maintain the same patient
between applications.
Specialty Laboratory Management System
(PathNet)
Clinical and management applications are
automated and integrated into eRecord. It also
automates the process of organ transplant
services across UPMC.
Structured Clinical Documentation
(PowerNote)
Care documentation and ordering are
combined and alleviates the repetition
physicians encounter during note taking.
Surgical Scheduling and Documentation
(SurgiNet)
SurgiNet provides electronic surgical case
scheduling, picklists, intra-operative
documentation, and automated charging. Note. Adapted from ERecord status report. (2004, September). Copy Editor, 2-4.
CareNet and UPMC- St. Margaret’s Emergency Department 28
D. McCormick (personal communication, October 26, 2004), the Chief Information
Officer at UPMC- St. Margaret, discussed the costs involved in design and development,
implementation, and support of the electronic health records. As previously mentioned, SMH
was targeted for participation, since its financial status enabled support for the implementation.
Monetary costs involve three items of interest: cost of hardware and software, cost of education,
and intellectual resources (Simpson & McCormick, 2001). UPMC negotiated a twelve-year, $40
million dollar agreement with Cerner Corporation for the suite of software applications and
discounts on third party agreements. Of the $4.7 million dollars budgeted for SMH capital costs,
$1.5 million dollars was allotted toward the required hardware. In order to prepare SMH for the
upcoming information system, $250, 000 was allocated for implementation and support.
Education and intellectual resources fall under the capital annual budget for information science
(IS) services, and UPMC allowed for $50-60 million dollars toward these services for the entire
health system. Half of the initial IS figure was intended for implementation of the eRecord. For
the 2005 fiscal year, SMH has a budget of $1.5 million dollars in capital costs.
Relationship Between Administrative and Clinical Components
The clinical data input of CareNet provides the opportunity for administrative aggregate
analysis. The Institute of Medicine (2001, pp. 170-171) claims that “automated clinical and
administrative data enable …[assessments] of clinical outcomes…and care processes;
identification of best practice; and evaluation of effects of different methods of financing,
organizing, and delivering services.” Performance improvement measures provide a link between
the administrative and clinical components of CareNet. There are corporate benchmarks that the
UPMC Health System is targeting for performance improvement. These include community
acquired pneumonia, congestive heart failure, acute myocardial infarction, and central line
CareNet and UPMC- St. Margaret’s Emergency Department 29
infection. Theoretically, the functions of CareNet should theoretically facilitate improvements in
these areas by enhancing patient care. Performance improvement targets specific to the
Emergency Department are (1) leaving the Emergency Department prior to or following being
seen by a physician, (2) inquiries concerning a patient’s financial information prior to triage, (3)
length of stay, (4) and the use of moderate sedation. CareNet, and other components of the
greater clinical information system, also help facilitate improvements in these areas by forcing
health care providers to assess and evaluate a number of different aspects of their delivery of
patient care.
SMH’s own set of benchmarks was discussed earlier. SMH has developed an initiative to
improve and standardize clinical documentation through benchmarking particular areas for
measurement prior to and following implementation of the electronic health record (Electronic
Health Record Benchmarking Committee, 2003). Two targeted areas are advance directive
documentation which was only 61% compliant in September, 2003 and the time to admit a
patient to a general medical-surgical unit. Benchmarking is a quality assurance tactic and
important in the delivery of quality health care (D. Wolf, personal communication, November 3,
2004). Reports are generated on the benchmarked items and reviewed for quality assurance and
performance improvement. Currently it is not simple to retrieve data on any new item of interest
or query an investigator might have. The reports have to be customized, planned and scheduled
and are a time-consuming effort.
In addition to benchmarking, administrative and clinical components meet at the billing
function. Cerner applications send Charge Description Master (CDM) codes to the UPMC
billing system (McKesson’s MediPac) which is the patient billing application (D.McCormick,
personal communication, November 8, 2004). This is an automated function of the Cerner
CareNet and UPMC- St. Margaret’s Emergency Department 30
applications and cuts down on the time it takes for coding done by an employee devoted to that
function.
Finally, another source of interrelatedness of administrative and clinical components
takes place not within CareNet, but rather, outside the technology and in the meeting room. Both
administrators and clinicians, the end users of the administrative and clinical components, work
as a team to promote successful pre-implementation, implementation, and post-implementation
phases of the clinical information system. Relationships are formed among these
multidisciplinary groups of people. The success of the eRecord, comprised of CareNet and other
applications of the clinical information system, is the ultimate goal.
Nurses Roles in the Management of CareNet and other Applications
The success of the clinical information system is “increasingly dependent upon how well
the people and organizational issues are managed” (Lorenzi, Riley, Blyth, Southon, & Dixon,
1997, p. 79). Nurses are one group of primary end-users of the clinical applications, specifically
CareNet. Nurses do the majority of documentation and are held accountable for errors and
impediments to correct and accurate data recording. Therefore, it is logical that they should be
involved early in the process of adopting a new clinical information system. M. Berg (1999, p.
94) recognizes the need for a user-centered system and understands that being user-centered
involves more than “[graphical user interfaces], good communication or adequate training
programs.” Berg suggests that the end-users need to be the driving force behind design and
implementation and involved “early, thoroughly, and systematically” (Berg, 1999, p. 94).
Involving nurses in the process aids in the preparation and acceptance of the impact a
new system has on the organization. Organizational change will occur as a result of the
information system, but the information system must also change in response to the end-users
CareNet and UPMC- St. Margaret’s Emergency Department 31
needs. Nurse management of the information system facilitates this process. Lorenzi et al.
(1997) use Field Theory to explain the need for nurse involvement in the change process. Field
theory is based on the need for involvement of the people within the change to motivate them to
make it a success. If there is no involvement there will be no motivation, and the change might
be seen as a threat. Nurse involvement might be considered a tactic with positive impacts such
as having more involved staff, a better understanding of the influence of the changes on the
organization, a better understanding of the changes, and an enhanced ability to cope with the
changes (Lorenzi et al., 1997).
One specific example of how nurses manage the clinical information system are the use
of champions and superusers. Champions and superusers are nurses and physicians who act as
liaisons between their professional groups using the applications and the administrators
mandating them. The champion role begins early in the design and development process and
evolves into the post-implementation phase. The restructuring phase occurring after
implementation also involves nurses, but not as champions. Nurses’ roles as champions and
restructuring entities will be the focus of the next two sections.
Champions. The role of champions in the management of clinical applications is the
foundation for an increased acceptance of change. Champions do not serve a passive role in
success of the information system. They are involved in the “aggressive seeking of inputs at the
earliest possible stages of the overall process. . . . with continuous feedback on the status of the
inputs and detailed explanations of why some inputs cannot be utilized or implemented”
(Lorenzi et al., 1997, p. 88). J. Ash (1997, p. 103) describes champions as those who take
creative ideas and “bring them to life.” According to Ash, their contribution may include
promoting the new idea, building support, dampening resistance, and facilitating implementation.
CareNet and UPMC- St. Margaret’s Emergency Department 32
The champion structure (see Figure 4) is composed of nurses, administrators, and
physicians assigned specific roles. While acting within their roles, the champions act to create a
“smooth landing” for the end-users and facilitate communication between the project team and
the end-users. Champions allow the organization to influence the information system and the
information system to influence the organization.
Figure 4. St. Margaret Hospital’s Champion Structure.
___________________________________________________________________ Reprinted with permission from D. Wolf, Director of Nursing and Operational Informatics (2004).
Three topics of user involvement are discussed by Lorenzi et al. (1997). These include
cognitive, motivational, and situational topics. Nurses, and specifically champions, use each of
CareNet and UPMC- St. Margaret’s Emergency Department 33
these topics in the management of the clinical applications. Cognitive functions involve the
actual knowledge of technology. One role of the champions is to ensure that the end-users are
receiving sufficient knowledge and support. Therefore, they are not only motivators as Lorenzi
et al. (1997) indicate, but they are also reinforcers. Knowledgeable champions act as positive
reinforcers by explaining the system and designing the training. Superusers are other individuals
involved in cognitive functions. They are nurses and physicians on each unit or floor considered
to be the point-of-contact if any application support is needed.
Champions also serve a motivational function to try to understand the end-users’
motivation for using or not using the technology. Motivation encompasses a person’s self-
efficacy, beliefs and expectations, and interest. Situational topics involve those inherent to the
organization itself. Champions seek to understand the environment on particular units or floors.
If the environment is well understood, influencing application acceptance might be approached
appropriately. That is, if a particular floor is more resistant to change than others, advocating for
the system might be approached differently than if the floor was open to change.
Restructuring. The role of champions is primarily for the design and development and
implementation phases of adopting a new clinical information system. However, their roles do
not cease once implementation has occurred. Inherent in the word change is the notion that it
does not seem to come to an end. Implementation is not so distinct from the evaluation phase
and nurses’ management of the applications continues. The support structure changes and the
champion structure is phased out, but nurses continue to manage the application by acting as
superusers and voicing requests for application adjustments to the IS department.
CareNet and UPMC- St. Margaret’s Emergency Department 34
Utilization
Nurses Involvement in the Utilization of CareNet
The Emergency Department nurses utilize CareNet for their nursing documentation.
However, documentation has more to do with nursing data and support of nursing practice.
Nursing utilization involves more than just the functions within the application. Utilization also
involves acceptance and ownership of the application by the nurses. Nurses are involved in the
utilization by championing it and also by seeking ownership of it. If nurses do not feel as if they
own the application, they will not utilize it. Therefore, nurses need to be involved in seeking
ownership in order for it to be successfully utilized. Three themes emerge out of the concept of
nurse utilization—acceptance, ownership, and success.
Acceptance and ownership. As the primary users of CareNet, nurses must be willing to
accept the application in order for it to be successfully utilized. UPMC’s unsuccessful attempt to
implement CareNet is an example of a good system that was rejected by the end-users due to
their inability to “own” the system. There are numerous theories on acceptance and rejection of
various information systems, so the focus will be limited to ownership. Lorenzi et al. (1997)
create the idea of owning the problem and the solution and allowing technology to be an enabler
rather than a prohibitor. Lorenzi and Riley (as cited in Aarts et al., 2004, p. 209) expand on the
concept of ownership by describing how a “technically best” system can be brought to its knees
by people who do not feel ownership and resist implementation, whereas a “technically
mediocre” system may be extremely valued by its users.
If the Emergency Department nurses “perceive they own the problem and the solution,
they will work with the developers to make the system work” (Lorenzi et al., 1997, p. 94). If
CareNet is viewed as an enabler and empowerer for the Emergency Department nurses, they will
CareNet and UPMC- St. Margaret’s Emergency Department 35
support its development and implementation. The Emergency Department nurses, as a collective
unit at SMH, have gained ownership of both the existing problems and the solutions CareNet is
able to offer.
How nurses come to own the problem and the solution lies in how useful they perceive
the technology to be. Ash (1997) suggests that users must see the need for change in order to
support a change. The benchmarked areas that the UPMC network and SMH have indicated are
areas that need to be changed. For example, if bringing multiple disciplines together and
expediting the receipt of lab values and images decreases the time a patient spends in the
Emergency Department, CareNet has provided a solution to the problem of lengthy Emergency
Department stays.
Successful utilization. Success is distinct from acceptance. A clinical information system
can be successful and not accepted or accepted and not successful. How success is defined is
central to whether or not it exists (Ammenwerth, Mansmann, Iller, & Eichstadter, 2003, Aarts,
Doorewaard, & Berg, 2004). Delone (as cited in Ammenworth et al., 2003, p. 82) gives six
categories of success. These include “comprising system quality, information quality,
information use, user satisfaction, individual impact, and organizational impact.” Although it is
early in the course of its implementation, CareNet appears to be accepted by the majority of
Emergency Department nurses and some physicians. If its success is viewed in terms of
individual and organizational impact, deficits in the nursing process are visualized more clearly
and able to be rectified. Rectifying potential problems is useful in that it provides a solution
before the problem has ever been created.
CareNet and UPMC- St. Margaret’s Emergency Department 36
How Applications are Used to Capture Nursing Data and Support Nursing Practice
In November 24, 2003, CareNet was the only document management solution recognized
by the Nursing Information and Data Set Evaluation Center (NIDSEC) (American Nurses
Association, 2003). The NIDSEC cited CareNet for completeness, accuracy, use of appropriate
nomenclature, clinical content, clinical data repository, and good general system characteristics.
Beyond supporting nursing practice, information systems also hold the potential to advance
nursing knowledge (Graves & Corcoran, 1988). The application captures nursing data and
supports nursing practice in three ways—documentation, health care collaboration, and quality
assurance.
Documentation, health care collaboration, and the information gap. Although there are
different types of data, data specific to the nursing practice is considered patient-specific data
which is concerned with a particular patient and may be acquired from a variety of sources
(Henry, 1995). Data entry is facilitated by the use of a user-friendly graphical user interface
(GUI). There are a number of windows available for the nurse to capture patient data. Having
well-designed windows or screens discourages data entry errors (Nelson, 2001) because the
workflow of the Emergency Department nurse is replicated in the flow of windows presented to
him or her. In addition, the application is flexible enough to allow for the creation of specialty
documentation appropriate for a particular care area such as the Emergency Department.
Specialty documentation allows for what Feied, Smith, Handler, Gillam, & Pietrzak (2004,
p.121) refer to as a series of “rights” which include “the right information to the right clinician at
the right time, formatted in the right way to meet the information needs of the moment”.
Once the patient demographics are entered, the next available window might be vital
signs and pain assessment followed by a brief medical history including current medications. All
CareNet and UPMC- St. Margaret’s Emergency Department 37
of the entered data may be used many times “by different users for different purposes” (Nelson,
2001). In fact, the Institute of Medicine (2003) recommends having result management to allow
all providers to access data quickly to increase patient safety and the effective care. This reuse
and additive effect of data reduces redundancy and results in a streamlined approach to
documentation. By accessing data from a single location each time, PowerChart, geography no
longer becomes an issue. Multiple healthcare providers, including nurses, can simultaneously
access patient data from various locations (Cerner Corporation, 1998). This promotes healthcare
collaboration by allowing speedy communication among a variety of disciplines.
If a patient has been to a community facility such as SMH, which is different from the
academic core facilities, a patient history will be available to the triage nurse as he or she enters
the patient demographics into the system. Having a patient history available when a patient
presents to the Emergency Department reduces the patient’s length of stay, a benchmark for all
UPMC Emergency Departments (Stiell, Forster, Stiell, & van Walraven, 2003). A lack of
available information, termed infopenia by Feied et al. (2004), results in a large amount of time
dedicated to locating documents and test results and recording the information that someone else
has more than likely already recorded. Nursing practice is supported by eliminating the need for
the nurse to shuffle through papers and spend lengthy periods of time communicating to other
members of the team in person or on the phone. This allows the nurse to have a total picture of
the patient in a short amount of time in order to assess and plan an intervention.
Quality assurance. Identifying deficits in healthcare and gaps in nursing is a secondary
function of CareNet, or any electronic documentation system. The identification of deficits aids
in the process of quality assurance and supports nursing practice by demonstrating where
improvements should be made and allowing for standards to be created based on information the
CareNet and UPMC- St. Margaret’s Emergency Department 38
documentation provides. Hospitals ultimately compete with each other in the healthcare market
and the measures used to outrank one another are often based on the quality of care they provide
(Institute of Medicine, 2001). Henry (1995) suggests information on the quality and cost of
health care are needed for both internal quality management and external reporting to regulatory
agencies. Data that quality assurance assessments are based on might come from data entered by
a health care team member or data shared between various information systems (Henry, 1995).
One way CareNet promotes quality care is its elimination of errors related to poor handwriting.
Data that once might have been handwritten had the potential to be illegible and a source of
erroneous actions. If correct data is entered into an eRecord, erroneous actions directly linked to
illegible handwriting might be reduced thus increasing quality of care.
Analysis of data in the form of reports of benchmarked areas can help identify gaps. The
identification of gaps is essential to their elimination, and anticipation of gaps allows for
preparedness if they are encountered (Cook, Render, & Woods, 2000). If there is a deficit in
nursing practice, electronic documentation facilitates the auditing process in order to identify and
remedy those deficits. Nurses who were deficient prior to the implementation of CareNet will
most likely continue to be deficient after its implementation, but easier auditing of
documentation might increase the identification of nurses in need of additional support.
An example of improving an individual’s nursing practice is the case of a patient exposed
to rabies who entered SMH’s Emergency Department. The nurse responsible for her care needed
guidance from pharmacy as to an alternative route for administering the intramuscular rabies
vaccine due to the patient’s relatively small muscle mass. When the documentation was
retrieved to evaluate the situation, no skin assessment was made in the documentation. Since
skin assessment is a window available to the nurse, this should have guided her documentation
CareNet and UPMC- St. Margaret’s Emergency Department 39
and practice. If a paper chart was used, it might have taken longer for the pharmacy to retrieve
and evaluate the patient documentation. Among the number of papers involved in Emergency
Department cases, skin assessment might have been overlooked and not targeted by the evaluator
either. CareNet allows those with queries about particular assessments to locate that
documentation quickly and be skeptical about whether the assessment was made if the window
lacks data. Nursing practice is again supported by making nurses aware of their deficits so they
may be more effective practitioners.
If the documentation was not made, it might be assumed the care was not given.
Neglecting to provide appropriate care drives litigation against health care organizations.
Electronic documentation is a component of quality assurance and anti-litigation tactics. One
way CareNet ensures this by supporting accountability. Although all information on paper charts
should have the appropriate initials with it, the omission of this information can be a challenge to
accountability. CareNet embeds a security measure wherein all data that is accessed, inputted, or
updated is tagged with the end-user’s identification. Appropriate identification results in the
correct individual being held accountable for a medical error. A provider might be more diligent
in what he or she documents in he or she knows they will always be directly linked to that data.
Standardized Languages in CareNet
The use of standardized languages is another way a healthcare organization can support
quality assurance. CareNet’s standardized language is limited to SNOMED, although it does use
an in-house UPMC-accepted language (M. Bradley, personal communication, October 2004).
The SNOMED standardized language is a joint effort between SNOMED International and the
United Kingdom’s National Health Service (NHS) (SNOMED International, n.d.). It is a
common language enabling consistent “capturing, sharing and aggregating [of] health data across
CareNet and UPMC- St. Margaret’s Emergency Department 40
clinical specialties and sites of care” (SNOWMED International, n.d., p. 3). The use of
SNOMED enables accurate data recording, and it operates with various software applications
and other medical classifications such as ICD-9-CM, ICD-03, ICD-10, Laboratory LOINC and
OPCS-4. Having a common language helps to ensure the best health outcomes and to facilitate
the identification of disease trends.
SNOMED is a language primarily used by physicians. No standardized nursing language
is used. Without a standardized nursing language, it becomes difficult for nursing practice to
capture, store, analyze, and report on nursing-specific data (Zielstorff, 1998). CareNet would
benefit from a standardized nursing language that provides domain completeness, granularity,
parsimony, synonymy, non-ambiguity, non-redundancy, clinical utility, multiple axes, and a
combinatorial nature as suggested by Zielstorff (1998). The previously mentioned single entry,
multi-use data is a strong benefit to CareNet’s documentation. Standardized languages can
expedite storage and retrieval of patient-specific data, agency-specific data, and domain-specific
data (Henry, 1995).
Quality assurance and support of nursing practice also benefits from standardization. If
all the UPMC facilities used the same nursing language, gaps in practice might be even more
apparent leading to improvements of standards. If everyone is using the same language, similar
errors or similar effective practices are easier to identify and avoid or replicate. Graves and
Corcoran (1988) address the issue of a standardized nursing language when they discuss the need
for a nomenclature consistent with the discipline in order to facilitate data aggregation for the
purpose of guiding future practice. Telescoping further, Henry (1995) suggests the usefulness of
standardization in comparing organizations, communities, and regions. If all health care
CareNet and UPMC- St. Margaret’s Emergency Department 41
facilities used the same standardized language even more gaps in practice and more evidence for
changes in standards might occur.
Automated Decision Support
Data refers to points of information about a variable (Graves & Corcoran, 1989). Data is
processed into information, and information is processed into knowledge (Graves & Corcoran,
1989; Henry, 1995). Knowledge, specifically nursing knowledge, is “simultaneously the laws
and relationships that exist between the elements that describe the phenomena of concern in
nursing . . . and the laws or rules that the nurse uses to combine the facts to make clinical nursing
decisions” (Graves & Corcoran, 1989, Knowledge section ¶1). McCargar, Johnson, &
Billingsley (2001) explain how knowledge base systems process knowledge into decisions. New
information is inferred to enhance decision-making.
PowerChart uses Cerner’s Discern Knowledge System to translate knowledge into
actions (Cerner Corporation, 1989). The Discern Knowledge System’s use in automated
decision support appears to be a function utilized by physicians more than nurses. The decision
support function of CareNet in SMH’s Emergency Department, however, is limited to food-drug
interactions and drug-drug interactions (D. Wolf, personal communication, November 3, 2004).
If an interaction is identified by the information system, an alert window appears to gain the
attention of the provider. It is important to note that although a system might indicate (through
decision support) an interaction, the nurse is the ultimate decision maker because it is the nurse
who collects data on signs and symptoms of adverse drug events.
Despite the Institute of Medicine’s (2003) recommendation that electronic health records
have decision support for the promotion of best clinical practice, screening, drug interactions,
and diagnoses and treatments, SMH did not approach their information system with the objective
CareNet and UPMC- St. Margaret’s Emergency Department 42
of finding one with abundant decision support. One explanation why SMH has not adopted more
automated decision support applications is their reluctance to overlook the skills their employees
currently have and practice daily. Berg (1999) suggests that information technology is best at
aggregating and monitoring data and less so at making patient-specific judgments about that
data.
Support and Satisfaction
End-user Training and Technical Support
End-user training. Lorenzi & Riley (2000) discuss change management and personal
loss. One source of personal loss is the loss of an employee’s time and energy and its
reallocation to learning the new. Another source of loss is the loss of a “good feeling” related to
work. With a proper training phase, both of these losses are temporary.
Douglas, M. (2001) outlines various phases of the clinical information system process.
The phase Douglas positions prior to implementation is the training phase. Douglas outlines
objectives for the training phase. There are two levels of training. The first level involves the
training of the project team and select departmental members by the information system
developer or vendor. The second level involves the training of the end-users. All of the training
should occur no more than six weeks prior to and during the activation of the new system.
Douglas also suggests refresher courses and new employee training courses for the new system
as well. Training rooms are recommended with computer-assisted instruction so end-users have
hands-on simulation activities. Discipline-specific training is an additional recommendation
given by Lorenzi et al. (1997).
Prior to implementation, administration worked closely with the end-users of the
information system to assess the readiness of staff to adopt such a large scale change in their
CareNet and UPMC- St. Margaret’s Emergency Department 43
organization. This was an action not addressed by Douglas, but one in which the Institute of
Medicine (2001) might conclude is a wise decision. The Institute of Medicine recognizes that
“the workforce is highly variable in terms of IT-related knowledge and experience and probably
also in terms of receptivity to learning or acquiring these skills” (p. 175). Two assessments were
made, a readiness assessment and a change acceptance assessment. The results indicated it was
prudent for SMH to move forward with the integration of a new information system.
Prior to the eRecord implementation, SMH did have training integrated into their plan.
Douglas’ suggestions can be identified in SMH’s training process. Both champions and
superusers were identified and both nurses and physicians were integrated into these roles. One
of the core facilities, UPMC- Presbyterian University Hospital, provided training staff to train
SMH’s champions. The champions trained the superusers, and the superusers trained the end-
users. In July, CareNet training was provided as an eight hour course for nurses. Physicians
received two 1.5 hour training courses. The eRecord system was activated in September, so the
July training time was appropriate according to Douglas’ (2001) six-week timeframe. The
training took place in a computer-training lab, also suggested by Douglas, housed in the
Electronic Health Record Office that was built specifically for the implementation of the
eRecord. A checklist was made to be sure training was complete, but a common complaint was
that there was no focus on specialty areas such as the Emergency Department. No discipline-
specific training was provided.
Technical support. As the information system moves from one phase to another so do the
training and technical support plans. Superusers, individuals identified from each unit or
department to act as support for that area, were scheduled during all shifts without patient
assignments during the first two weeks of system activation. Refresher courses occurring in
CareNet and UPMC- St. Margaret’s Emergency Department 44
November were being implemented with the hopes that end-users have a greater capacity to
retain detailed information about the system than they were when they were first introduced.
Following Douglas’ (2001) suggestion, this is occurring post-implementation. The roles of
champions were primarily during the pre-implementation and early implementation phases.
Now that implementation is drawing to a close, restructuring is occurring and champions are
being replaced by traditional IS support as the information system is being maintained more than
implemented. At first unit directors were meeting daily to discuss issues with the information
system, and now they are emailing more rather than having formal meetings (D. Wolf, personal
communication, November 3, 2004). Interdisciplinary meetings will be occurring every two
months and then quarterly rather than daily.
During implementation, there were support individuals named rounders assigned to
particular floors to act as additional support when paged. The role of rounders is now less of a
physical presence and more of a phone presence. There is also an electronic box maintained by
the IS department in which a user can submit a heat ticket for a support request or a request to
change the application for a particular reason. The current chain of command when a user is in
need of support is the floor superuser first, rounder second, and obtaining and contacting
someone from the list of superusers third.
Before and After: Barriers to Implementation and User Satisfaction
Barriers to implementation. There were a number of barriers to implementing the
eRecord. Among these, the two largest barriers were a learning curve including a lack of
technical knowledge of most end-users and physician acceptance. Both of these were listed by
Bowles (as cited in McMcCargar, Johnson, & Billingsley, 2001) as individual and organizational
factors. Ammenworth et al. (2000) found similar barriers in their study which analyzed user
CareNet and UPMC- St. Margaret’s Emergency Department 45
acceptance of a computer-based nursing documentation system. The barriers to nurses’
acceptance of the system were a low level of computer experience and acceptance of the nursing
process. SMH’s comprehensive training initiative to increase technical knowledge and available
technical support reduced the learning curve to an acceptable level, and implementation was
possible.
It is difficult to determine if these, or any, barriers arose out of a pre-existing
organizational environment resistant to change of any kind. Interactional theories suggest that
resistance is a product of interactions between users, the system, and the organization (Kaplan,
1997). A learning curve might be more individual, but physician acceptance has its roots in both
individual and organizational influences. Physician acceptance of the eRecord was low prior to
implementation. Reasons for physician resistance are numerous and have been studied.
Reluctance of physicians to change is a topic beyond the scope of a discussion on CareNet, but it
is prudent to review some reasons SMH’s Emergency Department physicians were reluctant to
change. One barrier to implementation physicians perceived was the schedule for training. They
were resistant to attend the two 1.5 hour training classes. Physicians also indicated dissatisfaction
with the lack of Emergency Department-specificity in physician order entry. Physicians
perceived the change as a process that slowed workflow.
User satisfaction. User satisfaction is part of the evaluation phase according to Douglas
(2001) and leads to system revisions. Evaluation is done on a microscopic level through
champions, superusers, and heat tickets. No formal evaluations are being conducted on the
benchmarked areas or user satisfaction until six months after implementation. The user
satisfaction part of the evaluation is how satisfied the users are with the system and how the
system improves patient care and operations. The readiness assessment and change acceptance
CareNet and UPMC- St. Margaret’s Emergency Department 46
assessment were two tools to gauge the feasibility of implementing the new system. Now that it
has been implemented, the users’ satisfaction with the system must be assessed as well.
Lorenzi et al. (1997) suggest user satisfaction evaluations to take the form of surveys,
interviews, or observations in order to impact the organization positively by determining actual
versus expected system outcomes and obtaining information to improve future implementation
processes. SMH plans on using a satisfaction survey six months from the date of
implementation. The amount of feedback the champions have received was expected, and no
major issues detrimental to practice were found outside of a larger-than-expected learning curve
and acclimation period. Specific populations such as physicians and nurses had suggestions for
system improvements or identification of software bugs that they reported to the champions and
IS department for resolution.
Whether or not users are satisfied with a system influences that system’s success in the
institution. The concept of a successful information system was discussed with the nurses’
utilization of CareNet. Success is often measured by increased productivity. Kling (1999)
challenges the notion that computers increase productivity based on evidence that the statistics
don’t reflect this assumption. Kling, along with some economists, refer to the lack of
productivity increases as the productivity paradox. Users and organizations are often most
satisfied when productivity is increased, but it is not always easy to measure productivity.
Nursing practice might be considered a product offered by healthcare organizations, but nursing
practice is not an easily quantifiable product. Berg (1999) describes nursing practice as invisible
with no clear products. The Institute of Medicine (2001, p. 174) also concedes that the benefits
of information technology are difficult to quantify because “clinical transactions have only an
indirect effect on profitability.”
CareNet and UPMC- St. Margaret’s Emergency Department 47
Kling (1999) offers an explanation for why certain organizational and individual practice
gains do not always translate into productivity. According to Kling, computers are more like
“productivity tools” which “improve the appearance of documents and presentations,…deepen
analysis, and …improve control” (The Productivity Paradox section ¶6). There are no standards
to measure all of the processing of data and information that nurses do on a daily basis. If it is
not measurable prior to a system implementation, measurement remains elusive following
implementation. Therefore, although documentation systems might improve quality of care and
reduce medical error, productivity gains are not necessarily observed or the objective.
Kling (1997) also postulates that organizations underestimate the skilled work involved
in extracting value from computerized systems. If users are not using the system to full capacity
and taking advantage of all its benefits, the users might not appreciate all the system has to offer.
User satisfaction might be increased if end-users were given the opportunity to utilize the system
to its potential. One of the objectives of the refresher courses being offered in November is to
help nurses realize the potential that exists in the details of the system now that they have an
understanding of its basic functions.
Analysis
The observation of CareNet at SMH provided an enhanced understanding of the field of
nursing informatics. Attending meetings, observing the information system in use, having a
hands-on opportunity with the information system in its intended setting, and having frank
discussions with the end-users about the system resulted in a global picture of CareNet’s life
cycle. The relationship between the information system and the organization became visible and
appeared to be in the forefront of every encounter at SMH. As such, the focus of a reflection on
CareNet and UPMC- St. Margaret’s Emergency Department 48
how the observation has influenced a better understanding of nursing informatics is best
demonstrated via the Socio-technical perspective.
Socio-technical Perspective and Model
The eRecord has fulfilled every component of nursing informatics as defined by the
American Nurses Association (ANA). The ANA (n.d.) defines nursing informatics as
a specialty that integrates nursing science, computer science, and information science to
manage and communicate data, information, and knowledge in nursing practice. Nursing
informatics facilitates the integration of data, information, and knowledge to support
patients, nurses, and other providers in their decision-making in all roles and settings.
This support is accomplished through the use of information structures, information
processes, and information technology. (Nursing info section)
The eRecord, specifically CareNet, processes data, information, and knowledge to support
healthcare practice. What is most interesting are the effects the information system has on the
organization in order to fulfill these processes and the effects the organization has on the
information system to facilitate those processes being utilized.
The most appropriate term to describe the relationship between SMH and its information
system is “socio-technical.” According to Kling (1999), a socio-technical system is an
interdependent system comprised of people, hardware, software, techniques, support resources,
and information structures. Kling and Scacchi (as cited in Aarts et al., 2004) describe all the
components as forming a seamless web. Adopting a new information system is a social process
where both the technology and the organization are transformed (Aarts et al., 2004). The
information system and the organization are not two distinct parts coming together, but rather,
they are two interdependent parts that form the whole (Berg, 1999). Figure 5 demonstrates the
CareNet and UPMC- St. Margaret’s Emergency Department 49
Ecology Structure Politics Culture
Psychology Human Resource
Intelligence Decision Making
Information System
Organization
Design & Development Implementation Evaluation
interconnectedness of SMH (the organization) and CareNet/ eRecord (the information system).
One is able to influence the other, and the means of influence are people as represented by the set
of arrows in Figure 5. Exactly what they influence is another topic of interest.
Figure 5. Representation of SMH’s Interconnectedness with its Information System.
________________________________________________ Note. Adapted from concepts taken from Lorenzi, N.M., Riley, R.T., Blyth, A.J.,
Southon, G., & Dixon, B. (1997). Antecedents of the people and organizations aspects
of medical informatics: Review of the literature. Journal of the American Medical
Informatics Association, 4(2), 79-93.
Using concepts adopting from Lorenzi et al. (1997), an information system is able to
influence changes in an organization’s
ecology (related to the competition of an organization in the healthcare market),
structure (control and accountability),
politics (of physicians, nurses, and administrators),
culture (customs, values, and assumptions of an organization),
psychology (how an organization mimics human behavior),
CareNet and UPMC- St. Margaret’s Emergency Department 50
human resource (the people of an organization),
intelligence (assets of an organization),
and decision making (the basis of an organization).
To expand on Lorenzi et al.’s concepts, the organization is able to influence an information
system at any phase of its life cycle including its design and development, implementation, and
evaluation.
How the Information System Influences the Organization
Ecology
The ecology of a particular organization involves elements related to competition in the
healthcare market (Lorenzi et al., 1997). The organization has no measurable product; its
services are its only product, and they remain difficult to measure. Using information systems to
its benefit, an organization is able to attempt to hold a place in the healthcare market by
quantifying its quality of care using the information system. As a result, SMH is able to change
based on the knowledge obtained from aggregating data and processing it into information.
UPMC-St. Margaret is thus able to compete by adjusting itself to hold a place in the competitive
market of healthcare. Accordingly, informatics can be viewed as a driving force behind
consumer-driven healthcare.
Structure
An organization is structured on control and accountability (Lorenzi et al., 1997). An
organization seeks to control its practices by holding those who threaten them accountable.
When addressing organizational change in response to the introduction of an information system,
Kaplan (1997) mentions control within an organization as being a crucial element involved in
resistance. Administrators are able to maintain control by evaluating institutional data in the form
CareNet and UPMC- St. Margaret’s Emergency Department 51
of reports generated from an information system. When errors are made, control is threatened.
Control is regained by identifying the errors and holding those causing them accountable.
Accountability is achieved by tagging all data entered with the end-user’s identity. Those held
accountable have the opportunity for performance improvement. Quality assurance practices are
then able to better nursing practice through the use of informatics. The information system is
able to drive an increased emphasis on accountability and facilitate organizational control.
Politics
All organizations have politics, healthcare institutions included. The politics occurring at
a healthcare facility involve nurses, physicians, and administrators. Lorenzi & Riley (2000)
concede that what might be considered system problems are actual internal policy problems.
Politics among the various professional groups are only accentuated by the adoption of a new
information system. Berg (1999, p. 88) refers to the “politically textured process of
organizational change.” Physicians bring in patients, and thus revenue, for a health care
institution and that provides them with a certain amount of control over administration.
However, administrators are the ultimate decision makers. Nurses, on the other hand, are
responsible for patient care and without them no healthcare institution would exist.
It was observed that politics played a larger role than perhaps it should have in adopting a
clinical information system. Each group had its own opinion and reasons for supporting or
resisting its implementation. The political tensions that existed prior to the introduction of the
information system were simply enhanced by the introduction of technology. Informatics has the
capacity to either disintegrate an already unstable political climate or help people move beyond
politics and toward a common goal.
CareNet and UPMC- St. Margaret’s Emergency Department 52
Culture
Culture refers to those customs and values an organization holds (Lorenzi et al., 1997).
Because politics is often part of the culture of healthcare institutions, the changes information
systems have on culture are similar to those it has on politics. The culture at SMH is one of
teamwork where each player on the team has his or her own responsibilities in relation to the
patient he or she is taking care of. When an information system is introduced, reluctance to
accept it might be based on a clash between professional conventions and the system itself
(Kaplan, 1997).
Documentation, a once private affair, is now a team effort with the implementation of
eRecord. Each player reads, reviews, and updates documentation of the others. Multiple-user
access decreases redundancy, but it also fosters cooperation among colleagues and potential
criticism (Berg, 1999). Work practices become more visible, and this might have the effect of
straining interprofessional relationships. What was once a culture of teamwork has the potential
to become an environment of hostility when informatics is applied to documentation.
Psychology
During a meeting involving eRecord problems related to the Emergency Department, the
issue of physicians taking too long to enter patient care orders and the nurses’ subsequent refusal
to take verbal orders and enter them into the computer was raised. The physician’s response was
that if you have a dysfunctional family, you have a dysfunctional family -- an information system
will not be able to change that. Because organizations are made up of people they have their
own distinct behavior.
Again, the concept is similar to politics and culture. An information system will not
make a dysfunctional organization functional. That is beyond the scope of any information
CareNet and UPMC- St. Margaret’s Emergency Department 53
system. What an information system can do is motivate changes in an organization by helping
that organization visualize where its deficits are. The issue of physicians refusing to take the
time to enter patient care orders and, instead, giving verbal orders has been brought to the
forefront with the increased emphasis on accountability and documentation. Therefore,
informatics can facilitate progress toward a more cooperative and less dysfunctional workgroup
by forcing issues to be raised that might otherwise not have been addressed.
Human Resource
“Without people, we don’t have an organization” (Lorenzi & Riley, 2000). Human
resource is the recognition that staff is the most valuable asset to any organization (Lorenzi et al.,
1997). This is realized by the reluctance of St. Margaret to implement more automated decision-
support applications. The information system simply cannot replace healthcare workers.
However, the system can drive organizational change by adapting the users in such a way as to
make the system work. The system cannot work without people, but people also need the
system. The work process must be redesigned to facilitate the function of the information system
(Lorenzi & Riley, 2000).
Intelligence and Decision Making
Intelligence is the core asset of a healthcare institution. With the use of information
systems, intelligence is not only more available to all those collaborating on a case but it is able
to be improved on and built. Information systems enable multiple health care providers to see
the same data about a patient and make clinical decisions in a quick and efficient manner. In
addition, with the aid of a standardized language, best practice and identification of errors are
promoted by aggregating data. Knowledge is thus built upon previous intelligence. Knowing
CareNet and UPMC- St. Margaret’s Emergency Department 54
this, an organization can adapt their workflows and practices by knowing that the knowledge a
system generates is a benefit to them.
How the Organization Influences the Information System
Just as the information system was able to alter the organization, the organization is able
to alter the information system. Organizations do this by altering developers’ and
administrators’ approach to design and development, implementation, and evaluation.
Design and Development
In Lorenzi & Riley’s (2000) overview on change and change management, they comment
on the rate of change and the necessity to develop information systems to support changed
environments. Socio-technical approaches to system design take the end-users, and ultimately
the organization, into account. Insight into the work practices of the end-users is where design
and implementation should start, especially when designing for professionals (Berg, 1999).
UPMC directly influenced the development of SMH’s information system by hiring Cap Gemini,
a health care consultant firm, to provide guidance on development strategies.
Design is rooted in the organizational conditions according to Aarts et al. (2004).
Working through champions, superusers, and IS support, end-users are able to request alterations
in design to better fit their needs. A design the end-user is unable to use is not beneficial to the
organization. Information systems need to be developed “step by step” staying central to an
organization’s needs while allowing for changes in work practices and technology to “evolve
together” (Berg, 1999, p. 95). An example of end-user design modification is the Emergency
Department’s requests for additional room for documentation and a reordering of the triage
sections available in CareNet. Physicians also had requests for changes in the design of the
CareNet and UPMC- St. Margaret’s Emergency Department 55
physician order entry application with regard to typographical errors, incorrectly built order sets,
and lengthy forms.
As a customer, a healthcare organization is able to request changes in the design of an
information system. Changes in design increase end-user satisfaction and a better utilization of
the information system.
Implementation
Part of the implementation of SMH’s information system involved the training and re-
training of the end-users. Champions were an asset during implementation, since they led
trouble-shooting meetings to discuss problems with the implementations. As a result of the
meetings, immediate changes in the implementation plan could be made.
Knowledge gained by the organization’s readiness and acceptance assessments guided
implementation as well. Knowing the large and diverse nature of the UPMC-network,
implementation was chosen to be activated only in certain facilities rather than the entire network
at once. The experiences of the hospitals undergoing implementation can be shared and
improved with other facilities planning to adopt the information system. The implementation
plan was adjusted to fit the needs of the organization. Similarly, financial resources guided
which hospitals were most equipped to handle the required manpower and support of
implementation.
Evaluation
When implementation ends and evaluation begins, users continue to “shape and craft the
information system to fit their particular requirements…often in a way unanticipated by
designers” (Aarts et al., 2004, p. 209). During an evaluation, an information system may be
considered a success or a failure based on how the system functions within the organization’s
CareNet and UPMC- St. Margaret’s Emergency Department 56
needs and working patterns (Aarts et al., 2004). Evaluation should be guided by how well the
information system has met those needs. An evaluation should also be flexible enough to
address issues unpredicted prior to implementation. Issues raised by champions and end-users
are integrated into the evaluation process. In general, evaluations should consider
“relationships between system characteristics, individual characteristics, organizational
characteristics, and effects among them. Such approaches encourage evaluating an information
system’s impact upon an organization while evaluating organizational features’ impacts on the
system” (Kaplan, 1997, p. 95).
Because most implementations don’t have a specific end-point, evaluation is being done
on a constant basis as feedback is given by the end-users. As the system is affecting the end-
users, the end-users attempt to adjust by altering the system.
Conclusion
Observing SMH’s information system at work was a valuable experience and provided a
global perspective on how much time and work is dedicated to designing, implementing, and
evaluating a new information system. Sitting in on meetings gave a bird’s eye view of the
benefits and obstacles encountered when trying to apply new technology on a massive scale. An
information system’s life cycle unfolds as a sort of narrative in which every detail being
contemplated and assessed.
CareNet’s ability to streamline the documentation process for the Emergency Department
nurses provided many benefits including illustrating the need for organizational change. As the
organization adjusted itself for the technology, the technology was also adjusted to fit the
organization. Needs were met by continually evaluating and making the necessary adaptations.
CareNet and UPMC- St. Margaret’s Emergency Department 57
The information system helps initiate discussion about topics which otherwise would not
have been addressed. More than ever before, the human element behind the processes automated
by the information system can be analyzed and critiqued. The technology serves as a mirror
which reflects the organization back to itself where all the deficits are able to be re-examined.
Based on the present experience, the future looks promising at SMH. It has been
demonstrated that no major change to a large organization is entirely smooth and some
unexpected events will occur. However, the organization has been able to quickly adapt and
address these events. Serving as a model of hope for other large-scale information system
adoptions, SMH has been recognized.
CareNet and UPMC- St. Margaret’s Emergency Department 58
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