Health Care (NHS) has always being looking into improving and development of new software for patient’s data record system. They implemented the ‘Patient Care Information System’ or ‘PCIS’, which is an online computer system that comprises of full patient’s medical care data. Berg (1999) suggests that ‘Patient Care Information system is a broader term than ‘electronic patient record’ and its main users are doctors, nurses and other health professionals. The implementation of ‘Patient Care Information System’ in health organisations has turned out to be a big challenge for Health Care (NHS). Some examples of ‘Patient Care Information System’ as illustrated by Berg 2004, p.7-8 in table 1.1 are as follows:
Electronic Patient Record ( EPR)
Patient Information System (PIS)
Medication System
Physician Order Entry ( POE)
Decision Support Technique (DST)
Hospital Information System (HIS)
General Practitioner Information System ( GPIS)
Data Warehouse
It has being observed that there are more failure stories to narrate as compare to the success stories. It is true that inadequate design of the software or an information system and slow performance for example delay in response time of the information system or software may decrease the over all success rate but the final decision whether the implementation was successful or total failure is usually taken depending upon the situation. For example some health organisations might suggest for to improve the information system and readily agree to invest more resources where as other might decide to diffuse the project. In the end still the importance of the challenges the Health Care (NHS) faced during the implementation of the ‘Patient Care Information System’ can not be ignore. The list of challenges is long but few main challenges or issues are discussed in this essay. Along with this the essay also describes the problems or issues that were intend to be solved by the implementation of the ‘Patient Care Information System’ for example the issue of ‘poor practice’ by taking care of the ‘problem-oriented patient record’ and the issue of improving the coordinating function of the patient record among the professionals. Moreover, the essay states the recommendations that are the viewpoints drawn after the literature review.
2) ISSUES THAT WERE INTEND TO GET SOLVE BY PATIENT CARE
INFORMATION SYSTEM
2.1) TO SOLVE THE ISSUE OF PROBLEM-ORIENTED PATIENT RECORD:
It is being quiet clearly observed that, “medical record is a key to all patient care activities in a hospital. It serves several important functions. First, the medical record is a guide to, and continuous record of, treatment while the patient is in hospital. After discharge, it becomes an archival record available for retrieval if the patient is re-admitted or requires further treatment as an out-patient. Medical record also serves as working documents for medical audit and utilization review by members of the medical staff. Finally, particularly in teaching hospitals, the depository of medical records serves as a database for research studies”. (Smith, 2000, p.207). Smith (2000) suggested that to achieve all these functions, it is necessary to have good record management. Berg (2004) criticized the paper record and argued that the information in the paper record can appears vague, ambiguous, and incomplete; thus, it may be hard to extract from its chaotically arranged handwritten page. Berg (2004, p.53) further support his argument by quoting Bleich’s 1993 words, which were as follows: “The medical record is an abomination…(I)t is a disgrace to the profession that created it. More often than not, the chart is thick, tattered, disorganised and illegible; progress notes, consultant’s notes, radiology reports and nurses’ notes are all co-mingled in accession sequence. The charts confuse rather than enlighten; they provide a forbidding challenge to anyone who tries to understand what is happening to a patient.”
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The idea of re-arranging or re-organising the patient record and to improve the problem- oriented patient record by making it simple and well structured lead to the implementation of computerised tools. According to this information system, the patient data will be enters directly on to the computer in which the details will be well arranged on the basis of the patient’s situation. Larry Weed (1968) as cited by Taylor (2007,p.18) supports the suggestion and states that to deal with these problems it is necessary to develop a more organised approach to the patient’s medical record, to develop a more rational acceptance along with well use of medical personnel and to grow a more positive attitude about the computer in medicine. Larry Weed (1968) as cited by Taylor (2007,p.18) furthermore supports the idea that it would be very logical to have the physician enter patient’s medical record directly onto the computer. Thus it has being observes that by implementing the Patient Care Information System the problem of complicated or problem oriented patient record will get solve. Taylor (2007) similarly agrees that this approach may solve the issue of problem-oriented patient record and greatly benefits the clinicians’ because clinicians will format their observations on to the computer in such a way that each time they need to make a decision about a problem, they can easily find the information they requires.
2.2) TO IMPROVE THE SYSTEM FOR MEDICATION DISTRIBUTION
Berg (2004) describes the ‘Kardex System’ as a widely used system for medication distribution in UK for example the ‘Regional General Hospital, Neurology Ward’.
i) WHAT IS A KARDEX SYSTEM?
Berg (2004) defines the Kardex System as a system use for the distribution of medication especially of a patient admitted in a hospital. He further describes that the system comprises of a form known as the ‘medication order’. The yellow slip part of the form is for the pharmacist, the pink slip part of the form is for the physician’s patient record and the white slip part of the form goes into the medication folder. The white part of the form is use to indicate whether the medication is given to the patient. The initiating, stopping and changing of the patient’s medication are all done by the help of ‘medication order form’ (Berg 2004).
ii) PATIENT CARE INFORMATION SYSTEM REPLACES THE KARDEX
SYSTEM
By the introduction of the ‘Patient Care Information System’, the procedure of the medication distribution was intended to be change. Berg (2004) observes that the time of medication distribution will get reduce because in the Kardex System the work is done manually and requires double checking to correct if any information is missing or unclear for it might hamper the medication distribution order and also the coordinating function of the patient record among the health care professionals will become more powerful and accurate. He concludes that, “the active, coordinating function of the Patient Care Information System also enables the close collaboration between the client’s case manager and the health care professionals working at a variety of locations. (Berg 2004, p.60)
Like wise Berg (2004) states that the system will also serves as a reminder aid to nurses by automatically prompting them about the time to distribute out patient’s medication. He further suggested that, “it offers various direct opportunities to monitor medication orders and automating stock records” (Berg 2004, p.59).
Taylor (2007) argues that the system will indeed help in saving the money by reminding the user of drugs that are useful to the patient and also give support in making decisions like laboratory test and radiological procedures.
To summarise the implementation of the Patient Care Information System will greatly improve the medication distribution system.
2.3) TO MAKE THE ‘INFORMATION’ MOBILE
Berg (2004) states that one of the core tasks of the Health Care (NHS) is to access the patient record easily whenever requires by the health professionals. The implementation of the Patient Care Information System was believed to solve the issue of making the patient medical record information mobile. Berg (2004) suggest that the accumulation of medical record inscription is a medical work carried out by the doctors, nurses and other health professionals which enter their notes for example laboratory results or clinician’s notes onto the computer that accumulate in the form of record and will be useful in to make different calculations for example the Patient Care Information System calculates the total fluid balance of a patient automatically after the values are enter in the appropriate manner that in turns triggers alarms or reminders for nurses and doctors working in the hospital and this patient record is easily approachable every time a clinician need for to solve the diagnosis-related issues or treatment-related issues. He supports the idea further with this statement, “An electronic PCIS could change the accumulation function in four ways: It could draw upon larger database… it could perform more powerful operations on these data… it could more easily allow for changing the logics of the information handling…” (Berg 2004, p. 73-74).
Berg(2004) considered the computer based Patient Care Information System from a technical perspective as a useful tool for it helps the reader to know what normally happens in comparable situation and therefore plays a part to supply a data needed for particular situation that may helps the clinician in practice. He compares the paper record and electronic patient care information system and suggests that on searching for the information of patient’s record, if presented in the paper it will always be presented per patient and only by source where as compare to ‘electronic PCIS’ it can be found by disease- category, by the year of admission and by the name of treating specialist (Berg 2004).
It is quite clearly observes that the main purpose for the implementation of the Patient Care Information System is to solve the issue of poor practice or to improve the quality of care in Health.
3. IMPLEMENTATION CHALLENGES
Collen(1995, cited by Berg,1999) concluded that, ” developing a comprehensive medical information system, a more complex task than putting a man on the moon” (pp. 87-101). Berg (1999) quiet clearly confirms the fact that after implementation most of the Patient Care Information System projects have failed or either appeared to be not useful as they failed to deliver the specific context in which they were developed.
The issues or challenges that came forward were considered as reasons for its failures. These issues later became challenges for Health Care ( NHS) and major obstructions face by the health organisation when implementing the Patient Care Information System.
These are as follows:
3.1) TECHNICAL ISSUES
After the implementation of the Patient Care Information System, the technical issues that came forward were mostly concerned with the design of the Information System and the realities’ into which it was introduced. Armoni (2000) observes that, “overall, there was too great a gap between the design conceptions of the expert system and the realities of the hospital context into which it was being introduced” (p.104). Berg (2004,p.183) support the idea of Armoni (2000,p.104) and states that the ‘Patient Care Information System’ developed for use in hypertensive patient was designed by the designers in which the doctors could enter the patient’s complaints, diagnosis, vitals for example blood pressure, examination results and medications. Berg (2004,p.183) further observed that it functioned well in a way that when doctors required any information for clinical investigations, they could easily draw directly from the data base, where as, the system appeared less functional in the ‘Out-Patient Department (OPD)’ because the physicians` complained that they are facing difficulty in to capture the essence of a patient’s visit for example they could not capture that the main reason of patient visit was increase anxiety that may be due to some secondary reasons for example recent death of his/her father lead to hypertension. However, Berg (2004,p.183) states that to over come this problem many physicians started to enter such information in the text box ‘conclusion’, resulting in the awkward use of the system. Pare and Elam (1998, cited by Armoni 2000,p.109) accepts the idea of Berg (2004, p.183) and states that, ” a patient care information system in the intensive care unit of a North American Health centre failed for similar reasons…it was designed according to a formal, managerially rational model of nursing that did not match realities”.
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Berg (2004) also observed that, “the one field that generated unstructured data that were almost impossible to aggregate was heavily used…often at the expense of the more structured fields” (p.184). The fault in the design of the Patient Care Information System may also be due to the limited or perhaps due to no ‘User-involvement’. Berg (2004) suggested that it is not enough to include few users in the project group rather to achieve good results; the user involvement should be more encourage. Lorenzi, Riley, Blyth, Southon and Dixon (1997,cited by Berg 1999, pp. 87-101) also feels that, ” Closing one’s eyes for these realities can only lead to failure through résistance and even sabotage by ‘users’ who are not taken seriously”.
Berg (2004) believes that the ‘User-Involvement’ will greatly affect the implementation’s work process and confirms by this statement, ” adequate user-involvement, first of all is of paramount important to foster ownership of the system by the future users, and to allow the implementation of systems that will actually match work processes- current or future”. (Berg 2004, p.180) Moreover, Drazen, Metzger, Ritter and Schneider (1995, cited by Berg 1999, pp.87-101) argues about the need of the ‘user-involvement’ from the beginning and ensures that the user-driven design and implementation will involve the user’s feedback from early implementation process and helps in further analysis and designs. Berg (2004) think that the center staged involvement of the ‘Users’ may help in solving the issue of what kind of data can be recorded in the Information System and what kind of the training should be given to the ‘Users’.
3.2) SOCIO-CULTURAL ISSUES
The main socio-cultural issue that came forward was to gain the support from the clinicians and nurses, who are consider as the prime users of the ‘Patient- Care Information System. Berg (2004) observed that mostly the practitioners’ prefers the paper-based record because they consider the computer-based record more complicated and difficult to approach. He states about the practitioner’s perspective that, “with paper record you had a better over view, now you really have to go and search the various windows” (Berg 2004.p.55). Berg (2004) states that the technology also affected the distribution and content of work task and the flow of the information. For example he observed that ‘computer-based patient record’ inevitably change the recording practices and the questions were raise about who will get access to whose data, under which conditions (Berg 2004, p.178). Even though Berg (2004) argues that the issues of recording and access of information can get solve politically or socially but it may affect the relationship among the health professionals for example doctor- nurses relationship or doctor- patient relationship. The coordination among health professionals is important in the ‘Health Organisation’, to provide maximum good quality of care to the patient. Berg (2004) supports this idea and states that, “the coordination function is pivotal for western medical work” (p.56).
Stevenson, Nilsson, Petersson and Johansson (2010) also observed that besides doctor other end users of the computer-based record system were nurses and they were almost completely ignored during the making of the information system. They argued that even the nurses are not satisfied with the ‘Patient Care Information System’ and support the idea with this statement, “Current systems are not designed to meet the needs of clinical practice as they are not user-friendly, resulting in a potentially negative impact on individualized care and patient safety. There is an urgent need for nurses to be directly involved in software design to ensure that the essence and complexity of nursing is not lost in the system” (Stevenson, Nilsson, Petersson and Johansson 2010, pp.63-72) Berg (2004) further argues about the failure of the information system may also be due to provision of insufficient training and increase pressure on the implementation staff because of increase work load and ‘users’ believe that it takes up too much time.
The lack of motivation among the physicians and nurses were considered as a major obstacle or challenge during the implementation of the ‘Patient Care Information System.
3.3) POLITICAL AND LEGAL ISSUES
Though the planning of the ‘Patient Care Information System was being done since long on the other hand politically the making and implementation was carried out as comparatively at a shorter span of time. That is politically it was enforced on the Health Organisation as a result of which a large gap was created between its context of design and implementation that in turns lead to the inevitable risks of failures. Dhillon (1998, cited by Armoni,2000,p.108) states that the information system was introduced into health organisation in a very ‘messier’ manner, leading to a clear mismatch between the formal model and the perceptions of system users. Also it is being quite clearly observed by Berg (2004) professionals working in Health Organizations’ independently beholds very powerful positions especially doctors and nurses, they cannot be simply told to change their work patterns by their senior management.
He states about the other political issues that made the implementation difficult and express his views with this statement, ” after years of promises, technological problems and political fights about who would pay what and who would do what for who, the project was declared ‘dead’ in 2002″, (Berg 2004,p.35) . In this statement it is clearly evident that politically the project was declared dead but at the same time the need for Patient Care information System or more specifically states that the need of computer-based patient record has not reduced. Similarly Berg (2004) confirms the failure cases of the ‘national hospital information system project that cost around £32 million and started in the 1980s.
The legal issue that later became an important challenge was whether the computer-based patient record fulfill the legal function or in other words, whether it can be accepted as a relevant document in court cases. Berg (2004, p.16-17) criticised with this statement,
“…it was not clear who had written what and at what date or time, or when the exact status of individual notes failed to be clear, records could hardly fulfill a legal function”. However later it was accepted as a way of standardized recording of patient data by courts.
3.4) FINANCIAL ISSUES
Significant upfront cost of the Patient Care Information System can not be ignored. Berg(2004, p.35) states about the cost of two UK cases, which are as follows:
” Wessex Health Authority Regional Information System, cancelled in 1990 after spending more than £20 million,
National Hospital Information System projects, started in the 1980s that cost over £32 million and have yielded only minimal result”.
From the above it may also be concluded that the disruption bought after the implementation resulted in the loss of the national funds leading to the multiple blights for example loss or reduce stake holders and less funds available for future projects.
4. CONCLUSION
This assignment has considered a literature review including the definition of the Patient Care Information System and about the issues that were intend to get solve after the implementation of Patient Care Information System in the Health Organisation (NHS). The aim of this assignment was to answer the question based on the literature review. The consideration had been given to the various challenges or issues including technical, political, social and financial face by the health organisation (NHS) when implementing Patient Care Information system
5. RECOMMENDATIONS
The question when is a Patient Care Information System successful or how to make it a successful project is still being under consideration. Berg (2004, p.175) defines the success as, “the system that is up and runs on time and is appreciate by the ‘users”. Where as McDonald et al (1984 cited by Berg 2004, p. 175) defines success as, “the system in which a success measure could be a reduction in errors in medication deliveries”. Success has many different concepts and is define differently by different parties involve. Berg (2004) feels that may the concept vary but the parties involve should share the same goal. Overlooking at the fact how to make successful implementation of the Patient Care Information System possible Ash et al (2003, cited by Berg 2004, p. 184) suggested that, “When carefully nurtured and acted upon, they can help further the creation of truly powerful ‘PCIS”.
Berg (2004) concluded that the Patient Care Information System implementation intended to transform the organisation, and the technology if allowed to grow along it may become part and parcel of the organisational work routine. Ciborra et al (2000 cited by Berg 2004, p.186) support the recommendation with this statement, “…one does not redesign according to some plan; one rather drift with the currents, attempting to steer one’s project through the ever changing environment”. Berg (2004) stressed the need of support from both the central management and future users and states that , “…user-input can become a coherent, steering force that in its turn transforms and specifies the over all vision…and that creates a solid basis for the organisational transformations that will then certainly ensue”(p.188). Armoni (2000,p.119) also support the suggestion of Berg (2004,p.188) with this statement, ” that there are gaps between the developers and users . One way to close these gaps almost is through end-user development…this will close the design-reality gaps of information needs and of objectives and values”. Edward and Busko(1995 cited by Armoni 2000, p.119) too recommended about the end-user development approach may bring the success of information system and states that, “end-user development should greatly increase the chance of producing a successful health care information system, as has been found in practice”.
Moreover, Berg (2004) suggested that the needs and desires of different user group can only be noticed if the users’ presence in the project group is properly balanced by the upper management. On the contrary Armoni (2000) suggested that there is another way of increasing the participation of ‘users’ and reducing the gap between the developers and users to allow them to get incorporate with other range of stakeholders.
To win the support of the physicians and nurses so that they make maximum use of the information system Berg (2004, p.183) recommends that, “…unexpected problems should be taken as instances to learn from and adapt to rather than as obstacles to over come”. Similarly, Ciborra (1997, cited by Berg 2004, p. 183) suggested on the alternative ways adopted by the doctors and nurses while using the system with this statement, “Unforeseen spontaneous alternative uses of the system should be carefully investigated as possible unexpected ways to draw out unforeseen benefits from the system”.
Berg (2004) proposed the idea of redesigning of the health care delivery process rather than redesigning of the information system from the scratch. Chassin et al (1998 cited by Berg 2004, p.84) support the idea with this statement, “meeting this challenge demands a readiness to think in radically new ways about how to deliver health care services…”
Berg (2004) believed that redesigning of the health care delivery process requires the redistribution of tasks through proper standardisation of care path. Massero (1993 cited by Berg 2004, p.95) equally agrees that, ” in this way, it would also no longer mainly be the most highly trained professional… with the greatest opportunity cost…who ends up… in the data entry role”. Berg (2004 , p.95) further suggest by giving the example that, “When the health care process is restructured so that the secretary, nurse practitioners and the patient themselves enter data in a standardised way, a much more complete file becomes feasible without any individual care professional carrying too large a burden”.
Finally, to bring the change in the delivery system and to improve the project, it states quite clearly that effective communication and interaction with the people who are asked to use the new technology can change the excepted consequence into reality. (Berg 2004)
It is concluded after reviewing and analysing the literature that by involving the ‘USERS’ at large scale ,the success in the implementation of the Patient Care Information System can be achieve .
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