Rewrite:
Issues
with the current system in the hospital include modular fragmentation, lack of
a standard language, and free text that cannot be searched. A short-term
work-around for this could be to create a temporary data dictionary and
standardized templates for documentation to increase consistency and
searchability. There exist two standard languages which entail, SNOMED CT and
LOINC. SNOMED CT is applied in all disciplines. It is bi-annually updated and
offers broad clinical terminology (Abraham
et al., 2022). LOINC is used in laboratory and clinical observations. It
is updated twice a year which promotes interoperability between systems. Focus
groups or feedback sessions may be conducted regularly to gain the input of
clinical staff. Specific techniques to help in this transition include
comprehensive training programs, phased implementation, and continuous support
through the help desk and super-users. The scripture that relates to this
discussion is in Proverbs 15:22 which highlights the importance of involving
all people in an initiative for it to succeed.
A small community hospital in the Midwest has used a homegrown information system for years. The system began in the early 1970s with a financial module. Over time, additional modules were added. A limited number of departments selected a commercial system and interfaces were used to integrate these into the overall functionality of the hospital information system. Except for physicians, most in-house clinical or care-related documentation is online. However, about 15% to 20% of this documentation is done by free text and is not effectively searchable. In addition, the screens, including the drop-down and default values, were built using terms selected by the in-house development team in consultation with clinical staff; thus there is no data dictionary or specific standard language. In the last few years, the hospital has purchased two outpatient clinics (obstetrics and mental health) and a number of local doctor practices. The clinics and doctors’ offices are now being converted to the hospital administrative systems. A few of the clinical applications that are tied directly to the administrative systems such as order entry and results reporting are also being installed.
A major change is being planned. A new chief information officer (CIO) was hired last year, and she has appointed a chief medical information officer (CMIO) and a chief nursing information officer (CNIO). No other significant staff changes were made. With her team in place, one of the CIO’s first activities was to complete an inventory of all applications. Rather than continue to build, a decision was made to switch to a commercial vendor, and the hospital selected a commercial system.
Identify issues with the existing system. Provide staff with an appropriate “work-around” for using the existing system. Provide an overview of two of the standard languages used within the new system including discipline or specialty, updating frequency, and available cross-maps. Describe ways to obtain clinical staff input and specific methods to support the transition to the new system.