DEPENDABLE

SYSTEMS FOR

QUALITY CARE

BEFOREInefficientCostlyManually intensiveCrisis-driven model of care delivery

AFTEREfficientConsumer-centricScience-based model

Changes brought by:Skyrocketing cost of healthcare deliveryExposure of patient-safety problemsAging “baby boom” population

Key technologies that enable the transformation

Attributes of transformed Healthcare

Technology Enablers

Medical decisions are based on the current state of medical knowledge interpreted within the context of the patient’s complete health profile

Electronic Health Record (EHR)Electronic, outcomes-based clinical decision supportWireless communicationsTablet personal computers (PCs), personal data assistantsContinuous speech recognition

Current, synthesized clinical knowledge is available at the point of care

Clinical knowledge basesNew models for knowledge representation, integration, and interpretation

Errors are detected before information is acted on. Orders and prescriptions are clear and unambiguous

•Ambulatory and in-patient computerized physician order entry (CPOE)•Electronic prescribing

Consumers are partners in their own care. Patients with chronic diseases and conditions are monitored continuously

•Consumer knowledge bases•Electronic sensors•Wireless communications•Radio frequency identification (RFID) tagging•Decision support•Home health systems

Equipment, supplies, patients, and delivery staff are accurately tracked and efficiently managed

•RFID tagging•Wireless communications•Supply chain automation

Authorization, adjudication, inquiry, billing, and payment are handled electronically in real time

•Standardized electronic transactions•Rules-based decision support•Enterprise application integration (EAI)

High-quality care is delivered to rural areas

•High-quality communication services•Robotics•Telemedicine applications

Drugs are dispensed efficiently and safely

•Robotics•RFID tagging

International Council of Nurses (ICN) Code of Ethics for Nurses affirms that:“the nurse holds in confidence personal information” and“ensures that use of technology… compatible with the

safety, dignity, and rights of people” Dependability

Is a measure of the extent to which a system can justifiably be relied on to deliver the services expected from it

Six attributes:○ System reliability○ Service availability○ Confidentiality○ Data integrity○ Responsiveness○ Safety

Guidelines for Dependable Systems1. Architect for Dependability

Principle: an enterprise system architecture should be developed from the bottom up so that no critical component is dependent on a component less trustworthy than itself

2. Anticipate failures Consistent with Moore’s law: the speed of

processors is doubling every 18 months, while the cost for that computing power is halving within the same time period

User Interface

CPOE Electronic Prescribing

Bar-Code Reader

Rules-based Decision Support

Single Sign-On

Operating Systems

Networks

User Authentication

Access Control

Audit

Enterprise Architecture

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Security Functions

Interventions: Application-specific features should be implemented

To detect faultsTo fail over to redundant components when faults are

detectedTo recover from failures before they become catastrophic

Security features must be implemented against “opportunities” for malicious attack

Safety-critical systems should be designed and built to fail in a safe stateExamples of industries with these systems: aerospace,

chemical, nuclear power industriesThese methods include: fault tree analysis, failure modes

and effects analysis, state-machine hazard analysis, formal verification, and independent verification and validation

3. Anticipate success Allows valuable input into planning for scalability

and future integration4. Hire meticulous managers

Know failures will occur Monitor and manage system and network

performances Use middleware to manage the workload across

the network Take emergency and disaster planning very

seriously Develop, maintain, and judiciously exercise plans

and procedures for managing emergencies and recovering from disasters

5. Don’t be adventurous

ASSESSING THE HEALTHCARE INDUSTRY

Year: 2004Student name:

Clinical Care Provider Community

Subject: Information Technology DependabilityGUIDELINE GRADE COMMENTS

1 D Builds systems top down instead of bottom up. Too complex

2 D Assumes systems will work3 C Assumes systems and networks are

infinitely expandable and adaptable, but does not plan for system expansions and consolidations

4 C Sometimes, but doesn’t give them adequate support

5 C Yes and No

Complies with security regulations

Insists on sound science as the foundation of good science

Recognizes the importance of correct data

Insists on sound systems engineering as the foundation of dependable systems

Understands the role of security in system dependability, service availability, data integrity, and patient safety

Systems play well together

Optimistic attitude Values information technology as core business asset

X

X

X

X

HEALTHCARE ARCHITECTURES HIPAA prescribes administrative, physical, and

technical safeguards for protecting the confidentiality and integrity of health information and the availability of critical system services

8 required administrative safeguards:Security managementAssigned security responsibilityInformation access managementSecurity awareness and trainingSecurity incident proceduresContingency planningEvaluationBusiness associate contracts

5 specified physical safeguards:○ Access control, including unique user identification

and an emergency access procedure○ Audit controls○ Data integrity protection○ Person or entity authentication○ Transmission security

ANTICIPATING FAILURES Therac-25 (example of failure to anticipate failures)

Occurred between June 1985 and January 1987Overdosed 6 people resulting to deaths and serious

injuries○ Initial response was a temporary “fix” distributed as a

memo containing a warning not to use the up-arrow key for editing, removing the key cap and using electrical tape to fix switch contacts in an open position

○ Failures identified: overconfidence in the software and overconfidence in risk assessment

Due to this, FDA has improved its reporting system and augmented its procedures and guidelines to include software

ANTICIPATING SUCCESS The clinical care provider community

Expects their software applications, computer systems, and networks to work

Assumes their systems will work as well as any other medical equipment

However, they do not foresee that their business success may increase their need for processing power and networking capability○ Nor they foresee mergers’ and acquisitions’

creating the need to consolidate their systems with those of another healthcare enterprise

Example: Boston CareGroup

IT MANAGEMENT Clinical care provider community

Have hired IT managers who:○ Appreciate the important role of IT in a healthcare

environment○ Recognize the need for a dependable systems that

can anticipate and recover from failures

○ But hired IT managers may not understand the fragile nature of IT or the importance of guideline 1These IT environments tend to be loose composites of

proprietary, departmental systems, designed for specific business functions

Healthcare’s spending for IT lags far behind other industriesHealthcare invested only 2% of its revenue in

IT compared to 10% for other information-intensive industries

Other industries spend $8000 per worker per year for technology, compared to $1000 per worker for healthcare

Thus, even IT managers who are conscientious, meticulous, and capable often forced to operate within meager budget

ADVENTUROUS TECHNOLOGIES IN HEALTHCARE The most difficult to assess Healthcare clinicians, historically and

typically are very resistant to change

NURSING MINIMUM DATA SET SYSTEMS

CHAPTER 16

NMDS visionary work begun in the US in 1980s by Werley and Lang

History:NMDS – identifies essential, common, and core

data elements to be collected for all clients receiving nursing care○ A standardized approach that facilitates the

abstraction of these minimum, common, essential core data elements to describe nursing practice from both paper and electronic records

○ Intended for use in all settings○ Conceptualized through a small group work at the

NISs conference held in 1977 at the University of Illinois College of Nursing

Developed during the 1985 conference at the University of Wisconsin-Milwaukee School of Nursing through the efforts of 64 conference participants

Included 3 broad categories of elements:○ Nursing care

Nursing diagnosisNursing interventionNursing outcomeIntensity of nursing care

○ Patient or client demographicsPersonal identificationDate of birthSexRace and ethnicityResidence

Service elements Unique facility or service agency number Unique health record number or patient or client Unique number of principle registered nurse provider Episode admission or encounter date Discharge or termination date Disposition of patient or client Expected payer for most of this bill

AIM of the NMDs: Not to be redundant of other data sets but rather to

identify what are the minimal data needed to be collected from records of patients receiving nursing care

Developed by building on the foundation established by the US UHDDS

8 benefits of NMDS adaptation and implementation:○ Access to comparable, minimum nursing

care, and resources data on local, regional, national, and international levels

○ Enhanced documentation of nursing care provided

○ Identification of trends related to patient or client problems and nursing care provided

○ Impetus to improved costing of nursing service

○ Improved data for quality assurance evaluation

○ Impetus to further development and refinement of NIS

○ Comparative research on nursing care, including research on nursing diagnoses, nursing interventions, nursing outcomes, intensity if nursing care, and referral for further nursing services

○ Contributions toward advancing nursing as a research-based discipline