University Medical Centre Ljubljana, Slovenia

Abstract

Knowledge and understanding of processes and procedures in health care organizations is the basis for successful planning and implementation of a hospital information system (HIS). Collaboration and good communication between nurses and information technology (IT) professionals in all phases of this complex project are essential to ensure that the system will provide appropriate information support for the nursing process. The aim of this paper is to describe the role of nurse managers in individual phases of HIS development.

Experience shows that the success of the project depends on a number of factors. During the phases of planning and implementation, we must adopt a unified methodological approach, prepare quality standardized documentation, develop a flexible system that is easily modified, and ensure active involvement of the end users. There must be continuous communication between the developers of the system and its users. The changes that will result from its implementation must be anticipated and presented to the users as a positive development and not as an additional burden in their daily work. The entire project can be successfully completed only if experts from all relevant fields actively participate in all its phases.

Keyword: hospital information system, nursing management, information system development

Introduction

Nurse managers are involved in determining the structure and policy of health care organizations, planning resources and work programs, setting standards, administering resources, ensuring information flow, budgeting, training and developing staff, and in monitoring, evaluating and co-ordinating activities [1]. They assist in establishing relevant systems, developing strategies and defining objectives for activities, and they participate in administrative routines concerned with these functions. In making their decisions they must consider the current situation within the organization and the nursing service.

The development of information technology and health information systems has had a major impact on nursing care. Quality nursing information is becoming a powerful tool for decision-making and management. However, because of the growing quantity of information, nurses need an efficient information system in order to be able to use all available information to the patient's maximum benefit.

Such a system must provide clinical data as well as data on the costs of care. Analysis of all these data makes it possible to evaluate the relationships between the care offered to patients and its outcome as well as between the outcome of care and its costs [2].

If the system is to provide quality information for decision-making, management and research, the information needs of its prospective users must be accurately defined and quality data entry must be assured.

1. Hospital information system development

An information system can be defined as the use of computer hardware and software to process data into information to solve a problem. The term hospital information system (HIS) refers to a group of systems used within a hospital that support and enhance health care. The HIS comprises two major types of information systems: clinical information systems and administrative information systems. Clinical information systems are large, computerized database management systems that support several types of activities: medical, nursing, laboratory, diagnostic, pharmacy, radiology. Administrative information systems support the process of client care by managing non-clinical, client-related information, including demographics, codes for procedures and insurance [3].

Clinical and administrative information systems may be designed to meet the needs of one or more departments or functions within the organization. They can be implemented as stand-alone systems, or they may work with other systems to provide information sharing and seamless functionality for the users.

The hospital information system can be developed from the start by information technology professionals co-operating with healthcare professionals in the hospital. However, it is also possible to purchase a commercially available system that meets the hospital's needs. Being familiar with the organization and all aspects of work in their hospital, nurse managers play an important part in selecting and implementing a suitable information system.

2. The system development life cycle

The system development life cycle (SDLC) is the traditional method used by organisations for large IT projects. The SDLC consists of sequential processes by which information systems are developed: analysis, design, programming, testing, implementation, and maintenance. A hospital information system is a complex system, and nurse managers have a key role to play in practically all phases of its development [4].

The beginning of the (life) cycle is a clear vision of the business process. What do we want to do with the new system? How are we going to do it? What do we need for the system to operate efficiently? So, we must determine the purpose and goals of the project, assure the necessary financial resources, carry out cost-benefit and feasibility analyses, form a project team consisting of a variety of specialists and draw up a project plan.

It is very important to appoint a suitable project leader, who must come from within the organization. The ideal project leader is a senior manager who has a working knowledge of all aspects of the business and good people skills to interface with the entire user community; delegation of the role to a junior person in the organization diminishes its perceived importance to both management and the user community. To ensure that continuity in the project is maintained, it is also imperative that the project leader be assured of a permanent position in the organization once the project is considered to be completed [5].

2.1. System analysis

System analysis is the examination of the business problem that the organization plans to solve with an information system. This step is of extreme importance. In too many cases, an information system is developed or purchased to achieve vague and somewhat idealistic goals that cannot possibly be accurately measured. An example of this type of goal would be to "reduce papers or save time." What exactly does that phrase mean? Reduce what papers, save what time? A business needs analysis is a careful, step-by-step examination of how our business functions. It includes the collection of data from a variety of areas within an organization. For this purpose we can use various techniques, such as process observation, interview and documentation study [4,5,6].

Nurses are analysts, they have been taught to analyze the situation thoroughly before making critical decisions. These skills and knowledge must be used when analyzing hospital processes. The quality of the information system to be developed will depend largely on our understanding how the real world functions and our knowledge of specific features of our work. Numerous analyses have shown that the majority of errors in information system development projects are the result of incorrect definition of requirements due to lack of understanding of the field of business. The end product of this stage is a model of the existing system and a set of information requirements.

The model of the existing system illustrates all its procedures and their functional interdependence. It provides a clear insight into the structure of the existing system, facilitates communication between system analysts and users, and is of help in solving the problem of complexity. It serves as a basis for identification of opportunities for improvement.

The next step is modelling the future system. The model of the existing system may differ considerably from that of the future one, especially if our objective in developing the new system is also to optimize and rationalize our procedures. Requirements that support the philosophy and practice of different professions must be carefully defined. Expectations regarding data output and effects of the new system must be defined on the basis of measurable results. In order that the system can provide quality support to all its end users, the requirements of individual departments and professions must be co-ordinated at a point where their information needs meet.

2.2. System design, programming and testing

The deliverable of the system design phase is the technical design that specifies the user interfaces, hardware, software, databases, telecommunications and how these components are integrated. The hospital may buy the software or construct it in-house.

Development of application software belongs among activities of programming and testing. Generally, it is impossible to determine with certainty if an application that has been developed is correct, without errors. We usually select trial data and check if the required tasks are performed correctly. The co-operation of nurse managers in the phase of testing an application is obligatory. We must verify that the application is functional, that it meets all legal requirements and that information generated from data that has been entered into the system (statistical data, comparative analyses) is appropriate. A well-designed hospital information system must provide data for decision-making and management.

2.3. Implementation

Implementation is the process of converting from the old system to the new one. A hospital information system is a complex system. We may use different strategies: parallel, direct, pilot or phased. In a parallel conversion, the old system and the new system operate simultaneously for a period of time while data outputs are equal. In a direct conversion, the old system is cut off and the new system is turned on at a certain point of time. A pilot conversion introduces the new system in one part of the hospital organization for a period of time, so that it can be assessed. If it works properly, it is then introduced in other parts of the hospital. A phased conversion introduces components of the new systems, such as individual modules, in stages until the entire new system is operational [4].

Nurses can play an extremely valuable part in the implementation phase because they have more direct hands-on interaction with and knowledge of the different departments than perhaps any other member of the project and implementation team. Nurses also provide helpful input into the restatement of policy and procedures and the workflow within healthcare organization departments during a system implementation.

Implementation of the new system can result in various changes, which can be minor (soft - variation) or radical (hard - redirection). Soft changes refer to ordering the existing condition and automation of work and are designed to simplify processes. Hard changes are fundamental changes of processes, relationships and rules. When implementing a HIS, we are changing the practices and procedures in our hospital.

Studies show that fear of changing traditional procedures may lead to a decline in morale and workplace satisfaction. The main reasons for the development of resistance to such changes are unrealistic expectations, alteration of traditional procedures, a new way of work, inadequate involvement of users in information system development and, last but not least, fear of the unknown [7].

In order to reduce possible opposition of hospital staff during the implementation phase we need to organize a workshop or a kick-off meeting to inform staff of the goals and objectives of the project. Communicating expectations, defining desired outcomes, and letting everyone know about their respective roles and commitments will set the stage for the forthcoming events.

For successful implementation of an information system, it is important to prepare a strategy, appoint a suitable team and make sure that the end users understand the system and actually use it. Information, education and satisfaction of the users are essential. In each department a team should be appointed that will participate in the implementation of the system, follow its course and report any difficulties that may arise.

Very important skills needed during the implementation phase are communication, co-ordination and reporting [8,9].

2.3.1. Communication

Nurse managers must inform end users about the importance of the system and the reasons for changing it. A new system does not mean automation of old processes but rather support for a new, more efficient way of work. It is essential that users understand how the system functions and accept it as an aid in their daily work and not as a new additional task. They must be provided with detailed instructions for its use, including descriptions of individual procedures and the user's responsibilities. This will reduce the likelihood of complications, ensure smooth operation and increase user satisfaction. The rules for carrying out individual procedures and mechanisms for safe access to and use of the data must be defined already during the planning phase.

2.3.2. Co-ordination

Co-ordination includes organizing meetings, planning education, planning implementation of the information system and setting priorities. The implementation of a new system may evoke negative reactions on the part of its users, which may be the result of inadequate computer knowledge or fear of change. A basic computer course covering keyboard skills, screen navigation and software help functions should be organized before the implementation phase. Training in the use of the new system must be organized in the form of workshops. Continuous assistance to system users must be provided.

2.3.3. Reporting

By regularly informing the management about the progress of implementation of the hospital information system, we secure the management's support for the project and maintain it. Exchange of information between departments contributes to better understanding of the patient care process and better co-operation between clinical departments and auxiliary services. Changes in processes that are part of nursing care lead to changes in the processes of other units.

2.4. Maintenance

Maintenance includes debugging the program (elimination of errors), updating the system to accommodate changes in business conditions and adding new functionality to the system [4].

The procedure for submitting requests for a change must be carefully defined. Experience shows that it is best to appoint a person who will be responsible for communication and co-ordination between users and programmers. In hospital information systems, this role, for the needs of nursing care, is taken over by nurse managers.

The process of HIS development is not completed with its implementation and use. The information system lives, changes and grows to include an increasing number of work processes. After the completed implementation of the system, we must not forget to provide continuous support to its users, organize refresher courses and training for new users, supervise the use of the system, organize working meetings and make every effort to solve promptly any problems that may arise.

3. Conclusion

Nurse managers play an important role in all phases of development of a hospital information system. Their role changes from that of analysts in the analysis phase through that of organizers, co-ordinators and mediators in the implementation phase, to that of revisers in the phase of evaluation. Therefore nurses must be taught already during the training process to analyze the systems within which they function and solve problems on the basis of acquired information.

Since organizational changes and implementation of information technology are mutually dependent processes, the implementation of a hospital information system calls for attention to be focussed on human factors and organizational culture. Experience shows that successful acceptance of a new HIS by the nursing staff depends on a number of factors. It is important to:

• ensure active co-operation of nurses already in the phase of strategic planning;
• appoint a nurse manager in each department to co-ordinate implementation of the system;
• form a team of co-ordinators from individual departments to encourage exchange of experience;
• provide sufficient staff to assist with the implementation;
• organize a kick-off meeting or a workshop for nurses to provide them with information on new procedures, nurses' responsibilities in using the new system, and expected effects of the new system on nurses' work, patient care and the hospital as a whole;
• train nurse managers and other experienced nurses to assist with the training of other nursing staff.

When planning and implementing an information system, we must adopt a unified methodological approach, prepare quality standardized documentation, develop a flexible system that can be readily modified, and actively involve the end user. Continuous communication between system developers and users is of vital importance. The organizational changes that will occur with the implementation of the new system must be anticipated and presented to its users as a positive development and not as an additional task in their daily work. The participation of experts from all relevant fields in all phases of the project is essential for its successful completion.

References

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