Editorial: The Fundamentals




Angela Lewis, BSN, RN, BC, Editor-In-Charge of Clinical Information Systems



The U.S. healthcare system is faced with many challenges. Per the Institute of Medicine's (IOM) 1999 report, To Err Is Human, 44,000 to 98,000 deaths a year were caused by medical errors. In October of 2001, a spokesperson for the Centers for Disease Control and Prevention (CDC) compared the current public health IT infrastructure to the 'pony express'. Healthcare consumers reported being concerned that private medical information may be made available to others without their consent. To top it off, there is a nursing shortage! 


Although a great deal has been written about what we do not have, what about what we do have? What we do have are advances in clinical informatics never before dreamed about by our predecessors: computers that fit not just in the 'palm of your hand' but that can be ingested and used as diagnostics tools. We do have the ability to communicate, teach, and deliver care across geographical distances and time zones; and access to evidence-based practice (EBP) guidelines and research databases 24/7. Today, invasive surgery via robotics is a reality. All from information systems and technological tools that have been proven to aid in the delivery of patient care, improve clinical practice, support decision-making and decrease care delivery costs. What we do have is the ability to collect, track and trend patient data, transform that data into information and that information into knowledge. 


We have the tools to deal with the challenges at hand. So why, per the IOM, is our healthcare system "plagued by a serious quality gap"? Put simplistically, we may be overlooking our fundamentals and not working with what we do have. These fundamentals are process redesign, EBP, and change management. The limitations do not lie in the technological possibilities but in the oversight of these fundamentals, which are required for successful technological adoption. 


Many organizations are struggling because they are trying to use technological tools without adequate knowledge. A lack of knowledge not just with the actual technology but, more importantly, with the foundational fundamentals needed to ensure the success of the technology's use in practice. 


New systems are put into place over existing ineffective processes within an institution. Anecdotal nursing and medicine are still being practiced instead of evidence-based healthcare. Insufficient attention has been given to establishing the social, cultural, and practice changes that have to precede technological initiatives. The magnitude of change required in implementing clinical information systems, telehealth care, medication bar coding, and computerized provider order entry (CPOE) is frequently underestimated. 


Without the fundamentals in place first, unrealistic expectations are formed relating to the technology's ability to provide a solution. A lack of attention to the fundamentals results in costly systems that go under-utilized. When the system falls short, the credibility of future

initiatives may also be diminished. 


What we do have is the ability to re-design ineffective processes, implement evidence-based research into practice, and proactively manage the changes. These fundamentals serve to facilitate, promote, and bring to the hands-on clinician the tools necessary to improve clinical practice and patient care. Without these fundamentals, we cannot thoroughly utilize the technological tools and address the challenges our healthcare system faces today.