A small community hospital in the Midwest has used a home-grown 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. As part of this process each application and the system as a whole was assessed for the ability to meet Meaningful Use criteria. Based on this analysis, Stage 1 criteria are currently being met. Additional programming and upgrades are needed to meet Stage 2 criteria. Meeting anticipated Stages 3 and 4 criteria will require a significant investment in hardware, software, and additional staff. Rather than continue to build, a decision has been made to switch to a commercial vendor. The hospital is now in the process of selecting a commercial system. Because of your background as a member of the clinical staff with informatics education, you have been appointed to the selection committee. It is also anticipated that you will serve on the implementation committee.
Questions What role, if any, should standard language play in the selection process? What key standard languages and coding systems should be incorporated in the new system? Can the work done in building the screens and developing the terms that are used for documentation of care in the old system be used in the new system or will this delay customizing the new system applications?It is expected that clinical staff will participate in site visits and vendor displays. What, if any, preparation related to standard languages should be given before these activities? How should clinical staff who will be using the new system be prepared for the introduction of new or different terms in the clinical documentation system?