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Stories - ARMC

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Alamance Regional Medical Center 

Implementation Planning

Prior to the introduction of a clinical information system, ARMC operated almost exclusively with stand alone systems.  Ward clerks used a core healthcare information system (HIS) with basic order entry for the lab and radiology departments, but the system lacked meaningful order sets or rules for clinicians. The system relied on a mainframe with either dumb terminals or Telnet access. ARMC’s new automated solution would give clinicians a single-source, full patient profile and detailed clinical information in a timely manner. With information more readily available, and the ability to access more sources of information simultaneously, clinicians’ decision-making would be improved.


Implementation Process

At the beginning of its clinical information system initiative, ARMC's nurses and finance vice-presidents signed on as co-sponsors, providing invaluable collaborative leadership to guide progress. A group of clinical resources representatives, including nurses and pharmacy analysts, served as project champions, testing the system and facilitating optimal communication between clinicians and IT staff members.


Intertwining the disciplines better enables staff members to view the project as an organization-wide effort, augmenting its overall success.


Prior to implementation, ARMC planners built 800 nursing items and 100 nursing order forms into the facility's clinical information system. Following its shared governance model, new committees facilitated clinician involvement in system design and created or modified practice policies, as necessary.


Specifically, the Clinical Informatics Shared Governance Council meets monthly and offers representatives from every hospital discipline, which serve as "super-users" for their departments and assist in communicating any system additions or modifications. A documentation task force, which includes a representative from each nursing unit, meets weekly to help design and test new and modified features.


In short, the council ensures that the system meets the needs of all clinicians. Nurse leaders rally support for this model, as well as for assigning appropriate nursing resources to councils and ensuring that staff schedules allow for optimal participation.


In November 1998 results reporting was available hospital wide with CPOE introduced on a pilot unit. ARMC successfully achieved organization-wide rollout of SCM and its Knowledge-Based Orders in the summer of 2000. They recognized the importance of demonstrating success of the system by thoroughly measuring key indicators that align with a healthcare organization’s strategic goals. Thus, ARMC established benchmarks to measure how the system improved care. They provided statistically significant information touting the benefits of the clinical information system and conveyed this to all employees throughout the health system. ARMC believes that this was key to maintaining and expanding clinician acceptance and support of the new IT system.


To ensure an optimum transition process, the implementation team required that CPOE “go live” be divided into 28-bed units, one at a time, floor by floor. For the first two weeks of the CPOE implementation in each unit, the head of Clinical Informatics Council, the Informatics Educator and IT clinical analysts made frequent rounds and held daily meetings with the clinicians and staff. They were also available by pager to answer any questions. At the time of completing the enterprise-wide rollout, 150 workstations and 18 Medical Logic Modules (MLMs) were in use.


Project Governance and Staffing

The purpose of the Physician Review Board is to represent the physician perspective in the design and implementation of our CIS.  The Review Board will support the Clinical Analysts and Project Team by reviewing functionality as configured in the database and by offering feedback and guidance as needed.  Information exchange, issue identification, and consensus building are essential to the success of the project.  Other responsibilities include:


  • communicate issues back to the staff at large
  • recognize opportunities to change current practices and policies  
  • to take advantage of the CIS in order to improve the quality and efficiency of care delivery
  • develop the policies and procedures necessary to facilitate use of the CIS by the medical staff
  • act as advocates for the CIS


In order to ensure success during the implementation of a new clinical information system, much thought was given to the structure of the project.  Three teams were formed to support automation efforts.  Information exchange, issue identification, and consensus building of the three teams were essential to the success of the project.


The Project Team was charged with day-to-day management of the implementation and testing phases of the project.  A team of clinical analysts, interface analysts, technical resources, practicing clinicians, and physicians meet on a weekly basis until each phase of the project is completed.  The Project Team reports to two administrative sponsors – the Vice President of Nursing and the Chief Information Officer.


The Physician Review Board was created to represent the physician perspective in the design and implementation of the clinical information system.  The Physician Review Board supports the clinical analysts and Project Team by reviewing functionality as configured in the database and by offering feedback and guidance as needed.  The Physician Review also serves as a body of physician champions committed to the success of automation efforts at Alamance Regional Medical Center.  


Finally, the Clinical Informatics Council (CIC) was created to represent the nursing and ancillary perspective.  The Clinical Informatics Council’s purpose is to support the progression to new technologies whereby all health care providers will be able to utilize a clinical information system in order to improve the quality of health care provided.  In addition, the CIC is responsible for assisting the project team with workflow analysis and design decisions. 


The three-tier approach described above, ensured that all stakeholders had input into the design and implementation of our new clinical information system.  By incorporating feedback and input from practicing clinicians, our organization has built a system that is reflective of how we practice medicine and provides decision support capability and alerts that were previously unavailable in the paper world.      


Transition to New Processes

ARMC initially activated the system initially in one pilot unit, with the unit’s nurse manager serving on the project team. This helped ensure that the order-entry process incorporated appropriate elements and that the workflow made sense. Once the pilot unit achieved its goals, the facility began a systematic rollout, activating CPOE across the organization, one 28-bed unit at a time.


CPOE implementation immediately impacted nursing practice and workflow. The nurses' ability to act on real-time data available in the electronic patient record expedites care delivery. Physicians access patient charts remotely from their offices or homes and enter orders based on results and information stored within the electronic record, often doing so before making rounds.


Additionally, if a physician places an order for a diagnostic test, he or she can monitor the system for results and place additional orders remotely based on the outcome. Electronic alerts immediately notify clinicians of important information to aid in decision-making, including the rational for the order and insurance compliance information. Nurses no longer rely on the physical presence of physicians to review the paper chart for information and hand write orders. 


Training, Education, Support

ARMC began staff training four weeks before the implementation of SCM. Because physicians, nurses, and other clinicians vary in their comfort level with computers and technology, training was tailored to meet their unique needs. Novice computer users were scheduled for classes that included Keyboard and Mouse Survival Training prior to actual program training. Nurses and other clinicians received on-site instruction in a classroom setting. Classes were divided into two three-hour sessions. The first class covered navigation of the software, designing lists and filters, use of results reporting, finding and entering required patient information and flow sheet documentation. The second class was devoted to order entry functionality. Handbook references, flyers, e-mail, messages within applications and poster boards kept users informed.


Physicians responded well to individual training sessions with an IT analyst resource that was familiar with ARMC’s organizational policies and procedures. By training each of its physicians on the system, ARMC achieved exceptional voluntary adoption in a short time. Individual departments developed trainers to support their staff going forward. Critical issues are addressed immediately through IT support staff, the help desk, or online support features.


In addition to physicians, nursing administrators committed four hours per week to the Clinical Informatics Council. The purpose of the council is to respond to, build and customize the CPOE program based on departmental feedback from the weekly sessions. The goal of these efforts is to maintain a safe and functional computerized medical record system. ARMC is dedicated to providing continued training for core team members and has made a resource library available to staff that consists of reference materials on a variety of relevant HIT topics. ARMC believes that it is extremely important for all core team members to understand the needs of the HCO, the changing environment of IT solutions and the complex issues around regulatory guidelines and standards.


During the first 2 weeks of CPOE implementation within each unit, the head of the clinical informatics council, the informatics educator, and IT clinical analysts made rounds and held daily meetings with involved staff and managers. They also remained available by pager.



ARMC uses a three-prong approach to support end-users. Representatives from nursing, education, and information systems meet weekly to address clinical informatics issues. This team includes an RN clinical informatics educator who provides ongoing clinical training. New nurses receive training during orientation. Handbook references, flyers, e-mail, messages within applications, and poster boards keep users informed. An IT help desk provides round-the-clock support, and escalation procedures enable staff members to answer critical issues immediately.



Post-Implementation Upgrades

The project team relies heavily on user input to determine the best time for software upgrades.  Training and support methodologies used for the initial implementation are revised and scaled back according to the potential impact to the end-user.  Upgrades typically begin on a Friday evening as our volume statistics support this is the least busy time for clinicians.   An information systems hotline is utilized to keep users updated on how the upgrade is progressing and when the system is anticipated to be available again.