APAMI 2014 Keynote Presentation Plenary Paper

Conference: APAMI 2014, Day 4, Scientific Programme
Date: Sunday, 02 November 2014, 08:30 – 08:50 (14:00 – 14:20 Sydney time)
Venue: Stein Auditorium, India Habitat Centre, New Delhi, India
Session Name: Clinical Workflow and Human Factors

IT as the Controlling Influence in a hospital department

Jon Patrick PhD MSc, BSc, Dip LS, Grad Dip BHPsych
iCIMS, Sydney Australia


An investigation into methods to improve the design and implementation of clinical information systems (CIS) was conducted by using a process of Clinical Team Led Design (CTLD). The process of clinicians studying their own workflow processes demonstrated the extent to which clinical work is controlled by the IT implemented in a department. The ability to break out of the straightjacket created by the IT can only be attained when the design of the IT itself can be manipulated by the staff and altered as required by their needs.

It is demonstrated that Best-of-Breed clinical information systems developed under the principle of CTLD creates more efficiencies in the workplace than enterprise EMR systems (EEMR).

An important aspect of clinical care is the need to change workflows and operating procedures as the environment around the work changes either due to new professional practices or shifting regulatory and administrative requirements. Hence, an ability to perform Continuous Process Improvement (CPI) is fundamental to the good practices of a clinical team. Rigid EEMR systems that are slow and highly expensive to change are a significant sea anchor in the pursuit of CPI and frustrate staff to the limit of their patience.

A technology has been created that supports a methodology for creating user designs with an incremental iterative feedback process. In this technology, an underlying software engineering architecture, we denote as Emergent Clinical Information Systems (ECIS), automatically compiles the run-time code directly from the user designs, hence no programming is required to move from design to implementation. The ECIS architecture is defined on the principle of Ockham’s Razor of Design, that is, the elements of design that are engineered for the designer are a minimum number of design objects with maximal generalisation. The CIS design is created by a principle of Agile Design where designs are created and tested incrementally within an iterative process.

With this functionality, the capacity to make near real-time adaptation of an implementation is made available, giving enormous power to the design team to explore alternative designs before commissioning a specific implementation. At the same time, the underlying data management for all CISs built in the ECIS paradigm is the same, and hence it has the unification of the code base and data stores in a single application. In essence, it is a Best-of-Breed solution on the user side and an enterprise system on the server side.

The ECIS model with real-time changeability, native interoperability to move data to where it has to be used, and in-built analytics to monitor the effect of change represents a much superior approach to providing effective methods for CPI in any clinical setting. As a technology, it is ideally suited to the creation of a CIS for any clinical specialty.

A local clinical team at Nepean Hospital, Sydney, Australia, designed a CIS for their hospital emergency department, denoted the Nepean Emergency Department Information Management System (NEDIMS) using the ECIS approach and compared it to the EEMR incumbent system in the department.

A process analysis for each of the 6 activity centres in the ED described staff roles of: Clerking, Triage, CIN (Clinical Initiatives Nurse), Fast Track, Acute Care, and Nurse Unit Manager (NUM). The process analysis formed the basis of understanding the design needs of the department. It was also used subsequently to identify the task types that needed to be used in the quantitative comparison between the two systems. A total of 43 task types were identified of which 27 were present in the EEMR system, 40 were present in NEDIMS and 14 were completed on paper.

The department staff were observed for 22 days where each task instance was measured for time duration and number of mouse clicks in live usage on the EEMR and paper forms. A total of 722 task instances were recorded from 43 task types. Subsequently, 374 matched observations of 17 task types were measured for those tasks that could be repeated in NEDIMS of which 332 were matched task instances between NEDIMS and the EEMR, the remainder being matched to paper forms.

The final analysis showed that NEDIMS was 40% more efficient and had 30% less cognitive load than the incumbent EEMR system. Modelling of staff work for an average patient load of 165 patients per 24 hours indicated the staff would save an average time of 23.9 hours per day using NEDIMS.

iCIMS and HLA Technology Assists Basque Hospitals in Recording and Translating Clinical Records

iCIMS and sister company HLA have joined forces with researchers at the University of the Basque Country and the Department of Health of the Basque government, Osakidetza, for a unique project. The aim is for Basque speaking doctors to write their clinical records in Basque and then have basic information such as clinical history and diagnosis automatically translated into Spanish.

iCIMS and HLA Technology Assists Basque Hospitals in Recording and Translating Clinical Records

iCIMS and HLA Technology Assists Basque Hospitals in Recording and Translating Clinical Records

Translation with quality and surety, guaranteed.

Professionals of the health field will be able to write the clinical history in Basque thanks to the application Donostiarena and the Basque version of SNOMED-CT. SNOMED-CT is the repository of an ontology that is the most used in the health sphere.

iCIMS has contributed its clinical information systems software for the researchers to build Donostiarena, the system for storing the clinical records, and HLA has contributed its terminology server loaded with SNOMED CT in English, Basque and Spanish. The researchers are computational linguists from the IXA research group who have been developing language processing tools in Basque for 25 years. The Basque government has a long history of promoting the use of Basque in the professions. Donostiarena literally means “that which belongs to the city of San Sebastian”.

iCIMS Published in the Annals of Emergency Medicine

The iCIMS report, Efficiency Achievements From a User-Developed Real-Time Modifiable Clinical Information System, has just been published in the Annals of Emergency Medicine.

Study objective

This investigation was initiated after the introduction of a new information system into the Nepean Hospital Emergency Department. A retrospective study determined that the problems introduced by the new system led to reduced efficiency of the clinical staff, demonstrated by deterioration in the emergency department’s (ED’s) performance. This article is an investigation of methods to improve the design and implementation of clinical information systems for an ED by using a process of clinical team–led design and a technology built on a radically new philosophy denoted as emergent clinical information systems.


The specific objectives were to construct a system, the Nepean Emergency Department Information Management System (NEDIMS), using a combination of new design methods; determine whether it provided any reduction in time and click burden on the user in comparison to an enterprise proprietary system, Cerner FirstNet; and design and evaluate a model of the effect that any reduction had on patient throughput in the department.


The methodology for conducting a direct comparison between the 2 systems used the 6 activity centers in the ED of clerking, triage, nursing assessments, fast track, acute care, and nurse unit manager. A quantitative study involved the 2 systems being measured for their efficiency on 17 tasks taken from the activity centers. A total of 332 task instances were measured for duration and number of mouse clicks in live usage on Cerner FirstNet and in reproduction of the same Cerner FirstNet work on NEDIMS as an off-line system. The results showed that NEDIMS is at least 41% more efficient than Cerner FirstNet (95% confidence interval 21.6% to 59.8%). In some cases, the NEDIMS tasks were remodeled to demonstrate the value of feedback to create improvements and the speed and economy of design revision in the emergent clinical information systems approach. The cost of the effort in remodeling the designs showed that the time spent on remodeling is recovered within a few days in time savings to clinicians. An analysis of the differences between Cerner FirstNet and NEDIMS for sequences of patient journeys showed an average difference of 127 seconds and 15.2 clicks. A simulation model of workflows for typical patient journeys for a normal daily attendance of 165 patients showed that NEDIMS saved 23.9 hours of staff time per day compared with Cerner FirstNet.


The results of this investigation show that information systems that are designed by a clinical team using a technology that enables real-time adaptation provides much greater efficiency for the ED. Staff consider that a point-and-click user interface constantly interrupts their train of thought in a way that does not happen when writing on paper. This is partially overcome by the reduction of cognitive load that arises from minimizing the number of clicks to complete a task in the context of global versus local workflow optimization.

DOI: http://dx.doi.org/10.1016/j.annemergmed.2014.05.032

A full report for the project can be downloaded from our Publications page.

iCIMS about to Be Published

We are about to have published our paper on ED-IMS in a leading international journal. This paper will reveal our next generation technology with 40% improved clinical efficiency and 30% reduction in cognitive load for clinical users. This technology enables staff to design their own systems and yet no programming is required to turn it into an operational CIS. At the interface level, staff can create designs exactly conformant to their local needs and change it at will as their environment changes. Yet at the server end, the iCIMS technology enables multiple clinical specialities to run off the one software installation, preventing the siloing of data and lowering the maintenance load on IT Services. Our systems are fully adaptable Best-of-Breed for the clinical users but underneath have enterprise wide software functionalities.

iCIMS Ticks the Boxes for a Good EMR/CIS

A colleague recently wrote on a professional group list a set of deficiencies of the contemporary EMR in this vein:

All current EMRs get a maximum of a D- degree. They miss:

  1. The adaptive adding of data elements in compositions (Detailed Clinical Models);
  2. Adaptive creation of integrated pathways to support better co-ordination between different disciplines such as medical and dental treatment, plus nursing care, psychology and social care;
  3. A data element / valueset binding to standardised terminology;
  4. Options for standardised electronic data communication for various purposes, such as continuity of care, quality, decision support, management data, epidemiology, clinical trials, etc.

iCIMS can be judged by this list and comes out in good shape. Our real-time adaptability covers items 1 and 2, our in-built coding covers item 3, and we satisfy 4 — there might be more intended here by the author than what we can read in the words — by our ability to use HL7 messaging, and also our in-built analytics functions and the API for reading the data stores.