GROUP 3: Nursing Informatics - Complex Applications

A. Planning, Design, and Implementation of Information Technology in Complex Healthcare

Systems

• OBJECTIVES
1. Define complex systems in the context of General Systems Theory.
2. Describe complex adaptive systems, a special case of complex systems.
3. Illustrate challenges and solutions for planning and designing information technology in
complex healthcare systems.
i. Wicked problems
ii. High-reliability organizations
iii. Structured and agile design methods
4. Provide examples of tools and methods used to plan and design information systems in
complex healthcare processes.
iv. Computer-Aided Software Engineering
v. Discrete Event Simulation
vi. Network Analysis Tools
• KEY WORDS
 Complex adaptive systems
 Wicked problems
 Agile design
 Discrete event simulation
 Network science
 Nurse informaticist
 Electronic Medical Record
 Systems analyst

Introduction

1. Overview
a. The introduction of information technology into the workflow of clinicians requires
thoughtful planning, design, and implementation

(1) Healthcare organizations of today are among some of the most complex systems in the
world

(2) They are composed of diverse specialties and multiple providers linked through a complex
information network

(3) Understanding and predicting the impact of new technology on healthcare system
behavior is an ongoing challenge for nurse informaticists

(4) That is because complex systems are unpredictable and what works in one organization
doesn’t guarantee success in another
b. Nurse informaticists play a critical role in the successful deployment of healthcare
information technology

(1) Their unique blend of clinical knowledge and information systems expertise make them
ideal systems analysts
(2) As complex systems research discovers new findings, nurse informaticists must remain
informed on how new knowledge can be translated into practice settings
(3) The objective of this chapter is to provide a review of complex systems from the context
of a GST and then provide an overview of new strategies to plan, design,
and implement information systems in healthcare organizations

General Systems Theory

1. Overview
a. A system can be defined as a set of interacting units or elements that form an
integrated whole intended to perform some function
(1) GST provides a general language which (3) Although healthcare is a discipline in
ties together various areas in and of itself, it integrates with many other
interdisciplinary communication systems from fields as diverse as biology,
(2) It endeavors toward a universal science economics, and the physical sciences
that joins together multiple fields with
common concepts, principles, and properties

b. Systems can be closed, isolated, or open

(1) A closed system can only exchange (5) Healthcare systems are considered open
energy across its borders and are continuously exchanging
(2) Isolated systems cannot exchange any information and resources throughout
form of heat, energy, or matter across their their many integrating subsystems
borders
(3) Examples of closed and isolated systems (6) Some fundamental properties
are generally restricted to physical sciences collectively comprise a
such as physics and chemistry GST of open systems
(4) An open system is always dependent on
its environment for the exchange of matter,
energy, and information

2. Open systems
a. All open systems are goal seeking
(1) Goals may be as fundamental as survival
and reproduction (living systems) to
optimizing the flow of information across
computer networks
(2) To achieve goals, systems must
transform inputs into outputs
(3) An input might include the entry of
information into a computer where it is
transformed into a series of binary digits
(outputs)
(4) These digits can then be routed across
networks to end users more efficiently than
other forms of communication
(5) As simple systems interact, they are
synthesized into a hierarchy of increasingly
complex systems, from subatomic particles
to entire civilizations
(6) Levels within the hierarchy have novel
characteristics that apply universally upward
to more complex levels, but not downward
to simpler levels
(7) In other words, at lower or less complex
levels, systems from different fields share
some characteristics in common
(8) It is the interrelationships and
interdependencies between and across levels
in hierarchies that create the concept of a
holistic system separate and distinct from its
individual components
(9) As commonly noted, a system is greater
than simply the sum of its individual parts

3. Complex systems
a. System behavior can be related to the concept of complexity
(1) As systems transition from simple to complex it is important for nurse informaticists to
understand that system behavior also changes
(2) This is especially important in the management of data and information for clinical and
administrative decision-making

b. As healthcare systems become increasingly complex it

becomes progressively more difficult to predict how changes
in provider workflow are impacted by new information
technology
(1) This is especially important for those individuals responsible for planning, designing, and
implementing information systems in the healthcare environment of
today

c. The evolution of information systems in healthcare is

replete with failed implementations, cost overruns, and
dissatisfied providers
(1) It is important to understand, however, that healthcare systems of today are some of the
most complex in the world
(2) The unpredictable nature of complex healthcare systems results from both structural and
temporal factors
(3) The structure of complex systems is composed of numerous elements connected through a
rich social network
(4) The way information flows through this complex web of channels depends on the
technology used, organizational design, and the nature of tasks and relationship
d. As systems evolve from simple to complex systems a hierarchy of levels emerges
within the organization
(1) From a theoretical standpoint, complex systems form a “fuzzy,” tiered structure of macro,
intermediary, and micro-systems
e. At the micro-system level, the relationship between cause
and effect is somewhat predictable
(1) However, as the organizational structure expands to include meso- and macro-system
levels, causal relationships between stimulus and response become blurred

4. Complex adaptive systems

a. Complex adaptive systems (CAS) are special cases of complex systems; the key
difference being that a CAS can learn and adapt over time
(1) From biologic to man-made systems, CAS are ubiquitous
(2) The human body, comprised of its many subsystems (cardiovascular, respiratory,
neurologic) is a CAS and continuously adapts to short- and long-term changes in the
environment
(3) The same principles can be applied to social organizations such as clinics or hospitals
(4) Organizational learning is a form of adaptation and it has the capacity to change the
culture
(5) New reporting relationships can alter the structure of a social network and act as the
catalyst for adaptation to environmental change

A. CAS exhibit specific characteristics that are different than simple systems and the
terminology used to define them may be unfamiliar to healthcare providers
B. . As healthcare systems become increasing complex, those individuals challenged with
planning, designing, and implementing information technology must be knowledgeable of
CAS principles as well as the tools and methods to analyze their behavior.

1. Overview
a. A key concept to understand is that all systems, whether they are natural (rivers,
trees, weather) or man-made (stock markets, the Intranet, health systems) have currents
that flow through them
(1) Oxygen and blood flow through animate (2) Patients flow through hospitals and
systems such as trees or humans while water clinics while information flows through
and electricity flow in currents through computer networks and electronic health
inanimate systems such as rivers or records
lightening
(3) Without flow, a system cannot exist and for optimal designs to transport water and
to survive, it must evolve in a direction that oxygen from the ground back
improves its access to designs that improve to the atmosphere
the flow of currents through them
(4) In nature, the branching pattern in trees (6) This treelike branching pattern is so
is not accidental efficient it is also seen in other structures
(5) Rather the configuration of branches is such as river basins, the human respiratory
the result of natural selection and the search system, computer networks, and road
systems
b. Just as water flows fast for long distances through wide river channels, digitized
information flows fast for long distances through large cable networks connecting
institutions
(1) As rivers fan out to create deltas, smaller make up about 80% of total channels while
channels form and flow slows and travels a the remaining 20% are fast and long
shorter distance (5) And this ratio shows up not only in
(2) As computer networks branch out to rivers, but in tree branches, the human
users within organizations, the flow of circulatory system, and computer networks
digital information also slows and travels (6) Although flow is faster in large river
shorter distances as it supplies multiple channels than in smaller tributaries, the total
users flow is maintained by the creation of
(3) To optimize and maintain flow, fast and numerous tributaries that as a whole, are
long flow must equal short and slow flow equal to the flow of the larger channels
(4) In natural systems such as rivers, the
ratio of channels that are slow and short
c. This fundamental concept can also be applied to the flow of electronic data and the
design of information systems
(1) When information is delayed, either as a from being communicated in a timely
result of poorly designed systems and manner through the health systems
cumbersome processes and policies, it is computer network to the pharmacy (long
usually a mismatch between “short and fast)
and slow” and “fast and long” information (3) As a result, orders stack up (develop
flow queues) and delay the flow of information
(2) If it is overly time-consuming to enter (4) Whenever, delays occur, nurse
provider orders into an EHR (short and informaticists should look for imbalances
slow) then it delays those orders between “short and slow” and “fast and
long” information flow

Information System Planning

1. Overview
a. The interrelatedness of subsystems characteristic of com
plex healthcare processes requires participation by many
different stakeholders in the planning cycle
(1) In complex systems, outputs from one process often become inputs to many others
(2) A new admission on a nursing unit (input) can generate orders (output) to pharmacy,
radiology, respiratory care as well as many other departments
(3) As various levels of care (clinic, hospital, long-term care) become increasingly connected,
interoperability of computer systems becomes crucial
(4) In addition, as clinical and administrative areas become more specialized, it is essential
that domain experts participate in the planning process

2. Wicked problems
a. Problems encountered in complex systems are commonly
described as “wicked”
(1) A wicked problem is difficult or impossible to solve because of incomplete, contradictory,
and changing requirements that are often difficult to recognize
(2) Wicked problem are
 i. Very difficult to define or formulate
 ii. Not described as true or false, but as better or worse
 iii. Have an enumerable or exhaustive set of alternative solutions
 iv. Inaccessible to trial and error; solutions are a “one shot” deal
 v. Unique and often a symptom of another problem

(3) Wicked problems cannot be solved by the common rubric of defining the problem,
analyzing solutions, and making a recommendation in sequential steps; the
reason being, there is no clear definition of the problem
(4) By engaging all stakeholders in problem solving, those people most affected participate in
the planning process and a common, agreed approach can be formulated
(5) Of utmost importance is understanding that different problem solutions require different
approaches

3. High-reliability organizations
a. Key attributes of HROs include a flexible organizational structure, an emphasis on
reliability rather than efficiency, aligning rewards with appropriate behavior, a
perception that risk is always present, sensemaking (an understanding of what is
happening around you), heedfulness (an mutual understanding of roles), redundancy
(insuring there is sufficient flex in the system), mitigating decisions (decisionmaking that
migrates to experts), and formal rules and procedures that are explicit
(1) Employing information technology, such as bar-coded medication administration, must be
implemented in the context of an overall strategy to become an HRO
(2) For example, BCMA emphasizes reliability over efficiency and integrates formal rules
and procedures into the medication management process
(3) Collectively, these features reduce the probability of multiple failures converging
simultaneously
b. On the other hand, planning for clinical decision support (CDS) applications may
require a different approach than implementation of BCMA
(1) CDS systems link health observations with health knowledge to influence health choices
by clinicians for improved healthcare
(2) These applications cover a broad range of systems from simple allergy alerts to
sophisticated algorithms for diagnosing disease conditions
(3) The cognitive sciences inform and shape the design, development, and assessment of
information systems and CDS technology
(4) The subfield of medical cognition focuses on understanding the knowledge structures and
mental processes of clinicians during such activities as decision-making and problem solving
c. Optimizing the capabilities of CDS systems to allow better decision-making requires
an understanding of the structural and processing patterns in human information
processing
(1) For example, knowledge can be described as conceptual or procedural
(2) Conceptual knowledge refers to a clinician’s understanding of specific concepts within a
domain while procedural knowledge is the “how to” of an activity
(3) Conceptual knowledge is learned through mindful engagement while procedural
knowledge is developed through deliberate practice
(4) If CDS planners are not careful, they may inadvertently design a system that transforms a
routine task such as checking a lab value (procedural knowledge) into a cumbersome series of
computer entries
(5) If the clinician is simultaneously processing conceptual knowledge (problem solving and
decision-making) and complex procedural tasks, it will place an unnecessary burden on
working memory and create frustration
d. In summary, the frequent occurrence of wicked problems in complex healthcare
systems highlights the challenges faced by information system planners today
(1) Successful planning for the introduction of information technology requires participation
by a diverse group of stakeholders and experts
(2) There is no “cookie cutter” solution in system planning
(3) Each application must be aligned with an overall organizational strategy which drives the
implementation approach

3. High-reliability organizations
a. Key attributes of HROs include a flexible organizational structure, an emphasis on
reliability rather than efficiency, aligning rewards with appropriate behavior, a
perception that risk is always present, sensemaking (an understanding of what is
happening around you), heedfulness (an mutual understanding of roles), redundancy
(insuring there is sufficient flex in the system), mitigating decisions (decisionmaking that
migrates to experts), and formal rules and procedures that are explicit
(1) Employing information technology, such as bar-coded medication administration, must be
implemented in the context of an overall strategy to become an HRO
(2) For example, BCMA emphasizes reliability over efficiency and integrates formal rules
and procedures into the medication management process
(3) Collectively, these features reduce the probability of multiple failures converging
simultaneously
b. On the other hand, planning for clinical decision support (CDS) applications may
require a different approach than implementation of BCMA
(1) CDS systems link health observations with health knowledge to influence health choices
by clinicians for improved healthcare
(2) These applications cover a broad range of systems from simple allergy alerts to
sophisticated algorithms for diagnosing disease conditions
(3) The cognitive sciences inform and shape the design, development, and assessment of
information systems and CDS technology
(4) The subfield of medical cognition focuses on understanding the knowledge structures and
mental processes of clinicians during such activities as decision-making and problem solving
c. Optimizing the capabilities of CDS systems to allow better decision-making requires
an understanding of the structural and processing patterns in human information
processing
(1) For example, knowledge can be described as conceptual or procedural
(2) Conceptual knowledge refers to a clinician’s understanding of specific concepts within a
domain while procedural knowledge is the “how to” of an activity
(3) Conceptual knowledge is learned through mindful engagement while procedural
knowledge is developed through deliberate practice
(4) If CDS planners are not careful, they may inadvertently design a system that transforms a
routine task such as checking a lab value (procedural knowledge) into a cumbersome series of
computer entries
(5) If the clinician is simultaneously processing conceptual knowledge (problem solving and
decision-making) and complex procedural tasks, it will place an unnecessary burden on
working memory and create frustration
d. In summary, the frequent occurrence of wicked problems in complex healthcare
systems highlights the challenges faced by information system planners today
(1) Successful planning for the introduction of information technology requires participation
by a diverse group of stakeholders and experts
(2) There is no “cookie cutter” solution in system planning
(3) Each application must be aligned with an overall organizational strategy which drives the
implementation approach
2. Structured design
a. Historically, design and implementation of healthcare
information systems relied heavily on structured methods
(1) The most common structured design and implementation method used is the System
Design Life Cycle (SDLC)
(2) The SDLC acts as a framework for both software development, implementation, and
testing of the system
b. An SDLC approach prescribes the entire design, testing, and implementation of new
software applications as one project with multiple subprojects
(1) Project deadlines can extend over many months and in some cases years
(2) The method encourages the use of standardization
(e.g., programming tools, software languages, data dictionaries, data flow diagrams, and so
forth)
(3) Extensive data gathering (interviews, questionnaires, observations, flowcharting) occurs
before the start of the project in an effort to predict overall system behavior, after full
implementation of the application
3. Agile design
a. As healthcare systems have become increasingly complex, the SDLC approach has
come under fire as being overly rigid
(1) Behavior, characteristic of complex systems (sensitivity to initial conditions, nonlinearity,
and wicked problems), is often unpredictable, especially after the introduction of information
technology in clinical workflow
(2) Equally challenging is the difficulty of trialing the impact of new information systems
before having to actually purchase them
(3) Site visits to observe a successful application in one facility are no guarantee of success in
another
(4) Many healthcare organizations have spent countless millions in failed system
implementations
b. To overcome these problems, healthcare organizations are turning to “agile” methods
for design and implementation of information systems
(1) Agile design is less prescriptive than (5) This “timeboxing” of projects forces the
structured methods and allows for frequent team to search for simple, but elegant
trial and error solutions
(2) Rather than mapping the entire project (6) Developers often work in pairs to cross
plan up front, agile methods clearly define check each other’s work and distribute the
future milestones, but focus on short-term workload
successes (7) Communication is free flowing between
(3) To do so the implementation team and developers and the implementation team
software developers collaboratively evaluate (8) Once a solution is developed it is rapidly
and prioritize the sequence of task to tested in the field and then continuously
implement first modified and improved
(4) Priority is assigned to tasks that can be (9) There is a philosophy that the interval
accomplished within a short time frame, between testing and feedback be as close as
with a minimum of cost while maintaining possible to sustain momentum in the project
high-quality standards

c. Agile design is one example of how to manage information

technology projects in complex systems
(1) Rather than trying to progress along a rigid project schedule, simple elegant solutions are
rapidly designed, coded, and tested on a continuous basis
(2) Over time, layer upon layer of elegant solutions evolve into a highly integrated, complex
information system
(3) Ironically, this is the same process that many naturalsystems have used to evolve into their
current state

The Systems Analyst Toolbox

1. Overview
a. Whether structured or agile design methods are used during project implementation,
systems analysts rely heavily
on various forms of modeling software
(1) Modeling applications visually display the interaction and flow of entities (patients,
providers, information) before and after implementation of information technology
(2) Models link data dictionaries with clinical and administrative workflow through logical
and physical data flow diagrams
(3) Models can be connected through a hierarchy of parent and child diagrams to analyze
system behavior locally (at the user level) and globally (management reports).
There are many commercial modeling tools available
2. Discrete event simulation
a. Two software applications that are well suited for the analysis of complex systems are
discrete event simulation (DSA) and network analysis (NA)
(1) DSA is a software application that allows analysts to flowchart processes on a computer
and then simulate entities (people, patients, information) as they move through individual
steps
(2) Simulation allows the analyst to quickly communicate the flow of entities within process
and compare differences in workflow after the introduction of new technology
(3) DSA applications contain statistical packages that allow analysts to fit empirical data
(process times, inter-arrival rates) to theoretical probability distributions to create life like
models of real systems
(4) Pre- and post-implementation models can be compared for differences in cycle time,
queuing, resource consumption, cost, and complexity
(5) DSA is ideal for agile design projects because processes can be quickly modeled and
analyzed prior to testing
(6) Unanticipated bottlenecks, design problems, and bugs can be solved ahead of time to
expedite the agile design process

3. Network analysis
a. NA applications plot the pattern of relationships that exist between entities and the
information that flows between them
(1) Entities are represented as network nodes and can identify people or things (computers on
nursing units, handheld devices, servers)
(2) The information that flows between nodes is represented as a tie and the resulting network
pattern can provide analysts with insights on how data, information, and knowledge move
throughout the organization
(3) NA tools measure information centrality, density, speed, and connectedness and can
provide an overall method for measuring the accessibility of information to providers
(4) NA graphs can uncover power laws in the distribution of hubs in the organization’s
network of computers and servers) This can be beneficial in investigating the robustness of
the computer network in the event a key hub crashes

Organizational Fragility
1. Overview
a. The potential impact of growing healthcare complexity is enormous
(1) Beyond a certain level, organizational complexity can decrease both the quality and
financial performance of a health system
(2) In his book, “Antifragile,” Taleb describes the concept of fragility in complex systems
such as healthcare
(3) As certain systems become increasingly complex, unexpected events can create an
exponentially negative impact
b. One can get a sense of the impact of size and complexity on the fragility of
organizations by scanning the Centers for Medicare and Medicaid’s Hospitals
Consumer Assessment of Healthcare Providers (HCAHPS) survey scores (HCAHPS
Online)
(1) The HCAHPS provide a standardized survey instrument and data collection methodology
for measuring patients’ perspectives on hospital care
(2) The HCAHPS is administered to a random sample of patients continuously throughout the
year in hospitals
(3) From “Communication with Nurses” to “Pain Management,” of the 10 hospital
characteristics publicly reported, scores decrease with an increase in hospital bed size in
nearly every category
(4) Just as an elephant falling 5 ft suffers significantly more damage than a mouse, large,
complex organizations suffer exponentially greater harm than smaller ones for similar events