Commentary: Implementation Is an Iterative Process
In VHA, CPRS is currently in Version 26, after its original testing and distribution in 1997. It is a nationally programmed application, with one new substantial version every four to six months, each of which needs to be tested, validated and then deployed across more than 160 medical centres and 600 outpatient clinics, with new training and support resources involved at each step. Having clinical champions heavily involved is crucial to the success of this process.
Second, computers are ruthless enforcers of rules - that's their real power in impacting clinical care - but they don't care what the rules are. In healthcare, practice patterns have evolved to such a point that no one person actually knows what all the rules are, at least not enough to guide programmers. They just know what they do. Front-line clinicians need to meet, discuss, bribe, cajole and then come to a consensus on what the rules are. Our experience has been that rules frequently have to be created in situations where we didn't know we needed any. Not only is clinical informatics not a spectator sport, it is a contact sport!
Third, healthcare really is different from other industries. Complex decision-making, non-linear workflow, shared responsibilities, extreme time-sensitivity of information flow and recognition of previously unrecognized patterns define medical care in the 21st century. Programmers and other technical staff have much to learn from clinicians. By and large, programmers enjoy it and can deliver better products and systems when clinicians can work with them to demonstrate what it is they really need to accomplish to take good care of other human beings.
About the Author
Ben Davoren, MD, PhD, is Director of Clinical Informatics at the San Francisco VA and has served as an advisor to the VA's national CPRS development for the past seven years. He is also Associate Professor of Medicine in Hematology/Oncology at University of California - San Francisco.
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