Computerized Emergency Department System

The project manager is Frank Hsu: A currently graduate student in the biomedical information department of the University of Utah. He has more than ten years working experience in software design, coding, implementation, and maintenance in the areas of regulatory publishing, finance analysis, and computer electronic manufacture.

2. Introduction of the CEDS

The ED staff deals with a large quantity of information for their operations, even when they have only few patients in emergency care. Finding pertinent decision support information for patient treatment based on the latest knowledge is the central vision of this implementation.

In the United States, even though emergency physicians only represent 3.3 percent of active physicians [1] among all ambulatory medical care encounters, it was estimated that approximately 11 percent of these visits take place in the ED [2]. According to the 2006 IOM report titled Hospital-Based Emergency Care: At the Breaking Point, the rapid diagnosis and early intervention in acute illness or acutely decompensated chronic illness improves patient outcomes [3].

At the local level, the lack of availability of ED physicians will reduce the productivity of the ER services as well as affecting the high quality of patient care which is a constant challenge at the healthcare center. Simultaneously, the lack of provider access to vital patient data constantly impairs the ED diagnoses and delays the delivery of care. As emergency care has become more sophisticated and complex in the recent decades, a computerized emergency system accessible to clinical workstations could result in more organized and efficient operations with tracking patient records, ordering lab tests, documenting interpretations and sharing information among other providers. Potential benefits of the CEDS include reducing healthcare costs, improving quality, minimizing duplication of effort, and reducing error [5-7].

Since time pressures are inherent to providing emergency care, a patient’s chance of survival and recovery is significantly increased if a number of criteria can be satisfied: 1.) The outcomes of medical exams are quickly attainable, 2.) Patient medical histories can be immediately tracked, 3.) Knowledge-based information is acquired, assembled, and transmitted to the ED staff needs, and 4) Patients effectively receive definitive treatments. These visions define the fundamental guidelines for choosing the appropriate ED system: to accelerate the emergency services in diagnoses, treatments, disposition for the healthcare center at all levels. Eventually, a successful implementation of such an ED system will advance the quality of care and affordability of the healthcare center to the leading edge statewide in Utah.

The primary motive to implement an ED system is to compete with other healthcare care providers in the area. After facing competitive pressures from others with computerized systems, the healthcare center board realizes the need for an enterprise clinical information system (ECIS) and computerized primary care support to improve the efficiency of their healthcare services and to retain their ED residents. To implement the best ED system would let the healthcare center survive in this very competitive healthcare market.

The secondary motive for the project is to provide an increased quality of acute care management with the implementation of a niche ED system. The ED system operates and interacts with other healthcare center facilities to make their workflow processes and functions efficient. The operations management includes electronic registries, clinical documentation, practices of triage, knowledge-based clinical guidelines, specific interventions, computerized prescription writing, utilization allocation, and care coordination post-ED.

Since the ED is a fast paced, high stress environment, medical errors [16] can easily occur. Computerized information systems have the potential to help minimize medical errors [8]. A reliable ED information system can provide ED clinicians with instant retrieval of a patient’s medical history, lab results, radiology images, evidence-based medicine and expertise, as well as the prevalence of diseases and infections. The implementation of accurate procedures and rules for the ED staff to follow will not only prevent common medical errors, such as adverse drug events and never-events, but also can alert the ED staff that a patient has a critical condition and needs the most appropriate immediate intervention.
As emergency care is intensified by high competition based on elevated costs, the provision of high-quality treatments and high-performance services in a timely format is an increasingly difficult challenge to successfully implement the ED system. Failure to sustain effective care through this implementation can deny necessary emergency medical services and exacerbate patients’ medical conditions. This would indubitably paralyze the effects of investments in the ED competition.
On the other hand, whenever a system has been implemented too hastily, there are increased risks of failure, errors, resentment, and caregiver-resistance.

Previously, the healthcare center had a contract with another vender to implement an ED system which focused on patient tracking and nursing documentation. Yet after the ED system was used for two weeks, the system was shut down due to complaints from ED nurses that the documentation system slowed them down. Also, physicians complained that the lab review could not be accessed through that ED system. Finally, the director of Medical Intensive Care Unit (MICU) aligned with the director of internal medicine and demanded a complete stop of the application at the healthcare center.

3. Application functions of this ED system

The following ED functions will be accessible through the networks of the healthcare center.

Existing application system:
1. Laboratory information system
2. Standalone pharmacy system
3. Registration system
4. UPS power system
Proposed new functions:
1. Provider Clinical Documentation
2. To enter patient medical data
3. To document patient care and interventions
Computerized patient monitoring system
1. To monitor and record patient vital signs
2. To alert the ED staff a patient is in critical conditions
3. Patient medical record tracking system
4. To track patient previous medical record
Provider orders for lab and diagnostic tests.
1. To order patient lab tests
2. To review test results
3. To provide some basic therapeutic recommendations.
To view patient’s radiology images
A patient tracking board

The ED staff will see a dynamic view of all activity within the ED. By interfacing with the heath care center system, the patient tracking board is continuously updated, providing a real-time view of where patients are and who is currently treating them, what tests they´re undergoing in the ED.

The CEDS system will admit authorized users to access its clinical data repository with the highest level of current network security. Health services researchers will be able to examine the access to care, health care costs and processes, as well as the outcomes of health services for individuals and populations.

Customized reports can be generated with just a few mouse clicks. The specific procedures being performed and the charge levels assigned can all be captured and reported. A more accurate diagnosis, as well as the latest available treatments, can be efficiently applied to a patient. A complete and accurate picture of the ED will be at the user’s fingertips. Thus, computerized information management in the ED system with the convenient operational designs, powerful decision support algorithms, as well as coordinative management services will all contribute to a positive return-on-investment (ROI) in this project.

4. The vision of the project

Most medical literature and resources have become accessible over the internet with or without payments. The establishment of internet connections with the healthcare intranet and the use of wireless services at the healthcare center are the important steps which will allow the ED staff to access the latest patient’s records anywhere.

To quickly identify and solve patient medical problems and make appropriate decisions, a basic knowledge support system will be used in the ED system. The ED system must transform the patient data into useful information and knowledge to guide meregency decision support, continuous quality improvement, and reduce the cost of healthcare [5].

Whenever the ED staff can trust and facilitate the CEDS for the emergency services, we may predict a significantly greater number of clinical contributions for the improvement of quality care. Likewise, when the ED staff benefits from the reduction of many manual workloads, user satisfaction at the healthcare center will gradually be increased. Acceptable utilization of the CEDS will be a direct factor to advnce patient satisfaction.

5. Several major, projected benefits for the project

The project will integrate the processes of an ED’s workflow to expedite ED operations.It helps the ED staff practice more smoothly and decreases the pressure associated with clinical documentation. All patients’ data will be accumulated, stored, analyzed, and interpreted to sustain evidence-based treatments. ED clinicians will have extensive information and instructions about what is occurring and what needs to be done. Clinicians will also have detailed data of all medical examinations and accurate information that they can use to act upon and later, if necessary, justify decisions.

With the information provided by the system, patients’ ED visit times will decrease. Patients will spend less time waiting, rooms will turn over faster, and patient frustration associated with long visits will decrease. Patients will be more likely to continue utilizing the medical services of a specific ED. The decreased visit times will mean the clinicians can see more patients with the same resources, increasing revenue without increasing fixed costs.

ED clinicians need to get patient data as quickly as it is available in an intuitive format. With screens that are easy to use, the patient medical reports can be identified at a glance without navigating through many pages. The clinical data can be categorized with classified key words, thus making it possible to search immediately for patient groups with a particular diagnosis.

6.Needs for the project

The following deficiencies were addressed when the previous ED system was used - there was a great deal of inefficiency in the integration of the healthcare center and poor layouts when the ED nurses worked on the documentation system. For example, their one-sheet paper form was spread across 4 pages on the computer system. Thus, physicians felt that it took a too long to log on to the computer system so they would rather use paper forms in their practice. The laboratory system was also not viewable and the homunculus on the paper form was not available to allow physicians to draw injuries. The e-prescribing system was also very complex to follow. The lack of user-driven designs increased the time necessary for the ED staff to do their jobs.

It is obvious, from the observations noted above, that streamlining the processes of emergency workflow has become imperative to strengthen the competitiveness of the healthcare center in a cost-effective manner in this region.

Developing a robust system and providing the best quality emergency services without making the mentioned mistakes have become a high priority goal at the healthcare center. The adoption of both a reliable and accountable computerized prescribing system as well as a decision support system has become an important approach to minimize potential medication errors and create a competitive advantage over competition.

To facilitate a seamless continuum of patient care, this project would also serve as a standardized communication system linking the emergency department information to the rest of the health care center facilities for inpatient admissions and disposition. It would also reserve many flexible functions for future expansion and integration of the ED system.

7. Integration of the project with existing applications

The CEDS has several components. There is both a database which collects all lab and radiology test results and a medical information database which routinely compiles peer-reviewed medical literature and reports from trusted resources such as the Cochrane Library, an information analysis tool which analyzes the stored medical information. There is also a database which saves the analysis results and can be overwritten by authorized experts. This serves as a tool which compares the analysis results and patient medical data, and a view and display application which provides suggested medical solutions and guidelines.

The data elements of clinical information displayed on the clinical workstation would include, but are not limited to: electrocardiograms, discharge summaries, medication lists, laboratory results, radiology reports, problem lists, provider information, cardiology reports, allergies information, endoscope reports, as well as patient demographics in image format or written reports [9]. The types of information include clinical data, demographics, financial reports, and references to be integrated. All components of the CEDS must be comprehensively integrated, interconnected, and networked with the healthcare center. All patients’ information generated in each encounter should be stored into central data repositories.

A loose coupling of services, such as service-oriented architecture(SOA), with operating systems, programming languages, and other technologies will be used to implement the ED system. SOA separates functions into distinct units, which are made accessible over the internet so that either the developers themselves or others can combine and reuse these services to implement the CEDS and to assimilate and expand more functions in the future.

Finally, to reduce unanticipated effects and user-resistance before the CEDS system used in health care center, functional tests for every component will be phased and performed through users’ involvement. Their feedback will then be closely monitored and strictly assessed to program necessary actions in response.

8.Project team organization and their responsibilities:

The project manager should understand that proper use of human resources, organizational structure and politics, implementation skills, and data management by managing project scope, time, cost, and quality to achieve the project objectives of on-time and on-budget delivery of the system. The manager should lead the project through documenting the ED’s needs and expectations from the ED clinicians, and coordinating with technical services throughout the implementation process to guarantee the overall success of the project. He or she should assign the appropriate resources to an implementation team or administrative unit so that they can determine how to best implement the software. In the event that differences arise and attempts to find a common ground are not reached, the project manager should take the matter to the steering committee.

The responsibilities of the project manager will be to:
1. Provide the team with project structure and development guidelines.
2. Document customization needs as they are identified for future review.
3. Ensure the project requirements are completed and fulfilled.
4. Coordinate project activities, set priorities, schedule tasks, anticipate and mitigate conflicts. Ensure timely progress toward full implementation.
5. Coordinate different ED groups’ decisions on functional use, code decisions, reporting analysis, data conversion, policies, and standards within the application area of the ED.
6. Manage the implementation issues, including identify risks, and direct coding toward correction.
7. Coordinate project plans and schedules.
8. Synergize disparate points of view to maximize the implementation efforts.
9. Promote project achievement and results to the future users.
10. Communicate the implementation of project progress with the steering committee.
11. Structure meetings and develop agenda.
12. Identify interfaces, components, modules for team tasks.
13. Make or coordinate key decisions for budge, time, and human resources.
Key team members will be specially selected from those who are knowledgeable about the current workflow and processes of ED at the health care center. As the implementation process unfolds, the implementation team structure may need to be modified. The key team members are responsible for interfacing and converting their areas of responsibility to the CEDS. They will need to lead, analyze, motivate, organize and facilitate the functions of the ED as necessary. Each key team member will serve as a liaison and member of the Project Team. He or she will seek out expertise as identified by the team to work towards the goal of the implementing their portion of the CEDS.

Furthermore, a key team member should be familiar with the implementation and provide user instructions for future training purpose. Other key team members should have comprehensive practical ED experiences; the person can streamline the workflow in the CEDS and direct the testing of the system. Another key team member should have a strong technical background so he or she can figure out system bugs and provide the best solutions to fix the problems. These members will also be the departmental representatives at training classes and will need to understand how to use the application fully, as well as code files, parameters, and data files for their specific areas.

Team member number one’s responsibility is to:
1. Analyze and design any data conversion plans.
2. Outline the display of disease symptoms and signs within their application areas.
3. Determine components requested and useful interfaces for current and future needs.
4. Design the GUI in an intuitive way.
Team member number two’s responsibility is to:
1. Document integration events critical to implementation of processes.
2. Build a testing procedure manual for each component of the CEDS.
3. Support cross module information within and between groups in the ED.
4. Recommend interdepartmental reporting needs.
5. Comment the test results and likely solutions.
Team member number three’s responsibility is to:
1. Monitor the deployment of the application integrations.
2. Provide scheduled status reports to application the team leader.
3. Propose recommendations to the project team on any changes needed to the implementation policy and procedure.
4. Produce their technical supports to the users on time.

9. The top 3 risks to the project and risk mitigation tactics

The first risk is the potentially difficult challenge of smoothly integrating the existing functions, systems and database into the CEDS during implementation [10]. A thorough study, close examination, and detail-oriented analysis of the current ED environment and future needs, based on learning from the past experiences of other vendors’ implementations, will be imperative steps before the CEDS is implemented. An assessment of this investigation should be fully documented to record the current hardware infrastructure and software configuration. Before the implementation, every prerequisite transformation, adaption, and middleware for integrating the CEDS should be meticulously analyzed and carefully designed. To facilitate the expandability of the CESD, SOA design should be used in this implementation. The existing ED facility should be adapted to this architecture and its effects should be included in this analysis and design as well. While the strategies may look like a waste of time, at the beginning, the plans will eventually optimize many concealed integration issues while implementing the CEDS, and maximize the benefits of effectiveness and costs of the implementation in a feasible format.

The second risk involves the appropriate summarization of applicable medical literature from the proper resources. This information will then need to be combined with the medical records of patients in the ED and their test results in a concise and specific manner. If that can be done it will effectively improve the ED clinicians’ access to a significant body of relevant information. At the current phase of implementation, the information organization and update may be managed through manually inputting to the CEDS by authorized ED staff. However, inputting will ultimately be done automatically to better absorb ontology concepts, semantic webs and networks, even artificial intelligence; to collect medical resources in the future implementation.

The third risk involves practical difficulties that can still be envisioned after the system has been introduced. These could impede an appropriate diagnosis if there are lots of different disease possibilities, despite the fact that statistical analysis and probability theory had been programmed into the various computerized decision systems [10-11]. Due to the complexity of medical data structure and a lack of maturity and uniformity in the current translational science; clinical reasoning and therapeutic recommendations still could be reversed by the accredited ED staff with reasonable explanations, which will be recorded in the CEDS, if necessary.

Finally, there will always be a degree of user resistance to new software implementation in the emergency workplace since no application will ever be perfect or meet each individual’s needs [12]. Good implementation satisfies user acceptance of the software. On the other hand, this acceptance can be affected by many complex issues, such as a corporate culture, the complicity of operations, and displayed content and individual human factors, that are difficult to understand. Several approaches can be taken to minimize this uncertainty.

User involvement should be proactively committed to increase both program quality as well as user friendly design, in the software implementation life cycle. For example, user suggestions for functions and features in the CEDS can be transferred to requirement specifications. This would then let the development team investigate the possible program solutions. The development team could then use these requirements to customize programs to fit their workflow in the CEDS.

Communications and Technical skills, needed to design and operate the CEDS, should be clearly identified as early as possible, as well as existing programs and systems. Current worker should be recruited from involved areas to avoid customizing in a vacuum. Working with a small, core group of staff members and enlisting their help in validating business process, system design, communication their coworkers, is priceless for success and acceptance of the implementation.

The Project’s scope defines the activities and services that the CEDS will perform; it also indicates project boundaries, features, functions, affected users, timeline, budget and other resources. A clear identification of the Project’s scope will facilitate understanding for all team members about their roles and responsibilities. The Project’s scope should be clearly defined, electronically documented, and highly visible to whole team members.

A realistic and reasonable timeline should be approved by the stakeholders and the project team and it should be highly visible to them. Project resource should be precisely calculated to circumvent any possible budget overruns.

Instructor–led classes, as well as on-site or online training classes should be available to users.

Efficient user support should be used to provide positive results or solutions as well as to collect feedback for continual improvement.

Combining patients’ medical records and test results in a concise and specific manner will effectively improve the ED clinicians’ access to all relevant information [13].

10.) Education and training support a plan to incorporate into the project

The purpose of the program is to integrate current knowledge and skills of trainees to become proficient in the use of the CEDS within emergency care settings. The training program provides the trainees with needed knowledge, skills, and practical competence when using the system. The training materials and content are carefully designed to accurately reflect the ED workflow processes that make up the emergency room workforce.
A combination of training programs will be adopted to ensure proper user familiarity with the application. These training programs should be tailored to maximize trainees’ memory retention, target user learning styles, and proactively engage trainees in learning processes. Various combined disciplines will be incorporated into the following sessions:

An instructor-led session which is specific to each user group using the CEDS and is conducted in a classroom setting where interruption and distractions during training can be avoided.
A computer-based training session, with an interactive web site, may also allow trainees to share their relevant personal experiences, gain strength from others, and bring all of their experience and medical knowledge together.
An on-the-job training session, led by mentors, which will include trainees participating in real-time operations with the CEDS. This method will emphasize how to effectively use the CEDS to cope with critical issues in the ED.
Several factors that must be considered when arranging such training include: the number of training hours, replacement staff and their job coverage, classroom capacities, monetary payment for the training, and hardware and software preparation to target different learning styles and the promotion of knowledge acquisition.
The maximum ratio of trainers and trainees should be no more than one to ten. The necessary ED personnel training and total hours needed are estimated as follows:
1. Physicians and Residents (40 hours)
2. Nurse practitioners (40 hours)
3. Physician assistants (20 hours)
4. Registered nurses (30 hours)
5. Licensed practical nurses (30 hours)
6. Dieticians and dietary personnel (30 hours)
7. Patient care and medical assistants (20 hours)
8. Support Personnel (10 hours)
9. Admission clerks (20 hours)
10. Social service staff (20 hours)
11. Case mangers (40 hours).

All trainees will be required to undergo proficiency assessments to ensure that they have acquired the necessary skills and knowledge relevant to the positions they hold in the ED. Then the training needs that are necessary for each specific team member can be determined. The type of certification for training for each position will be determined by their professional ED functions and their job class responsibilities as well as their predetermined competencies. Participants’ feedback will be assessed to analyze their learning curves and to direct the development of useful curriculum for the future.

A quality structured training program for the ED staff will make a big contribution to the final success of the CEDS implementation. Gartner Research found that each hour of effective training is worth five hours to an organization. Thus the time as well as the financial and manpower costs of training is a good investment in the success of the CEDS. Additionally, well-planned training programs can provide useful information on improving both learning and instruction to increase job satisfaction and productivity. Industry standard financial investment indicators will be employed to determine the return on investment.

11.) The main testing strategies intended for use

In order to meet the specifications and requirements for proper implementation, the testing strategies will include the development of a test plan, the deployment of test sequences, the creation of test scripts and the collection of pertinent data for each functional testing,. Identification of data exchanges with current existing systems for integration testing will also be included.

An effective test plan cannot be completely developed until the current ED workflow has been thoroughly analyzed and the implemented system has been smoothly integrated into the ED working processes. The format and content of prescription order entry, lab results, evidence-based recommendations, clinical documentations, and managerial reports must be verified in the test environment. The test platform and agreement should be approved by all responsible executives at all levels.

The testing timeframe will be covered in three months. The involvement and careful selection of end users is necessary to ensure that the testing is valid and accurate. The end users must have experience in performing emergency room services. They will test the implemented system under the same kind of stress and rigidity present in a typical ED work setting. Any identified software problem should be documented and resubmitted to the development team for corrections. Afterwards, the same issue must be retested in an identical setting. If the issue is a minor problem, it should be fixed to meet the timeline requested. If the issue cannot be resolved in a short period of time, the issue should be forwarded to the implementation committee or to the steering committee for further discussion and negotiation.

Since testing in live environments involves more complicated procedures and strategies as well as occasional unpredictable factors, live testing must be conducted when system use is lowest and support is most available to reduce any risk of interruption of the usual ED services. The implementation team, the system administration group, the integration group, the quality assurance group, and a number of senior end users must fully participate in this live testing stage.

Three backup plans must be prepared to prevent any accidents in this testing. All functions and features should be thoroughly approved for testing. Even though live testing can be very successful, all testing should be closely monitored. Likewise, all the implementation rules should be strictly enforced for at least two weeks to detect any software defects. Every user feedback should be collected for future modifications and upgrades.

12.) Evaluation criteria and methods you will use to determine the success of the project

No business can survive without gaining a sufficient financial return. It is imperative to conduct a cost/benefit analysis to determine the ROI for the CEDS. However, to identify an ROI analysis in an emergency setting may be affected by challenging situations. The two issues which may affect the ROI are those who come to the ED without emergency care needs and those who rush into the ED without any medical insurance.

Even though using the CEDS will take time for the provider to enter the orders, the CEDS can quickly provide assessment of the condition of the patients upon arrival in the ED. Unlike searching for paper charts, the CEDS facilitates a fast retrieval of an organized patient’s history and the ability to enter orders from anywhere in the organization. Since there is a reduction in time spent for emergency care delivery, the CEDS should also be considered for the analysis of the ROI.
Other than the above factors, several criteria and methods can be used to determine the benefits of the project, which are discussed in the following paragraphs.

The most the important criterion for an emergency care application is always through validating the response time while using the system. This validation can be assessed by the number of clicks or buttons required for specific functionality of the CEDS.

How to seamlessly incorporate the CEDS with the current clinical information system without a significant time delay will also affect the ROI analysis. Many other criteria that can be quantified to determine the success of the CEDS include improvement of the ED quality of care, reductions of medication errors, speedy clinical documentation, minimization of duplicate diagnostic tests, maximization of treatment efficacy, and enhancement of patient and provider satisfaction.

The attitude of the ED staff towards using the CEDS is an important human factor which can explicitly influence the ROI analysis. A thorough conduction of anonymous surveys may help to understand the ED staff’s acceptance or resistance of the CEDS. A systematic approach such as a Total Quality Management or Continuous Quality Improvement mode will be used to weigh and compare answers to reveal the true mentality of the ED staff when adapting the CEDS. Additionally, evaluating user satisfaction will simultaneously depend on what type of job that he or she works on and how fast one can facilitate the CEDS, as well as the user’s learning ability, knowledge, skills, and experiences.

Adequate follow-up evaluation shall be adopted to ensure that expected benefits have been achieved and the ED’s work has been transformed in a more effective manner. Some literature suggests that at least six months should be given before documentation mastery and technology success can be measure and determined [14]. Likewise, patient satisfaction may take several months, even years, to emerge for the ROI analysis.

To understand the effectiveness of the CEDS, the clinical pathways of the ED will provide a better understanding if the pathways are carefully analyzed and accurately documented in detail. Closely monitoring the ED processes will provide better observation to comprehend the complexity of interactions between the ED staff and the CEDS. Another purpose of clinical pathways analysis is to understand the entire emergency care processes associated with the use of the CEDS and to create a management framework for ongoing quality improvement.

Similar to the PRECEDE-PROCEED model which functions in a continuous cycle, the evaluation of an ROI produces a foundation for the accessing of financial benefits before and after the implementation can now be used as a software development life cycle. The outcomes of the evaluation of the implementation can be used to improve the CEDS in future designs. Patient information gathered in PRECEDE can guide the development of program goals, objectives, and policies in the implementation phase of PROCEED in future designs.

13.) A high-level discussion of the technical equipment required

Servers

Business logic is implemented as Enterprise Java Beans (EJB) components using a Java 2 platform, enterprise edition (J2EE). Web logic will be used as application server.
Common Object Request Broker (CORBA) server will be used for distributed objected
applications.
Internet Inter-Inter-ORB Protocol will define the transport service for all business logic communication.
A Web server is used to serve up the web-based application and to run the Servlets/JavaServer pages that provide dynamic interaction in the Web client.
Oracle Database 11g server will be used to store all information of emergency care.
Hypertext Transfer Protocol over Secure Socket Layer (HTTPS) will be used to indicate a secure communication such as clinical documentation and other clinical information systems.
Windows NT servers and Sun Solaris Server

User devices

Clinical workstations
Notebooks
Personal digital assistants
Tablet PC
Biomedical system check
Installation on work unit
Function and network connectivity check

software licenses: The software licenses required for the deployment falls into three categories.

Application software for the mainframe, servers, personal computers, and Personal digital assistant.
Interface engineering software
Database software
Operation system software or hardware affected by implementation
Compatibility with network software A commercial vendor typically provides release notes with each software version, explaining changes in function.

Maintenance costs
Since the main purpose of using the CEDS is for emergency care, the system will be operated and monitored 24/7. A common pitfall of system maintenance is an inadequate estimate how much effort is required to actually maintain a system, resulting in the underestimation of necessary time and personnel needed. The maintenance of the system should include repairing software faults (bugs), adapting the software to a different configuration and operating environment, and adding to, or modifying the system’s functionality. Distribution of maintenance efforts makes the system more adaptive in order to prevent mistakes or costly errors.

In general, the maintenance costs of the system can be categorized into four types: fixed cost, variable cost, direct cost, and indirect cost. Operations of the system may involve many complicated procedures for emergency care and many costs that cannot be easily and accurately traced to maintain the system, so it will be very difficult to estimate overall maintenance costs. Usually, the maintenance fees will cost around 50% of total implementation costs.

Like the tip of the iceberg, maintenance of the system encompasses many back-end operations, such as the system configuration, networking connection and security, content of decision support update, integration of a patient’s data, database upgrade and backup, etc. Most of IT maintenance activities are hidden from the users, to provide the ED staff with an accountable and reliable CEDS is a long term investment and does not immediately get charged to the front-end operations. Looking at system maintenance in the long-term period also provides insights on software evaluation for a better understanding and knowledge for the next implementation. Based on all the above factors, the overall estimate of maintenance costs will be around one million dollars.

14.) Create a table of estimated human resources for the project

Position	Number of Persons	Average Annul Salary	Total Group Budget
Technical team	10	60k	1,000k
Network administrator	5	80k	1,000k
database administrators	5	100k	1,000k
integration/interface Engineers	5	70K	700k
Clinical/system analysts	6	100K	900k
Education team	4	50K	500k
Testing team	5	60K	500k
Business/clinical personnel	5	80k	500k
Help desk	10	50k	600k
Clinical liaison/super users	5	90k	500k
Evaluation person or team	6	70k	500k
Total employees	66	810K	7,700k

15. The main elements of the go-live plan

The implementation strategy of the go-live plan will use a phased implementation. This implementation will be approached by five different components of the system in an area which are incrementally deployed throughout the entire organizational systems, while subsequent components will be added until the entire components of the CEDS are installed in the live environment of the ED. On average each module will take one month to install. The entire go-live plan will be finished in the span of six months. Due to the ongoing assessment by the project team, extension of the timeline may be necessary, as unexpected problems will arise.

The go-live team will be assembled which consists of the project manager, two system analysts, three emergency physicians, three emergency nurses, three medical technicians, two case managers, two ED social workers, two ED administrative managers, two pharmacists, one pathologist, two network administrators, three medical informaticians, two database administers, three interface and integration engineers. Since the ED environment could be a life or death situation, the vendor shall send four technical supporters to the ED on-site.

According to their expertise, the go-live team members will be assigned to their responsible areas as the go-live plan takes place. The members will reassess system functionality after each module is operated. All necessary hardware, software, interface, network, and database shall be installed and tested before each phase of deployment. Before go-live starts, technical team members will need to set up configuration to fit the live environment.

The system analysts will evaluate what data will need to be converted and prepared for each phase of deployment. The test patient data will be closely monitored through by flowing all the way through each system. During the go-live period, team members, such as emergency nurses and physicians, shall carefully monitor the accuracy of the data displayed on their screens.
Because the ancillary system will cross departmental boundaries, each department shall be communicable during each relevant phase of the go-live plan. Departmental related functions and interfaces, which may run with the CEDS and associated ancillary systems, shall be closely examined on each respective side, such as in the laboratory department, pharmacy department, administration office, and radiology department.

Well constructed fallback plans will be built in to cope with unexpected failures. Contingent recovery plans will flip back to pre-installation status if any unwanted events occur. A buy-in among all relevant divisions and departments shall be approved to lay out the management of a triage and reporting mechanism after go-live.

However, the characteristics of the ED environment are unique. If a patient arrives by ambulance, the ambulance team will inform the ED staff by wireless utility before arrival, and then the patient’s record will be tracked through accessing the CEDS. Emergency physicians and nurses will be notified of who needs immediate intervention and what latest information is available by the CEDS. After patients are sent to the ED unit, the nursing stations will automatically monitor all patients’ vital signs through the CEDS. All diagnostic tests can be ordered and accessed through the CEDS. All medications can be ordered and delivered from the pharmacy by the CEDS.

In case of network traffic jam, the ED staff still can use hotline phones for emergency physicians. All conversation will be recoded by the CEDS for future reviews. Front desk supporters will provide general clinical and technical questions by phone. If they are unable to answer specific questions, contact persons of each shift for different types of issues will be called in to provide immediate assistance.

16.A project timeline for major milestones

The Expanded Systems Life Cycle(ESLC) model provides the framework for the series of implementation. The model represents a logical process for planning, analyzing, designing, implementing, and maintaining in the system life cycle for evaluating all types and sizes of healthcare applications.

The first step of the system life cycle is to conduct project planning. All relevant resources for this implementation will be assessed to determine what costs and duration for each activity can be allocated to each resource. Performing this evaluation will take six months.

In order to optimize the appropriate timeline between resource usage and project duration to comply with the ultimate project objectives and goals, project managers and team members need to thoroughly investigate availabilities of resources, including knowledge of technological skills, experiences of system integration, understanding of interface engines, design of user graphic interfaces, networking security and authentications, utilization of databases, system maintenance, education, and training. The project scope and approach will be accurately defined to allocate human resources and time management for successful implementation. The analysis step focuses on in-depth assessment of the identified problem to determine requirements for the optimal solution. The project analysis will involve technology, finance, database, network, emergency care environment, support, education, and so on. The possible risk and contingency plan should be considered to deliver useful solutions in a rational and justifiable manner when facing problems and barriers with the project.

Project analysis can also help the development team frame the mission statement of the system implementation, as well as realize and resolve the challenges of the development. The project analysis also can promote and construct strategy to understand current ED configurations and situations and to prepare contingency and risk plans during the implementation. Another purpose of project analysis is to create early, well-defined tasks which force a collaborative relation among the vendor, the ED staff, and informatics department to implement the CEDS together. The overall analysis will cover the span of eight months.

The purpose of the project design is to give the implementation team members a clear idea of what each component and module functions is and to feature the ED workflow. Project design will develop a clear, accurate and comprehensive project design document requiring gathering, synthesizing, and analyzing ED patient data and information with sufficient objectivity and detail to support the implementation decision that makes optimal use of resources to achieve successful implementation. The project design of the CEDS may take nine months to achieve the above goals.

The implementation process will define roles and responsibilities for the project teams. Throughout the implementation process, the development team may identify errors and create solutions to make the new system available to the ED staff and to position ongoing support and maintenance of the system within the healthcare center. In the post-implementation period, the development team shall provide all documentations and steps necessary to educate the users about the use of the CEDS, placing the newly developed system into production, confirming that all data required at the start of operations is available and accurate for the ED staff. As mentioned on the above section, the implementation process will take approximately six months.

Data derived from maintenance evaluation activities can be input for the design of a new solution to the same information management problem [15]. Therefore, using the PRECEDE-PROCEED model, all implementation processes will be documented, and the CEDS will be evaluated for the ROI analysis. Consequently, any suggestions and recommendations generated will direct the future training, developments, and managements. As long as the CEDS is used in the ED, the maintenance activities shall always be visible to the user support.

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