Survey of information technology in Intensive Care Units in Ontario, Canada

The intensive care unit (ICU) is a data-rich environment, where information technology may enhance patient care by improving access to clinical data, reducing errors, tracking compliance with quality standards, and providing decision support [1–3]. The presence of more sophisticated information systems in the ICU has been associated with improved care [4]. Despite these potential benefits, utilization of information technology in ICUs is variable, with approximately 10–15% of U.S. ICUs in 2003 having fully implemented clinical information systems [5]. In contrast, electronic health records in other practice settings are becoming well established. For example, almost all general practices in the United Kingdom are computerized [6], as are the majority in Australia [7].

In the province of Ontario, Canada, the Ministry of Health and Long Term Care provides medical services for the province's population of 11 million through 134 acute care not-for-profit hospital corporations and an annual budget over $30 billion Canadian [8]. This single payer system offers the opportunity for standardization of information systems, but little is currently known about the implementation and availability of information technology in the province. The ICU plays a central role in the flow of patients through the health system, as the destination of transfer of the sickest patients from the emergency room and operating room. Our objective in this study was to survey ICUs across the province to identify the availability of various types of information technology and the systems and vendors utilized. We believe that this information will be essential to integrate clinical information systems into a province-wide electronic record and to identify areas for quality improvement and future research.

We obtained responses from 50 hospitals representing 68.5% of hospitals with level 3 ICUs in the province. Of these, 21 (42%) were university-affilated and 31 (62%) used a intensivist-led management model. Twelve hospitals (24%) were in small towns (<50,000 population) and 14 (28%) in large cities (>500,000). The number of ICU beds varied, with 15 hospitals (30%) having less than 10 ICU beds, 22 hospitals (44%) having 10 to 19 beds and 13 sites (26%) with 20 or more ICU beds. The majority (64%) were medical-surgical ICUs, but various subspecialty ICUs were also represented, including trauma, cardiovascular and burns.

The hospitals used a large variety of software vendors. Fifteen clinical information system vendors were reported, the most frequent being Meditech (Westwood, MA), GE Healthcare (Bucks, U.K.) and Cerner (Kansas City, MO). Similarly, there was no conformity in the use of PACS vendors with 8 reported, the most frequent being Agfa Impax (Mortse, Belgium) and GE Healthcare.

Computer terminal availability in the ICU varied from as few as one computer (in small, 4 bed units) to at least one computer per bed (24% of units). Computer availability was reported as being insufficient in 21 sites (46%) (Fig 1). The perception that there are sufficient computers per bed is most differentiated by a cutpoint of 0.44 computers per bed (95% percentile confidence interval: 0.37, 1.13). Specifically, for those physicians who reported a computer to bed ratio less than 0.44, the majority, 10/12 (83%), indicated dissatisfaction. For those respondents who reported a computer to bed ratio greater or equal to 0.44, the majority, 23/37 (62%), indicated satisfaction. Multiple logins were often required to access clinical information, with the majority of sites (68%) needing 2 or more passwords. Wireless networks were installed in 23 units (46%) and mobile electronic tools were used in 28 sites (56%) (Table 5). The policy regarding use of cellular telephones varied, with 28 sites (56%) prohibiting their use throughout the hospital and 24% allowing the use of cellular telephones in some hospital areas but prohibiting use in the ICU. A policy specifying a 1 meter distance from medical devices applied to 14% of sites and 10% reported unclear or changing policies.

Tool	n	%
PDA*	13	26
Tablets	2	4
Mobile computer carts	19	38
None	20	40
Unknown	2	4

*PDA, personal digital assistant (includes Palm, Pocket PC and BlackBerry devices)

This self-administered internet-based survey of Ontario ICUs demonstrated a high prevalence of implementation of information technology, with 92% of sites having electronic access to laboratory results and medical imaging reports and 76% using PACS systems. The use of electronic decision support systems was less prevalent and very few sites had fully capable clinical information systems or electronic medication administration systems. We found a wide variation in the use of vendors for clinical information and PACS systems, which may significantly impair information exchange and interoperability. The availability of hardware was variable, with 46% of the sites perceiving the number of computers available to be insufficient. CART analysis, using all sites including those with and without computerized provider order entry, demonstrated a cutoff between physicians satisfied with the number of computers available and those dissatisfied at a value of approximately 0.4 to 1.1 computers per bed. Approximately half the sites surveyed utilized wireless networks with mobile computing systems.

Our survey is the first inventory of information technology capacity in ICUs in a Canadian jurisdiction and provides data on a variety of information technology domains. Our response rate was typical for healthcare surveys [11]. Nonetheless, there are several limitations to this study. Common to all self-administered surveys, responses indicate self-reported rather than directly observed implementation of information technology. This methodology aimed to identify the technology available to practising physicians, but may have failed to identify existing technology that was not in common use. The information was obtained from physician-users of the systems, rather than from information technology specialists or other users, such as nurses. Nurses knowledge of available technology and requirements may be very different to physicians. We did not survey individual intensive care physicians or nurses to understand their attitudes, knowledge and behaviour regarding this information technology.

While rapid advances in computing technology are evident in commerce and industry, healthcare has lagged behind [1, 2]. Information technology has the potential to improve patient safety by optimizing access to information, specifically in operations with a high information and transaction load such as drug interactions and evaluation of monitoring data [1]. The potential benefits include reduced medication errors [12], improved practitioner performance [13], and enhanced diagnostic accuracy [14]. The degree of sophistication of computing technology in the ICU has been associated with improved outcome of quality improvement initiatives to reduce catheter related bloodstream infections [4]. Although the literature demonstrating a benefit of computerized clinical decision support is growing [13, 14], several studies have documented the many impediments still to be overcome [15–17]. An expectation and benefit of an ICU clinical information system is that the time that a nurse spends with documentation should be reduced, allocating more time for patient care [18, 19]. However, others have demonstrated an increased documentation time following the implementation of an ICU clinical information system [20]. Furthermore, new software systems can actually facilitate rather than reduce some types of error [21]. Appropriate assessment of any new technology prior to implementation remains essential [22].

An often quoted barrier to implementation of clinical information systems is the required change in culture to healthcare workers [23, 24]. While this may be true in other clinical areas, our study demonstrates that computing systems are currently an integral component of the ICU. Having overcome these initial barriers, the next step is to introduce the more sophisticated and potentially more beneficial components of the clinical information system. The ICU is a data-rich environment at risk for data overload, and there may be significant benefit to safety and quality of care from decision support applications, medication administration systems and computerized order entry [24]. Our data confirm the lack of standardization of software across the province, with 15 vendors of clinical information systems being used. As new systems are implemented or updated, it is essential that standardization be addressed, to allow data transfer between systems and to reduce the potential for errors related to inadequate familiarity with the software [21].

Providing efficient, safe, individualized care in the data-rich environment of the ICU can only be achieved with the use of information technology. We have demonstrated a significant level of early implementation in Ontario ICUs but further investment is needed. The variation in systems in use is concerning, and standardization and interoperability need to be addressed.

• Almost all ICUs in the province of Ontario, Canada, have electronic access to some component of patient information, most frequently laboratory data and imaging.

• In contrast, use of decision support systems, electronic medication administration systems and full clinical information systems is very uncommon.

• Multiple different IT vendors are used, which may impair information exchange and interoperability.