A. Case managers and the care management team have numerous tools at their disposal to assist in the efficient performance of their work. These tools include guidelines, practice standards, pathways, critical pathways, and “tickler” or reminder systems. Case managers traditionally have relied on guidelines to simplify and standardize their interactions with the patient. Since many organizations have migrated their traditional paper-based systems to computer-based systems, case managers must be prepared to fully appreciate and utilize the functionality of these increasingly sophisticated systems.

B. This chapter focuses on automated case management information systems (CMISs) that are designed to streamline the case manager’s workflow and eliminate much of the “busy work” that comes with managing patients, such as duplicate documentation, photocopying files to share with associates, placing “yellow stickies” everywhere to remember interventions, and filling out numerous forms to authorize services. The power of a CMIS comes from its ability to efficiently facilitate data collection, data storage, data sharing, data retrieval, information generation, and decision-making functions. These systems are purposefully designed to bring people, data, information, and procedures together for the purpose of managing information to support case management at the individual, team, and organizational levels.

C. CMISs are rapidly becoming key elements of case management, disease management (DM), and medication reconciliation. These systems encompass computer networks, the Internet, and telecommunication networks including telephonics. The Internet provides potent resources including Internet-based communication to the patient and providers, as well as tools to explore this vast new frontier of information. Currently, most of these tools are simply used for data collection or information gathering. With the exception of computer-based demand management, the majority of these tools do not support decision making based on the information gathered. Case managers independently determine which actions to take. New CMISs are incorporating more decision-making tools and artificial intelligence (AI).

D. The use of CMISs to enhance the value chain is extremely important since an organization’s primary goal when using any tool is to produce results that are valued by its customers. Customers include not only the patients but also the users of the tools, the providers of services, and the organization’s management. The concept of a “value chain,” as defined by Koulopoulos and Champy (2005) is “the coordinated series of activities leading to the creation and delivery of any product or service that is deeply embedded in the collective wisdom of today’s business leaders” (p. 24). Recklies (2001) describes the importance of value chain analysis in linking an organization’s activities with its competitive advantage. This evaluation of each activity and determining the value added creates the value chain. The Society of Management Accountants of Canada (1999) defined value chain as, “how customer value accumulates along a chain of activities that lead to an end product or service” (p. 2). The rapid change over the last 10 to 15 years in the business market due to the evolution of ecommerce and a global marketplace have impacted the way value chains are perceived and developed. Current value chains reflect more complexity than did their recent predecessors. In the health care industry, the entire service path from organization to the end user, or patient, constitutes a value chain. Health care value can be calculated by factoring the overall financial, time, resource, and problem costs into improved clinical, economic, service, and humanistic outcomes.

E. In today’s era of cost containment, case management organizations of all sizes and structures cannot afford not to automate, and today’s case managers must be computer literate (Daus, 1997). The terms medical and nursing informatics should be expanded to include all levels of health care and be termed health care informatics. Health care informatics is becoming pervasive in all areas of the health care delivery system. Case managers must become knowledgeable in all aspects of health care informatics to maximize the benefits of these systems. They must be open to whatever technology is available to them, be consistent and persistent in using them to their maximum potential, and generate ideas to improve and enhance these systems.

F. The return-on-investment (ROI) issue continues to loom and will not go away in the difficult economic times health care is experiencing. Case managers are encountering heavier caseloads, both in the quantity and the complexity of their cases, and they are increasingly required to justify their own value. Tools are needed to be able to provide proof of effectiveness. CMISs are increasing their capability to gather information to provide indicators of the value of case management in beneficial outcomes for their patients and in the health care industry.

G. Case managers who use computer-based CMISs estimate that they can complete a comprehensive plan in one third to one half of the time previously required (Smith, 1998). As case managers become more adept at the use and integration of CMISs in their work they continue to demand more functionality from the systems they use. This pushing of the envelope will cause CMISs to continue to evolve to enhance the valuable work of the case manager.

H. Usability is a key factor in the success of any CMIS. The users who work with the systems are the most important resource in helping developers understand current needs as well as new and innovative approaches to enhance the work of the case manager and to meet the ultimate goal—successful patient outcomes. Career opportunities are available for case managers and other health care providers to work as consultants to developers of information systems (IS) and organizations who wish to use this technology.

A. Algorithms—Flow diagrams that consist of branching logic pathways that permit the application of defined criteria to the task of identifying a terminus. The terminus can be an identification, a classification, or an activity (Horan, 1994). Algorithms, both formally and informally defined, have been used in health care for many years—for example, the algorithm for approaching an unconscious heart attack victim. Algorithms have been criticized as being too rigid. Opponents say that patients are too variable to fit into any one box. Another criticism is that algorithms impose too many restrictions, preventing the health care professional from using his or her own expertise. However, any reasonable system that incorporates algorithms provides the ability to override decisions made by the algorithm or to customize any embedded algorithm.

B. Database—A collection of data or records that is stored in a systematic fashion that allows you to search through the data for specific aims. You can run a query (ask or request information) from the database. For example, you could ask: How many people have asthma? How many people have been readmitted following an appendectomy?

C. Data mart—A subset of a data warehouse that supports a specific business process and is limited in its scope or capacity. For example, it could be tailored for the decision support applications needed by specific end user(s).

D. Data mining—According to Wikipedia, data mining is also known as knowledge-discovery in databases (KDD). This is the practice of automatically searching for meaningful patterns and relationships among data. For example, data mining could help to identify patients at risk based on their lifestyle/behaviors and medical history.

E. Data model—A chart, map, or diagram that illustrates the data entities of a database and their relationships.

F. Data warehouse—A collection of enterprisewide business information garnered from many sources in the organization. This information covers all aspects of the organization’s products or services, processes, and customers. It is the integration of many resources (databases and other informational sources) into one, single repository or warehouse. This singular access point is capable of being queried, processed, or analyzed.

G. Decision support system—A decision support system (DSS) enriches a case manager’s professional judgment by quickly verifying or invalidating business decisions. The user has at his or her fingertips all of the pertinent elements needed for evaluation.

H. Digital divide—There is a gap between those who know how to use computers and the IS available to them to obtain vital, timely information they need, versus those who do not have access or do not know how to use the systems well enough to reap these same benefits. According to Jessup and Valacich (2006), “In the new economy there is a digital divide, where those with access to information technology have great advantages over those without access to information technology” (p. 8).

I. Domain—This term has different meanings; it could mean a field of study, the acceptable values for data attributes, or the knowledge area addressed by an expert system. As the acceptable value, according to Stair and Reynolds (2006), “The domain for an attribute such as gender would be limited to male or female” (p. 202).

J. Entity—A thing about which we collect and maintain data such as a person, place, item, or event. For example, a CMIS could include entities named patient, medications, primary care physician, etc.

K. Explicit knowledge—Information that can be documented, archived, and standardized such as manuals, documents, procedures, and stories.

L. Extended care pathway (ECP)—A set of policies and procedures that providers use to address a specific disabling chronic condition over time and across various service settings. It is a standardized approach to the multidisciplinary care of an individual with a particular diagnosis. An ECP is designed to increase the continuity of care between settings, and thereby improve both the quality and cost effectiveness of care. ECPs indicate what key events are necessary for patients to meet expected outcomes. They are tools to be used for managing, monitoring, and evaluating care (National Health Care Consortium [NHCC], 1995).

M. Health care informatics—The synthesis of discipline-specific science, information management science, cognitive science, and computer science to enhance the “input, retrieval, manipulation, and/or distribution” of health care data with the ultimate goal of creating and disseminating knowledge to improve patient care and advance the discipline (McGonigle and Eggers, 1991, p. 194).

N. Heuristics—Rules, standards, or guidelines, such as “rules of thumb.”

O. Protocol—A tool for deciding which care to provide under which circumstances. To assist in decision making, it may contain a decision tree or flow chart. It frequently covers a smaller segment of care rather than the whole illness. It can describe the particular order of events, but in most cases it does not suggest a timeline.

P. Rule-based systems—Systems that generate patient-specific recommendations based on all of the information gathered up to that point.

Q. Tacit knowledge—Knowledge that resides within an individual’s mind based on his or her education and experience. It cannot be standardized; rather, it represents implicit processes in the worker’s mind that can only be transferred through training.

R. Telemedicine—Accessing health care services using any medium besides hands-on, direct patient contact. Although it can include simple telephonic contact like telephonic triage, the more accepted definition includes the use of computers, video equipment, and remote medical monitoring (Wrinn, 1998b), for example, electrocardiogram (EKG) hookups, blood pressure monitoring, quality-of-life assessments, and self-risk assessments. Case managers should be aware of the uses, benefits, and limitations of telemedicine so that they can use the technology in the appropriate way. In addition, case managers can perform long-term monitoring of patients using the same telemedicine tools. This is addressed in detail in Chapter 16.

A. An IS is a combination of hardware, software, telecommunications networks, and the Internet. These interconnected elements “collect (input), manipulate (process), store, and disseminate (output) data and information and provide a feedback mechanism to meet an objective” (Stair and Reynolds, 2006, p. 15). The IS is a purposefully designed system that brings people, data, information, and procedures together for the purpose of managing information to support operations, management, and decision functions important to an individual, team, or organization.

B. Graves and Corcoran (1989) pioneered the focus on nursing data, information, and knowledge. This innovative thinking changed the way documentation and technology were viewed and enhanced the exchange of nursing-related information and knowledge. It is from their classic writings that the data, information, and knowledge triad came to the forefront. Understanding this triad is important because an IS relies on correct input or clean data in order to provide appropriate information. Therefore, at the core of the system are the data, or raw facts, that it processes. Data that has been given meaning is considered information. Information is processed data that has value beyond the facts or data themselves. Information is a critical resource for organizations, necessary for their day-to-day operation and management. The IS is designed to perform specific functions and must be able to meet the data and information processing needs of individuals, teams, and the organization.

C. According to McGonigle and Goshow (2003), the value of the information generated is directly related to how it helps decision makers achieve their goals currently and prospectively. It is the interplay between the IS’s generated information and the knowledge and wisdom of the users or decision makers that makes the process potent. “Knowledge and wisdom are based in the collective organization, teams, and individuals. Knowledge is related information or information that has been processed through one’s knowledge base of experience, education, and intelligence” (McGonigle and Goshow, Slide 3). Woods (1999) states that “Knowledge adds color to information” (Slide 3). Wisdom “is the ability to insightfully use knowledge or experience or understanding to make correct decisions or judgments. Wisdom is an intangible attribute gained through actively experiencing life” (McGonigle and Goshow, Slide 7).

D. According to Stair and Reynolds (2006), “Information systems must be applied thoughtfully and carefully so that society, business, and industry can reap their enormous benefits” (p. 2). The ethical issues inherit with such data collection and the threats to security and privacy must be addressed. These threats affect businesses; however with the sensitive information dealt with in health care, it is paramount that the systems in place are secure. Everyone in health care has a responsibility to make sure that they do not breach the security of these systems, such as giving out their passwords, attempting to access areas that are not available to them, and entering incorrect data.

E. The IS performs an essential and continually intensifying role in society, business, and industry. IS are everywhere in our lives—at the bank, grocery store, etc. Our interaction with these systems becomes routine and seamless after repetitive use. We even have ideas about ways in which these systems can be improved or enhanced to better meet our needs. Health care is just scratching the surface and beginning to reap the benefits of the superior information processing and decision support tools available in our ever-evolving information age.

F. The IS should provide the information users need, when and where it is needed.

A. The goals of a CMIS are derived from the general goals of case management. Case management strives to create a collaborative partnership between providers of services and the service recipients to ensure that services are “appropriate, effective, cost efficient, and focused on patient needs” (Rossi, 2003, p. 17). Thus, the system used to manage case information must allow for collaboration, identification of appropriate services, effectiveness, efficiency, and focus.

B. Case managers need appropriate and timely data about the service recipient. Traditionally, case managers have relied on the patient as the source of timely and accurate data. Owen (2003) estimates that 40% of a provider’s time is inappropriately spent looking for critical pieces of case information or in recollecting critical data. A well-designed CMIS can provide access to critical data in a timely and efficient manner.

C. A CMIS needs to be designed for intuitive usability (Hamilton et al., 2004), such that a PC-proficient operator would need little training to master.

D. Newer CMIS systems are designed to meet both individual-level care delivery and population-level management. The traditional individual-level system includes such features as clinical workstations, physician ordering systems, clinical decision support, and drug dispensing. The population-level system is designed to support the collection and analysis of aggregate data through clinical registries, data warehouse development, provision of benchmarking data, and pharmaceutical surveillance (Weiner et al., 2004).

E. A well-designed CMIS will:

A. The benefits of using a CMIS can be divided into three categories: workflow, patient care, and organizational.

B. Limitations of the CMIS reflect not only internal limitations such as software, interfacing, and enhancements that may be lacking but also external factors such as decreased data transmission rates or bandwidth that can compromise data sharing and communication.