Clinical Information Systems
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Clinical Information Systems

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Teaching at Rangsit University, Bangkok, Thailand

Teaching at Rangsit University, Bangkok, Thailand

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    Clinical Information Systems Clinical Information Systems Presentation Transcript

    • Clinical Information Systems Nawanan Theera-Ampornpunt, MD, PhD Faculty of Medicine Ramathibodi Hospital Jun 29, 2013 http://www.slideshare.net/nawanan
    • 2003 M.D. (Ramathibodi) 2009 M.S. in Health Informatics (U of MN) 2011 Ph.D. in Health Informatics (U of MN) Deputy Chief, Informatics Division Faculty of Medicine Ramathibodi Hospital nawanan.the@mahidol.ac.th http://groups.google.com/group/ThaiHealthIT Research interests: • EHRs & health IT applications in clinical settings • Health IT adoption • Health informatics education & workforce development • Standards and interoperability A Bit About Myself
    • Class Outline • Health Care & Health IT • Clinical Information Systems • Electronic Health Records
    • Health Care & Health IT
    • Manufacturing Image Source: Guardian.co.uk
    • Banking Image Source: Cablephet.com
    • Health care ER - Image Source: nj.com
    • • Life-or-Death • Many & varied stakeholders • Strong professional values • Evolving standards of care • Fragmented, poorly-coordinated systems • Large, ever-growing & changing body of knowledge • High volume, low resources, little time Why Health care Isn’t Like Any Others?
    • • Large variations & contextual dependence Why Health care Isn’t Like Any Others? Input Process Output Patient Presentation Decision- Making Biological Responses
    • But...Are We That Different? Input Process Output Transfer Banking Value-Add - Security - Convenience - Customer Service Location A Location B
    • Input Process Output Assembling Manufacturing Raw Materials Finished Goods Value-Add - Innovation - Design - QC But...Are We That Different?
    • But...Are We That Different? Input Process Output Patient Care Health care Sick Patient Well Patient Value-Add - Technology & medications - Clinical knowledge & skills - Quality of care; process improvement - Information
    • Information is Everywhere in Health Care
    • Various Forms of Health IT Hospital Information System (HIS) Computerized Provider Order Entry (CPOE) Electronic Health Records (EHRs) Picture Archiving and Communication System (PACS)
    • Still Many Other Forms of Health IT m-Health Health Information Exchange (HIE) Biosurveillance Information Retrieval Telemedicine & Telehealth Images from Apple Inc., Geekzone.co.nz, Google, PubMed.gov, and American Telecare, I Personal Health Records (PHRs)
    • Why Adopting Health IT? “To Computerize”“To Go paperless” “Digital Hospital” “To Modernize” “To Get a HIS” “To Have EMRs” “To Share data”
    • • “Don’t implement technology just for technology’s sake.” • “Don’t make use of excellent technology. Make excellent use of technology.” (Tangwongsan, Supachai. Personal communication, 2005.) • “Health care IT is not a panacea for all that ails medicine.” (Hersh, 2004) Some Quotes
    • Health IT: What’s In A Word? Health Information Technology Goal Value-Add Tools
    • • Safety • Timeliness • Effectiveness • Efficiency • Equity • Patient-centeredness Dimensions of Quality Healthcare (IOM, 2001)
    • • Guideline adherence • Better documentation • Practitioner decision making or process of care • Medication safety • Patient surveillance & monitoring • Patient education/reminder Value of Health IT
    • Fundamental Theorem of Informatics (Friedman, 2009)(Friedman, 2009)
    • Is There A Role for Health IT? (IOM, 2000)
    • Landmark IOM Reports (IOM, 2001)(IOM, 2000)
    • • Humans are not perfect and are bound to make errors • Highlight problems in the U.S. health care system that systematically contributes to medical errors and poor quality • Recommends reform that would change how health care works and how technology innovations can help improve quality/safety Landmark IOM Reports: Summary
    • • Health care is very complex (and inefficient) • Health care is information-rich • Quality of care depends on timely availability & quality of information • Clinical knowledge body is too large • Short time during a visit • Practice guidelines are put “on-the-shelf” • “To err is human” Why We Need Health IT
    • • Perception errors To Err Is Human Image Source: interaction-dynamics.com
    • Image Source: aafp.org • Lack of Attention To Err Is Human
    • • Cognitive Errors - Example: Decoy Pricing The Economist Purchase Options • Economist.com subscription $59 • Print subscription $125 • Print & web subscription $125 Ariely (2008) 16 0 84 The Economist Purchase Options • Economist.com subscription $59 • Print & web subscription $125 68 32 # of People # of People To Err Is Human
    • • It already happens.... (Mamede et al., 2010; Croskerry, 2003; Klein, 2005) • What if health IT can help? What If This Happens in Healthcare?
    • Health IT Across Settings
    • M/B/H Informatics As A Field (Shortliffe, 2002)
    • M/B/H Informatics As A Field (Hersh, 2009)
    • Various Forms of Health IT Hospital Information System (HIS) Computerized Provider Order Entry (CPOE) Electronic Health Records (EHRs) Picture Archiving and Communication System (PACS)
    • Still Many Other Forms of Health IT m-Health Health Information Exchange (HIE) Biosurveillance Information Retrieval Telemedicine & Telehealth Images from Apple Inc., Geekzone.co.nz, Google, PubMed.gov, and American Telecare, I Personal Health Records (PHRs)
    • Health IT in Clinical Settings (“Clinical Information Systems”)
    • • Master Patient Index (MPI) • Admit-Discharge-Transfer (ADT) • Electronic Health Records (EHRs) • Computerized Physician Order Entry (CPOE) • Clinical Decision Support Systems (CDSSs) • Picture Archiving and Communication System (PACS) • Nursing applications • Enterprise Resource Planning (ERP) Enterprise-wide Hospital IT
    • • Pharmacy applications • Laboratory Information System (LIS) • Radiology Information System (RIS) • Specialized applications (ER, OR, LR, Anesthesia, Critical Care, Dietary Services, Blood Bank) • Incident management & reporting system Departmental IT
    • Workflow Hospital Information System Master Patient Index (MPI) ADT Scheduling Order Pharmacy IS Operation Theatre Billing Clinical Notes LIS RIS PACS CCIS Medical Records Portals Modified from Dr. Artit Ungkanont’s slide
    • HIT Systems (Inpatient) Clinical Decision Support: “Any system designed to improve clinical decision making related to diagnostic or therapeutic processes of care.” From Dr. Artit Ungkanont’s slide
    • Master Patient Index (MPI) • A hospital’s list of all patients • Functions – Registration/identification of patients (HN) – Captures/updates patient demographics – Used in virtually all other hospital service applications
    • Admission-Discharge-Transfer (ADT) • Functions – Supports Admission, Discharge & Transfer of patients (“patient management”) – Provides status/location of admitted patients – Used in assessing bed occupancy – Linked to billing, claims & reimbursements
    • Bed Management (from ADT System)
    • Insurance Eligibility System • Functions – Determines if a patient is eligible or is covered by a particular insurance scheme – Determines the services covered by the patient’s insurance plan – May need to link with the eligibility verification system of the government agencies
    • Appointment Scheduling • Functions – Records appointments of patients – Pre-specified number of open slots – Ability to postpone/cancel appointments – Displays list of patients with appointments in a specific date – Ability to adjust number of open slots
    • Computerized Physician Order Entry (CPOE)
    • Values • No handwriting!!! • Structured data entry: Completeness, clarity, fewer mistakes (?) • No transcription errors! • Entry point for CDSSs • Streamlines workflow, increases efficiency Computerized Physician Order Entry (CPOE)
    • • The real place where most of the values of health IT can be achieved – Expert systems • Based on artificial intelligence, machine learning, rules, or statistics • Examples: differential diagnoses, treatment options Clinical Decision Support Systems (CDSSs) (Shortliffe, 1976)
    • – Alerts & reminders • Based on specified logical conditions • Examples: –Drug-allergy checks –Drug-drug interaction checks –Drug-disease checks –Drug-lab checks –Drug-formulary checks –Reminders for preventive services or certain actions (e.g. smoking cessation) –Clinical practice guideline integration Clinical Decision Support Systems (CDSSs)
    • Example of “Alerts & Reminders”
    • – Evidence-based knowledge sources e.g. drug database, literature – Simple UI designed to help clinical decision making • E.g., Abnormal Lab Highlights Clinical Decision Support Systems (CDSSs)
    • Clinical Decision Support Systems (CDSSs) External Memory Knowledge Data Long Term Memory Knowledge Data Inference DECISION PATIENT Perception Attention Working Memory CLINICIAN From a teaching slide by Don Connelly, 2006
    • Clinical Decision Support Systems (CDSSs) External Memory Knowledge Data Long Term Memory Knowledge Data Inference DECISION PATIENT Perception Attention Working Memory CLINICIAN Abnormal lab highlights
    • Clinical Decision Support Systems (CDSSs) External Memory Knowledge Data Long Term Memory Knowledge Data Inference DECISION PATIENT Perception Attention Working Memory CLINICIAN Drug-Allergy Checks
    • Clinical Decision Support Systems (CDSSs) External Memory Knowledge Data Long Term Memory Knowledge Data Inference DECISION PATIENT Perception Attention Working Memory CLINICIAN Drug-Drug Interaction Checks
    • Clinical Decision Support Systems (CDSSs) External Memory Knowledge Data Long Term Memory Knowledge Data Inference DECISION PATIENT Perception Attention Working Memory CLINICIAN Diagnostic/Treatment Expert Systems
    • • CDSS as a replacement or supplement of clinicians? – The demise of the “Greek Oracle” model (Miller & Masarie, 1990) Clinical Decision Support Systems (CDSSs) The “Greek Oracle” Model The “Fundamental Theorem” (Friedman, 2009)
    • Clinical Decision Support Systems (CDSSs) Issues • Alert sensitivity & alert fatigue
    • Clinical Decision Support Systems (CDSSs) Issues • Unintended Consequences (e.g. workarounds)
    • Nursing Applications Functions • Document nursing assessments, interventions & outcomes • Facilitate charting & vital sign recording • Utilize standards in nursing informatics • Populate and documents care-planning • Support communication within teams & between shifts – e-Kardex • Risk/incident management
    • Pharmacy Applications Functions • Streamlines workflow from medication orders to dispensing and billing • Reduces medication errors, improves medication safety • Improves inventory management
    • Stages of Medication Process Ordering Transcription Dispensing Administration CPOE Automatic Medication Dispensing Electronic Medication Administration Records (e-MAR) Barcoded Medication Administration Barcoded Medication Dispensing
    • Laboratory Information System (LIS) Functions • Receives and processes lab orders • Matches tube & specimen • Internal workflow within labs – Order processing – Specimen registration & processing – Lab results validation & reporting – Specimen inventory • Lab results viewing
    • Imaging Applications Picture Archiving and Communication System (PACS) • Captures, archives, and displays electronic images captured from imaging modalities • Often refers to radiologic images but sometimes used in other settings as well (e.g. cardiology, endoscopy, pathology, ophthalmology) • Values: reduces space, costs of films, loss of films, parallel viewing, remote access, image processing & manipulation, referrals Radiology Information System (RIS) or Workflow Management • Supports workflow of the radiology department, including patient registration, appointments & scheduling, consultations, imaging reports, etc.
    • Billing System • Functions – Calculates service charges for services provided – Calculations based on patient’s insurance coverage and eligibility – Records amount of money paid by the patient and remaining amount – Sends information to accounting or Back Office ERP to send reimbursement claims to government agencies
    • Enterprise Resource Planning • Some Functions – Finance • Accounting • Budgeting • Cost control and management – Materials Management • Procurement • Inventory management – Human Resources • Recruitment, evaluation, promotion & disciplinary actions • Payroll
    • The Bigger Picture: Health Information Exchange (HIE) Hospital A Hospital B Clinic C Government Lab Patient at Home
    • Strategic Operational ClinicalAdministrative 4 Quadrants of Hospital IT CPOE ADT LIS EHRs CDSS HIE ERP Business Intelligence VMI PHRs MPI Word Processor Social Media PACS
    • Electronic Health Records/ Electronic Medical Records
    • What Is A Medical Record?
    • What Is A Medical Record? • A record or documentation of a patient’s medical history, examination, and treatments. • Medical Record vs. Health Record – Essentially the same
    • Potential Uses of Medical Records • Continuity of providing care – Note important information for later use – Especially important in chronic diseases (e.g. hypertension, diabetes) or in follow-up (e.g. after surgery) • Patient safety – Preventing something bad because of lack of information – Such as drug allergies, list of current medications, “problem list”
    • Potential Uses of Medical Records • Communications between providers – Referral to specialists or other physicians – Consulting among physicians – Communications between physicians and nurses, pharmacists, physical therapists, etc. – Transfer from a hospital to another • Medico-legal purposes – e.g. Court evidence against malpractice – What was done or provided to the patient? Why? By whom? When? – Was the care provided up to the professional standard?
    • Potential Uses of Medical Records • Claims and reimbursements – What services were provided to the patient – How (and how much) will the hospitals/doctors be paid? – Audit of medical records by “payers” • Patient’s uses – Health insurance claims – Self-education & self-care • Clinical research – Find ways to improve health care through new knowledge
    • Data Elements in Medical Records • Patient demographics • General information about each visit (visit = encounter) – Type (outpatient, inpatient, emergency) – Date/Time – Location (clinic or ward) “Clinical Notes” • Patient’s problems (“Patient history”) – Chief complaint – Present illness – Past history – Family and social history
    • Data Elements in Medical Records • Clinical findings by physicians (“Physical examination”) – Any important positive (usually abnormal) findings – Also important negative (usually normal) findings • “Investigations” – Laboratory tests (blood tests, urine, etc.) – Radiological examinations (X-rays, CT, MRI, ultrasound) – Other diagnostic procedures • Electrocardiography (EKG/ECG) -- heart’s function • Electroencephalography (EEG) -- brain wave scans • Etc.
    • Data Elements in Medical Records • “Problems” or “Diagnoses” – Summary of problems relevant to this visit • Treatments – Medications – Surgical procedures – Advice to patients – Admission (hospitalization) • Plans – Surgeries – More investigations to be done later – Follow-up appointments
    • Data Elements in Medical Records • Inpatient clinical notes – Admission notes – Orders (medications, procedures, investigations, nursing care, etc.) – Medication administration records – Vital signs and other measurements – Results of lab tests and radiological examinations – Progress notes – Discharge summary
    • “Electronic” Medical Records • Electronic Medical Records (EMRs) vs. Electronic Health Records (EHRs) • Debate about similarities & differences • Summary – Definitions subjective, depending on how people think – EMRs mostly refer to electronic documentation of medical care at one visit – EHRs mostly refer to electronic documentation that is longitudinal in nature (may be several visits) – EMRs commonly used in Thailand (but means the same as EHRs)
    • Longitudinal Records • Records documented over time (multiple encounters) • Ideally, “life-long” is a complete record of the patient’s health
    • Electronic Medical Records (EMRs) Computer-Based Patient Records (CPRs) Electronic Patient Records (EPRs)Electronic Health Records (EHRs) Personal Health Records (PHRs) The Confusing Acronyms Hospital Information Systems (HIS)
    • • Are they just electronic documentation? • Or do they have some other values? Diag- nosis History & PE Treat- ments ... Electronic Health Record (EHR) Systems
    • • Literature suggests improvement in health care through – Guideline adherence – Better documentation – Practitioner decision making or process of care – Medication safety – Patient surveillance & monitoring – Patient education/reminder – Cost savings and better financial performance Literature Shows Benefits of Health IT
    • • Patient Demographics • Physician Notes • Computerized Medication Order Entry • Computerized Laboratory Order Entry • Computerized Laboratory Results • Problem Lists • Medication Lists • Discharge Summaries • Diagnostic Test Results • Radiologic Reports Functions That Should be Part of EHR Systems
    • EHR Adoption: Thailand (2011) Estimate (Partial or Complete Adoption) Nationwide Basic EHR, combined inpatient & outpatient settings 49.8% Comprehensive EHR, combined 5.3% order entry of medications, combined 90.2% order entry of all orders, combined 79.4% Basic EHR: a score > 1 in a 5-point scale for IT support for demographics, MD notes, nursing assessments (inpatient only), discharge summaries (inpatient only), test results, order entry for medications Comprehensive EHR: a score > 3 in a 5-point scale for Basic EHR functions + electronic image viewing, order entry for lab tests and radiologic tests, drug-allergy alerts, drug-drug alerts
    • EHR/HIS Adoption in Thailand (2004) Pongpirul et al., 2004
    • EHR/HIS Adoption in Thailand (2011) HOSxP 50% Self-developed or outsourced 16% Hospital OS 7% SSB 4% Mit-Net 2% MRecord 2% H.I.M. Professional 2% MedTrak/ TrakCare 2% HoMC 2% None 2% THIADES 2% HIMS 1% Abstract ePHIS 1% Other 7% Theera-Ampornpunt, 2011 [Dissertation]
    • EHRs and the Bigger Picture
    • Health Information Exchange (HIE) Hospital A Hospital B Clinic C Government Lab Patient at Home
    • Google Flu Trends (Biosurveillance) Source: Google.org/FluTrends
    • • EHRs (or EMRs) are both – Electronic documentation of patient care and – a broad term for an information system used to improve the process of patient care through better documentation and other care processes such as ordering medications, lab tests, or x-rays and viewing lab results and x- ray reports (among others) Summary
    • • There are various kinds of applications in hospitals • HIS often refers to the “Front Office” part of hospital IT • Sometimes HIS refers to the entire hospital IT • HIS and EHRs are used to support clinical workflows, improve decision-making and care quality, and reduce costs • EHRs and HIS are just one piece of the big puzzle for the whole healthcare system Summary
    • Questions?