Theera-Ampornpunt N. Health informatics: the next “stethoscope” in healthcare. Presented at: Intelligent logistics for innovation hospitals; 2010 Dec 23; Faculty of Engineering, Mahidol University,
Theera-Ampornpunt N. Health informatics: the next “stethoscope” in healthcare. Presented at: Intelligent logistics for innovation hospitals; 2010 Dec 23; Faculty of Engineering, Mahidol University, Thailand. Invited speaker, in Thai.
Why Healthcare Isn’t Like Any Others?• Life-or-Death• Many & varied stakeholders• Strong professional values• Evolving standards of care• Fragmented, poorly coordinated Fragmented poorly-coordinated systems• Large, ever-growing & changing body of knowledge• High volume, low resources, little time Source: nj.com
Why Healthcare Isn’t Like Any Others?• Large variations & contextual dependence g p Input Process Output Patient Patient Decision‐ Decision Biological Biological Presentation Making Responses Source: nj.com
But...Are We That Different? Banking Input Process Output Transfer Location A Location A Location B Location B Value‐Add ‐ Security ‐CConvenience i ‐ Customer Service
But...Are We That Different? Manufacturing Input Process Output Raw Raw Assembling Finished Finished Materials Goods Value‐Add ‐ Innovation ‐ Skills ‐ QA
But...Are We That Different? Healthcare Input Process Output Sick Patient Patient Care Well Patient Value‐Add ‐ Medical technology & medications g ‐ Clinical knowledge & skills ‐ Quality of care; process improvement ‐ Information
Various Forms of Health ITHospital Information System (HIS) Computerized Provider Order Entry (CPOE) Electronic Health Records Picture Archiving and g (EHRs) Communication System (PACS)
Still Many Other Forms of Health IT Health Information Exchange ( g (HIE)) m-Health m Health BiosurveillancePersonal Health Records (PHRs) Telemedicine &Information Retrieval Telehealth Images from Apple Inc., Geekzone.co.nz, Google, PubMed.gov, and American Telecare, Inc.
Why Adopting Health IT? “Go paperless” Go paperless “Computerize” Computerize “Get a HIS” “Digital Hospital” Digital Hospital“Have EMR ”“H EMRs” “Modernize” “Share data” Share data
Some Quotes• “Don’t implement technology just for technology s sake.” Don t 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)• “We worry, however, that [electronic records] are being touted as a panacea for nearly all the ills of modern medicine.” (Hartzband & Groopman, 2008)
Health IT: What’s In A Word?Health GoalInformation f Value-AddTechnology Tools
Dimensions of Quality Healthcare• Safety• Timeliness• Effectiveness• Efficiency• Equity E it• Patient-centeredness at e t ce te ed ess (IOM, 2001)
Value of Health IT• Guideline G ideline adherence• Better documentation• Practitioner decision making or process of care• Medication safety• Patient surveillance & monitoring• Patient ed cation/reminder education/reminder
Fundamental Theorem of Informatics (Friedman, 2009)
Landmark IOM Reports: Summary• Humans are not perfect and are bound to make errors p• High-light 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
Why We Need Health IT• 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”
To Err Is Human• Perception errors Source: interaction-dynamics.com
To Err Is Human• Lack of Attention Source: aafp.org
To Err Is Human• Decoy Pricing # of The Economist Purchase Options People• Economist.com subscription $59 16• Print subscription $125 0• Print & web subscription $125 84 # of The Economist Purchase Options People• Economist com subscription Economist.com $59 68• Print & web subscription $125 32 (Ariely, 2008)
What If This Happens in Healthcare?• It already h l d happens.... (Mamede et al., 2010; Croskerry, 2003; Klein, 2005)• What if health IT can help?
U.S.’s Efforts on Health IT Adoption ? “...We will make wider use of electronic records and We other health information technology, to help control costs and reduce dangerous medical errors.” President George W. Bush Sixth State of the Union Address, January 31, 2006Source: Wikisource.org Image Source: Wikipedia.org
Public Policy in Informatics: A US’s Case1991: IOM s CPR Report published1991: IOM’s CPR Report published 1996: HIPAA enacted 2000‐2001: IOM’s To Err Is Human & Crossing the Quality Chasm published 2004: George W. Bush’s Executive Order establishing ONCHIT (ONC) 2009‐2010: ARRA/HITECH Act & “Meaningful use” regulations Meaningful use regulations
U.S. Adoption of Health IT Ambulatory (Hsiao et al, 2009) Hospitals (Jha et al, 2009) Basic EHRs w/ notes 7.6% Comprehensive EHRs p 1.5% CPOE 17% • U.S. lags behind other Western countries (Schoen et al, 2006;Jha et al, 2008) • Money and misalignment of benefits is the biggest reason
We Need “Change” “...we need to upgrade our medical records by switching from a p p to y g paper an electronic system of record keeping...” President Barack Ob P id t B k Obama June 15, 2009
The Birth of “Meaningful Use” “...Our recovery plan will invest in yp electronic health records and new technology that will reduce errors, bring down costs, ensure privacy, and save lives. ensure privacy and save lives ” President Barack Obama Address to Joint Session of Congress Address to Joint Session of Congress February 24, 2009Source: WhiteHouse.gov
American Recovery & Reinvestment Act • Contains HITECH Act ( (Health Information Technology for Economic and gy Clinical Health Act) • ~ 20 billion dollars for Health IT investments • Incentives & penalties for providers
National Leadership Office f th N ti Offi of the Nationall Coordinator for Health Information C di t f H lth I f ti Technology (ONC -- formerly ONCHIT) David Blumenthal, MD, MPP National Coordinator for Health Information Technology (2009 - Present) Photo courtesy of U.S. Department of Health & Human Services
“Meaningful Use” gPumpkin “Meaningful Use” of a Pumpkin Image Source & Idea Courtesy of Pat Wise at HIMSS, Oct. 2009
“Meaningful Use” of Health IT g Stage 1 Stage 1 ‐ Electronic capture of Better health information ‐ Information sharing Stage 3 St 3 Health ‐ Data reporting Stage 2 Use of EHRs to to Use of EHRs improve to improve outcomes processes of care (Blumenthal, 2010)
Enterprise-wide Hospital IT• Master Patient Index (MPI)• Admit-Discharge-Transfer (ADT)• Electronic Health Records (EHRs)• C Computerized Ph i i O d E t (CPOE) t i d Physician Order Entry• Clinical Decision Support Systems (CDSSs) pp y• Picture Archiving and Communication System (PACS)• Nursing applications• Enterprise Resource Planning (ERP)) l (
Departmental IT• Pharmacy applications y pp• Laboratory Information System (LIS)• Specialized applications (ER, OR, LR, Anesthesia, Critical Care, Dietary Services, Blood Bank)• Incident management & reporting system
EHRs & HISThe Challenge ‐ Knowing What It Means Electronic Health Records (EHRs) Hospital Information Hospital Information System (HIS) Electronic Medical Records (EMRs) Records (EMRs) Electronic Patient Records (EPRs) Clinical Information System (CIS) Personal Health Computer‐Based C B d Records (PHRs) Patient Records (CPRs)
EHR SystemsJust electronic documentation? History Diag‐ Treat‐ ... & PE nosis mentsOr d th have th l ?O do they h other values?
Functions that Should Be Part of EHR Systems• Computerized Medication Order Entry• Computerized Laboratory Order Entry• Computerized Laboratory Results p y• Physician Notes• Patient Demographics P ti t D hi• Problem Lists• Medication Lists• Discharge Summaries• Diagnostic Test Results• Radiologic Reports (IOM, 2003; Blumenthal et al, 2006)
Computerized Physician Order EntryValues• No handwriting!!!• Structured data entry: Completeness clarity Completeness, clarity, fewer mistakes (?)• No transcription errors!• E point for CDSS Entry i f CDSSs• Streamlines workflow, increases efficiency
Clinical Decision Support Systems (CDSSs)• 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 – Alerts & reminders • Based on specified logical conditions • Examples: drug-allergy checks, drug-drug interaction checks, reminders for preventive services or certain actions (e.g. smoking cessation), clinical practice guideline integration – Evidence-based knowledge sources e.g. drug database, literature – Simple UI designed to help clinical decision making
Clinical Decision Support Systems (CDSSs) PATIENT Perception CLINICIAN Attention Long Term Memory External Memory Working Memory Knowledge Data Knowledge Data Inference DECISION From a teaching slide by Don Connelly, 2006
Clinical Decision Support Systems (CDSSs) PATIENT Perception CLINICIAN Abnormal lab Attention highlights Long Term Memory External Memory Working Memory Knowledge Data Knowledge Data Inference DECISION
Clinical Decision Support Systems (CDSSs) PATIENT Perception CLINICIAN Drug-Allergy Attention Checks Long Term Memory External Memory Working Memory Knowledge Data Knowledge Data Inference DECISION
Clinical Decision Support Systems (CDSSs) PATIENT Drug-Drug Perception Interaction CLINICIAN Checks Attention Long Term Memory External Memory Working Memory Knowledge Data Knowledge Data Inference DECISION
Clinical Decision Support Systems (CDSSs) PATIENT Perception Clinical CLINICIAN Practice Guideline Attention Reminders Long Term Memory External Memory Working Memory Knowledge Data Knowledge Data Inference DECISION
Clinical Decision Support Systems (CDSSs) PATIENT Perception CLINICIAN Attention Long Term Memory External Memory Working Memory Knowledge Data Knowledge Data Inference Diagnostic/Treatment Expert Systems DECISION
Clinical Decision Support Systems (CDSSs)• CDSS as a supplement or replacement of clinicians? – The demise of the “Greek Oracle” model (Miller & Masarie, 1990) The “Greek Oracle” Model The “Fundamental Theorem” (Friedman, 2009)
Clinical Decision Support Systems (CDSSs)Some risks• Alert fatigue
Health IT for Medication Safety Ordering g Transcription p Dispensing p g Administration Automatic Electronic CPOE C O Medication Medication Dispensing Administration Records (e-MAR) Barcoded Medication Barcoded Dispensing Di i Medication Administration
Health Information Exchange (HIE) Government Hospital A Hospital B Clinic C Lab L b Patient t H P ti t at Home
4 Quadrants of Health IT Strategic Business Intelligence g HIE CDSS CPOEAdministrative Clinical VMI EHRs ERP LIS ADT Operational (Theera-Ampornpunt [unpublished], 2010)
Biomedical/Health Informatics • “[T]he field that is concerned with the optimal use of information, often aided by the use of technology, to improve individual health, health care, public health, health care health and biomedical research” (Hersh, 2009) • “[T]he application of the science of information as data l d t plus meaning t problems of bi di l i to bl f biomedical interest” (Bernstam et al, 2010)
Data-Information-Knowledge-Wisdom Pyramid Wisdom Knowledge Information Data
M/B/H Informatics As A Field (Shortliffe, 2002)
M/B/H Informatics and Other Fields Social Sciences (Psychology, (Psychology Statistics & Statistics & Sociology, Research Linguistics, Law Methods Cognitive & & Ethics) Medical Decision Decision Sciences & Sciences & Science Public Health Engineering Management Computer & Computer & Biomedical/ Library Science, Library Science, Information Health Information Science Informatics Retrieval, KM And More!
Balanced Focus of Informatics People Techno‐ Process logy
Informatics & EngineeringProcess-focusProcess focus• Industrial Engineering / Operations Research g g p & Management / Business Process ReengineeringTechnology-focus• Computer & Software Engineering• Biomedical Engineering• Electrical Engineering
Summary• Healthcare will benefit from health IT through – Information deliveryy – Process improvement• The world is moving toward health IT• H lth iinformatics needs expertise f engineering & Health f ti d ti from i i other fields• Health informatics will be crucial to future’s healthcare
Let s Let’s Build TheNext Generation’s Healthcare! H lth !
References• Bernstam EV, Smith JW, Johnson TR. What is biomedical informatics? J Biomed Inform. 2010 Feb;43(1):104‐10.• Blumenthal D. Launching HITECH. N Engl J Med. 2010 Feb 4;362(5):382‐5.• Blumenthal D, DesRoches C, Donelan K, Ferris T, Jha A, Kaushal R, Rao S, Rosenbaum S. Health information technology in the United States: the information base for progress [Internet]. Princeton (NJ): Robert Wood Johnson Foundation; 2006• Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003 Aug;78(8):775‐80. 81 p. Available from: A d M d 2003 A 78(8) 775 80 81 A il bl f http://www.rwjf.org/files/publications/other/EHRReport0609.pdf• Friedman CP. A "fundamental theorem" of biomedical informatics. J Am Med Inform Assoc. 2009 Apr;16(2):169 70. 2009 Apr;16(2):169‐70• Hersh W. A stimulus to define informatics and health information technology. BMC Med Inform Decis Mak. 2009;9:24.• Hsiao C, Beatty PC, Hing ES, Woodwell DA. Electronic medical record/electronic health record Hsiao C, Beatty PC, Hing ES, Woodwell DA. Electronic medical record/electronic health record use by office‐based physicians: United States, 2008 and preliminary 2009 [Internet]. 2009 [cited 2010 Apr 12]; Available from: http://www.cdc.gov/nchs/data/hestat/emr_ehr/ emr_ehr.pdf
References• Institute of Medicine, Board on Health Care Services, Committee on Data Standards for Patient Safety. Key Capabilities of an electronic health record system: letter report [Internet]. f bl f l h lh d l [ ] Washington, DC: National Academy of Sciences; 2003. 31 p. Available from: http://www.nap.edu/catalog/10781.html• Jha AK DesRoches CM Campbell EG Donelan K Rao SR Ferris TG Shields A Rosenbaum S AK, DesRoches CM, Campbell EG, Donelan K, Rao SR, Ferris TG, Shields A, Rosenbaum S, Blumenthal D. Use of electronic health records in U.S. hospitals. N Engl J Med. 2009;360(16):1628‐38.• Jha AK, Doolan D, Grandt D, Scott T, Bates DW. The use of health information technology in , , , , gy seven nations. Int J Med Inform. 2008;77(12):848‐54.• Klein JG. Five pitfalls in decisions about diagnosis and prescribing. BMJ. 2005 Apr 2;330(7494):781‐3.• Mamede S, van Gog T, van den Berge K, Rikers RM, van Saase JL, van Guldener C, Schmidt HG. Effect of availability bias and reflective reasoning on diagnostic accuracy among internal medicine residents. JAMA. 2010 Sep 15:304(11):1198‐203.• Miller RA, Masarie FE Th d i Mill RA M i FE. The demise of the "Greek Oracle" model for medical diagnostic f h "G k O l " d lf di l di i systems. Methods Inf Med. 1990 Jan;29(1):1‐2. • Schoen C, Osborn R, Huynh PT, Doty M, Puegh J, Zapert K. On the front lines of care: primary care doctors office systems experiences and views in seven countries Health Aff care doctors’ office systems, experiences, and views in seven countries. Health Aff (Millwood). 2006;25(6):w555‐71.• Shortliffe EH. JBI status report. Journal of Biomedical Informatics. 2002 Oct;35(5‐6):279‐80.