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  1. 1. Clinical reviewABC of health informaticsHow computers help make efficient use of consultationsFrank Sullivan, Jeremy C WyattEfficient consultations deal with patients’ problems promptly This is the seventh in a series of 12 articlesand effectively while taking into account other relevant A glossary of terms is available at Sometimes the relevant circumstance is another content/full/331/7516/566/DC1health problem in the patient or their family, or it could be anissue affecting society at large, such as resource constraints. Theimmediate role of the team caring for Patrick Murphy (see boxopposite) is to deal with his severe asthma. Patrick Murphy is a 5 year old boy who has been To do so the team needs information on the current brought to the accident and emergency department withproblem, which is quickly obtained from Patrick’s mother (who status asthmaticus. He is cyanosed with a poor respiratoryaccompanied him in the ambulance) and background details effortfrom her or from his medical records. They also need to assessPatrick’s physical status using clinical examination and otherdiagnostic methods. The information obtained enables theclinicians caring for Patrick to take the most effective Assess asthma severitymanagement steps. In the longer term, data from the Moderate exacerbation Severe exacerbation Life threatening asthmaconsultation may be used to redesign the service locally, or at • SpO2 ≥92% • SpO2 <92% • SpO2 <92% • Peak expiratory flow ≥50% best or • Peak expiratory flow <50% best or • Peak expiratory flow <33% best orthe level of the health system. This article shows how predicted predicted predicted • No clinical features of severe asthma • Heart rate >120/min • Silent chestinformatics tools can make it easier to record important data, NB: If a patient has signs and • Respiratory rate >30/min • Poor respiratory effort symptoms across categories, always • Use of accessory neck muscles • Altered consciousnessand that this processing can produce useful information for a treat according to their most severe • Cyanosis featureslow cost. • Give nebulised β2 agonist: Most doctors focus on assessing the patient and carrying • β2 agonist 2-10 puffs via spacer salbutamol 2.5 mg or terbutaline 5 mg with oxygen as • Reassess after 15 minutes driving gasout immediate management steps. Some clinicians see the • Continue O2 via face mask/nasal prongs • Give soluble prednisolone 30-40 mgrecording of what happened and why as a necessary evil to be or intravenous hydrocortisone 100 mgdone in the minimum time, with the least effort. Legal Responding Not responding If life threatening features presentresponsibilities ensure that most encounters are recorded, but • Continue inhaled β2 agonist 1-4 hourly • Repeat inhaled β2 agonist • Add 30-40 mg soluble oral Discuss with senior clinician, paediatric intensive care unit team, or paediatricianthe quality of data is often constrained, partly because so much • Add 30-40 mg soluble oral prednisolone prednisolone Arrange admission Consider: • Chest x ray and blood gasesdata are required. (lower threshold if concern over social circumstances) • Bolus intravenous salbutamol 15 µg/kg of 200 µg/ml solution over 10 minutes • Repeat nebulised β2 agonist Plus: Discharge plan • Ipratropium bromide 0.25 mgData to be recorded for acute medical admissions • Continue β2 agonist 4 hourly nebulised • Consider prednisolone 30-40 mg daily for up to 3 daysx Patient’s registered general practice details • Advise to contact GP if not controlled on above treatment • Provide a written asthma action plan Arrange immediate transfer to paediatric intensive care unit/x Admission details (administrative) • Review regular treatment high dependency unit if poor response to treatment • Check inhaler technique Admit all cases if features of severe exacerbation persist afterx Reason for clinical encounter • Arrange GP follow-up initial treatmentx Presenting problemx History of presenting problem Acute asthma management flow chart for children >5 years in accident andx Current diagnoses, problems emergency department. Adapted from Scottish Intercollegiate Guidelinesx Drugs, allergies, and diets Network, guideline 63 ( Past illnesses, procedures, and investigationsx Social circumstancesx Functional statex Family history Clinical datax Systems review Results of care-based and cohort auditx Examination results Health needs assessmentx Results of investigations External data (eg national comparators)x Overall assessment and problem list Informationx Management plan Evidence including researchx Intended outcomes Guidelinesx Information given to patient and carers Experience External comparison Textbooks Knowledge ProtocolsWrite once, read many Formularies RemindersOther tasks in the emergency consultation include gathering Feedback on performance Commissioningand recording information that may be useful to Patrick or Changeother patients in the future. Paper or electronic records, or Clinical effectivenessother information tools, may make it easier to record items of Cost effectivenessdata that can be aggregated and analysed after the event. The Clinical governance Outcomes auditdata can improve efficiency when they are entered into clinical Improved outcomesrecords and made available to other members of the clinicalteam. Wireless networks allow data to be transmitted to andfrom handheld computers, laptops, or desktop computers. This Turning clinical data into improved patient outcomes1010 BMJ VOLUME 331 29 OCTOBER 2005
  2. 2. Clinical reviewenables data to be shared early. An improved standard of recordkeeping probably means better data in the electronic patientrecord, which increases knowledge about the range of problemsseen in clinical practice. This new knowledge informs decisionsmade at several levels, and contributes to better outcomes for Classification, coding, and nomenclaturepatients. x Classification is a method for systematically grouping something—for example, diseases. In most classifications, classes are designated by codes, which allow aspects of the things to be captured (a systematic arrangement of similar entities on the basisStructured recording of data of certain characteristics) x A code is usually a unique numeric or alphabetic representation ofAlthough modern computers have massive processing and items in a classificationstorage capacity, data needs to be recorded in code to be x Nomenclature is a system of naming used in a branch of“understood” by computers. The computer processes and knowledge. Medical nomenclature attempts to standardise theanalyses the data to add meaning. Free text notes are too names used for patient findings, diseases, interventions, anddifficult for computers to process so that clinicians and outcomespolicymakers can carry out analyses on them. Although there are many coding and classification systems,according to Gardner, one system aims to “create a new worldstandard for computerising medical terminology.” It is called the Secondary uses of data captured during consultationssystematised nomenclature of medicine and clinical terms(SNOMED-CT) system. This coding system will be used in the x Reminders and decision support x Communication of clinical data between healthcare workers—forNHS. It is a detailed, coded classification of medical terms and example, discharge summaries, referrals, ordering, and requestsconcepts, and has more than 150 000 terms and codes that are x Identifying and monitoring the health needs of a populationorganised into 11 linked, hierarchical modules. Doctors will not x Reducing bureaucracy while managing and funding care deliverysee, and do not have to remember, all these codes. They use the x Enabling reporting of externally specified health statistics—forinterface provided by their clinical system, which is intuitive and example, for infection controlcarries out all the necessary translation to and from English. x Effective and efficient resource allocation and healthcare To realise all potential efficiencies, the electronic record management x Researchmust comply with several requirements. The variables to be x Educationcollected and their format may be agreed at different levels: x Local clinical audit and governancehospital, region, organisation, or country. The electronic recordsshould also be shared appropriately among differentorganisational units using standard communicationsprocedures, and they must be subject to security and Lateral view Medial viewconfidentiality protocols. Computer systems designed withsharing in mind are called “open.” They can run programs that A Posterior Malleolar zone B Posterior edge or tip edge or tipconnect with systems of the same type, and can accept of lateral Midfoot zone of medialprograms or connections from other sources. malleolus 6 cm 6 cm malleolus D Navicular C BaseRapid decisions and the human brain of 5th metatarsalIn Patrick Murphy’s case, effective use of consultation data may An ankle x ray series is required only if A foot x ray series is required only ifnot require a computer. Most clinical decision making is done there is any pain in malleolar zone and there is any pain in midfoot zone andfaster than current computer technologies can manage. any of these findings: any of these findings: • Bone tenderness at A • Bone tenderness at C • Bone tenderness at B • Bone tenderness at D • Inability to bear weight both • Inability to bear weight bothClinical prediction rules immediately and in emergency department immediately and in emergency departmentA clinical prediction rule, sometimes called a clinical decisionrule, is a method that quantifies the individual contributions Ottawa ankle rules for use of radiography in acute ankle injuries. Adaptedmade by various components of the history, examination, and from Stiell IG, et al. JAMA 1994;271:827-32basic laboratory results towards the diagnosis, prognosis, orlikely response to treatment in a specific patient. Clinicalprediction rules increase the accuracy of clinicians’ diagnosticand prognostic assessments. They have been developed to help Factors predicting a future risk of developing near-fatal ordiagnose and manage patients with a wide range of diseases fatal asthmaand in different settings. They reduce the uncertainty inherent x Socioeconomic deprivationin medical practice by defining how to use clinical findings to x Previous near fatal asthma—for example, previous ventilation ormake predictions. respiratory acidosis Every rule should assist the doctor in making a decision, and x Previous admission for asthma, especially if in past yeareach one is based on factors drawn from a patient’s history, x Requiring three or more classes of asthma medicationphysical examination, or diagnostic tests. The Ottawa ankle rule x Overuse of ß2 agonist x Repeated attendance at accident and emergency department foris often used. The Ottawa Health Research Institute keeps an asthma care, especially if in past yearinventory of clinical prediction rules. In August 2004 it x Brittle asthmarecorded 523 prediction rules, 337 of which were validated x Poor adherence to drug regimenusing Cochrane methods.BMJ VOLUME 331 29 OCTOBER 2005 1011
  3. 3. Clinical review After decisions about how to manage a clinical problemhave been made, admissions that are potentially avoidable Continuity of care*should be considered. Using data to stratify the risk of For patients and their families the experience of continuity is therecurrence may enable doctors to vary the level of follow-up perception that providers know what has happened before, thatand to tailor treatment depending on the risk—for example, the different providers agree on a management plan, and that a provider who knows them will care for them in the future. For providers, therisk of Patrick’s asthma recurring. experience of continuity relates to their perception that they have sufficient knowledge and information about a patient to best apply their professional competence, and they have the confidence thatEstablishing trust their care inputs will be recognised and pursued by other providers.An effective consultation instils trust and develops the *From Haggerty JL, Reid RJ, Freeman, GK, Starfield BH, Adair, CE, McKendryrelationship between doctor and patient. In Patrick’s case, his R. Continuity of care: a multidisciplinary review. BMJ 2003;327:1219-21family will probably consider returning to the team who dealtwith his problems on this occasion for further care. When apatient sees the same doctor over time in a general practicesurgery or outpatient clinic, it makes the consultation more Useful material on websitesefficient for both parties. The patient’s story need not berepeated, and clinical examinations provide data that are x To read about the information strategy of the UK NHS seecomparable. When personal continuity of care is not possible, x Background reading and justification on proposed record keepingthe electronic patient record provides some organisational standards can be found at Complete and accurate recording of data by clinicalstandards/recordsstandards/index.aspclinicians becomes more important when a different member of x The Ottawa Health Research Institute inventory of validatedthe healthcare team needs to know what information is already decision rules can be accessed at, or deduced, about the patient. clinical_epidemiology/OHDEC/clinical.aspEfficient use of consultation timeThe time available during consultations is often constrained,and doctors may need to select the most important problems to Further readingdeal with. In a case like Patrick’s, this is simple: the severity of his x Berwick DM. A primer on leading the improvement of systems.physical disease means that his acute respiratory problem must BMJ 1996;312:619-22be managed. On a later occasion (for example, at the next x Gardner M. Why clinical information standards matter. BMJ 2003;326:1101-2outpatient visit) discussing parental smoking or pets in the x Wasson JH, Sox HC. Clinical prediction rules: have they come ofhouse may be the best use of time. Looking over the patient’s age? JAMA 1996;275:641-2records before a consultation may alert the doctor to x Wyatt JC, Altman DG. Prognostic models: clinically useful, oropportunities for efficient use of time. Patients often forget quickly forgotten? BMJ 1995;311:1539-41much of what is said during a consultation, and giving them an x Schatz M, Cook EF, Joshua A, Petitti D. Risk factors for asthmaaudio recording of consultations is an easy and cheap way for hospitalizations in a managed care organization: development of a clinical prediction rule. Am J Manag Care 2003;9:538-47patients to listen to the advice provided after their visit is x Guthrie B, Wyke S. Does continuity in general practice reallyover. Providing patients with a written leaflet or advice about matter? BMJ 2000;321:734-6a self help organisation with materials on its website is also x Bates DW, Kuperman GJ, Wang S, Gandhi T, Kittler A, Volk L, et al.useful. Ten commandments for effective clinical decision support: making the practice of evidence-based medicine a reality. J Am Med Inform Assoc 2003;10:523-30SummaryThe strengths of human thought processes may becomplemented by the strengths of electronic tools. The initialcosts of developing and implementing new information systems Frank Sullivan is NHS Tayside professor of research and developmentmay be high, but the costs thereafter can be lower than the in general practice and primary care, and Jeremy C Wyatt is professornon-electronic source that is being replaced. In 2003, American of health informatics, University of Dundee.policymakers said that $120 billion a year could be saved by The series will be published as a book by Blackwell Publishing inusing information systems. Well designed, new, informatics tools spring 2006.typically improve effectiveness by 10-15%. Lower costs and Competing interests: None declared.better outcomes mean that informatics tools are moving froman era of hype to one in which real benefits are seen. BMJ 2005;331:1010–21012 BMJ VOLUME 331 29 OCTOBER 2005