Clinical Information Management in Electronic Age (PPT)

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  • Let’s go through an illustrative case that occurred not long ago here at UVA
  • During the formal case review conducted by our quality office, a number of communication/handoff issues were identified.
  • Clinical Information Management in Electronic Age (PPT)

    1. 1. <ul><li>Information Management in the “Electronic Age”: </li></ul><ul><li>The benefits and limits of technology for managing patient data </li></ul><ul><li>Stephen M Borowitz </li></ul><ul><li>Department of Pediatrics </li></ul><ul><li>[email_address] </li></ul><ul><li>April, 2009 </li></ul>
    2. 2. What is your job? <ul><li>Information Management </li></ul><ul><ul><li>1 st and 2 nd years </li></ul></ul><ul><ul><ul><li>Accumulate “academic” knowledge </li></ul></ul></ul><ul><ul><ul><ul><li>textbooks, lectures, notes, handouts, review books, computer resources </li></ul></ul></ul></ul><ul><ul><ul><li>Focus </li></ul></ul></ul><ul><ul><ul><ul><li>tests, boards </li></ul></ul></ul></ul>
    3. 3. What is your job? <ul><li>Information Management </li></ul><ul><ul><li>3 rd and 4 th years </li></ul></ul><ul><ul><ul><li>Accumulate “academic” knowledge </li></ul></ul></ul><ul><ul><ul><ul><li>textbooks, lectures, notes, handouts, review books, computer resources </li></ul></ul></ul></ul><ul><ul><ul><li>Collect patient data </li></ul></ul></ul><ul><ul><ul><ul><li>H & P, chart(s), computer repositories </li></ul></ul></ul></ul><ul><ul><ul><li>Focus </li></ul></ul></ul><ul><ul><ul><ul><li>Integrate what you learn academically with what you see clinically </li></ul></ul></ul></ul>
    4. 4. What is your job? <ul><li>Information Management </li></ul><ul><ul><li>3 rd and 4 th years </li></ul></ul><ul><ul><ul><li>Accumulate “academic” knowledge </li></ul></ul></ul><ul><ul><ul><ul><li>textbooks, lectures, notes, handouts, review books, computer resources </li></ul></ul></ul></ul><ul><ul><ul><li>Collect and assimilate patient data </li></ul></ul></ul><ul><ul><ul><ul><li>H & P, chart(s), computer repositories </li></ul></ul></ul></ul><ul><ul><ul><li>Focus </li></ul></ul></ul><ul><ul><ul><ul><li>Integrate what you learn academically with what you see clinically </li></ul></ul></ul></ul>
    5. 9. To access the UVA Clinical Portal, type “portal” in the browser address window
    6. 10. What is your job? <ul><li>Information Management </li></ul><ul><ul><li>3 rd and 4 th years </li></ul></ul><ul><ul><ul><li>Accumulate “academic” knowledge </li></ul></ul></ul><ul><ul><ul><ul><li>textbooks, lectures, notes, handouts, review books, computer resources </li></ul></ul></ul></ul><ul><ul><ul><li>Collect and assimilate patient data </li></ul></ul></ul><ul><ul><ul><ul><li>H & P, chart(s), computer repositories </li></ul></ul></ul></ul><ul><ul><ul><li>Focus </li></ul></ul></ul><ul><ul><ul><ul><li>Integrate what you learn academically with what you see clinically </li></ul></ul></ul></ul>
    7. 11. How will you best do your job? <ul><li>What are the best sources of patient data/information? </li></ul><ul><li>What are the best ways to organize and store patient information? </li></ul><ul><li>What are the benefits/limits of paper and electronic information resources? </li></ul>
    8. 12. Sources of Clinical Information <ul><li>Low-Tech </li></ul><ul><li>the patient and his/her family </li></ul><ul><li>the patient’s paper chart(s) </li></ul><ul><li>paper flowsheets </li></ul><ul><li>nurses, therapists, physicians, other students </li></ul>
    9. 13. The Patient and His/Her Family <ul><li>Often, the most important, reliable and valuable source of information </li></ul><ul><li>>90% of the time, you can make (or nearly make) the diagnosis with a careful history and physical examination (POM-1) </li></ul>
    10. 14. The Patient and His/Her Family <ul><li>Sometimes, the information you obtain/elicit is better/more correct/more useful than the information in the “chart” </li></ul><ul><ul><li>the game “telephone” </li></ul></ul><ul><ul><li>“ urban legends” </li></ul></ul><ul><ul><li>cognitive errors </li></ul></ul>
    11. 15. The Patient’s Paper Chart(s) <ul><li>The “blue chart” </li></ul><ul><ul><li>H & P’s </li></ul></ul><ul><ul><li>Progress notes </li></ul></ul><ul><ul><ul><li>Many (most) services have templated forms </li></ul></ul></ul><ul><ul><li>Handwritten consults </li></ul></ul><ul><li>The “bedside chart” </li></ul><ul><ul><li>Nursing flowsheets and nursing notes </li></ul></ul><ul><ul><li>Some respiratory therapy documentation </li></ul></ul><ul><ul><li>Paper copy of the PTP (patient treatment plan) </li></ul></ul><ul><li>Physician “working” charts </li></ul><ul><ul><li>Phone notes/memos </li></ul></ul><ul><ul><li>Outside records </li></ul></ul>
    12. 16. Patient Flowsheets <ul><li>Inpatient flowsheets provide 12 – 24 hour snapshots of patient data </li></ul><ul><ul><li>vital signs, medications administered, nursing and housestaff interventions, selected labs, etc </li></ul></ul><ul><li>Outpatient flowsheets may provide long-term views of patient problems/progress/interventions </li></ul>
    13. 17. Colleagues <ul><li>May offer insight about the patient’s story, problems, and treatments </li></ul><ul><li>May provide you with a sense of how sick a patient is and what they are like </li></ul><ul><li>May be the only way to learn the narrative thread of the patient’s hospitalization </li></ul><ul><li>May be the only real source for learning the “plan of care” (what we are doing and why we are doing it) </li></ul>
    14. 18. Electronic Sources of Patient Data/Information <ul><li>MIS </li></ul><ul><li>Centricity Enterprise (CE) </li></ul><ul><li>PACS </li></ul><ul><li>PICIS </li></ul><ul><li>MedHost (ED) </li></ul><ul><li>Other departmental systems </li></ul>
    15. 19. MIS <ul><li>First major commercial electronic order entry and results retrieval system </li></ul><ul><ul><li>Installed at UVA and MCV in 1987/88 </li></ul></ul><ul><li>Portal for order entry </li></ul><ul><ul><li>In 1987, <1% of US Hospitals had computerized order entry </li></ul></ul><ul><ul><li>In 2009, <10% of US Hospitals have computerized order entry </li></ul></ul><ul><li>Retrieval Functions </li></ul><ul><ul><li>Patient lists </li></ul></ul><ul><ul><li>Medication orders and charting (eMAR) </li></ul></ul><ul><ul><li>Other “medical” orders </li></ul></ul><ul><ul><li>Labs </li></ul></ul>
    16. 25. MIS <ul><li>Rounds Report </li></ul><ul><ul><li>Provides a list of patients along with recent labs, orders, radiographs and medications </li></ul></ul><ul><ul><li>Need to print this out daily to stay current </li></ul></ul><ul><ul><li>Need to ensure that the medications are accurate </li></ul></ul><ul><ul><ul><li>just because it is in the computer doesn’t mean it’s right! </li></ul></ul></ul>
    17. 26. GE Centricity Enterprise <ul><li>Currently, the “core system” of the UVA Electronic Medical Record </li></ul><ul><li>Newer technology than MIS </li></ul><ul><ul><li>more powerful </li></ul></ul><ul><ul><li>more flexible </li></ul></ul><ul><ul><li>more user-friendly than MIS </li></ul></ul>
    18. 27. GE Centricity Enterprise <ul><li>Currently, the “core system” of the UVA Electronic Medical Record </li></ul><ul><li>Newer technology than MIS </li></ul><ul><ul><li>contains much more data </li></ul></ul><ul><ul><ul><li>ALL lab data </li></ul></ul></ul><ul><ul><ul><li>ALL radiology reports </li></ul></ul></ul><ul><ul><ul><li>ALL transcribed AND paper documents </li></ul></ul></ul>
    19. 28. GE Centricity Enterprise <ul><li>Currently, the “core system” of the UVA Electronic Medical Record </li></ul><ul><li>Newer technology than MIS </li></ul><ul><ul><li>Data are easier to find and view </li></ul></ul><ul><ul><ul><li>in lists by chronology, data type and/or data source </li></ul></ul></ul><ul><ul><ul><li>spreadsheet format </li></ul></ul></ul><ul><ul><ul><ul><li>sub-tables </li></ul></ul></ul></ul><ul><ul><ul><ul><li>graphing capability </li></ul></ul></ul></ul>
    20. 29. GE Centricity Enterprise <ul><li>Currently, the “core system” of the UVA Electronic Medical Record </li></ul><ul><li>Newer technology than MIS </li></ul><ul><ul><li>Powerful patient list functions </li></ul></ul><ul><ul><ul><li>system generated/maintained lists (e.g. inpatient unit, service, attending, clinic) </li></ul></ul></ul><ul><ul><ul><li>personal lists </li></ul></ul></ul>
    21. 30. GE Centricity Enterprise <ul><li>Currently, the “core system” of the UVA Electronic Medical Record </li></ul><ul><li>Newer technology than MIS </li></ul><ul><ul><li>some “active” functionality in some clinics </li></ul></ul><ul><ul><ul><li>Problem list, medication list, allergy list </li></ul></ul></ul><ul><ul><ul><li>e-prescribing (paper and FAX) </li></ul></ul></ul><ul><ul><ul><li>Lab/radiology order entry </li></ul></ul></ul><ul><ul><ul><li>limited nurse/physician charting </li></ul></ul></ul><ul><ul><ul><li>suspended order functions </li></ul></ul></ul>
    22. 31. GE Centricity Enterprise <ul><li>Currently, the “core system” of the UVA Electronic Medical Record </li></ul><ul><li>Newer technology than MIS </li></ul><ul><li>Will be replaced by UVA EpiCare during the fall of 2010 </li></ul><ul><ul><li>all clinics will go live one night during the fall of 2010 </li></ul></ul><ul><ul><li>the hospital will go live one night during the spring of 2011 (MIS will go away) </li></ul></ul>
    23. 52. PACS <ul><li>Easy to use </li></ul><ul><li>Relatively intuitive interface </li></ul><ul><li>Allows for comparison of multiple films </li></ul><ul><li>Saves an enormous amount of time by allowing clinicians to view films at the site of care </li></ul><ul><li>Decreases the amount of face time with radiologists </li></ul>
    24. 56. Information Management <ul><li>How will you keep track of all the information that you need? </li></ul><ul><li>Best resource: </li></ul><ul><ul><li>Efficient – gives you the information you need with easy access to things you might need/want </li></ul></ul><ul><ul><li>Easy/ubiquitous access </li></ul></ul><ul><ul><li>Easy to manage (structured in a way that makes sense) </li></ul></ul><ul><ul><li>Easy to read (including being legible) </li></ul></ul>
    25. 57. Information Management
    26. 58. Information Management <ul><li>There is no single, perfect way to manage patient information </li></ul><ul><ul><li>information needs differ depending on role and setting </li></ul></ul><ul><ul><li>information needs evolve </li></ul></ul><ul><ul><li>people have different learning styles </li></ul></ul><ul><ul><li>different institutions have different resources </li></ul></ul><ul><li>You will spend at least 6 months figuring what works best for you </li></ul>
    27. 59. Information Management <ul><li>Lower tech solutions (paper-based) </li></ul><ul><li>Notecards </li></ul><ul><li>Loose sheets of paper </li></ul><ul><ul><li>rounds reports </li></ul></ul><ul><ul><li>MIS lists </li></ul></ul><ul><li>Notebooks/folios </li></ul>
    28. 60. Information Management <ul><li>Note Cards </li></ul><ul><ul><li>Pros </li></ul></ul><ul><ul><ul><li>Easy to enter “data” </li></ul></ul></ul><ul><ul><ul><li>Open ended format </li></ul></ul></ul><ul><ul><ul><li>Fit in your pocket </li></ul></ul></ul><ul><ul><ul><li>Easy to get to </li></ul></ul></ul><ul><ul><li>Cons </li></ul></ul><ul><ul><ul><li>Don’t leave lots of room for patient data (history alone might take up half the space) </li></ul></ul></ul><ul><ul><ul><li>Easy to get confused when you are caring for lots of patients </li></ul></ul></ul><ul><ul><ul><li>Easy to lose </li></ul></ul></ul>
    29. 61. Information Management <ul><li>Higher Tech </li></ul><ul><li>External drives </li></ul><ul><li>PDA’s </li></ul>
    30. 62. Information Management <ul><li>External Flash Drives </li></ul><ul><ul><li>Pros </li></ul></ul><ul><ul><ul><li>fit in your pocket </li></ul></ul></ul><ul><ul><ul><li>can store lots of data </li></ul></ul></ul><ul><ul><li>Cons </li></ul></ul><ul><ul><ul><li>need to develop format/structure to store/retrieve data </li></ul></ul></ul><ul><ul><ul><li>need a computer and ?printer </li></ul></ul></ul><ul><ul><ul><li>easy to lose </li></ul></ul></ul><ul><ul><ul><li>may not be secure </li></ul></ul></ul>
    31. 63. Information Management <ul><li>PDA’s </li></ul><ul><ul><li>Pros </li></ul></ul><ul><ul><ul><li>May fit in your pocket </li></ul></ul></ul><ul><ul><ul><li>Easy to get to </li></ul></ul></ul><ul><ul><ul><li>Can store lots of data </li></ul></ul></ul><ul><ul><ul><li>Can serve other purposes (peripheral brain – e.g. Epocrates, InfoRetriever etc) </li></ul></ul></ul><ul><ul><li>Cons </li></ul></ul><ul><ul><ul><li>Data entry can be slow/tedious </li></ul></ul></ul><ul><ul><ul><li>May be hard to read </li></ul></ul></ul><ul><ul><ul><li>devices and software may not be HIPAA compliant </li></ul></ul></ul>
    32. 64. HIPAA? <ul><li>Health Insurance Portability and Accountability Act (1996) </li></ul>
    33. 65. HIPAA Privacy Rule <ul><li>Privacy Rule of 2003 </li></ul><ul><li>Promotes confidentiality and security of patient protected health information (PHI) </li></ul><ul><li>Requires notification of patients about how their PHI may be used and disclosed, and requires specific written authorizations for certain uses and disclosures </li></ul>
    34. 66. <ul><li>Privacy Rule of 2003 </li></ul><ul><li>Patients have the right to inspect their medical records, request restrictions on the use of their information, receive an accounting of disclosures , and have access to a formal complaint process.  </li></ul><ul><li>Requires physical, administrative, and technical safeguards to maintain the security of oral communications, paper records and electronic records </li></ul>HIPAA Privacy Rule
    35. 67. HIPAA and PDA’s at UVa <ul><li>What this means for you: </li></ul><ul><li>PHI should not be stored or downloaded or leave the institution unless there is an ongoing need to access this information away from the Health System for patient treatment, patient payment or approved Health System business operation use. </li></ul><ul><li>Patient information should not be stored on PDA’s unless appropriate security measures have been implemented. </li></ul>
    36. 68. Summary <ul><li>For the rest of your professional life, most of your job will be managing information </li></ul><ul><li>You will spend the first 6 mos of your clerkships trying to figure out the best way(s) to do this </li></ul><ul><ul><li>solutions that work now may not work later </li></ul></ul><ul><ul><ul><li>roles and responsibilities differ and evolve </li></ul></ul></ul><ul><ul><ul><li>Institutional resources, policies and procedures differ and evolve </li></ul></ul></ul><ul><li>Technology is a tool to help you do your job better. It is not a magic bullet. </li></ul>
    37. 69. <ul><li>Electronic resources may help you, but they are not always the best way to manage information </li></ul><ul><ul><li>it will depend on the resources available </li></ul></ul><ul><ul><li>it will depend on your information needs in a given clinical setting </li></ul></ul><ul><ul><li>it will depend on the way you like to organize and the needs/wants of the clerkship </li></ul></ul><ul><li>Patient privacy is always a concern regardless of what format/tools you use </li></ul>Summary
    38. 70. <ul><li>Keep in mind that the principle reason to “write” in a chart should be to communicate to other care-providers </li></ul><ul><ul><li>communication problems are far and away the most common cause of preventable in-hospital disability and death </li></ul></ul><ul><ul><ul><li>more than 60% of root causes of sentinel events reported to JCAHO are due to failures of communication between healthcare personnel </li></ul></ul></ul><ul><ul><ul><li>residents believe communication difficulties play a major role in the vast majority of medical mishaps they experience </li></ul></ul></ul>Summary
    39. 71. <ul><li>A 69 year old with a history of Cushing’s syndrome due to an adrenal tumor presented to Interventional radiology for a venous sampling procedure. Her baseline HCT was 42% She had a history of DVT and PE for which she chronically takes warfarin, insulin dependent diabetes, HTN, obesity, lower extremity weakness and chronic back pain </li></ul><ul><ul><li>several attempts at right femoral vein access were unsuccessful and the procedure was completed via her left femoral vein.  </li></ul></ul><ul><ul><li>she was admitted to the Interventional Radiology service for monitoring </li></ul></ul>Communication problems are the most common cause of in-hospital disability and death
    40. 72. <ul><ul><li>on post-procedure day 2 her HCT had dropped from 42% to 28% The IR nurse practitioner called the General Medicine chief resident to request a transfer </li></ul></ul><ul><ul><li>the patient was transferred to the General Medicine service without direct physician to physician report or a written transfer note </li></ul></ul><ul><ul><li>the admitting resident believed the patient was being admitted for “placement issues”. The intern was a psychiatric resident </li></ul></ul><ul><ul><li>shortly after transfer, the night float resident assumed care and a heparin infusion and daily Coumadin were ordered </li></ul></ul>Communication problems are the most common cause of in-hospital disability and death
    41. 73. <ul><ul><li>on post-procedure day 3, her HCT was 25.7% The intern was the psychiatric resident and upper level coverage was provided by a nephrology fellow due to a resident retreat </li></ul></ul><ul><ul><li>her heparin PTT was > 140 and the heparin infusion was held for one hour and then resumed at a lower rate </li></ul></ul><ul><ul><li>on post-procedure day 4 the heparin drip was discontinued and enoxaparin begun </li></ul></ul><ul><ul><li>on post-procedure day 5, enoxaparin and coumadin were held for elective surgery scheduled the next day; her HCT was 31% after one unit of PRBC’s </li></ul></ul>Communication problems are the most common cause of in-hospital disability and death
    42. 74. <ul><ul><li>in the early morning of post-procedure day 6, the patient complained of severe back pain and two verbal orders were given to administer pain medication </li></ul></ul><ul><ul><li>the patient was later found hypotensive at which time her HCT was 22% </li></ul></ul><ul><ul><li>she subsequently experienced a cardiorespiratory arrest and died </li></ul></ul><ul><ul><li>autopsy revealed a large retroperitoneal bleed extending to the diaphragm, and a defect in the right femoral artery </li></ul></ul>Communication problems are the most common cause of in-hospital disability and death
    43. 75. <ul><li>Communication/Handoff Issues identified during the case review </li></ul><ul><ul><li>The General Medicine team had no knowledge of the vein sampling procedure performed on hospital day one </li></ul></ul><ul><ul><li>The attending physician changed 3 times in 5 days </li></ul></ul><ul><ul><li>The house staff changed 11 times in 5 days </li></ul></ul>Communication problems are the most common cause of in-hospital disability and death
    44. 76. <ul><li>Keep in mind that the principle reason to “write” in a chart should be to communicate to other care-providers </li></ul><ul><ul><li>most humans prefer narrative stories over data </li></ul></ul><ul><ul><li>think about what the data you have assembled and reviewed means and try to convey that to the other people who read the chart </li></ul></ul><ul><ul><ul><li>summation </li></ul></ul></ul><ul><ul><ul><li>abstraction </li></ul></ul></ul><ul><ul><ul><li>synthesis </li></ul></ul></ul>Summary
    45. 77. <ul><li>Information Management in the “Electronic Age”: </li></ul><ul><li>The benefits and limits of technology for managing patient data </li></ul><ul><li>Stephen M Borowitz </li></ul><ul><li>Department of Pediatrics </li></ul><ul><li>[email_address] </li></ul><ul><li>April, 2009 </li></ul>

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