Austin and Boxerman chapter 8


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Austin and Boxerman chapter 8

  1. 1. Austin and Boxerman chapter 8 HSPM J713
  2. 2. Applications Learning Objectives <ul><li>Write about: </li></ul><ul><li>Types of application software used in health care organizations </li></ul><ul><ul><li>Functionality </li></ul></ul><ul><ul><li>End users </li></ul></ul><ul><li>Medical records evolution from paper to EHR </li></ul><ul><li>Clinical decision support software vs. [?] </li></ul><ul><li>Executive information systems </li></ul><ul><li>Applications for research and medical education </li></ul>
  3. 3. Application software <ul><li>An “application” is a piece of software designed to do something specific </li></ul><ul><li>E.g. Microsoft Office comprises a number of major applications </li></ul><ul><ul><li>Word </li></ul></ul><ul><ul><li>Excel </li></ul></ul><ul><ul><li>Powerpoint </li></ul></ul><ul><ul><li>Access </li></ul></ul><ul><ul><li>Outlook </li></ul></ul>
  4. 4. Standalone vs. Integration <ul><li>Best of its type vs. best integrated suite </li></ul><ul><li>Basic functionality – pretty much solved? </li></ul><ul><li>Interoperability </li></ul><ul><li>Standards favor integration </li></ul>
  5. 5. Migrating <ul><li>Migrating from “legacy” standalone to integrated system can be daunting </li></ul><ul><ul><li>Different applications came into use at different times </li></ul></ul><ul><ul><ul><li>Financial earliest </li></ul></ul></ul><ul><ul><ul><li>Clinical information systems more recent </li></ul></ul></ul><ul><ul><li>Mr. Strickland’s COBOL joke – just maintaining legacy systems can be a problem </li></ul></ul>
  6. 6. A digression about COBOL <ul><li>Grace Hopper, 1959. Common Business-Oriented Language </li></ul><ul><li>Example of COBOL statement </li></ul><ul><li>ADD YEARS TO AGE </li></ul><ul><li>By comparison, C and Java use </li></ul><ul><li>age := age + years; </li></ul><ul><li>Or </li></ul><ul><li>age += years; </li></ul>
  7. 7. Health Records (intro to electronic health records) <ul><li>Document patient care for later reference by provider </li></ul><ul><li>Communication among providers </li></ul><ul><li>Document patient care for </li></ul><ul><ul><li>accounting and billing </li></ul></ul><ul><ul><li>data for health services research </li></ul></ul><ul><ul><li>Management to improve quality, reduce cost </li></ul></ul>
  8. 8. Health records <ul><li>Mostly paper, still </li></ul><ul><li>Electronic data entry or electronic communication -> paper inserted into record </li></ul>
  9. 9. Institute of Medicine <ul><ul><li>An independent non-profit agency which gives advice to the US government </li></ul></ul><ul><li>1991, 1997 reports favoring electronic medical records </li></ul><ul><li>Laid out what electronic medical records (called EHR in textbook) should do </li></ul>
  10. 10. IOM: EHR should <ul><li>Data about diagnostic and treatment events retrievable electronically </li></ul><ul><ul><li>No redundancy </li></ul></ul><ul><li>Real time data entry and retrieval </li></ul><ul><ul><li>What you enter goes straight in </li></ul></ul><ul><ul><li>You can get out what you need now </li></ul></ul>
  11. 11. EHR should (continued) <ul><li>Link scheduling, billing, referrals </li></ul><ul><li>Data can be interchanged with oversight agencies and partner organizations </li></ul><ul><li>Real time access by providers to diagnosis and treatment information </li></ul><ul><li>Individual patients can access their own records </li></ul><ul><ul><li>Last two subject to confidentiality rules </li></ul></ul>
  12. 12. Progress towards EHR <ul><li>Electronic medical records (their term) are common. </li></ul><ul><ul><li>Images of paper, or optical character reader to create electronic information from paper </li></ul></ul><ul><li>Electronic patient record (their term) less common </li></ul><ul><ul><li>Works across organizations </li></ul></ul>
  13. 13. EHR <ul><li>All medical and health records connected by unique identifier, no matter where data stored </li></ul><ul><ul><li>New definition of EHR? </li></ul></ul><ul><li>Will require national standards </li></ul><ul><li>Now, competing standards by vendors for communication among their applications </li></ul>
  14. 14. VistA <ul><li>Veterans Health Information Systems and Technology Architecture </li></ul><ul><ul><li>Most advanced in US </li></ul></ul><ul><li>Other efforts </li></ul><ul><ul><li>Vendors’ systems for hospitals, doctors’ offices </li></ul></ul><ul><ul><li>Academic medical centers </li></ul></ul>
  15. 15. Clinical Information Systems <ul><li>Support diagnosis, treatment, and evaluation </li></ul><ul><li>Most systems in place have limited scope </li></ul><ul><li>Embed clinical practice guidelines </li></ul><ul><ul><li>Require justification for going beyond rules </li></ul></ul><ul><li>Standard (“evidence based”) treatment plans for comparison with your idiosyncratic effort </li></ul><ul><li>Often, separate systems, not integrated </li></ul><ul><ul><li>Departmental decisionmaking (“best of breed”) </li></ul></ul><ul><ul><li>The following slides are about departmental systems </li></ul></ul>
  16. 16. Clinical Information System: Laboratory systems <ul><li>Automated test processing </li></ul><ul><ul><li>Computer-driven analysis of samples </li></ul></ul><ul><li>Functions </li></ul><ul><ul><li>Record test requisitions (orders) </li></ul></ul><ul><ul><li>Schedule specimen collection </li></ul></ul><ul><ul><li>Output from instruments goes to computer </li></ul></ul><ul><ul><li>Calculations </li></ul></ul><ul><ul><li>Record test results </li></ul></ul>
  17. 17. Laboratory systems <ul><li>Functions (continued) </li></ul><ul><ul><li>Alerts for follow-up </li></ul></ul><ul><ul><li>Summary reports for patient </li></ul></ul><ul><ul><li>Summary reports for lab </li></ul></ul><ul><ul><li>Maintain records for quality control </li></ul></ul><ul><ul><li>Monitoring productivity </li></ul></ul>
  18. 18. Clinical Information System: Pharmacy information systems <ul><ul><li>Errors! </li></ul></ul><ul><ul><li>ordering </li></ul></ul><ul><ul><li>dispensing </li></ul></ul><ul><ul><li>administering </li></ul></ul><ul><ul><li>recording </li></ul></ul><ul><ul><li>Cited in 1999 IOM report </li></ul></ul><ul><ul><li>Good records can help! </li></ul></ul>
  19. 19. Pharmacy <ul><li>History of standalone systems </li></ul><ul><ul><li>Control of controlled (legal requirements) substances </li></ul></ul><ul><ul><li>Drug ordering and inventory (including formulary) </li></ul></ul><ul><ul><li>Drug distribution to patients </li></ul></ul><ul><ul><li>Drug information for retrieval by staff </li></ul></ul><ul><ul><ul><li>Patient drug profiles </li></ul></ul></ul><ul><ul><li>Billing </li></ul></ul>
  20. 20. Pharmacy <ul><li>Once good standalone systems were developed, </li></ul><ul><li>The next move is to intergrated systems, </li></ul><ul><ul><li>So pharmacy orders can be made or viewed from anywhere </li></ul></ul><ul><li>Screening and flagging functions not standardized </li></ul><ul><ul><li>Competing systems for spotting drug interactions, dose checking, allergy flagging, duplicate prescription flagging, weight-based dosing for pediatric patients, … </li></ul></ul>
  21. 21. Clinical Information System: Medical Imaging and Radiology <ul><li>Imaging </li></ul><ul><ul><li>Image processing and storage </li></ul></ul><ul><ul><li>Image enhancement </li></ul></ul><ul><li>Radiology </li></ul><ul><ul><li>Test orders </li></ul></ul><ul><ul><li>Scheduling </li></ul></ul><ul><ul><li>Reporting results </li></ul></ul><ul><ul><li>Billing and reports to management </li></ul></ul>
  22. 22. Complex images and applications <ul><ul><li>3-D images like: </li></ul></ul><ul><li>Computed tomography </li></ul><ul><li>Magnetic resonance imaging </li></ul><ul><li>Computers integral to image creation process </li></ul><ul><li>Radiation therapy – computer-directed </li></ul>
  23. 23. Archive problem <ul><li>Film deteriorates </li></ul><ul><li>Digital formats and storage devices and standards change </li></ul>
  24. 24. Clinical Information System: Order Entry and Results Reporting <ul><li>Enter diagnostic test orders and treatments </li></ul><ul><li>Output test results and treatment summary </li></ul><ul><li>CPOE – computerized physician order entry </li></ul><ul><ul><li>Checks during data entry </li></ul></ul><ul><ul><li>Limited choices on menus </li></ul></ul>
  25. 25. Clinical Information System: Nursing Information Systems <ul><li>Planning care </li></ul><ul><li>Patient histories </li></ul><ul><li>Monitoring patients </li></ul><ul><li>Manage nursing unit </li></ul><ul><li>Graphical displays </li></ul><ul><li>Point-of-care data entry and reporting </li></ul><ul><ul><li>Clunky terminals in 1990s </li></ul></ul><ul><ul><li>Handheld units today </li></ul></ul>
  26. 26. Nursing point of care systems savings <ul><li>Less time and inconvenience when data entry and report retrieval are with the patient instead of central station </li></ul><ul><li>Better quality care – more time at bedside </li></ul><ul><li>Timely access to information </li></ul><ul><li>Reduced costs </li></ul><ul><ul><li>Time savings above </li></ul></ul><ul><ul><li>Productivity monitoring? </li></ul></ul>
  27. 27. Management/Administrative and Financial Systems <ul><ul><li>Next big category after clinical information systems in book </li></ul></ul><ul><ul><li>Historically, older than clinical information systems </li></ul></ul><ul><ul><li>But hospitals are relatively recent adopters </li></ul></ul><ul><li>Standalone financial and accounting systems giving way to </li></ul><ul><li>ERP </li></ul><ul><ul><li>Enterprise Resources Planning </li></ul></ul>
  28. 28. ERP <ul><li>In health services organizations: </li></ul><ul><ul><li>Financial </li></ul></ul><ul><ul><li>Human resources </li></ul></ul><ul><ul><li>Resource (non-human?) utilization and scheduling </li></ul></ul><ul><ul><li>Materials management </li></ul></ul><ul><ul><li>Facilities and project management </li></ul></ul><ul><ul><li>Office automation </li></ul></ul><ul><li>Single (distributed) database links them </li></ul><ul><li>Used to inform top management decisions </li></ul>
  29. 29. ERP: Financial Information Systems <ul><li>Payroll – link to human resources system </li></ul><ul><li>Accounts payable – link to purchasing and inventory </li></ul><ul><li>Patient accounting, billing, accounts receivable </li></ul><ul><li>Cost accounting, including allocating overhead </li></ul><ul><li>General ledger </li></ul>
  30. 30. Financial Information Systems (continued) <ul><li>Budgeting </li></ul><ul><li>Internal auditing </li></ul><ul><li>Forecasting </li></ul><ul><li>Planning financial investments </li></ul><ul><ul><li>Cash flow vs. cash need </li></ul></ul><ul><li>Financial statements </li></ul><ul><li>Financial reporting for top management </li></ul>
  31. 31. ERP: Human Resources <ul><ul><li>In hospitals, labor is 60-70% of operating cost </li></ul></ul><ul><li>Employee information </li></ul><ul><li>Position control – link to budget </li></ul><ul><li>Labor analysis reports, including turnover and absenteeism </li></ul><ul><li>Inventory of skills and certifications </li></ul><ul><li>Information for labor cost allocation – link to payroll system </li></ul>
  32. 32. Human resources (continued) <ul><li>Productivity information </li></ul><ul><li>Compare compensation with competitors </li></ul>
  33. 33. Human Resources data <ul><li>Personal: Name, address, birthdate, SSN, marital </li></ul><ul><li>Job: Title, department, date started, date promoted, salary </li></ul><ul><li>Benefits: Health insurance, other insurance, pension </li></ul><ul><li>Other: Skills, physical limits, disciplinary actions, awards, bonuses </li></ul>
  34. 34. Human Resources database <ul><li>Relational database </li></ul><ul><li>Security </li></ul><ul><li>Reports </li></ul><ul><li>Physicians, too, for planning and recruitment </li></ul>
  35. 35. ERP: Resource (fixed capital, in economics sense) utilization systems <ul><li>Patient scheduling </li></ul><ul><ul><li>Occupancy rates for inpatient beds, operating rooms </li></ul></ul><ul><li>Clinic use </li></ul><ul><li>Emergency department use </li></ul><ul><li>Ambulatory surgery centers </li></ul>
  36. 36. Resource (capital allocation) systems <ul><li>Connect with clinical decision-making system (CPOE) to flag procedures that precede or require other procedures </li></ul><ul><li>Connect with inventory system to automatically order (or flag for order) needed supplies for scheduled procedure </li></ul><ul><li>Connect with HR to assess personnel need, allocate personnel </li></ul><ul><li>Connect with patient database to remind patient to do prep, show up </li></ul>
  37. 37. ERP: Materials Management (inventory is non-fixed capital) <ul><li>Requisitions for suppliers checked against budget </li></ul><ul><li>Electronic data interchange with suppliers (computerized buying) </li></ul><ul><ul><li>“ Just in time” – reduce inventory </li></ul></ul><ul><li>Bar codes </li></ul><ul><li>Food service management </li></ul><ul><ul><li>Menu planning </li></ul></ul>
  38. 38. ERP: Facilities and project management <ul><li>Maintenance of buildings </li></ul><ul><li>Manage new projects or renovations </li></ul><ul><ul><li>PERT (Program Evaluation and Review Technique) [CPM] </li></ul></ul><ul><li>Efficiency </li></ul><ul><li>Safety </li></ul><ul><li>Energy conservation </li></ul><ul><li>Waste management </li></ul>
  39. 39. Office Automation <ul><li>Word processing, e-mail, calendar </li></ul><ul><li>Groupware </li></ul><ul><ul><li>E.g. Microsoft Office </li></ul></ul><ul><ul><ul><li>Macros, object linking and embedding </li></ul></ul></ul>
  40. 40. Non-hospital settings <ul><ul><li>Specialized applications/information systems for </li></ul></ul><ul><li>Ambulatory care centers </li></ul><ul><li>Long-term care (late adopter?) </li></ul><ul><li>Home health care </li></ul>
  41. 41. Other <ul><li>(some of these seem to repeat from earlier categories) </li></ul><ul><li>(but there are some jargon terms in here worth knowing) </li></ul>
  42. 42. CDS <ul><li>Clinical decision support systems </li></ul><ul><ul><li>Assist physicians and others in diagnosis and treatment choices </li></ul></ul><ul><li>Passive </li></ul><ul><ul><li>Present information culled from other systems about patient and about medical science </li></ul></ul><ul><li>Active </li></ul><ul><ul><li>Present information </li></ul></ul><ul><ul><li>Suggest diagnoses and treatment </li></ul></ul>
  43. 43. Active CDS categories <ul><li>Expert systems </li></ul><ul><ul><li>Knowledge base of practice guidelines </li></ul></ul><ul><ul><li>Patient-specific information from clinical database </li></ul></ul><ul><ul><li>Rule-based inference engine </li></ul></ul><ul><ul><ul><li>Combines above two to generate specific suggestions </li></ul></ul></ul>
  44. 44. Active CDS elements <ul><li>Probabilistic algorithms </li></ul><ul><li>Reminders and alerts </li></ul><ul><ul><li>(for physicians and other patient decision-makers) </li></ul></ul>
  45. 45. Active CDS <ul><li>Examples (hooray!) of reminders and warnings working at named hospitals </li></ul><ul><ul><li>Beth Israel in Boston: Alerts got docs to start treatment much sooner </li></ul></ul><ul><ul><li>Latter Day Saints in Salt Lake City: reduced antibiotics usage </li></ul></ul><ul><ul><li>UAB: Docs with handhelds more likely to order non-steroidal anti-inflammatory drugs considered safer on the stomach (Vioxx?) </li></ul></ul>
  46. 46. EIS <ul><li>Executive information systems </li></ul><ul><li>Business intelligence </li></ul><ul><li>Query clinical and administrative databases and drill down </li></ul>
  47. 47. Evidence-Based Medicine Disease-Management Systems <ul><li>Evidence-based? </li></ul>
  48. 50. Now “evidence-based” <ul><li> </li></ul>
  49. 51. Evidence-based guidelines <ul><li>National Guideline Clearinghouse of the US Agency of Healthcare Research and Quality </li></ul><ul><li> </li></ul>
  50. 52. Disease management systems <ul><li>Quality and cost </li></ul><ul><li>For prevalent high-cost chronic conditions </li></ul><ul><ul><li>Asthma, diabetes, congestive heart failure </li></ul></ul><ul><li>Patient self-management with feedback </li></ul><ul><ul><li>Blood and urine test data, Blood pressure, etc. </li></ul></ul><ul><ul><li>telephone , internet to remote computer </li></ul></ul><ul><ul><li>Info presented to provider </li></ul></ul>
  51. 53. Computer-assisted medical instruments <ul><li>Computer as part of equipment </li></ul><ul><li>Patient monitoring devices </li></ul><ul><li>Image enhancement, signal-to-noise improvement </li></ul>
  52. 54. Telemedicine <ul><li>Telephone, internet, audio-video conferencing communication between </li></ul><ul><ul><li>Physician, nurse, physician assistant </li></ul></ul><ul><ul><ul><li>And </li></ul></ul></ul><ul><ul><li>Specialists </li></ul></ul><ul><ul><ul><li>And </li></ul></ul></ul><ul><ul><li>Patient </li></ul></ul>
  53. 55. Telemedicine <ul><li>Audio-video conferencing requires ISDN line, dedicated equipment. </li></ul><ul><ul><li>Prisons and rural clinics in Texas </li></ul></ul><ul><li>High-speed internet much less costly. </li></ul>
  54. 56. Medical Research and Education <ul><li>Computerized patient records require less labor to mine for data </li></ul><ul><li>Computation </li></ul><ul><ul><li>Statistical analysis </li></ul></ul><ul><ul><li>Human genome project </li></ul></ul><ul><li>Indexed medical literature </li></ul><ul><ul><li>National Library of Medicine’s Medline </li></ul></ul><ul><ul><ul><li>They give </li></ul></ul></ul><ul><ul><ul><li> </li></ul></ul></ul>
  55. 57. Medical education <ul><li>Computer/internet transmitted movies, audio, books, articles </li></ul><ul><li>Interactive simulations of clinical problems </li></ul>
  56. 58. Summary of applications <ul><li>Financial -- earliest </li></ul><ul><li>Clinical services support -- labs, pharmacy, radiology </li></ul><ul><li>Medical records. EHR still a future goal </li></ul><ul><li>Outpatient and long-term care settings </li></ul><ul><li>Physician assistance in clinical decisions </li></ul><ul><li>Medical equipment, facilities </li></ul><ul><li>Research and education </li></ul>