Post on 15-Jan-2016
description
Hospital Information Systems:Where we’ve come from and where we’re going
Jonathan Pell, M.D. Assistant Professor, Hospital Medicine IS Physician Liaison University of Colorado at Denver and Health Sciences Center
Tuesday Morning Conference
Denver Veteran Affairs Medical Center
January 20th 2009
Objectives What is a Hospital Information System
(HIS) and why should I care? Brief history of hospital HIS’s Problems with development of HIS Barriers to clinician adoption of new
technologies Barriers to hospital adoption of HIS Potential future directions for HIS’s
Government employee
An Hour in the Life of a Hospitalist
Starting your 7pm-7am shift and get sign-out from 4 daytime teams (8-10 patients each)
ED calls you with a new admission Nurse calls about pt X’s headache 30min
later Finally get to the ED to admit patient Get back to the floor and sign orders
History of Computers
Punch card data processing 1890
First digital computer 1940
General purpose computers 1950
First minicomputer late 1960’s
First microprocessors and PC’s late 1970’s
World Wide Web early 1990’s
Wireless computers late 1990’s
Original Hospital Information Systems (HIS) 1962 Initiated by Bolt, Beranek and
Newman and carried out by Octo Barnett at MGH
Funded by NIH whose biggest concern was not enough MD input
Other HIS Pioneers
Warner at Latter Day Saints hospital, Utah
Collen at Kaiser Permanente, California
Wiederhold at Stanford University
Progression of Computer Use in Hospitals
One System for all?
Departmental systems became feasible in 1970’s
Departmental systems develop tailored to specific application areas
No common databases or database systems
Best of breed theory begins to develop
What makes up a HIS of today Admission, discharge, and transfer system (ADT) Electronic Medical Record (EMR) Picture Archiving and communication (PACS) Pharmacy Labs (including microbiology, pathology) Billing and Scheduling Active patient data systems (ER, Med/surg, OR,
ICU)
Electronic Health Record (EHR) Needs
Accessible Secure Acceptable to clinicians Acceptable to patients Integrated with both patient specific and
patient nonspecific information
Data that goes into an EHR
Clinician visit notes -ER visits -Hospitalization summaries
Labs, microbiology, pathology, and radiology results
Patient specific lists -problem list -medication list
Patient Demographics and billing
Patient phone calls
Procedure Reports
Prescriptions and medications administered
Active patient information -Vital signs -I’s and O’s
Clinician orders
Problem: Lots of forms of Data
Free text Lists of text (problem lists) Numbers with titles and error ranges (labs) Images in multiple forms (ECG,CXR) Multiple note formats Text with numbers (prescriptions) Trends of numbers (in hospital vitals, labs)
Shortliffe, EH (2006)
What do we want coming out of an EHR?
Clinician visit notes -ER visits -Hospitalization summaries
Labs, microbiology, pathology, and radiology results
Patient specific lists -problem list -medication list
Patient Demographics and billing
Patient phone calls
Procedure Reports
Prescriptions and medications administered
Active patient information -Vital signs -I’s and O’s
Clinician orders
And More…EHR Functional Components Clinical Decision Support – “clinical system,
application or process that helps health professionals make clinical decisions to enhance patient care” defined by HIMSS
Integrated view of patient data Clinician Order Entry Access to Knowledge Resources Integrated communication and reporting
support E-prescription when patients are discharged
How do solve the multiple data form problem? Original Solution- Substitution
Display information we already have on computer screen
What we need- TransformationRethink how we obtain patient information and
manage patients Understand computer technology to change
how we think about patient data use
How Physicians Enter Data
Transcription- dictated or written notes
Filling out structured encounter forms
Direct data entry
The Informatics World Solution: Coding Problem: You can’t put the art of medicine
into code (at least not easily) Coding Systems
ICD-9 (International Classification of Disease) SNOMED (Systemized Nomenclature of Medicine) CPT (Current Procedural Terminology) LOINC (Laboratory Observations, Identifiers, Names,
and Codes) Arden Syntax – medical decision logic
Lost in Translation
Amount given: 60meq, Site: Medication administered P.O., Correct patient, time, route, dose and medication confirmed prior to administration. Patient advised of actions and side-effects prior to administration, Allergies confirmed and medications reviewed prior to administration. (19:26 CK1) : Follow Up : Decreased symptoms. (21:29 DVB)
ORDERS BMP BASIC METABOLIC PANEL by TAI for BA on Wed Dec 31, 2008 18:06 Status: Done by System Wed Dec 31, 2008 18:58. PHOSPHORUS SERUM/PLASMA by TAI for BA on Wed Dec 31, 2008 18:06 Status: Done by System Wed Dec 31, 2008 18:58. CBC COMPLETE HEMATOLOGY PROFILE by TAI for BA on Wed Dec 31, 2008 18:06 Status: Done by System Wed Dec 31, 2008 18:24. MAGNESIUM SERUM by TAI for BA on Wed Dec 31, 2008 18:06 Status: Done by System Wed Dec 31, 2008 18:58. CT BRAIN by TAI for BA on Wed Dec 31, 2008 18:08 Status: Cancelled by System Wed Dec 31, 2008 18:20. XR SHOULDER 3 VIEW INCLUDING AXILLARY by TAI for BA on Wed Dec 31, 2008 18:15 Status: Cancelled by System Wed Dec 31, 2008 18:20. MR BRAIN by CK1 for CK1 on Wed Dec 31, 2008 20:43 Status: Cancelled by System Wed Dec 31, 2008 21:07. XR CHEST PA LAT by CK1 for CK1 on Wed Dec 31, 2008 21:04 Status: Done by System Wed Dec 31, 2008 22:14.
Narrative Text vs Coded Data Narrative PMedHx
DMII diagnosed 10 yrs ago now on insulin with last A1c 10.6 (12/15/08) suspectedly due to poor medication compliance
Chronic renal insufficiency secondary to diabetes with 1g proteinuria and baseline creatinine 2.1 (12/15/08)
Coded PMedHx-250.42 (DM 2 uncontrolled with renal
complications)
Benefits
TextEasy to document and interpretComprehensive and fully customizableGood for individual patient care
Coded DataAggregate analysisWell defined for billing Information system friendly
Data-Interchange Standards International Standards Organization
(ISO)’s Open Standards Institure (OSI) seven levels required for data exchangeHL7 (Health Level 7) - Data interchangeDigital Imaging Communications in Medicine
(DICOM) for PACSNational Council for Prescription Drug
Programs (NCPDP) - pharmacyASTM 1238 – lab information interchange
Partial Solutions
Extensive Interface Engine hardware, software ,and support
“At a minimum, difficult interfaces result in steep learning curves and structural inefficiencies in task performance. At worst, problematic interfaces can have serious consequences in patient safety”
Lin at al Applying human factors to the design of medical equipment. J. of Clin. Monitoring and Computing.14(4) 253-263.1998.
Transfer of patients between different systems
Medications dropped from lists Redundant admission orders written Documented patient information from
previous system lost or difficult to interpret Orders dropped on transfer Medications mistakenly given twice
Database standards
Single Vendor or Best of Breed Few single vendors out there
EpicMeditechCernerMcKessonGE/IDX
No longer best of breed in each department
Who is looking at the big picture?
HIMSS- Health Care Information and Management Systems Society
IHE- Integrating the Healthcare Enterprise CCHIT-Certification Commission for
Healthcare Information Technology HITSP- Healthcare Information
Technology Standards Panel
HITSP Programs of work topics
Lab results reporting Bio-surveillance Consumer empowerment Emergency Responder-HER Quality Medication management Personalized Healthcare Consultations and transfers of care Immunizations and response Patient-provider secure messaging Remote monitoring
Clinician Barriers to IT system implementation and change
Clinician Barriers to IT system implementation and change Clinician prefer computer use for
consultation but do not like data entry Opposed to extra effort unless clear
benefit Do not like the inflexibility Disrupts time for the clinician patient
encounter Clinician’s don’t like change
Mcdonald et al 1992.
What do Clinicians Care About
Does it have the information we are used to having
What is it’s usability: Learnability Efficiency Memorability Minimization of Errors Satisfaction
Nielson 1993
IT Industry Response
More code devoted to Graphic User InterfaceUnderstanding needs of different usersUnderstanding workflow
Budgets spent on usability increasing Implementation budgets increasing
What do hospitals care about?
Cost reductionProductivity enhancementQuality Improvement Competitive AdvantageRegulatory Compliance
2008 HIMSS Leadership Survey
National Level
The Computer-Based Patient Record: An Essential Technology for Health Care -IOM report in 1991 and revised in 1997
National commitment of 50 billion dollars over 5 years toward electronic health record for all?
IT czar in Washington RHIO’s and Potential for a National Health
Information Infrastructure (NHII)
NHII
Idea first raised in 2001 by the National Committee on Vital and Health Statistics
Distributed system of databases using standards for access
Benefits in: Cost of Care Compliance with national guidelines Public health notification Research
Physician Visit of the Future
Patient physician interaction is voice recognition recorded into standard history format
Physical exam is performed and commented on by device peripherals
Physician uses Tablet PC’s or PDA’s to review vitals, radiology, labs, and clinician notes, etc.
All physician orders are entered through the device and incorporated into note for plan
E and M billing recommendations made and verified
All this information could be viewed by itself and in aggregate from anywhere securely
What’s Happening at UCH
Evaluating use of a single vendor-EpicSingle database and interface systemCPOEDecision supportCustomized user views of patient information
CORHIO participation
ReferencesBarnett, GO. History of Medical Informatics: Proceedings of ACM conference on History of medical informatics .Bethesda, Maryland, United States, 43 – 49, 1987.
Barnett, GO. Computers and Patient Care N. Eng. J. of Med.1968. 269: 1321-1327.
Nielson 1993 Usability Engineering. Boston, Academic Press.
Mcdonald, C.J. et al The Regenstrief medical record system: 20 years of experience in hospitals, clinics, and neighborhood health centers. MD Computing. 9 (1992) 206-217.
Lin at al Applying human factors to the design of medical equipment. J. of Clin. Monitoring and Computing.14(4) 253-263.1998.
van Ginnekan, AM. The computerized patient record: balancing effort and benefit. Int. J. of Med. Informatics. 65 (2002) 97-119.
Shortliffe, EH (2006) Biomedical Informatics: Computer Applications in Health Care and Biomedicine 3rd Edition. New York. Springer