Transcript Government employee - University of Colorado Denver

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 signout 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 microprocessors
and PC’s late 1970’s
General purpose
computers 1950
Wireless computers
late 1990’s
First minicomputer
late 1960’s
First digital
computer 1940
World Wide Web
early 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
Patient Demographics and billing
Clinician orders
Patient phone calls
Patient specific lists
-problem list
-medication list
Labs, microbiology,
pathology, and
radiology results
Clinician visit notes
-ER visits
-Hospitalization summaries
Prescriptions and
medications
administered
Active patient
information
-Vital signs
-I’s and O’s
Procedure Reports
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?
Patient Demographics and billing
Clinician orders
Patient phone calls
Patient specific lists
-problem list
-medication list
Labs, microbiology,
pathology, and
radiology results
Clinician visit notes
-ER visits
-Hospitalization summaries
Prescriptions and
medications
administered
Active patient
information
-Vital signs
-I’s and O’s
Procedure Reports
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- Transformation
 Rethink
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
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)
Lost in Translation
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

Text
 Easy
to document and interpret
 Comprehensive and fully customizable
 Good for individual patient care

Coded Data
 Aggregate
analysis
 Well defined for billing
 Information system friendly
Data-Interchange Standards

International Standards Organization
(ISO)’s Open Standards Institure (OSI)
seven levels required for data exchange
 HL7
(Health Level 7) - Data interchange
 Digital Imaging Communications in Medicine
(DICOM) for PACS
 National Council for Prescription Drug
Programs (NCPDP) - pharmacy
 ASTM 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
 Epic
 Meditech
 Cerner
 McKesson
 GE/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
 Satisfaction
Nielson 1993
of Errors
IT Industry Response

More code devoted to Graphic User
Interface
 Understanding
needs of different users
 Understanding workflow
Budgets spent on usability increasing
 Implementation budgets increasing

What do hospitals care about?
 Cost
reduction
 Productivity enhancement
 Quality Improvement
 Competitive Advantage
 Regulatory 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-Epic
 Single
database and interface system
 CPOE
 Decision
support
 Customized user views of patient information

CORHIO participation
References
Barnett, 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: 13211327.
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