Transcript Computer Based Patient Records

Computer Based Patient Records
Overview
• Review the Computer Based Patient Record
• Describe the UI CBPR Project
• INFORMM Patient Record
Topics of Discussion
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What is a Computer Based Patient Record?
What are the Components?
What are the Main Issues?
Who are the Major Players?
What is the Value?
What is a CBPR?
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Documentation (e.g., Medical Record)
Workflow
Clinical quality improvement
Outcomes data
http://www.cpri.org/what.html
http://www.cpri.org/docs/docs.html
What are the Components?
• Summary Documentation
– Problem List/ Allergies Medications
• Encounter Documentation
– CC/HPI/PFSH/ROS/PE/Imp/Plan/Procedure
– Orders/Results
• Rules / Guidelines
• Tabular Information (Formularies etc..)
– Formularies / Lexicon
• Process Flow
Components (cont’d)
• Outcomes Tracking
– Health Status Indicators
– Problem Episode Tracking
– Randomized Impact Studies
What are the Main Issues
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Text versus Structured & Coded
Security versus Access
Buy versus Build
Human Interface
– GUI / Voice / Wearable
• Human Acceptance
Text versus Structured & Coded
• Structured & Coded
– What does a given [response] mean?
– If [response] then do [whatever]
– When or how many of a given [response] ?
• Text
– Extemporaneous
– Context Imbedded
– Tells a story
Structured and Coded
• Context
– Validity
• Question and Response
– Lexicon
– Metathesaurus
Transitioning: Text to Coded
• Incomplete Vocabularies
– In six defined vocabularies find only 60-80%
• Validity depends on context
• Context may be implicit for the educated
– nursing documentation
– physical exam
– test and therapy orders
In the Meanwhile:
• Text is necessary
• What can we do with it?
– Categorize it
• structured dictation
– Encapsulate it
• disallow it wherever possible
– Extract from it
• lexigraphical analyses have limited success
Security versus Access
• Security
– Who are you (authentication)
– What are your information rights
(authorization)
– What did you do (audit trail)
– How can we ensure integrity of communication
• Access
– Intuitive Design
– Online Intelligent Assistance
Buy versus Build
• Buy
– Turn-key versus Customizable
– Cost-sharing versus Cost-shifting
– Support versus Holding-the-Bag
• Build
– Personal Relationship with the Customer
– Talent Pool Stability
Human Interface
• GUI
– layout itself communicates information
– pointing supported
• Voice
– ready for prime time?
• Wearable
• Virtual
Human Acceptance
• Acceptable Interface
• Workflow Makes Sense
• Problems - More Solved than Created
Who Are the Major Players
• Non-profit Organizations
– Academies / Societies / CPRI
• Government Institutions
– NLM, ASTM
• Academic & Medical Institutions
– LDS/IMHC / Brigham / Columbia / Stanford
– http://ucsub.colorado.edu/~gorman/thesis/EMR
.html
• Commercial Product Vendors
http:\\www.telemedical.com/
Telemedical/Products/emr.html
Processes
• Macro
– Birth to Death
– Induction to Discharge
• Micro
– Check-in to Check-out
– Chief Complaint to Episode Resolution
Macro Process
Birth to Death Record
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Universal Identifier
Data Model
Vocabulary
Data Exchange
Security
Policy
Micro Process
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Patient Seeks Attention
Patient Responds to Questions
Provider Examines
Impression and Plan Formed
Plan Executed
Outcome Assessed
Patient Seeks Attention
• Now
– Patient Calls or Drops In
• Some Enhancements in Progress
– System Proactively Advises Patient
– Patient Seeks Online Information
Patient Responds to Questions
• Now
– Provider Assisted
– Mostly Text, Some Coded
• Some Enhancements in Progress
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Coded Questions and Responses
Context-sensitive Branching
Automated Capture of Information
Automated Intelligent Assessment
Provider Examines
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– Provider Documents After the Fact
– Mostly Text, Some Coded
• Some Enhancements in Progress
– Coded Questions and Responses
– Context-sensitive Branching
– Automated Capture of Information
Impression and Plan Formed
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– Information Reviewed (Hx, PE, Results)
– Mostly Narrative
• Some Enhancements in Progress
– Assisted Differential Diagnosis
– Guidelines
• Evidence Based Medicine
– Critical Path
Plan Executed
• Now
– Orders Written
– Procedures Performed
– Tests Done
• Some Enhancements in Progress
– Orders Captured Online with Problem
– Plan Process Tracked
Outcome Assessed
• Now
– Follow Up Visit Narrative
– A Few Objective Outcomes are Tracked
• Some Enhancements in Progress
– Episode Tracking
• CC to Assessment to Treatment to Resolution
• Beyond the Single Encounter
– Outcome Classification
• Health Status per Patient Report
Rules Span the Entire Process
• If Event Detected
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Demographics
History
Result
Order
• Then Response
– Communicate to Patient / Provider
– Execute a Plan
University of Iowa CBPR Project
• Phase I
• Health Resume and Guidelines
• Document System
• Phase II
• Outpatient Contact Summary
– Templates, Coding, Ordering
• Phase III
• Inpatient Contact Summary
– Templates, Coding, Ordering, Guidelines
• Images
INFORMM Patient Record
Patient Text Document System
Health Resume
Allergies & Adverse Reactions
Prescribing: Pre-written Orders
Online Guidelines
Online Guidelines
Immunization:
Hx, Reminders, Orders & Charting
Immunization: Adults
Immunization: Travel Vaccines
Online Clinical Help
Contact Summary: CC to Billing
Template Input: Large Format,
Touch Screen, Branching
Problem List (Coded)
Orders: Tracking by Problem
Teaching Documentation Compliance
Billing Code Documentation
Online Impact Assessment
Lessons Learned from Experiments
• Passive Information Increases Utilization
• In-your-face Information Decreases It
• If Seen, Information Changes Outcome
– second-vaccine ordering
– no vaccine ordering
– prescription drug ordering
University of Iowa CBPR Project
INFORMM Patient Record