Computer Based Patient Records

Overview

• Review the Computer Based Patient Record

• Describe the UI CBPR Project• INFORMM Patient Record

Topics of Discussion

• 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?

• 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

• 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

• Universal Identifier

• Data Model

• Vocabulary

• Data Exchange

• Security

• Policy

Micro Process

• 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– Coded Questions and Responses– Context-sensitive Branching– Automated Capture of Information– Automated Intelligent Assessment

Provider Examines

• Now– 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

• Now– 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– 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