Palm-Based Extensions to the New York Presbyterian Hospital

Clinical Information System: PalmCIS

James J. Cimino, M.D.

Department of Medical Informatics

Columbia University College of Physicians and Surgeons

Questions:

• How can hand-held wireless technologies be used to reduce medical errors?

• How can we study the impact of such interventions?

Medical Errors

• Slips vs. mistakes

• Proximal causes of mistakes:– inadequate information during decision-making– ineffective communication for coordination of

patient care team members

Preliminary Studies

• Studied nurses and physicians

• Three modalities

– Survey questionnaires

– Focus groups

– Direct observation

Physician Surveys• Patient-specific information

– A list of current medications and time administered– Problem lists– Outpatient notes (esp. subspecialty consultations)– List of current providers for patient (consults, nurses)– Laboratory and other test results

• Institution-specific information– Current providers on-call and how to contact them.

• Domain-specific information– Disease management information– Prescribing information– Medical formulas linked to patient data

• Communication difficulties– Identifying/contacting other providers (esp. consults)

Nursing Surveys

• Patient-specific information– Patient diagnoses – Laboratory and other test results

• Institution-specific information– Policies and protocols (IV care, blood bank)– Census reports

• Domain-specific information– Drug information (dosage, teaching info) – Diagnostic definitions– Educational materials (e.g. colostomy care)

• Communication difficulties– Identifying and contacting other care providers.

Observation of Information Needs

• Don’t KnowHS1: …medically he’s fine. Actually, we’re doing a follow-up

ESR today.A2: Good.HS1: Um, I don’t know what we’re going to do if it’s still high.

Because we’re still doing the standard treatment anyway. • Type: Medical Science - Use: Resource- Outcome: Pending

HS1: …actually, we discussed putting him on sub-q heparin. And, I didn’t, I don’t…

HS2: Yeah, I’ll have to, go and get a paper on this, because this actually seems to be a discussion often. But, you know, is there an existence of this self-anticoagulation…

Observation of Information Needs (cont.)

• Type: Administrative - Use: Human - Outcome: Success(A2 tells story of patient suing hospital)A2: So then, a few years later, we were in court, and it was,

because it was (hospital name), they sued (hospital name), and (another hospital name), the attending, and all the housestaff. Any housestaff that had written a note. So all the (2nd hospital name) housestaff who were rotating through…

HS1: Are, um, are we protected?A2: Yes. So, actually, yes, you are protected, that’s right.

Observation of Information Needs (cont.)

• Type: Patient - Use: Record - Outcome: FailureA1: How about his chest x-ray?MS1: His chest x-ray showed… it showed an enlarged heart,

but no obvious signs of CHF.A1: And no pleural effusions?HS1: No…HS2: I’m not sure what the timing of the chest x-ray was, in

relation to the Lasix.HS1: See, yeah that may have been after the Lasix. Usually it

doesn’t clear up that quickly.

Observation of Coordination

• Don’t KnowHS2: We were discussing whether she should really go to the

Neuro service, because it’s, it’s sort of, they were asking us for q4 hour neuro tests, which is not something we’re really set up to do here. And the nurses aren’t really prepared to do it, either. But, I don’t know.

• Pending Contact[re: Patient with liver failure] HS1: It looks like this is going to be a pretty rapid course.

You know, in the next few months.HS2: So, talks, you know, discussion, surrounding what he

feels about how this should go, should be entered into, obviously. But first is the breaking of the bad news, that…

HS3: Well, yeah, we should talk to GI and Oncology, and see what they’re going to do. And see what they want.

Observation of Coordination (cont.)

• Pending OutcomeA1: Is he going to get an upper GI series?HS3: Uh, it depends what, um, it depends what the Surgery

people want to do. • Success

HS1: …we treated him for diverticulitis, starting Friday night. We gave him iv-[unintelligible] and fluids. And he’s doing, he did spike in the ER, he had like one, a hundred and one, um, but he’s been doing great. He’s fine. His abdominal exam is totally benign, he’s been afebrile, um, we talked to GI, we switched him to PO antibiotics last night, and in fact he should be able to go later today. According to GI, and then follow up with them.

Observation of Coordination (cont.)• Failure

HS1: As far as the abscess, Ortho was not too impressed with his clinical exam, or with the MRI films, really. So they said, you know, you can call IR, and see if they want to do any further drainage. He’s been afebrile since the day we drained it, so I think that that’s a good thing. Um, so in fact, I did call IR yesterday, but being a holiday, the people who do the actual procedures weren’t in. But I talked to them and had them review the films, supposedly, so I called back today, and they’re really reluctant to; they want a follow-up study. They want a follow-up Doppler. But. But, when we drained it, it was by Doppler. So we have a film of us draining it, and what it looks like afterwards. So, I called radiology to set him up for a new Doppler. They are like, “No, that’s crazy, cuz IR’s gonna need to do a Doppler anyway, when they drain it.” So they don’t want to do it.

Improving Access to Information

• Study information needs

• Anticipate information needs in context of clinical information system

• Build "infobuttons" to respond to anticipated needs

Improving Communication

• Synchronous vs. asynchronous communication

• Identify common communication tasks

• Build "virtual whiteboard" to manage care team tasks

Virtual WhiteboardPatient Intern

John Smithb5151

ResidentMary Jonesb1234

AttendingWilliam Oslerb4321

NurseJan GomezX4567

Sandiego,Carmen

Check IV:Will do afterrounds

Talk to GI consult

Billings,John S.

Discuss DNR withpatient:DONE

Paroo,Marian

Call intern whenchanging dressing

Extension to Wireless Palm

• Access at point of care– rounds– bedside

• Local information resources

Technical Challenges

• Platform

• Integration with CIS

• User interface

• Security concerns

• Evaluation

Platform

• Off-the-shelf technology

• Web client

• Secondary features (beeper? phone?)

New York Presbyterian HospitalClinical Information Systems Architecture

Clinical Database

Database Monitor

Medical Logic Modules

Medical Entities Dictionary

DatabaseInterface

Research

Administrative

Alerts & Reminders

Results Review

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Summaries

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Security Issues

• Authentication– ID, password, device ID

• Confidentiality– SSL– no caching on device

Evaluation

• Triangulation on information needs and communication tasks– questionnaires– focus groups– direct observation

• Nurses and physicians• Phased roll-out of PalmCIS, with control group• Repeat three-pronged studies

Next Steps

• Modify WebCIS for Palm-based browsing

• Adapt patient list to handle whiteboard functions

• Develop infobutton manager

• Observations to determine specific whiteboard functions and infobuttons

• Seek funding to equip housestaff and carry out clinical trial