Computer Based Patient Records

1. Computer Based Patient Records

2. Overview • Review the Computer Based Patient Record • Describe the UI CBPR Project • INFORMM Patient Record

3. 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?

4. 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

5. 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

6. Components (cont’d) • Outcomes Tracking • Health Status Indicators • Problem Episode Tracking • Randomized Impact Studies

7. What are the Main Issues • Text versus Structured & Coded • Security versus Access • Buy versus Build • Human Interface • GUI / Voice / Wearable • Human Acceptance

8. 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

9. Structured and Coded • Context • Validity • Question and Response • Lexicon • Metathesaurus

10. 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

11. 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

12. 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

13. 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

14. Human Interface • GUI • layout itself communicates information • pointing supported • Voice • ready for prime time? • Wearable • Virtual

15. Human Acceptance • Acceptable Interface • Workflow Makes Sense • Problems - More Solved than Created

16. 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

17. http:\\www.telemedical.com/Telemedical/Products/emr.html

18. Processes • Macro • Birth to Death • Induction to Discharge • Micro • Check-in to Check-out • Chief Complaint to Episode Resolution

19. Macro Process

20. Birth to Death Record • Universal Identifier • Data Model • Vocabulary • Data Exchange • Security • Policy

21. Micro Process • Patient Seeks Attention • Patient Responds to Questions • Provider Examines • Impression and Plan Formed • Plan Executed • Outcome Assessed

22. Patient Seeks Attention • Now • Patient Calls or Drops In • Some Enhancements in Progress • System Proactively Advises Patient • Patient Seeks Online Information

23. 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

24. 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

25. 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

26. Plan Executed • Now • Orders Written • Procedures Performed • Tests Done • Some Enhancements in Progress • Orders Captured Online with Problem • Plan Process Tracked

27. 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

28. Rules Span the Entire Process • If Event Detected • Demographics • History • Result • Order • Then Response • Communicate to Patient / Provider • Execute a Plan

29. 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

30. INFORMM Patient Record

31. Patient Text Document System

32. Health Resume

33. Allergies & Adverse Reactions

34. Prescribing: Pre-written Orders

35. Online Guidelines

36. Online Guidelines

37. Immunization: Hx, Reminders, Orders & Charting

38. Immunization: Adults

39. Immunization: Travel Vaccines

40. Online Clinical Help

41. Contact Summary: CC to Billing

42. Template Input: Large Format, Touch Screen, Branching

43. Problem List (Coded)

44. Orders: Tracking by Problem

45. Teaching Documentation Compliance

46. Billing Code Documentation

47. Online Impact Assessment Randomize Intervention Group Physician Online Control Group Physician Online Event Detected Show Recommendation No Recommendation Compare Outcomes

48. 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

49. University of Iowa CBPR Project INFORMM Patient Record