Medical Data, Processing, e -Prescribing and PACS

1. Medical Data, Processing, e-Prescribing and PACS Week 4 – Part 1

2. First, an Announcement • Remainder of week 5 assigned as a reading week! NO tutorial NO practical • Use this time wisely!! • Assignment 2A. • ALL classes will run in week 6 etc.

3. Overview • What is medical data? • How is data processed? • What are Picture Archiving and Communication Systems • What is ePrescribing? • What about security?

4. Medical Data (1) • Gathering medical data (or simply data) and interpreting their meaning is central to providing healthcare to patients. • Medical data are crucial to information processing and decision making. • Computers are used for information processing in three ways: • Observation (measuring and data entry) • Diagnosis (data processing / analysis) • Therapy(output generation)

5. Medical Data (2) • Data provides the basis for categorising the symptoms that a patient presents or for identifying subgroups within a population of patients. • It also helps clinicians to decide what additional information is needed / what tests need to be performed to gain better understanding of the patient’s problem or to treat most effectively the problem that has been diagnosed.

6. Medical Data () • Data is anything which can be observed from a patient or generated based on previously collected or derived data. • Temperature, ECG, red blood cell count, age, gender, past history of disease, family history etc. • Medical data typical includes: • Details of the patient in question • The parameter being observed • The value(s) of the parameter • The time of the observation (if appropriate)

7. Types of Medical Data (1) • Narrative data: • Description of symptoms, family history etc. • Typically gathered from focused questions asked by the practitioner. • Discrete Numerical Values • Many data in medicine take on these values. • Temperature, pulse rate, lab test results. • Analog data • Some data is in the form of continuous signals. • Perhaps the best known example is the ECG. • Typically graphical tracing is included with written interpretation of its meaning. • Visual data (images) • Either acquired by machine or sketched by clinicians. • Radiological images is an obvious example.

8. Data Recording Techniques • It should be clear from these examples that the idea of data is inextricably bound to the idea of data recording. • Data recording techniques range from: • Hand-written text • Commonly recognised shorthand • Hand drawn sketches • Machine generated tracings of analog signals • Photographic images. • This range of data-recording conventions presents significant challenges to the person implementing computer-based medical-record systems.

9. Who Collects Medical Data? • Clinician staff – doctors and nurses • Office / Admin Staff • Lab personnel • Radiologists • Pharmacists • ICT devices – ICU monitors.

10. Medical Data Uses • Build up an historical record • Identify future health risks • Identify deviations from expected trends • Provide a legal record • Support training and development

11. Information Processing • We can only talk about information processing if a human is involved. • Computers cannot process information. • Computer can only process DATA. • Only a human being is able to interpret the data so that they become information. • As we previously discussed, computers in medicine exist to serve and complement human beings (clinicians) but not replace them.

12. Online Medical Data Source: http://www.scientificamerican.com/article.cfm?id=future-of-medical-data

13. Picture Archiving and Communication Systems (PACS) • PACS are computers, commonly servers, dedicated to the storage, retrieval, distribution and presentation of images. • Two main uses • Hard copy replacement: • PACS enables images such as x-rays and scans to be stored electronically and viewed on screens, creating a near filmless process and improved diagnosis methods. • Remote access: • Doctors and other health professionals can access and compare images at the touch of a button.

14. PACS (2) PACS allow image: • viewing at diagnostic, reporting, consultation, and remote computer workstations, • archiving of picture, typically to a central server (image repository). • communication using local / wide-area networks, public communication services, and gateways to healthcare facility and departmental information systems.

15. PACS (3) • Images are stored in an independent format. • DICOM (Digital Imaging and Communications in Medicine) standard. • PACS can handle images from: • Ultrasound • Magnetic Resonance Imaging • Computed Tomography • Digital X-ray

16. PACS Components Image sources Suitable Network Powerful and robust central computer to process information Client viewers available in at the office, home, or patient bedside

17. PACS Advantages • Replaces standard film – space saver! • Allow remote viewing and reporting – teleradiology • Digital images have a zoom feature • Computer Aided Detection (CAD) • Automatic classification • Able to ‘draw’ over scans

18. PACS 3D Reconstruction / Simulation

19. Content Based Image Retrieval Systems

20. PACS Drawbacks • Cost of initial setup – server purchase, digital radiology equipment. • Bandwidth limits • Some clinicians complain that images can take 15-20mins to load! • Black and white computer monitors not as bright as traditional x-ray view boxes. • Potential loss of detail.

21. PACS Summary • PACS systems are regarded as one of the more well received technologies. • There appears to be less concern about implementation and training. • Organisations worry about the initial setup fees. • Nevertheless, PACS are expected to become widespread, similar to WiFi, in the coming years.

22. PACS in Northern Ireland Source: http://www.prohealthservicezone.com/Customisation/News/Diagnostics_Equipment_Monitoring_and_Test/Radiology_Information_Systems_RIS/Northern_Ireland_hospitals_go_live_with_NIPACS_radiology_IT_solution.asp

23. Introduction to Electronic Prescribing • ePrescribing is defined as: • the use of electronic systems to facilitate and enhance the communication of a prescription or medicine order, • aiding the choice, administration and supply of a medicine through knowledge and decision support • and providing a robust audit trail for the entire medicines use process. (NHS Connecting for Health, 2007) http://www.connectingforhealth.nhs.uk/systemsandservices/eprescribing/baselinefunctspec.pdf

24. ePrescribing • Aims to replace paper-based prescriptions scripts to facilitate the development and delivery of systems to improve patient safety by reducing prescribing and administration errors. • It will allow medications and other prescribed therapies to be managed electronically at every stage, from prescribing to supply and administration.

25. The Need for Electronic Prescribing • The medications we use have increased in number and complexity. This demands more knowledge and understanding from clinical staff • This also leads to greater concern over the risk of errors and the harm they cause • Medication errors are indeed identified as a major preventable source of harm in healthcare. • Errors do occur, UK studies show that: • Prescribing errors occur in 1.5-9.2% of medication orders written for hospital inpatients • Dispensing errors are identified in 0.02% of dispensed items • Medication administration errors occur in 3.0-8.0% of non-intravenous doses and about 50% of all intravenous doses • The use of ePrescribing can help reduce such errors

26. The Paper Based System • It’s estimated that approximately 7,000 US citizens die each year due to medication prescription errors! • 1 in 20 hospital admissions within the UK are thought to be medications error related.

27. Problems with the Present System (1) • Fraud • Estimated that prescription fraud costs the NHS of the order of £70 – 100 million / year. • Data integrity • Approx. 40% of all US / UK prescriptions require clarification with 5% requiring a phone call to the doctor. • Administrative Workload • In 2001, the UK Prescription Processing Agency (PPA) handled 578 million prescriptions. • Each script has to be processed before payment can be dispensed to the pharmacy. • Patient Exemptions and Identification • At present within the NHS system, emphasis for checking for identity and exemptions rests with the Pharmacist. • Helps those seeking fraudulent benefits. Source: http://kar.kent.ac.uk/13770/1/SystemMundy.pdf

28. Problems with the Present System (2) • Efficiency • Script processing system is reasonably efficient between the prescriber (e.g. GP) and the dispenser (pharmacy). • It is waiting for payment through the PPA that takes time. • In order to be accepted by all stakeholders, one of the main objectives must be to ensure a lack of degradation of the efficiency of present working practices. • 60% of Pharmacists believe e-prescribing would lead to timesavings within the dispensation process. • 55% believe will lead to shorter waiting times for prescriptions. • Such high expectations place additional demands on the implementation of EPP (Electronic Prescription Processing). • One area where benefits may accrue from e-precribing could be improvements in the handling of repeat prescriptions. Source: http://kar.kent.ac.uk/13770/1/SystemMundy.pdf

29. What will E-Prescribing Provide? • Computerised entry and management of prescriptions. • Knowledge support, with immediate access to medicines information. • Decision support, aiding the choice of medicines and other therapies, with alerts for drug interactions. • Computerised links between hospital wards / departments and pharmacies. • Ultimately, links to other elements of patients' individual care records. • NPfIT (Week 6) • Improvements in existing work processes. • A robust audit trail for the entire medicines use process.

30. Simplistic System Overview

31. Realistic System Overview • Doctor = Computerised Physcian Order Entry (CPOE) • PAS = Patient administration system • EMR = Electronic medical records

32. Benefits of E-Prescribing • A reduction in the risk of medication errors as a result of several factors, including: • More legible prescriptions. • Reduced ‘paper’ work • Alerts for contra-indications (risks involved with using a particular drug), allergic reactions and drug interactions. • Guidance for inexperienced prescribers. • Process improvements as a result of: • Improved communication between different departments and care settings. • Reduction in paperwork-related problems, e.g. fewer lost or illegible prescriptions. • Clearer, and more complete, audit trails of medication administration. • Improved guidance and management and appropriate reminders within care pathways.

33. Potential Risks of E-Prescribing • Changing from paper to a computer based system is hard • Most people struggle at first, and tasks take longer • Some people are fearful that their computer skills are not sufficient • Systematic errors may be programmed in, e.g. terminating a course of antibiotics without warning • Assumption that ‘the computer must be right’, e.g. unthinking use of default doses • Errors using drug selection drop-down lists • Reduction in face-to-face communications within the care team

34. Example of Administration Screen • Legible • Two day context • Clear record of activity • Able to review allergies

35. E-prescribing Summary • Implementing ePrescribing is a challenge, a major project and a substantial change in the way care is delivered • But it is achievable, and others have achieved it and gained many benefits • Once it is in use most health care professionals would not want to go back to paper

36. SECURITY AND CONFIDENTIALITY Week 4 – Part 2

37. INTRODUCTION • Many of the topics discussed thus far have highlighted the benefits of: • databases for storing vast arrays of medical data and • computer networks for sharing this information between medical staff and different institutions. • Associated with these obvious benefits are a number of potential ‘risks’ in relation to the security of medical data.

38. Definition of secure • Free from fear, care, danger, doubt, etc. • Not worried, troubled • Firm, stable • Safe; in safekeeping • Reliable, dependable (Source: Collins Concise English Dictionary)

39. Definition of confidential • Told in confidence (the belief that another will keep a secret) • Entrusted with private or secret matters Derived: Latin con (with) fides (trust)

40. Why are they important? • Not all information is public • The best secret is one you tell to no one • Desirable qualities of information: • confidentiality • available to those who are authorised to use it • unavailable to those who are not • integrity • safe against unauthorised modification

41. Why is medical information sensitive? • Personal • Can highlight a weakness or lack of • One of a number of types of information deemed "sensitive personal data" by the Data Protection Act…

42. Sensitive personal data (DPA 1998) • the racial or ethnic origin of the data subject • political opinions • religious beliefs or other beliefs of a similar nature • whether they are a member of a trade union (within the meaning of the Trade Union and Labour Relations (Consolidation) Act 1992)  • physical or mental health or condition • sexual orientation  • the commission or alleged commission by them of any offence, or • any proceedings for any offence committed or alleged to have been committed by them, the disposal of such proceedings or the sentence of any court in such proceedings

43. Sensitive medical conditions • AIDS/HIV • Other STDs • Abortion • Fertility/embryology • Mental health problems • Can Impact on… • personal relationships • job • ability to get obtain insurance

44. Horror stories • Person told results of tests by their neighbour • Inappropriate calls to family practitioner committees • Hospital Episode Statistics contain date of birth and postcode • NHS Tracing Service • first database to contain up-to-date information on the whereabouts of every man, woman and child inengland.

45. Key questions • Are these… • ethical? • legal? • Have patients given their consent?

46. Caldicottreport (1) • Report on the review of patient-identifiable information: • Review commissioned by Chief Medical Officer of England • Chaired by Dame Fiona Caldicott • Reported December 1997 • Continually amended.

47. Caldicott report (2) • Looked at all patient-identifiable information transferred between NHS and non-NHS bodies • 86 flows of patient-identifiable information were mapped relating to planning, operation and monitoring purposes • 6 principles which should be applied to information flow were made • Read the article of webCT.

48. Caldicott Principles. • Principle 1 – Justify the purpose(s) for using confidential information • Principle 2 – Only use it when absolutely necessary • Principle 3 – Use the minimum that is required • Principle 4 – Access should be on a strict need-to-know basis • Principle 5 – Everyone must understand his or her responsibilities • Principle 6 – Understand and comply with the law

49. Caldicott recommendations • Reinforce awareness of confidentiality issues • Appoint "Caldicott guardians" • NHS number (ID) should replace other identifiers • Establish protocols for authorising access • Design systems that avoid patient-identifiable data being transmitted

50. Patient identifiable information • patient’s name, address, full post code, date of birth; • pictures, photographs, videos, audio-tapes or other images of patients; • NHS number and local patient identifiable codes; • anything else that may be used to identify a patient directly or indirectly. • E.g. Rare diseases, drug treatments or statistical analyses which have very small numbers within a small population may allow individuals to be identified.