Hospital Information Systems:Where we’ve come from and where we’re going

Jonathan Pell, M.D. Assistant Professor, Hospital Medicine IS Physician Liaison University of Colorado at Denver and Health Sciences Center

Tuesday Morning Conference

Denver Veteran Affairs Medical Center

January 20th 2009

Objectives What is a Hospital Information System

(HIS) and why should I care? Brief history of hospital HIS’s Problems with development of HIS Barriers to clinician adoption of new

technologies Barriers to hospital adoption of HIS Potential future directions for HIS’s

Government employee

An Hour in the Life of a Hospitalist

Starting your 7pm-7am shift and get sign-out from 4 daytime teams (8-10 patients each)

ED calls you with a new admission Nurse calls about pt X’s headache 30min

later Finally get to the ED to admit patient Get back to the floor and sign orders

History of Computers

Punch card data processing 1890

First digital computer 1940

General purpose computers 1950

First minicomputer late 1960’s

First microprocessors and PC’s late 1970’s

World Wide Web early 1990’s

Wireless computers late 1990’s

Original Hospital Information Systems (HIS) 1962 Initiated by Bolt, Beranek and

Newman and carried out by Octo Barnett at MGH

Funded by NIH whose biggest concern was not enough MD input

Other HIS Pioneers

Warner at Latter Day Saints hospital, Utah

Collen at Kaiser Permanente, California

Wiederhold at Stanford University

Progression of Computer Use in Hospitals

One System for all?

Departmental systems became feasible in 1970’s

Departmental systems develop tailored to specific application areas

No common databases or database systems

Best of breed theory begins to develop

What makes up a HIS of today Admission, discharge, and transfer system (ADT) Electronic Medical Record (EMR) Picture Archiving and communication (PACS) Pharmacy Labs (including microbiology, pathology) Billing and Scheduling Active patient data systems (ER, Med/surg, OR,

ICU)

Electronic Health Record (EHR) Needs

Accessible Secure Acceptable to clinicians Acceptable to patients Integrated with both patient specific and

patient nonspecific information

Data that goes into an EHR

Clinician visit notes -ER visits -Hospitalization summaries

Labs, microbiology, pathology, and radiology results

Patient specific lists -problem list -medication list

Patient Demographics and billing

Patient phone calls

Procedure Reports

Prescriptions and medications administered

Active patient information -Vital signs -I’s and O’s

Clinician orders

Problem: Lots of forms of Data

Free text Lists of text (problem lists) Numbers with titles and error ranges (labs) Images in multiple forms (ECG,CXR) Multiple note formats Text with numbers (prescriptions) Trends of numbers (in hospital vitals, labs)

Shortliffe, EH (2006)

What do we want coming out of an EHR?

Clinician visit notes -ER visits -Hospitalization summaries

Labs, microbiology, pathology, and radiology results

Patient specific lists -problem list -medication list

Patient Demographics and billing

Patient phone calls

Procedure Reports

Prescriptions and medications administered

Active patient information -Vital signs -I’s and O’s

Clinician orders

And More…EHR Functional Components Clinical Decision Support – “clinical system,

application or process that helps health professionals make clinical decisions to enhance patient care” defined by HIMSS

Integrated view of patient data Clinician Order Entry Access to Knowledge Resources Integrated communication and reporting

support E-prescription when patients are discharged

How do solve the multiple data form problem? Original Solution- Substitution

Display information we already have on computer screen

What we need- TransformationRethink how we obtain patient information and

manage patients Understand computer technology to change

how we think about patient data use

How Physicians Enter Data

Transcription- dictated or written notes

Filling out structured encounter forms

Direct data entry

The Informatics World Solution: Coding Problem: You can’t put the art of medicine

into code (at least not easily) Coding Systems

ICD-9 (International Classification of Disease) SNOMED (Systemized Nomenclature of Medicine) CPT (Current Procedural Terminology) LOINC (Laboratory Observations, Identifiers, Names,

and Codes) Arden Syntax – medical decision logic

Lost in Translation

Amount given: 60meq, Site: Medication administered P.O., Correct patient, time, route, dose and medication confirmed prior to administration. Patient advised of actions and side-effects prior to administration, Allergies confirmed and medications reviewed prior to administration. (19:26 CK1) : Follow Up : Decreased symptoms. (21:29 DVB)

ORDERS BMP BASIC METABOLIC PANEL by TAI for BA on Wed Dec 31, 2008 18:06 Status: Done by System Wed Dec 31, 2008 18:58. PHOSPHORUS SERUM/PLASMA by TAI for BA on Wed Dec 31, 2008 18:06 Status: Done by System Wed Dec 31, 2008 18:58. CBC COMPLETE HEMATOLOGY PROFILE by TAI for BA on Wed Dec 31, 2008 18:06 Status: Done by System Wed Dec 31, 2008 18:24. MAGNESIUM SERUM by TAI for BA on Wed Dec 31, 2008 18:06 Status: Done by System Wed Dec 31, 2008 18:58. CT BRAIN by TAI for BA on Wed Dec 31, 2008 18:08 Status: Cancelled by System Wed Dec 31, 2008 18:20. XR SHOULDER 3 VIEW INCLUDING AXILLARY by TAI for BA on Wed Dec 31, 2008 18:15 Status: Cancelled by System Wed Dec 31, 2008 18:20. MR BRAIN by CK1 for CK1 on Wed Dec 31, 2008 20:43 Status: Cancelled by System Wed Dec 31, 2008 21:07. XR CHEST PA LAT by CK1 for CK1 on Wed Dec 31, 2008 21:04 Status: Done by System Wed Dec 31, 2008 22:14.

Narrative Text vs Coded Data Narrative PMedHx

DMII diagnosed 10 yrs ago now on insulin with last A1c 10.6 (12/15/08) suspectedly due to poor medication compliance

Chronic renal insufficiency secondary to diabetes with 1g proteinuria and baseline creatinine 2.1 (12/15/08)

Coded PMedHx-250.42 (DM 2 uncontrolled with renal

complications)

Benefits

TextEasy to document and interpretComprehensive and fully customizableGood for individual patient care

Coded DataAggregate analysisWell defined for billing Information system friendly

Data-Interchange Standards International Standards Organization

(ISO)’s Open Standards Institure (OSI) seven levels required for data exchangeHL7 (Health Level 7) - Data interchangeDigital Imaging Communications in Medicine

(DICOM) for PACSNational Council for Prescription Drug

Programs (NCPDP) - pharmacyASTM 1238 – lab information interchange

Partial Solutions

Extensive Interface Engine hardware, software ,and support

“At a minimum, difficult interfaces result in steep learning curves and structural inefficiencies in task performance. At worst, problematic interfaces can have serious consequences in patient safety”

Lin at al Applying human factors to the design of medical equipment. J. of Clin. Monitoring and Computing.14(4) 253-263.1998.

Transfer of patients between different systems

Medications dropped from lists Redundant admission orders written Documented patient information from

previous system lost or difficult to interpret Orders dropped on transfer Medications mistakenly given twice

Database standards

Single Vendor or Best of Breed Few single vendors out there

EpicMeditechCernerMcKessonGE/IDX

No longer best of breed in each department

Who is looking at the big picture?

HIMSS- Health Care Information and Management Systems Society

IHE- Integrating the Healthcare Enterprise CCHIT-Certification Commission for

Healthcare Information Technology HITSP- Healthcare Information

Technology Standards Panel

HITSP Programs of work topics

Lab results reporting Bio-surveillance Consumer empowerment Emergency Responder-HER Quality Medication management Personalized Healthcare Consultations and transfers of care Immunizations and response Patient-provider secure messaging Remote monitoring

Clinician Barriers to IT system implementation and change

Clinician Barriers to IT system implementation and change Clinician prefer computer use for

consultation but do not like data entry Opposed to extra effort unless clear

benefit Do not like the inflexibility Disrupts time for the clinician patient

encounter Clinician’s don’t like change

Mcdonald et al 1992.

What do Clinicians Care About

Does it have the information we are used to having

What is it’s usability: Learnability Efficiency Memorability Minimization of Errors Satisfaction

Nielson 1993

IT Industry Response

More code devoted to Graphic User InterfaceUnderstanding needs of different usersUnderstanding workflow

Budgets spent on usability increasing Implementation budgets increasing

What do hospitals care about?

Cost reductionProductivity enhancementQuality Improvement Competitive AdvantageRegulatory Compliance

2008 HIMSS Leadership Survey

National Level

The Computer-Based Patient Record: An Essential Technology for Health Care -IOM report in 1991 and revised in 1997

National commitment of 50 billion dollars over 5 years toward electronic health record for all?

IT czar in Washington RHIO’s and Potential for a National Health

Information Infrastructure (NHII)

NHII

Idea first raised in 2001 by the National Committee on Vital and Health Statistics

Distributed system of databases using standards for access

Benefits in: Cost of Care Compliance with national guidelines Public health notification Research

Physician Visit of the Future

Patient physician interaction is voice recognition recorded into standard history format

Physical exam is performed and commented on by device peripherals

Physician uses Tablet PC’s or PDA’s to review vitals, radiology, labs, and clinician notes, etc.

All physician orders are entered through the device and incorporated into note for plan

E and M billing recommendations made and verified

All this information could be viewed by itself and in aggregate from anywhere securely

What’s Happening at UCH

Evaluating use of a single vendor-EpicSingle database and interface systemCPOEDecision supportCustomized user views of patient information

CORHIO participation

ReferencesBarnett, GO. History of Medical Informatics: Proceedings of ACM conference on History of medical informatics .Bethesda, Maryland, United States, 43 – 49, 1987.

Barnett, GO. Computers and Patient Care N. Eng. J. of Med.1968. 269: 1321-1327.

Nielson 1993 Usability Engineering. Boston, Academic Press.

Mcdonald, C.J. et al The Regenstrief medical record system: 20 years of experience in hospitals, clinics, and neighborhood health centers. MD Computing. 9 (1992) 206-217.

Lin at al Applying human factors to the design of medical equipment. J. of Clin. Monitoring and Computing.14(4) 253-263.1998.

van Ginnekan, AM. The computerized patient record: balancing effort and benefit. Int. J. of Med. Informatics. 65 (2002) 97-119.

Shortliffe, EH (2006) Biomedical Informatics: Computer Applications in Health Care and Biomedicine 3rd Edition. New York. Springer