Processing Health Information: Clinical Practice

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Contents

Introduction

Learning Objectives

With completion of this section it is intended that the student will have a high level understanding of the functionality and scope of the ‘clinician facing’ systems that are widely deployed in the current health system in Australia.

Aims of Unit

In this Section we review the different varieties of computer systems which are used by clinicians - as opposed to those used by managers and support staff. These systems can sensibly be divided into: 1. General Practice Record Keeping And Support Systems 2. General Practice Administrative and Billing Systems (See next section) 3. Specialist Practice Record Keeping and Support Systems. 4. Specialist Practice Administrative and Billing Systems (See next section) 5. Hospital Clinical Systems (Electronic Patient Records, CPOE (Clinical Physician Order Entry), Results Reporting Systems etc.) 6. Systems Which Provide Information To Support Clinical Care Delivery directly (Laboratory Systems, Radiology Systems and PACS (Picture Archive Communication Systems), Medication Management Systems etc. At the end of this unit the student should understand the key functions provided by the systems discussed and how they contribute to clinical care delivery. Chapters 4 and 5 of the Recommended Text cover this area - with slightly different but equally valid perspectives.

General Practice Clinical Systems

In many reports done over the last 10 years Australia has been found to have one of the highest levels of GP Automation in the world. A very recent report was conducted by the Commonwealth Fund. A Survey of Primary Care Doctors in Ten Countries Shows Progress in Use of Health Information Technology, Less in Other Areas November 15, 2012 Authors: Cathy Schoen, M.S., Robin Osborn, M.B.A, David Squires, M.A., Michelle M. Doty, Ph.D., Petra Rasmussen, M.P.H., Roz Pierson, Ph.D., and Sandra Applebaum, M.S. Journal: Health Affairs Web First, published online Nov. 15, 2012. The report can be downloaded from the following link

For Australia some of the key findings are:

  • 92% of doctors use Electronic Medical Records (EMR)
  • 88% receive alerts regarding potential prescribing problems
  • 60% of doctors use a multifunctional EMR.

Note: Multifunctional health IT capacity—uses electronic medical record and at least two electronic functions: for order entry management, generating patient information, generating panel information, and routine clinical decision support.

  • 27% of doctors can exchange patient summaries and test results outside their practices

Most of these figures are close to the best in the world - although there is clearly some room for improvement. What also flows from these statistics is some clarity about what GPs are using their computers for as part of their daily work - and separate from the patient administration (appointments and so on) and patient billing. Essentially the GP uses their system for recording the details of the patient, the key aspects of their history, their active clinical problems and the actions taken by the practitioner (prescribing, referral and so on.) (More on the information being captured is provided in Section 3.0). While the market for provision of GP software is very diverse two important providers (who have well over ½ of the total market between them) are Medical Director (provided by HCN Limited) and Best Practice provide very useful web sites and downloads that provide useful overviews of the clinical capabilities and functionality they offer their customers. For Medical Director the main website is found here

Usefully they offer a really detailed summary of their software here

For Best Practice the main website is found here

There is a good summary of the offering here

and a very good collection of screen shots showing key functions is found here

Review of these sites will provide the student with a comprehensive view of the capabilities presently offered for GPs. In recent times both these providers and most others in the area - as well as many in the Aged Care Domain - have been responding to requests from their clinician users which permit the clinician to gain some electronic health incentive payments - called e-PIP (e-Practice Incentive Program). As these payments can be worth up to $50,000 p.a. per practice it is not hard to see why the clinicians care keen to have compliant systems. Essentially the e-PIP requirements require improved electronic messaging and coding capabilities as well as the capacity to access the still evolving and politically contentious Personally Controlled Electronic Health Record (PCEHR) service provided by the Federal government. You can read all about the e-PIP program here

Interestingly the incentive payments are made for possessing particular technical capabilities - not their actual use. The best starting point to discover about the PCEHR System and associated matters is here It is important to note that with this high level of use of computers in General Practice to record patient information comes risk if the computers and the contained information are not properly managed and secured. This requires that appropriate technical support and advice is available either from the system providers or others. Key issues include information security, management of viral and malware attacks and the proper management of information backups as well as ensuring only properly authorised users can access the systems. There is extensive information available for GPs here (Note especially the downloads that are available from the bottom of this web page) Last but not least it is important to realise that the clinician using a computer during a consultation can be either re-assuring or concerning for a patient depending on how the computer is used. Most important is that the computer not be seen as a barrier to communication between the clinician and the patient by, for example, having it positioned between the two on a desk! Interestingly some patients find it reassuring that the clinician using the computer is checking what they are doing while others feel that the need to check possibly indicates incompetence. There is a very useful blog discussing the various room set-up options and mistakes found here

  • A useful summary of a survey of patient attitudes to computer use can be found in the paper

Patients’ perceptions of general practitioners using computers during the patient-doctor consultation Joanne Callen, Megan Bevis and Jean McIntosh Abstract In this study 85 adult patients attending a Sydney general practice were asked for their views on computer- assisted consultations; 77 (91%) agreed to participate. In general, patients agreed they could still talk easily with their doctor, and felt listened to, while the doctor used the computer (87% & 75% respectively). More than half the patients felt the computer contributed to better treatment, although a quarter believed consultations were prolonged. About half the patients agreed that the doctor did not often explain the role of the computer. Given the national plans for increasing computerisation of health records (Health Connect ), this research suggests that more attention should be given to involving patients in e-health developments. The full paper is found here

Benefits Of General Practitioner Computer Use

The purpose of automation of General Practice is to, ultimately, improve the quality and safety of the care offered to GP patients. To achieve this outcome the key objective is to support the record keeping, decision making, efficiency and treatment consistency of Australian General Practice. Among the key benefits that arise from the use of computers in the clinical context are:

  • Production of legible and drug-interaction assessed prescriptions which reduces the risks of prescribing and transcription errors. This is especially so if the prescription in bar coded to allow download of the prescription information from a prescription exchange.
  • Ease as speed of production of repeat prescriptions.
  • Accurate recording of information - again legibly and accurately dated and timed - which permits improved medico-legal defence as well as providing clear structured recording of information for future follow-up and use.
  • The ability to easily create clinical reminders and alerts to ensure that routine quality care in areas like vaccination and screening is provided.
  • The electronic receipt of pathology and radiology results and reports and internal processes within the software to ensure all incoming information is properly reviewed and actioned.
  • The ability to easily provide detailed background information for use in referrals.
  • The ability to receive prompt discharge summaries and specialist letters from those to who a patient is referred.
  • Overall enhanced co-ordination of care for chronic disease patients especially due to improved communication between each of the actors involved in their care.
  • Improved capability for practices to assess and improve the quality of care being provided overall and in specific disease states.

Overall these and other benefits mean there is a lot to be gained in both quality, safety and GP satisfaction from well designed and implemented systems. When used well they can make a positive real difference to the care the patient receives.

Specialist Practice Record Keeping and Support Systems

Office Specialist Practice can provide all sorts of interesting challenges as work is done to support the diverse needs of different specialties. All clinical specialist systems typically have a basic patient identification and other general functions (history recording, messaging for referrals and reports, prescribing and so on) but then can vary widely depending on the specialty. Examples might include:

  • Specialised information capture screens and templates individualised by specialty (dentists and oral surgeons are an obvious example).
  • Image management features for dermatologists, gastroenterologists etc.
  • Modified workflow support for the differing work patterns of some practitioners.
  • Video capture and video storage capability for cardiologists.
  • Audio capture and storage for dictated reports.

Key to the success of any of these systems - and indeed any systems - is careful engagement with users to ensure the business needs of these key users are fully met. For those who are interested here is a link to a sample system Guides to how to select software for a range of specialist purposes are here Each guide provides a list of interesting capabilities that may be considered. Worth having a look at one or two to see the range possible.

Hospital Clinical Systems

Patient facing systems used in hospital cover two broad areas. The first are the Patient Administration and Scheduling systems and the second are the Ward Use Clinical Systems. (The next section addresses the clinical support systems). Note that Chapters 4 and 5 of the recommended text book provide coverage of this area and what follows should be read in conjunction with these.

Patient Administration And Scheduling Systems

There are 2 major Patient Administration Systems.

  • The first, which is often seen as the central system in any clinical suite, is the Patient Master Index (PMI). The Patient Master Index holds the stable identification information for each patient (Name, Address, Date of Birth, Sex, Next of Kin, Contact Details and so on and then usually a numeric identifier (called a Medical Record Number (MRN) or something similar). Additionally other identifiers may be held - and in Australia the Individual Health Identifier - provided by the Australian Government Health Identifier Service - is often stored.

The core identifier is typically used to link information from all other system back to the individual patient and to make all the associated information available to any other application that needs it. Essentially the PMI acts as a ‘single source of truth’ for the basic patient identifying information and allows other systems to use that information as needed for its own operations. Additionally the PMI can be used to hold various historical registers and documents that are patient related - examples might include Advanced Directives and maybe immunisation history.

  • The second major system is the Admissions, Discharge and Transfer System (ADT) sometimes called (maybe for logically) an Admissions, Transfer and Separation System (ATS). As with the PMI knowing the ‘who’ for all other systems the ADT System is designed to provide the ‘where’ to other systems.

Typically the functionality provides for a view of the occupiable beds or cots to be created and then from that baseline patients are allocated to each potentially usable location on admission, re-located as needed (e.g. when moving to and from an intensive care bed, emergency unit or operating suite) and ultimately discharged from the facility. It is obvious that it is important that the information contained in the system both must be carefully and promptly updated and that errors could cause all sort of problems. The system provides a range of useful functions besides providing the patient location information needed by other systems. Among others it. a. Provides patient location information to allow for reception desks to guide visitors, the telephone exchange to connect patients to relatives and other relative and customer facing functions. b. A real time census of occupied and available locations which can be used to accommodate new arrivals. c. In information feed to the accommodation billing system so patients can be charged (correctly). d. Allows for patient service providers of all sorts to locate and service the patient. e. Permits the production of a range of reports to assess facility utilization and occupancy.

Knowing where patients - and indeed equipment and importantly paper medical records- has now been made a lot easier by the use of Radio Frequency Identity Devices - which can have the ATS keep track of changes of patient location and so updates of location can be fully automatic. While obviously advertising there is a lot of useful information on just how these systems can help found here

Being able to fully automate the tracking of patients, records and assets (even quite small ones) can have a real impact on the operational efficiency and safety of a hospital.

  • A third suite of administrative systems are those use to schedule the use of hospital facilities - operating theatres, diagnostic imaging equipment and so on, and to match their use in the best fashion possible to the demand for such services and facilities.

These systems can be relatively simple - where essentially a human staff member does their best to match patients with the service they require and much more complex where an attempt is made to automate the resource allocation task using both more information and a variety of algorithms. A flavour of the complexity that exists in this area can be gleaned by browsing this article on Operating Room Scheduling from Wikipedia. See here

An introduction to the sort of complexity and capability that can be found in modern commercial systems is here The investment of time and effort in the development and implementation of these systems is indicative of the level of real financial benefit that can be derived by improving the appropriate utilisation of resources - both human and facility wise.

Ward Based Clinical Systems

For the doctor working in the hospital ward for many years the standard application suite has covered patient information lookup (in the form of results and more recently images) and some form of patient ordering system which permits the ordering of investigations of all type - often supported by (integrated) Clinical Decision Support (CDS) systems. A major change in the last few years has been the emergence of mobile, network connectable devices such as the iPad and Android equivalents which can act as a terminal to these applications but also bring all sorts of educational and information based applications to the mobile environment to create a very valuable support for day to day clinical work. Of course such devices can also access, when authorised, the systems mentioned in the previous section to make finding patients and so on much more easy and convenient.

  • Taking information access (often called Results Reporting) first. Typically this application takes a current active patient list for the specific clinician and then, when a patient is selected provides a menu of available results along with some ways of, if relevant, plotting trends over time. For example if a patient has had a series of the same blood test undertaken to track their progress then these can be displayed - usually with the newest results at the right of the screen and historical results being increasingly to the left. For most results presentations there will be mechanisms to highlight abnormal results (usually with colour and / or asterisks) .
  • Presentation of clinical imaging reports and images can be a little more difficult since some terminals do not support adequate screen resolutions to provide a properly diagnostic image. This can be overcome by using dedicated imaging terminals. Interestingly the resolution of many mobile devices is such that they are pretty useful (and safe) in the interpretation of many imaging studies.

Typically the clinical front end of ward based systems will cover Results Reporting and a range of other services. Sensible design of the front end will typically involve selecting a ward, then the patient within the ward and then the functions that can be applied to the selected patient.

Diagnostic Test and Service Ordering

Other than information access the other major function offered at the ward access device (terminal, PC or mobile device) will be the capability to order and schedule services and diagnostic testing. The types of services might include dietary, physiotherapy and other specialist allied health services. Diagnostic services may well include laboratory services, imaging services and specialist testing (e.g. in cardiology, gastroenterology and so on.) Increasingly the ordering and scheduling of these activities is being supported by clinical decision support aiming to ensure the testing is appropriate. As such testing often involves use of specific limited facilities (e.g. a scanner etc.) the diagnostic system often needs to interact with a scheduling system to optimise the use of the facility and the timing of the service delivery. Such optimisation can become quite complex as order for service may have urgency ratings as well as a range of patient characteristics which may alter the time taken for a test to be completed. It is also important to remember another complexity in ordering relates to the capabilities and order privileges of the logged in individual. Obviously the transport porter may need access to the scheduling system to manage is patient transport task but they equally must be excluded from ordering drugs of addiction.

Medication Management And CPOE

CPOE stands for Clinical Physician Order Entry and is the functionality contained in Hospital Information Systems to allow specialised clinical ordering of diagnostics, medications and so on. Typically such a system will permit the creation of order templates or order sets to address common situations. This might be, for example, routine pre-op orders for a hip replacement or an admission for the investigation of chest pain. The power of such order sets is that - if well and carefully designed - they can help to ensure safe, consistent and efficient care by making sure important things are not forgotten and that unnecessary procedures and tests are not undertaken. Because the CPOE system can order such a wide range of tests, services and treatments with a single step there are also significant time savings possible by the use of such systems. Such time-saving is usually pretty attractive to clinicians.

  • Medication management is typically also provided via the CPOE System front end. However what follows once a medication is ordered can be more complex.

A slightly more specialised function will be the ordering of medicines and other treatment. Medication Management is a holistic application which, when fully implemented, will involve the prescriber, the pharmacist (dispenser and medication adviser), the administering entity (typically a nurse) as well as the patient. Medication Management (MM) is simple in concept - the system aims to get the right drug, in the right dose and form, to the right patient at the right time. Essentially the total MM system acts as a co-ordination and communication system between each of those involved - while aiming to help each do their job as well as possible. For the physician what is needed is a system that makes it easy to prescribe - which implies appropriate security - while at the same time providing decision support to avoid mistakes in drug selection or use in wrong combinations with medicines the patient may already be receiving. In most hospitals the front end of the MM system is part of the overall CPOE system and typically will also provide medication cost information etc. Better systems will also look for information from other systems (e.g. a dietary system) to encourage transition from injectable to oral formulations (which are cheaper and safer) when the patient is eating again post-surgery for example. Once a prescription is approved by the prescriber it moves electronically to a dispensing system where it is reviewed by the clinical pharmacist and the medication is labelled, packed and prepared for delivery to the ward where the patient is located. (Note in passing the way the system needs to interact with the patient locating system and possibly courier systems to deliver to the ward). Before considering what happens on the ward it is interesting to note that some key advances - namely barcoding and the use of RFID chips - are now increasingly use to label each individual container - or even tablet - to improve tracking and - when used with barcoded patient ID bands or medication charts to enable very positive identification of medication and patient.

Supporting Clinical Systems

In this section the systems that provide support to the front end hospital clinical systems are discussed.

Laboratory Information Systems (LIS)

Diagnostic laboratories are often a major part of the operations of a hospital and provide a wide range of services. Ideally the systems are well integrated into the overall hospital environment so information flows both in and out the laboratory are seamless and effectively instantaneous. The following diagram - sourced from a quite old paper makes the overall scope of the basic system clear.

Fig. - LIS Architecture

(Page 6 of A new clinical laboratory information system architecture from the OpenLabs project offering advanced services for laboratory staff and users Gerard Boran, Rory O'Moore, William Grimson, Margaret Peters, Arie Hasman, Torgny Groth, Frits Van Merode) : http://www.ncbi.nlm.nih.gov/pubmed/8740567 )

Consideration of the above activity circle shows the information flows from the request of a test through to the delivery of a completed report. The role of the LIS is to provide support to each of these six activities and the various sub-activities (e.g. quality control, sample management and tracking and so on.) The reader is advised to explore the following two links and relevant comments of the text-book. See here

and here

It is worth pointing out that the LIS, like the systems that are discussed below, have two distinct customers as it were. The first is the clinician who is caring for the patient who needs the information the diagnostic test will provide and the second are those undertaking the testing and need computerised support as the sample is processed and finally produces the end report. As a final point in 2013 there is no reason to develop a LIS internally, no matter how complex or simple the laboratory or organisation as there are excellent system providers in all possible niches.

Radiology Information Systems / Picture Archive Communication Systems (RIS/PACS)

Radiology Information Systems (RIS) are made quite complex because there is so much they have to co-ordinate and then execute in terms of the usual cycle of tracking a request from clinician back to a report provided to the clinician. In the meantime the patient needs to be scheduled to have an encounter with some (usually) expensive equipment which needs its utilisation optimised as well as ensuring as shorter patient wait as possible. The product of the imaging encounter (the images which are typically managed by an integrated Picture Archive Communication System (PACS) then needs to be made available to an expert clinician - a radiologist typically - to be assessed and reported upon. Getting optimal workflow to suit the patient, radiologist and equipment utilisation can be a quite challenging task which is made easier in an integrated environment where patient identity, location and so on is already being managed in other systems. (PMI, ATS etc.) You can read descriptions of the typical RIS here

And a very good article on where PACS fits in here

It is interesting to note that the cost / benefit of installing PACS is very high (benefits based on better interpretation, less repeat studies, no lost images, ease of access 24/7, no film and silver costs and so on). The UK has installed a national PACS system which reached virtually all significant hospitals in England providing seamless patient image access over the whole country.

Medication Management Systems

See discussion above. In addition to what is described in the section above it is important to be aware that at the pharmacist side of the medication orders there will be a Pharmacy Information System (PIS) . The functionality provided by such systems will include:

  • Dispensing and Medication Labelling Support.
  • Pharmacy Decision Support to permit pharmacists to carefully review prescriptions and to identify problems that may have been missed by the prescriber prior to dispensing. In this regard the PIS can take advantage of information held in other systems to obtain information on patient ID, Age, Sex, as well as some diagnostic information to assess prescription appropriateness and, taking advantage of the current medication list to check for adverse disease and medication interactions.
  • Backend Pharmacy Functionality to provide inventory control, medication drug expiry monitoring and alerts as well as medication supply location tracking. Where relevant these systems can also support specialist pharmacy sites in wards such as paediatrics and oncology.

A PIS is a good example of how an apparently isolated application can take advantage of all the other information what may be useful from other systems.

Dietary / Catering Systems

The systems used to manage food (and specialised nutrition) can be quite complex and can draw information from a range of different systems. At core the objective of such systems is to make sure the right patient receives the right meal at the right time consistent with their clinical condition while at the same time minimising waste as well as patients not receiving needed meals! At the heart of the system there is a catering system that produces a meal menu which can then be prepared by the kitchen based on the aggregate demand for a particular meal as determined by patient requests for their meals - modulated as needed by catering and nursing staff. Additionally there also needs to be nutritional analysis of menus to ensure appropriate nutritional intake. As well there are also systems to manage the distribution of meals as well inventory control and food purchasing systems. Taken as a whole it is interesting to note just how many touch points there are for integration of a dietary / catering system within a hospital and also to reflect on the time-criticality involved with a need to make sure all who need a meal can get one and that evolving needs for different diets are promptly responded to. In some ways how all this is choreographed is a good example of how getting the right information at the right time to the right people can improve overall hospital operations, cost and patient satisfaction. Lastly it is worth remembering many hospitals run active event hosting and fund raising occasions where the catering can be a major contributor to the overall success of a function. A system to support these activities can be a useful addition to the hospital system repertoire.

Specialist Support Systems

This is just to point out that many hospital departments have specialist needs for focussed systems that service their clinicians for research, quality control and patient care monitoring. Departments that provide specific services very commonly have special forms to record the delivery of the services and the results of any procedure.

Review Questions

  • Students might find it instructive to review a typical hospital admission for routine elective surgery and to map out the various systems that those delivering the care might use to assist with delivery of that care.
  • Students might find it useful to download a demonstration version of a General Practice system and then explore its capabilities to understand just what functionality is offered and how well the system fits into practice information capture and workflow.

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