Austin and Boxerman chapter 8

HSPM J713

Applications Learning ObjectivesWrite about:• Types of application software used in health

care organizations– Functionality– End users

• Medical records evolution from paper to EHR• Clinical decision support software vs. [?]• Executive information systems• Applications for research and medical

education

Application software

• An “application” is a piece of software designed to do something specific

• E.g. Microsoft Office comprises a number of major applications– Word– Excel– Powerpoint– Access– Outlook

Standalone vs. Integration

• Best of its type vs. best integrated suite• Basic functionality – pretty much solved?• Interoperability• Standards favor integration

Migrating

• Migrating from “legacy” standalone to integrated system can be daunting– Different applications came into use at different

times• Financial earliest• Clinical information systems more recent

– Mr. Strickland’s COBOL joke – just maintaining legacy systems can be a problem

A digression about COBOL• Grace Hopper, 1959. Common Business-

Oriented Language• Example of COBOL statementADD YEARS TO AGE • By comparison, C and Java useage := age + years; • Orage += years;

Health Records(intro to electronic health records)

• Document patient care for later reference by provider

• Communication among providers• Document patient care for – accounting and billing– data for health services research– Management to improve quality, reduce cost

Health records

• Mostly paper, still• Electronic data entry or electronic

communication → paper inserted into record

Institute of Medicine

– An independent non-profit agency which gives advice to the US government

• 1991, 1997 reports favoring electronic medical records

• Laid out what electronic medical records (called EHR in textbook) should do

IOM: EHR should

• Data about diagnostic and treatment events retrievable electronically – No redundancy

• Real time data entry and retrieval– What you enter goes straight in– You can get out what you need now

EHR should (continued)

• Link scheduling, billing, referrals• Data can be interchanged with oversight

agencies and partner organizations• Real time access by providers to diagnosis and

treatment information• Individual patients can access their own

records– Last two subject to confidentiality rules

Progress towards EHR

• Electronic medical records (their term) are common.– Images of paper, or optical character reader to

create electronic information from paper

• Electronic patient record (their term) less common– Works across organizations

EHR

• All medical and health records connected by unique identifier, no matter where data stored– New definition of EHR?

• Will require national standards• Now, competing standards by vendors for

communication among their applications

VistA

• Veterans Health Information Systems and Technology Architecture – Most advanced in US

• Other efforts– Vendors’ systems for hospitals, doctors’ offices– Academic medical centers

Clinical Information Systems

• Support diagnosis, treatment, and evaluation• Most systems in place have limited scope• Embed clinical practice guidelines– Require justification for going beyond rules

• Standard (“evidence based”) treatment plans for comparison with your idiosyncratic effort

• Often, separate systems, not integrated– Departmental decisionmaking (“best of breed”)– The following slides are about departmental systems

Clinical Information System:

Laboratory systems• Automated test processing– Computer-driven analysis of samples

• Functions– Record test requisitions (orders)– Schedule specimen collection– Output from instruments goes to computer– Calculations– Record test results

Laboratory systems

• Functions (continued)– Alerts for follow-up– Summary reports for patient– Summary reports for lab– Maintain records for quality control– Monitoring productivity

Clinical Information System:

Pharmacy information systemsErrors!

orderingdispensingadministeringrecording

Cited in 1999 IOM report

Good records can help!

Pharmacy

• History of standalone systems– Control of controlled (legal requirements)

substances– Drug ordering and inventory (including formulary)– Drug distribution to patients– Drug information for retrieval by staff• Patient drug profiles

– Billing

Pharmacy

• Once good standalone systems were developed,• The next move is to intergrated systems,– So pharmacy orders can be made or viewed from

anywhere

• Screening and flagging functions not standardized– Competing systems for spotting drug interactions,

dose checking, allergy flagging, duplicate prescription flagging, weight-based dosing for pediatric patients, …

Clinical Information System: Medical Imaging and Radiology

• Imaging– Image processing and storage– Image enhancement

• Radiology– Test orders– Scheduling– Reporting results– Billing and reports to management

Complex images and applications

– 3-D images like:

• Computed tomography• Magnetic resonance imaging

• Computers integral to image creation process

• Radiation therapy – computer-directed

Archive problem

• Film deteriorates• Digital formats and storage devices and

standards change

Clinical Information System:Order Entry and Results Reporting

• Enter diagnostic test orders and treatments• Output test results and treatment summary• CPOE – computerized physician order entry– Checks during data entry– Limited choices on menus

Clinical Information System:Nursing Information Systems

• Planning care• Patient histories• Monitoring patients• Manage nursing unit• Graphical displays• Point-of-care data entry and reporting– Clunky terminals in 1990s– Handheld units today

Nursing point of care systems savings

• Less time and inconvenience when data entry and report retrieval are with the patient instead of central station

• Better quality care – more time at bedside• Timely access to information• Reduced costs– Time savings above– Productivity monitoring?

Management/Administrative and Financial Systems

– Next big category after clinical information systems in book

– Historically, older than clinical information systems

– But hospitals are relatively recent adopters

• Standalone financial and accounting systems giving way to

• ERP– Enterprise Resources Planning

ERP

• In health services organizations:– Financial– Human resources– Resource (non-human?) utilization and scheduling– Materials management– Facilities and project management– Office automation

• Single (distributed) database links them • Used to inform top management decisions

ERP: Financial Information Systems

• Payroll – link to human resources system• Accounts payable – link to purchasing and

inventory• Patient accounting, billing, accounts

receivable• Cost accounting, including allocating overhead• General ledger

Financial Information Systems (continued)

• Budgeting• Internal auditing• Forecasting• Planning financial investments– Cash flow vs. cash need

• Financial statements• Financial reporting for top management

ERP: Human Resources

– In hospitals, labor is 60-70% of operating cost

• Employee information• Position control – link to budget• Labor analysis reports, including turnover and

absenteeism• Inventory of skills and certifications• Information for labor cost allocation – link to

payroll system

Human resources (continued)

• Productivity information• Compare compensation with competitors

Human Resources data

• Personal: Name, address, birthdate, SSN, marital

• Job: Title, department, date started, date promoted, salary

• Benefits: Health insurance, other insurance, pension

• Other: Skills, physical limits, disciplinary actions, awards, bonuses

Human Resources database

• Relational database• Security• Reports• Physicians, too, for planning and recruitment

ERP: Resource (fixed capital, in economics sense) utilization systems• Patient scheduling– Occupancy rates for inpatient beds, operating

rooms

• Clinic use• Emergency department use• Ambulatory surgery centers

Resource (capital allocation) systems

• Connect with clinical decision-making system (CPOE) to flag procedures that precede or require other procedures

• Connect with inventory system to automatically order (or flag for order) needed supplies for scheduled procedure

• Connect with HR to assess personnel need, allocate personnel

• Connect with patient database to remind patient to do prep, show up

ERP: Materials Management (inventory is non-fixed capital)

• Requisitions for suppliers checked against budget

• Electronic data interchange with suppliers (computerized buying)– “Just in time” – reduce inventory

• Bar codes• Food service management– Menu planning

ERP: Facilities and project management

• Maintenance of buildings• Manage new projects or renovations– PERT (Program Evaluation and Review Technique)

[CPM]

• Efficiency• Safety• Energy conservation• Waste management

Office Automation

• Word processing, e-mail, calendar• Groupware– E.g. Microsoft Office • Macros, object linking and embedding

Non-hospital settings

– Specialized applications/information systems for

• Ambulatory care centers• Long-term care (late adopter?)• Home health care

Other

• (some of these seem to repeat from earlier categories)

• (but there are some jargon terms in here worth knowing)

CDS

• Clinical decision support systems– Assist physicians and others in diagnosis and

treatment choices• Passive– Present information culled from other systems

about patient and about medical science• Active– Present information– Suggest diagnoses and treatment

Active CDS categories

• Expert systems– Knowledge base of practice guidelines– Patient-specific information from clinical database– Rule-based inference engine• Combines above two to generate specific suggestions

Active CDS elements

• Probabilistic algorithms

• Reminders and alerts– (for physicians and other patient decision-makers)

Active CDS

• Examples (hooray!) of reminders and warnings working at named hospitals– Beth Israel in Boston: Alerts got docs to start

treatment much sooner– Latter Day Saints in Salt Lake City: reduced

antibiotics usage– UAB: Docs with handhelds more likely to order

non-steroidal anti-inflammatory drugs considered safer on the stomach (Vioxx?)

EIS

• Executive information systems• Business intelligence• Query clinical and administrative databases

and drill down

Evidence-Based MedicineDisease-Management Systems

• Evidence-based?

Now “evidence-based”

• http://www.milliman.com/expertise/healthcare/products-tools/milliman-care-guidelines/index.php

Evidence-based guidelines

• National Guideline Clearinghouse of the US Agency of Healthcare Research and Quality

• http://www.ahrq.gov/clinic/epcix.htm

Disease management systems

• Quality and cost• For prevalent high-cost chronic conditions – Asthma, diabetes, congestive heart failure

• Patient self-management with feedback– Blood and urine test data, Blood pressure, etc.– telephone , internet to remote computer– Info presented to provider

Computer-assisted medical instruments

• Computer as part of equipment• Patient monitoring devices• Image enhancement, signal-to-noise

improvement

Telemedicine

• Telephone, internet, audio-video conferencing communication between– Physician, nurse, physician assistant• And

– Specialists• And

– Patient

Telemedicine

• Audio-video conferencing requires ISDN line, dedicated equipment. – Prisons and rural clinics in Texas

• High-speed internet much less costly.

Medical Research and Education

• Computerized patient records require less labor to mine for data

• Computation– Statistical analysis– Human genome project

• Indexed medical literature– National Library of Medicine’s Medline• They give http://medline.cos.com/• http://www.nlm.nih.gov/databases/

Medical education

• Computer/internet transmitted movies, audio, books, articles

• Interactive simulations of clinical problems

Summary of applications

• Financial -- earliest• Clinical services support -- labs, pharmacy,

radiology• Medical records. EHR still a future goal• Outpatient and long-term care settings• Physician assistance in clinical decisions• Medical equipment, facilities• Research and education