Clinical Information Management in Electronic Age (PPT)

Information Management in the “Electronic Age”: Information Management in the “Electronic Age”: The benefits and limits of technology for managing patient dataThe benefits and limits of technology for managing patient data

Stephen M BorowitzStephen M BorowitzDepartment of PediatricsDepartment of Pediatrics

[email protected]@virginia.eduApril, 2009April, 2009

What is your job?What is your job?

Information ManagementInformation Management» 11stst and 2 and 2ndnd years years

–Accumulate “academic” knowledgeAccumulate “academic” knowledge textbooks, lectures, notes, handouts, textbooks, lectures, notes, handouts,

review books, computer resourcesreview books, computer resources

–FocusFocus tests, boardstests, boards


Information ManagementInformation Management» 33rdrd and 4 and 4thth years years–Accumulate “academic” knowledgeAccumulate “academic” knowledge

textbooks, lectures, notes, handouts, review textbooks, lectures, notes, handouts, review books, computer resourcesbooks, computer resources

–Collect patient dataCollect patient data H & P, chart(s), computer repositoriesH & P, chart(s), computer repositories

–FocusFocus Integrate what you learn academically with what you see Integrate what you learn academically with what you see

clinicallyclinically




–Collect and assimilate patient dataCollect and assimilate patient data H & P, chart(s), computer repositoriesH & P, chart(s), computer repositories



To access the UVA Clinical Portal, type “portal”To access the UVA Clinical Portal, type “portal”in the browser address windowin the browser address window




–Collect and assimilate patient dataCollect and assimilate patient data H & P, chart(s), computer repositoriesH & P, chart(s), computer repositories



How will you best do your job?How will you best do your job?

What are the best sources of patient What are the best sources of patient data/information?data/information?

What are the best ways to organize and What are the best ways to organize and store patient information?store patient information?

What are the benefits/limits of paper What are the benefits/limits of paper and electronic information resources?and electronic information resources?

Sources of Clinical InformationSources of Clinical Information

Low-TechLow-Tech the patient and his/her familythe patient and his/her family the patient’s paper chart(s)the patient’s paper chart(s) paper flowsheetspaper flowsheets nurses, therapists, physicians, other nurses, therapists, physicians, other

studentsstudents

The Patient and His/Her FamilyThe Patient and His/Her Family

Often, the most Often, the most important, reliable and important, reliable and valuable source of valuable source of informationinformation

>90% of the time, you can >90% of the time, you can make (or nearly make) the make (or nearly make) the diagnosis with a careful diagnosis with a careful history and physical history and physical examination (POM-1)examination (POM-1)

The Patient and His/Her FamilyThe Patient and His/Her Family

Sometimes, the information Sometimes, the information you obtain/elicit is you obtain/elicit is better/more correct/more better/more correct/more useful than the information useful than the information in the “chart”in the “chart”» the game “telephone”the game “telephone”» ““urban legends”urban legends”» cognitive errorscognitive errors

The Patient’s Paper Chart(s)The Patient’s Paper Chart(s)

The “blue chart” The “blue chart” » H & P’sH & P’s» Progress notesProgress notes

– Many (most) services have templated formsMany (most) services have templated forms» Handwritten consultsHandwritten consults

The “bedside chart”The “bedside chart”» Nursing flowsheets and nursing notesNursing flowsheets and nursing notes» Some respiratory therapy documentationSome respiratory therapy documentation» Paper copy of the PTP (patient treatment plan)Paper copy of the PTP (patient treatment plan)

Physician “working” chartsPhysician “working” charts» Phone notes/memosPhone notes/memos» Outside recordsOutside records

Patient FlowsheetsPatient Flowsheets

Inpatient flowsheets provide 12 – 24 Inpatient flowsheets provide 12 – 24 hour snapshots of patient data hour snapshots of patient data » vital signs, medications administered, vital signs, medications administered,

nursing and housestaff interventions, nursing and housestaff interventions, selected labs, etcselected labs, etc

Outpatient flowsheets may provide Outpatient flowsheets may provide long-term views of patient long-term views of patient problems/progress/interventionsproblems/progress/interventions

ColleaguesColleagues

May offer insight about the May offer insight about the patient’s story, problems, patient’s story, problems, and treatmentsand treatments

May provide you with a May provide you with a sense of how sick a patient sense of how sick a patient is and what they are likeis and what they are like

May be the only way to learn May be the only way to learn the narrative thread of the the narrative thread of the patient’s hospitalizationpatient’s hospitalization

May be the only real source May be the only real source for learning the “plan of for learning the “plan of care” (what we are doing and care” (what we are doing and why we are doing it)why we are doing it)

Electronic Sources of Patient Electronic Sources of Patient Data/InformationData/Information

MISMIS Centricity Enterprise (CE)Centricity Enterprise (CE) PACSPACS PICISPICIS MedHost (ED)MedHost (ED) Other departmental systemsOther departmental systems

MIS

First major commercial electronic order entry First major commercial electronic order entry and results retrieval systemand results retrieval system» Installed at UVA and MCV in 1987/88Installed at UVA and MCV in 1987/88

Portal for order entryPortal for order entry» In 1987, <1% of US Hospitals had computerized In 1987, <1% of US Hospitals had computerized

order entryorder entry» In 2009, <10% of US Hospitals have computerized In 2009, <10% of US Hospitals have computerized

order entryorder entry Retrieval Functions Retrieval Functions » Patient listsPatient lists» Medication orders and charting (eMAR)Medication orders and charting (eMAR)» Other “medical” ordersOther “medical” orders» LabsLabs

MIS

Rounds ReportRounds Report» Provides a list of patients along with recent Provides a list of patients along with recent

labs, orders, radiographs and medicationslabs, orders, radiographs and medications» Need to print this out daily to stay currentNeed to print this out daily to stay current» Need to ensure that the medications are Need to ensure that the medications are

accurate accurate – just because it is in the computer doesn’t mean just because it is in the computer doesn’t mean

it’s right!it’s right!

GE Centricity Enterprise

Currently, the “core system” of the UVA Currently, the “core system” of the UVA Electronic Medical RecordElectronic Medical Record

Newer technology than MISNewer technology than MIS» more powerfulmore powerful» more flexible more flexible » more user-friendly than MISmore user-friendly than MIS



Newer technology than MISNewer technology than MIS» contains contains muchmuch more data more data – ALL lab data ALL lab data – ALL radiology reportsALL radiology reports– ALL transcribed AND paper documentsALL transcribed AND paper documents



Newer technology than MISNewer technology than MIS» Data are easier to find and viewData are easier to find and view – in lists by chronology, data type and/or data in lists by chronology, data type and/or data

sourcesource– spreadsheet formatspreadsheet format

sub-tablessub-tables graphing capabilitygraphing capability



Newer technology than MISNewer technology than MIS» Powerful patient list functionsPowerful patient list functions – system generated/maintained lists (e.g. inpatient system generated/maintained lists (e.g. inpatient

unit, service, attending, clinic)unit, service, attending, clinic)– personal listspersonal lists



Newer technology than MISNewer technology than MIS» some “active” functionality in some clinicssome “active” functionality in some clinics–Problem list, medication list, allergy list Problem list, medication list, allergy list –e-prescribing (paper and FAX)e-prescribing (paper and FAX)–Lab/radiology order entry Lab/radiology order entry – limited nurse/physician chartinglimited nurse/physician charting–suspended order functionssuspended order functions



Newer technology than MISNewer technology than MIS Will be replaced by UVA EpiCare during Will be replaced by UVA EpiCare during

the fall of 2010the fall of 2010» all clinics will go live one night during the fall all clinics will go live one night during the fall

of 2010of 2010» the hospital will go live one night during the the hospital will go live one night during the

spring of 2011 (MIS will go away)spring of 2011 (MIS will go away)

PACSPACS

Easy to useEasy to use Relatively intuitive interfaceRelatively intuitive interface Allows for comparison of multiple filmsAllows for comparison of multiple films Saves an enormous amount of time by Saves an enormous amount of time by

allowing clinicians to view films at the allowing clinicians to view films at the site of caresite of care

Decreases the amount of face time with Decreases the amount of face time with radiologistsradiologists

Information ManagementInformation Management

How will you keep track of all the How will you keep track of all the information that you need?information that you need?

Best resource:Best resource:» Efficient – gives you the information you Efficient – gives you the information you

need with easy access to things you might need with easy access to things you might need/wantneed/want

» Easy/ubiquitous access Easy/ubiquitous access » Easy to manage (structured in a way that Easy to manage (structured in a way that

makes sense)makes sense)» Easy to read (including being legible)Easy to read (including being legible)



There is no single, perfect way to manage There is no single, perfect way to manage patient information patient information » information needs differ depending on role information needs differ depending on role

and settingand setting» information needs evolveinformation needs evolve» people have different learning stylespeople have different learning styles» different institutions have different resourcesdifferent institutions have different resources

You will spend at least 6 months figuring what You will spend at least 6 months figuring what works best for youworks best for you


Lower tech solutions (paper-based)Lower tech solutions (paper-based) NotecardsNotecards Loose sheets of paper Loose sheets of paper » rounds reportsrounds reports» MIS listsMIS lists

Notebooks/foliosNotebooks/folios

Information ManagementInformation Management Note CardsNote Cards» ProsPros– Easy to enter “data”Easy to enter “data”– Open ended formatOpen ended format– Fit in your pocketFit in your pocket– Easy to get toEasy to get to

» ConsCons– Don’t leave lots of room for patient data (history Don’t leave lots of room for patient data (history

alone might take up half the space)alone might take up half the space)– Easy to get confused when you are caring for lots Easy to get confused when you are caring for lots

of patientsof patients– Easy to loseEasy to lose


Higher TechHigher Tech External drivesExternal drives PDA’sPDA’s


External Flash DrivesExternal Flash Drives» ProsPros– fit in your pocketfit in your pocket– can store lots of datacan store lots of data

» ConsCons– need to develop format/structure to store/retrieve need to develop format/structure to store/retrieve

datadata– need a computer and ?printerneed a computer and ?printer– easy to loseeasy to lose–may not be securemay not be secure


PDA’sPDA’s» ProsPros

– May fit in your pocketMay fit in your pocket– Easy to get to Easy to get to – Can store lots of dataCan store lots of data– Can serve other purposes (peripheral Can serve other purposes (peripheral

brain – e.g. Epocrates, InfoRetriever etc) brain – e.g. Epocrates, InfoRetriever etc)

» ConsCons– Data entry can be slow/tediousData entry can be slow/tedious– May be hard to readMay be hard to read– devices and software may not be HIPAA devices and software may not be HIPAA

compliantcompliant

HIPAA?HIPAA?

Health Insurance Portability and Health Insurance Portability and Accountability Act (1996)Accountability Act (1996)

HIPAA Privacy RuleHIPAA Privacy Rule

Privacy Rule of 2003Privacy Rule of 2003 Promotes confidentiality and security of Promotes confidentiality and security of

patientpatient protected health information (PHI) protected health information (PHI) Requires notification of patients about how Requires notification of patients about how

their PHI may be used and disclosed, and their PHI may be used and disclosed, and requires specific written authorizations for requires specific written authorizations for certain uses and disclosurescertain uses and disclosures

Privacy Rule of 2003Privacy Rule of 2003 Patients have the right to inspect their medical Patients have the right to inspect their medical

records, request restrictions on the use of their records, request restrictions on the use of their information, information, receive an accounting of receive an accounting of disclosuresdisclosures, and have access to a formal , and have access to a formal complaint process. complaint process.

Requires physical, administrative, and technical Requires physical, administrative, and technical safeguards to maintain the security of oral safeguards to maintain the security of oral communications, paper records and electronic communications, paper records and electronic records records

HIPAA Privacy RuleHIPAA Privacy Rule

HIPAA and PDA’s at UVa

What this means for you:What this means for you: PHI should not be stored or downloaded or PHI should not be stored or downloaded or

leave the institution unless there is an ongoing leave the institution unless there is an ongoing need to access this information away from the need to access this information away from the Health System for patient treatment, patient Health System for patient treatment, patient payment or approved Health System business payment or approved Health System business operation use. operation use.

Patient information should not be stored on Patient information should not be stored on PDA’s unless appropriate security measures PDA’s unless appropriate security measures have been implemented. have been implemented.

SummarySummary

For the rest of your professional life, most of your For the rest of your professional life, most of your job will be managing informationjob will be managing information

You will spend the first 6 mos of your clerkships You will spend the first 6 mos of your clerkships trying to figure out the best way(s) to do thistrying to figure out the best way(s) to do this» solutions that work now may not work latersolutions that work now may not work later

– roles and responsibilities differ and evolveroles and responsibilities differ and evolve– Institutional resources, policies and procedures Institutional resources, policies and procedures

differ and evolvediffer and evolve Technology is a tool to help you do your job Technology is a tool to help you do your job

better. It is not a magic bullet.better. It is not a magic bullet.

Electronic resources may help you, but they Electronic resources may help you, but they are not always the best way to manage are not always the best way to manage informationinformation» it will depend on the resources availableit will depend on the resources available» it will depend on your information needs in a given it will depend on your information needs in a given

clinical settingclinical setting» it will depend on the way you like to organize and it will depend on the way you like to organize and

the needs/wants of the clerkshipthe needs/wants of the clerkship

Patient privacy is always a concern regardless Patient privacy is always a concern regardless of what format/tools you useof what format/tools you use

SummarySummary

Keep in mind that the principle reason to Keep in mind that the principle reason to “write” in a chart should be to communicate to “write” in a chart should be to communicate to other care-providersother care-providers» communication problems are far and away the most communication problems are far and away the most

common cause of preventable in-hospital disability common cause of preventable in-hospital disability and deathand death– more than 60% of root causes of sentinel events more than 60% of root causes of sentinel events

reported to JCAHO are due to failures of reported to JCAHO are due to failures of communication between healthcare personnelcommunication between healthcare personnel

– residents believe communication difficulties play a residents believe communication difficulties play a major role in the vast majority of medical mishaps they major role in the vast majority of medical mishaps they experienceexperience

SummarySummary

A 69 year old with a history of Cushing’s syndrome due A 69 year old with a history of Cushing’s syndrome due to an adrenal tumor presented to Interventional radiology to an adrenal tumor presented to Interventional radiology for a venous sampling procedure. Her baseline HCT was for a venous sampling procedure. Her baseline HCT was 42% She had a history of DVT and PE for which she 42% She had a history of DVT and PE for which she chronically takes warfarin, insulin dependent diabetes, chronically takes warfarin, insulin dependent diabetes, HTN, obesity, lower extremity weakness and chronic HTN, obesity, lower extremity weakness and chronic back pain back pain » several attempts at right femoral vein access were several attempts at right femoral vein access were

unsuccessful and the procedure was completed via unsuccessful and the procedure was completed via her left femoral vein. her left femoral vein.

» she was admitted to the Interventional Radiology she was admitted to the Interventional Radiology service for monitoringservice for monitoring

Communication problems are the most common Communication problems are the most common cause of in-hospital disability and deathcause of in-hospital disability and death

» on post-procedure day 2 her HCT had dropped from on post-procedure day 2 her HCT had dropped from 42% to 28% The IR nurse practitioner called the 42% to 28% The IR nurse practitioner called the General Medicine chief resident to request a transferGeneral Medicine chief resident to request a transfer

» the patient was transferred to the General Medicine service without direct physician to physician report or a written transfer note

» the admitting resident believed the patient was being admitted for “placement issues”. The intern was a psychiatric resident

» shortly after transfer, the night float resident assumed care and a heparin infusion and daily Coumadin were ordered


» on post-procedure day 3, her HCT was 25.7% The intern was the psychiatric resident and upper level coverage was provided by a nephrology fellow due to a resident retreat

» her heparin PTT was > 140 and the heparin infusion was held for one hour and then resumed at a lower rate

» on post-procedure day 4 the heparin drip was on post-procedure day 4 the heparin drip was discontinued and enoxaparin begundiscontinued and enoxaparin begun

» on post-procedure day 5, enoxaparin and coumadin on post-procedure day 5, enoxaparin and coumadin were held for elective surgery scheduled the next day; were held for elective surgery scheduled the next day; her HCT was 31% after one unit of PRBC’sher HCT was 31% after one unit of PRBC’s


» in the early morning of post-procedure day 6, the in the early morning of post-procedure day 6, the patient complained of severe back pain and two verbal patient complained of severe back pain and two verbal orders were given to administer pain medicationorders were given to administer pain medication

» the patient was later found hypotensive at which time the patient was later found hypotensive at which time her HCT was 22%her HCT was 22%

» she subsequently experienced a cardiorespiratory she subsequently experienced a cardiorespiratory arrest and diedarrest and died

» autopsy revealed a large retroperitoneal bleed autopsy revealed a large retroperitoneal bleed extending to the diaphragm, and a defect in the right extending to the diaphragm, and a defect in the right femoral arteryfemoral artery



Communication/Handoff Issues identified Communication/Handoff Issues identified during the case reviewduring the case review» The General Medicine team had no knowledge of The General Medicine team had no knowledge of

the vein sampling procedure performed on hospital the vein sampling procedure performed on hospital day one day one

» The attending physician changed 3 times in 5 daysThe attending physician changed 3 times in 5 days» The house staff changed 11 times in 5 days The house staff changed 11 times in 5 days

Keep in mind that the principle reason to Keep in mind that the principle reason to “write” in a chart should be to communicate to “write” in a chart should be to communicate to other care-providersother care-providers» most humans prefer narrative stories over data » think about what the data you have assembled and

reviewed means and try to convey that to the other people who read the chart– summation– abstraction– synthesis

SummarySummary

Information Management in the “Electronic Age”: Information Management in the “Electronic Age”: The benefits and limits of technology for managing patient dataThe benefits and limits of technology for managing patient data

Stephen M BorowitzStephen M BorowitzDepartment of PediatricsDepartment of Pediatrics

[email protected]@virginia.eduApril, 2009April, 2009

Documents

Clinical Information Management in Electronic Age (PPT)