Physician Reminder System PRS

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Physician Reminder System (PRS)

• Herbert Diamond, West Penn Hospital
• John Engberg
• Michael Johnson
• Rema Padman
• The Heinz School

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Project

• A prototype reminder system for Western
  Pennsylvania Hospitals Internal Medicine clinic
  (Medical Ambulatory Care Clinic - MACC) to
  support the practice of evidence-based medicine
  and preventive care management.

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Evidence-Based Medicine

• the conscientious, explicit and judicious
  use of current best evidence in making decisions
  about the care of individual patients..by
  integrating individual clinical expertise with
  the best available external clinical evidence
  from systematic research Sackett et al. 1996
• - Our computer application uses clinical
  practice guidelines to present evidence in the
  form of rules and suggestions

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Background

• Errors in outpatient environment caused by
• Intermittent care
• Missed results
• Possible improper drug usage
• Patient misinformation
• Poor transfer of clinical information

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Examples

• 20 of Type 1 diabetic patients do not see a
  physician once a year
• 40 are not tested regularly for glycohemoglobin
  levels
• 41 do not have annual retinal exams
• (NEJM, April, 1999)
• How should these patients be managed such that
  patient outcomes are better and compliance with
  practice guidelines are improved?

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Challenges to the ideal office visit

• Difficulty of tracking patients medical history
• Difficulty of maintaining or extracting patient
  records
• Possibility of busy physicians overlooking
  critical examinations

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Motivation

• Proactive patient management
• Just-in-time physician reminders
• Compliance with practice guidelines
• These actions improve patient outcomes and
  reduce variation in care

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Reminder System Project Details

• Client
• Department of Medicine and Medical Ambulatory
  Care Clinic, Western Pennsylvania Hospital
• Developers
• MISM and MSPPM students at the Heinz School plus
  faculty advisors and advisory board members
• Medical Domain
• Chronic diseases hyperlipidemia, diabetes, low
  back pain
• Preventive care categories cervical cancer,
  breast cancer, pneumonia, influenza, cortico
  steroid-induced osteoporosis
• Project Success Measures
• Increased physician/staff productivity
• Improved compliance with medical guidelines
  (shorter-term)
• Improved population health outcomes (longer-term)
• System that is scaleable,generalizeable,
  interoperable and user-friendly

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Architecture for Reminder System
REMINDERS
REPORTS
Dialogue Management System
Database Management System
Model Management System
MODEL BASE
Clinical Guidelines Repository
Evidence- Based Medicine Cues
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IS Project Methodology
Query clients on the best medical practices, the
cueing methodology, and information requirements
for efficient decision making
Feasibility Analysis
Map client requirements into system functionality
requirements
Requirements Analysis
Create preliminary design and specification for
the system to be developed
System Design Specification
Develop system and integrate with the clients
current business process
System Implementation
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Data Sources

• Demographic data from patient registration system
• Diagnosis, visit, procedure and test results data
  from billing and laboratory systems
• Screening data from staff
• Specific clinical data entered by physicians

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Algorithms

• Derived from federal or major national
  organization consensus standards
• Based upon best available data
• Specific guidelines for each type of preventive
  care and each disease management program

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Users

• Physicians Reminders or suggestions for
  preventive care, treatment changes or referrals,
  patient education at time of visit
• Patients Reminders regarding appointments and
  compliance
• Office Staff Reminders of actions during current
  appointment and of future appointments

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System Implementation

• Database
• Data standards CPT-4 for medical procedures and
  ICD-9-CM for diagnoses
• Platform Oracle 8i, to accommodate multiple
  users, large datasets, Web-enabling
• Test data 30 dummy records
• Reminders
• SQL code for procedures
• Triggers, invoked by updates to other tables
• Stored procedures, invoked by the application
  program
• Packages storage of related programs, e.g.
  time-driven cues/visit-driven cues
• Key parameters are hard-coded ? application
  maintenance not trivial
• Interface
• Platform Visual Basic 6.0
• Low-level design flow diagrams, interface-table
  mapping
• Application security enable system
  administration functionality
• Connection with Oracle Active X Data Object
  controls

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Interface Forms
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Other Features

• Security and Privacy/confidentiality features to
  ensure that patient data cannot be accessed by
  unauthorized users
• Three-level security functions DBA,
  Administrator, Clinic Staff
• Audit trail
• Password management functions (time-out,
  expiry,reuse, complexity)

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Other Features

• Reporting capabilities
• summaries of treatment recommendations
• elementary outcomes evaluations
• automated reminder letters to patients
• Integration with West Penn hospital information
  system, patient scheduling and other information
  systems so that data stores can be updated
  automatically

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Next Steps

• Automated archiving and data retrieval
  capabilities
• Expand to include one or more new diseases
• Web-enabling
• Develop tools to extract data on an as-needed
  basis and to determine outcomes that deviate from
  norms and/or optimal clinical pathways
• Develop a graphical interface that allows the
  user to compare sub-population outcomes with
  population characteristics