Austin and Boxerman chapter 8

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Austin and Boxerman chapter 8

• HSPM J713

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Applications Learning Objectives

• Write 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

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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

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Standalone vs. Integration

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

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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. Stricklands COBOL joke just maintaining
  legacy systems can be a problem

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A digression about COBOL

• Grace Hopper, 1959. Common Business-Oriented
  Language
• Example of COBOL statement
• ADD YEARS TO AGE
• By comparison, C and Java use
• age age years
• Or
• age years

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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

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Health records

• Mostly paper, still
• Electronic data entry or electronic communication
  ? paper inserted into record

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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

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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

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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

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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

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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

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VistA

• Veterans Health Information Systems and
  Technology Architecture
• Most advanced in US
• Other efforts
• Vendors systems for hospitals, doctors offices
• Academic medical centers

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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

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Clinical Information SystemLaboratory 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

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Laboratory systems

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

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Clinical Information System Pharmacy
information systems

• Errors!
• ordering
• dispensing
• administering
• recording
• Cited in 1999 IOM report
• Good records can help!

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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

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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,

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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

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Complex images and applications

• 3-D images like
• Computed tomography
• Magnetic resonance imaging
• Computers integral to image creation process
• Radiation therapy computer-directed

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Archive problem

• Film deteriorates
• Digital formats and storage devices and standards
  change

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Clinical Information SystemOrder 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

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Clinical Information SystemNursing 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

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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?

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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

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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

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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

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Financial Information Systems (continued)

• Budgeting
• Internal auditing
• Forecasting
• Planning financial investments
• Cash flow vs. cash need
• Financial statements
• Financial reporting for top management

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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

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Human resources (continued)

• Productivity information
• Compare compensation with competitors

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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

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Human Resources database

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

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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

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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

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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

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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

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Office Automation

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

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Non-hospital settings

• Specialized applications/information systems for
• Ambulatory care centers
• Long-term care (late adopter?)
• Home health care

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Other

• (some of these seem to repeat from earlier
  categories)
• (but there are some jargon terms in here worth
  knowing)

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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

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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

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Active CDS elements

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

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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?)

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EIS

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

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Evidence-Based MedicineDisease-Management Systems

• Evidence-based?

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Now evidence-based

• http//www.milliman.com/expertise/healthcare/produ
  cts-tools/milliman-care-guidelines/index.php

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Evidence-based guidelines

• National Guideline Clearinghouse of the US Agency
  of Healthcare Research and Quality
• http//www.ahrq.gov/clinic/epcix.htm

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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

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Computer-assisted medical instruments

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

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Telemedicine

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

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Telemedicine

• Audio-video conferencing requires ISDN line,
  dedicated equipment.
• Prisons and rural clinics in Texas
• High-speed internet much less costly.

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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 Medicines Medline
• They give http//medline.cos.com/
• http//www.nlm.nih.gov/databases/

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Medical education

• Computer/internet transmitted movies, audio,
  books, articles
• Interactive simulations of clinical problems

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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