Chapter 5 Current and Emerging Use of Clinical Information Systems

1. Chapter 5Current and Emerging Use of Clinical Information Systems Yung-Fu Chen, Ph.D. Department of Health Services Management, China Medical University

2. Current and Emerging Use of Clinical Information Systems • Electronic medical record (EMR) • Other Major Types of Health Care IS • Computerized provider order entry (CPOE) • Medication administration • Telemedicine • Telehealth • Fitting Applications Together: The EMR is the Hub • Barrier to Adoption

3. Electronic medical record (EMR) • Five levels of computerization • Automated medical record • Although health-care organization may automate certain functions such as patient registration, scheduling, results reporting, and dictation, however, the paper-based medical record remains the primary source for patient’s clinical information • Computerized medical record • Digitizing the patient’s medical record through the use of a document imaging system • Patient’s records are scanned and stored as images • Does not allow the user to analyze or aggregate data for decision-making • Is merely a digitized version of paper-based medical record

4. Electronic medical record (EMR) • Five levels of computerization • Automated medical record • Computerized medical record • Electronic medical record • Patient record as an active tool that can provide the clinician with decision support capabilities and access to knowledge resources, reminders, and alerts • The EMR may trigger alert or notice to medication allergy, medication interaction, and examinations and tests • Maintained by a single organization • Electronic patient record • Includes all healthcare-related information concerning the patient-gathered across two or more organization • Brings together a central database all clinical information available on a patient • Electronic patient record

5. Electronic medical record (EMR) • Five levels of computerization • Automated medical record • Computerized medical record • Electronic medical record • Electronic patient record • Electronic patient record • Is broader than the electronic patient record • Includes wellness information (smoking habit, nutrition, level of exercise, dental health, alcohol use) and other information not maintained by health care organization • Patient is at the center • Is a longitudinal record and ultimately encompass a person’s relevant health information from before birth to death

6. Five Levels of Computerization of EMR Level 5: Electronic Health Record (longitudinal, comprehensive) Level 4: Electronic Patient Record (spans across organization) Level 3: Electronic Medical Record (active tool, organization level) Level 2: Computerized Medical Record (document imaging) Level 1: Automated Medical Record (clinical info systems)

7. To keep patients safe is one of the biggest concerns of health care organizations 98000 patients die each year in U.S. hospitals due to medical error (IOM, 2000, 2001) CPOE has the potential to reduce medication error & adverse drug events (Bates & Gawande 2003) CPOE is one of three changes that would most improve patient safety (Leapfrog Group 2004a) CPOE is a computer application that accepts physician orders electronically, replacing handwritten or verbal orders and prescriptions Current use of CPOE Approximately 5-13% of hospitals (Leapfrog group 2002, First Consulting Group 2003, Brailer & Terasawa 2003) Value of CPOE CPOE system can provide patient care, financial, and organizational benefits Potential to improve patient safety and reduce medication error Beneficial in ambulatory care setting (Johnston et al. 2003, 2004) The providers and patients are highly satisfied with their access to health care information , their wait times, and the quality of care delivered (Johnston et al. 2003) Computerized provider order entry (CPOE)

8. Medication administration • Barcode-enabled point of care (BPOC) has the potential to enhance productivity, improve patient safety such as those related to correctly identifying patients and medications, and ultimately improve quality of care (Low & Belcher 2002) • Each patient receives a barcode wristband at the time of permission for identification • The provider scan his or her bar-coded ID band to log into the medical administration system • Provide an audit trail of who has accessed what systems at what time and for what information • About half of medication errors occur during the ordering process, but errors also occur in dispensing, administrating, and monitoring medications (Kaushal & Bates 2002) • BPOC can be highly effectively in reducing all types of medication errors, yet only 1.1 % of U.S. hospitals have bed-side scanners (Barlas 2002) • Only 35% of medications come from the manufacturer with bar-coded labels in 2003 ??? • RFID is replacing barcode in medication administration

9. Use of telecommunication for the clinical care (diagnosing, treating, or following up) of patients at distant locations Current status of telemedicine programs 200 programs throughout the U.S. in 2004 (Brown) Univ. of Kansas provided clinical services to oncology patients and mental health services to patients in rural area and augmented school health services by giving school nurses to consult with physicians Univ. of Texas Medical Branch Provided services to inmates (400 patients a month) Primary delivery method Store and forward Is used to primarily for transferring digital images from one location to another by taking an image with a digital camera and stored on a server, and then sent to a health care provider Two-way interactive television Is used when a face-to-face consultation is necessary by giving patients living in rural communities access to providers in urban areas without traveling A number of devices can be linked to computers to aid in interactive examination Robotic equipment for telesurgery applications in battle fields Telemedicine

10. Patients have increasingly turned to the Internet to obtain health care information and seek health care services, and are interested in communicating with their physicians directly on the line On-line communication from a patient may be everything from requesting an appointment to viewing a bill to refilling on prescriptions to seeking advice or a consultant via e-mail Current use of E-mail communication between physicians and patients Currently 25% physicians use Email to communicate with patients; 90% of American adults would like to communicate with their physicians via Email Follow-up patient care, clarification on advice, prescription refills, and patient education Telehealth (1)

11. Value of E-mail communication system Is asynchronous Decrease telephone hold time Is legible Can automatically document a conversation Does not increase physicians’ workload or decrease their productivity Reduces patient visits and telephone calls Reduces administrative tasks Allows more uninterrupted time for patients during office visits Critical considerations should be addressed when instituting an e-mail communication system between patients & providers Complexity of infrastructure Degree of integration Message structure Cost Security reimbursement Telehealth (2)

12. The data that eventually make up each patient’s record originate from a variety of sources Admission or registration systems Patient demographic information, health insurance or payer, provider’s name, date and reason for visit or encounter, and so forth Accounting systems Patient billing information Ancillary clinical (laboratory, radiology) systems Diagnostic tests, therapeutic procedures, results, and so on CPOE systems Physician orders, date, time and status, and so forth Medication administrative systems Medications ordered, dispensed, and administrated, and so forth Other clinical and administrative systems Nursing, physical therapy, and nutrition education documentation; scheduling information; and so forth Knowledge-based reference systems Access to MEDLINE, the latest research findings, practice guidelines, and so forth Telemedicine and telehealth systems Documentation of provision of health care services, on-line communication with patients and providers, and so forth Fitting Applications Together: The EMR is the Hub

13. EMR: The Hub of Clinical Information Systems Admission/ Administration Other Clinical/AdministrativeSystem Accounting • ElectronicMedical Record • Patient Identification • Authentication Pharmacy-Medication Distribution LaboratoryResults Interface CPOE Radiology DecisionSupport KnowledgeBase/Reference TelemedicineTelehealth (for example,e-mail)

14. Barrier to Adoption (1) • Financial barriers • EMR and related systems can be expensive to develop, implement, and support • A significant amount of money invested and yet not realize a positive financial return even a return in term of quality • Behavior barriers • Physician acceptance to change in workflow to differences in state licensing regulations • EMR requires that physicians respond to reminders, alerts, and other knowledge aids which lead to better patient care but may also require more time • Most physicians receive no reimbursement or compensation for using EMR systems or for providing good-quality care • Regarding telemedicine and telehealth • Lack of hand-on interaction with patients • Fear of litigation or missing important information

15. Barrier to Adoption (2) • Technical barriers: standard and data definition • Understanding how emerging technologies fit with existing technologies, and engaging in continuing development and refinement of standards and data definitions • Following health care information standards is not an easy task • Inadequate standards combined with rapid changing technologies can be a barrier to widespread EMR adoption and use • Must have stable infrastructure to support clinical and administrative applications