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Computer Based Patient Records. Overview. Review the Computer Based Patient Record Describe the UI CBPR Project INFORMM Patient Record. Topics of Discussion. What is a Computer Based Patient Record? What are the Components? What are the Main Issues? Who are the Major Players?
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Overview • Review the Computer Based Patient Record • Describe the UI CBPR Project • INFORMM Patient Record
Topics of Discussion • What is a Computer Based Patient Record? • What are the Components? • What are the Main Issues? • Who are the Major Players? • What is the Value?
What is a CBPR? • Documentation (e.g., Medical Record) • Workflow • Clinical quality improvement • Outcomes data • http://www.cpri.org/what.html • http://www.cpri.org/docs/docs.html
What are the Components? • Summary Documentation • Problem List/ Allergies Medications • Encounter Documentation • CC/HPI/PFSH/ROS/PE/Imp/Plan/Procedure • Orders/Results • Rules / Guidelines • Tabular Information (Formularies etc..) • Formularies / Lexicon • Process Flow
Components (cont’d) • Outcomes Tracking • Health Status Indicators • Problem Episode Tracking • Randomized Impact Studies
What are the Main Issues • Text versus Structured & Coded • Security versus Access • Buy versus Build • Human Interface • GUI / Voice / Wearable • Human Acceptance
Text versus Structured & Coded • Structured & Coded • What does a given [response] mean? • If [response] then do [whatever] • When or how many of a given [response] ? • Text • Extemporaneous • Context Imbedded • Tells a story
Structured and Coded • Context • Validity • Question and Response • Lexicon • Metathesaurus
Transitioning: Text to Coded • Incomplete Vocabularies • In six defined vocabularies find only 60-80% • Validity depends on context • Context may be implicit for the educated • nursing documentation • physical exam • test and therapy orders
In the Meanwhile: • Text is necessary • What can we do with it? • Categorize it • structured dictation • Encapsulate it • disallow it wherever possible • Extract from it • lexigraphical analyses have limited success
Security versus Access • Security • Who are you (authentication) • What are your information rights (authorization) • What did you do (audit trail) • How can we ensure integrity of communication • Access • Intuitive Design • Online Intelligent Assistance
Buy versus Build • Buy • Turn-key versus Customizable • Cost-sharing versus Cost-shifting • Support versus Holding-the-Bag • Build • Personal Relationship with the Customer • Talent Pool Stability
Human Interface • GUI • layout itself communicates information • pointing supported • Voice • ready for prime time? • Wearable • Virtual
Human Acceptance • Acceptable Interface • Workflow Makes Sense • Problems - More Solved than Created
Who Are the Major Players • Non-profit Organizations • Academies / Societies / CPRI • Government Institutions • NLM, ASTM • Academic & Medical Institutions • LDS/IMHC / Brigham / Columbia / Stanford • http://ucsub.colorado.edu/~gorman/thesis/EMR.html • Commercial Product Vendors
Processes • Macro • Birth to Death • Induction to Discharge • Micro • Check-in to Check-out • Chief Complaint to Episode Resolution
Birth to Death Record • Universal Identifier • Data Model • Vocabulary • Data Exchange • Security • Policy
Micro Process • Patient Seeks Attention • Patient Responds to Questions • Provider Examines • Impression and Plan Formed • Plan Executed • Outcome Assessed
Patient Seeks Attention • Now • Patient Calls or Drops In • Some Enhancements in Progress • System Proactively Advises Patient • Patient Seeks Online Information
Patient Responds to Questions • Now • Provider Assisted • Mostly Text, Some Coded • Some Enhancements in Progress • Coded Questions and Responses • Context-sensitive Branching • Automated Capture of Information • Automated Intelligent Assessment
Provider Examines • Now • Provider Documents After the Fact • Mostly Text, Some Coded • Some Enhancements in Progress • Coded Questions and Responses • Context-sensitive Branching • Automated Capture of Information
Impression and Plan Formed • Now • Information Reviewed (Hx, PE, Results) • Mostly Narrative • Some Enhancements in Progress • Assisted Differential Diagnosis • Guidelines • Evidence Based Medicine • Critical Path
Plan Executed • Now • Orders Written • Procedures Performed • Tests Done • Some Enhancements in Progress • Orders Captured Online with Problem • Plan Process Tracked
Outcome Assessed • Now • Follow Up Visit Narrative • A Few Objective Outcomes are Tracked • Some Enhancements in Progress • Episode Tracking • CC to Assessment to Treatment to Resolution • Beyond the Single Encounter • Outcome Classification • Health Status per Patient Report
Rules Span the Entire Process • If Event Detected • Demographics • History • Result • Order • Then Response • Communicate to Patient / Provider • Execute a Plan
University of Iowa CBPR Project • Phase I • Health Resume and Guidelines • Document System • Phase II • Outpatient Contact Summary • Templates, Coding, Ordering • Phase III • Inpatient Contact Summary • Templates, Coding, Ordering, Guidelines • Images
Online Impact Assessment Randomize Intervention Group Physician Online Control Group Physician Online Event Detected Show Recommendation No Recommendation Compare Outcomes
Lessons Learned from Experiments • Passive Information Increases Utilization • In-your-face Information Decreases It • If Seen, Information Changes Outcome • second-vaccine ordering • no vaccine ordering • prescription drug ordering
University of Iowa CBPR Project INFORMM Patient Record