Hospital Information Systems: Where we’ve come from and where we’re going

1. Hospital Information Systems:Where we’ve come from and where we’re going Jonathan Pell, M.D. Assistant Professor, Hospital Medicine IS Physician Liaison University of Colorado at Denver and Health Sciences Center Tuesday Morning Conference Denver Veteran Affairs Medical Center January 20th 2009

2. Objectives • What is a Hospital Information System (HIS) and why should I care? • Brief history of hospital HIS’s • Problems with development of HIS • Barriers to clinician adoption of new technologies • Barriers to hospital adoption of HIS • Potential future directions for HIS’s

3. Government employee

4. An Hour in the Life of a Hospitalist • Starting your 7pm-7am shift and get sign-out from 4 daytime teams (8-10 patients each) • ED calls you with a new admission • Nurse calls about pt X’s headache 30min later • Finally get to the ED to admit patient • Get back to the floor and sign orders

5. History of Computers First microprocessors and PC’s late 1970’s Punch card data processing 1890 Wireless computers late 1990’s General purpose computers 1950 First minicomputer late 1960’s World Wide Web early 1990’s First digital computer 1940

6. Original Hospital Information Systems (HIS) • 1962 Initiated by Bolt, Beranek and Newman and carried out by Octo Barnett at MGH • Funded by NIH whose biggest concern was not enough MD input

8. Other HIS Pioneers • Warner at Latter Day Saints hospital, Utah • Collen at Kaiser Permanente, California • Wiederhold at Stanford University

9. Progression of Computer Use in Hospitals

10. One System for all? • Departmental systems became feasible in 1970’s • Departmental systems develop tailored to specific application areas • No common databases or database systems • Best of breed theory begins to develop

11. What makes up a HIS of today • Admission, discharge, and transfer system (ADT) • Electronic Medical Record (EMR) • Picture Archiving and communication (PACS) • Pharmacy • Labs (including microbiology, pathology) • Billing and Scheduling • Active patient data systems (ER, Med/surg, OR, ICU)

13. Electronic Health Record (EHR) Needs • Accessible • Secure • Acceptable to clinicians • Acceptable to patients • Integrated with both patient specific and patient nonspecific information

14. Data that goes into an EHR Clinician orders Patient Demographics and billing Patient phone calls Patient specific lists -problem list -medication list Prescriptions and medications administered Labs, microbiology, pathology, and radiology results Active patient information -Vital signs -I’s and O’s Clinician visit notes -ER visits -Hospitalization summaries Procedure Reports

15. Problem: Lots of forms of Data • Free text • Lists of text (problem lists) • Numbers with titles and error ranges (labs) • Images in multiple forms (ECG,CXR) • Multiple note formats • Text with numbers (prescriptions) • Trends of numbers (in hospital vitals, labs) Shortliffe, EH (2006)

16. What do we want coming out of an EHR? Clinician orders Patient Demographics and billing Patient phone calls Patient specific lists -problem list -medication list Prescriptions and medications administered Labs, microbiology, pathology, and radiology results Active patient information -Vital signs -I’s and O’s Clinician visit notes -ER visits -Hospitalization summaries Procedure Reports

17. And More…EHR Functional Components • Clinical Decision Support – “clinical system, application or process that helps health professionals make clinical decisions to enhance patient care”defined by HIMSS • Integrated view of patient data • Clinician Order Entry • Access to Knowledge Resources • Integrated communication and reporting support • E-prescription when patients are discharged

18. How do solve the multiple data form problem? • Original Solution- Substitution • Display information we already have on computer screen • What we need- Transformation • Rethink how we obtain patient information and manage patients • Understand computer technology to change how we think about patient data use

19. How Physicians Enter Data • Transcription- dictated or written notes • Filling out structured encounter forms • Direct data entry

20. The Informatics World Solution: Coding • Problem: You can’t put the art of medicine into code (at least not easily) • Coding Systems • ICD-9 (International Classification of Disease) • SNOMED (Systemized Nomenclature of Medicine) • CPT (Current Procedural Terminology) • LOINC (Laboratory Observations, Identifiers, Names, and Codes) • Arden Syntax – medical decision logic

21. Amount given: 60meq, Site: Medication administered P.O., Correct patient, time, route, dose and medication confirmed prior to administration. Patient advised of actions and side-effects prior to administration, Allergies confirmed and medications reviewed prior to administration. (19:26 CK1) : Follow Up : Decreased symptoms. (21:29 DVB) ORDERS BMP BASIC METABOLIC PANEL by TAI for BA on Wed Dec 31, 2008 18:06 Status: Done by System Wed Dec 31, 2008 18:58. PHOSPHORUS SERUM/PLASMA by TAI for BA on Wed Dec 31, 2008 18:06 Status: Done by System Wed Dec 31, 2008 18:58. CBC COMPLETE HEMATOLOGY PROFILE by TAI for BA on Wed Dec 31, 2008 18:06 Status: Done by System Wed Dec 31, 2008 18:24. MAGNESIUM SERUM by TAI for BA on Wed Dec 31, 2008 18:06 Status: Done by System Wed Dec 31, 2008 18:58. CT BRAIN by TAI for BA on Wed Dec 31, 2008 18:08 Status: Cancelled by System Wed Dec 31, 2008 18:20. XR SHOULDER 3 VIEW INCLUDING AXILLARY by TAI for BA on Wed Dec 31, 2008 18:15 Status: Cancelled by System Wed Dec 31, 2008 18:20. MR BRAIN by CK1 for CK1 on Wed Dec 31, 2008 20:43 Status: Cancelled by System Wed Dec 31, 2008 21:07. XR CHEST PA LAT by CK1 for CK1 on Wed Dec 31, 2008 21:04 Status: Done by System Wed Dec 31, 2008 22:14. Lost in Translation

22. Narrative Text vs Coded Data • Narrative PMedHx • DMII diagnosed 10 yrs ago now on insulin with last A1c 10.6 (12/15/08) suspectedly due to poor medication compliance • Chronic renal insufficiency secondary to diabetes with 1g proteinuria and baseline creatinine 2.1 (12/15/08) • Coded PMedHx- • 250.42 (DM 2 uncontrolled with renal complications)

23. Benefits • Text • Easy to document and interpret • Comprehensive and fully customizable • Good for individual patient care • Coded Data • Aggregate analysis • Well defined for billing • Information system friendly

24. Data-Interchange Standards • International Standards Organization (ISO)’s Open Standards Institure (OSI) seven levels required for data exchange • HL7 (Health Level 7) - Data interchange • Digital Imaging Communications in Medicine (DICOM) for PACS • National Council for Prescription Drug Programs (NCPDP) - pharmacy • ASTM 1238 – lab information interchange

25. Partial Solutions • Extensive Interface Engine hardware, software ,and support • “At a minimum, difficult interfaces result in steep learning curves and structural inefficiencies in task performance. At worst, problematic interfaces can have serious consequences in patient safety” Lin at al Applying human factors to the design of medical equipment. J. of Clin. Monitoring and Computing.14(4) 253-263.1998.

26. Transfer of patients between different systems • Medications dropped from lists • Redundant admission orders written • Documented patient information from previous system lost or difficult to interpret • Orders dropped on transfer • Medications mistakenly given twice

27. Database standards

28. Single Vendor or Best of Breed • Few single vendors out there • Epic • Meditech • Cerner • McKesson • GE/IDX • No longer best of breed in each department

29. Who is looking at the big picture? • HIMSS- Health Care Information and Management Systems Society • IHE- Integrating the Healthcare Enterprise • CCHIT-Certification Commission for Healthcare Information Technology • HITSP- Healthcare Information Technology Standards Panel

30. HITSP Programs of work topics • Lab results reporting • Bio-surveillance • Consumer empowerment • Emergency Responder-HER • Quality • Medication management • Personalized Healthcare • Consultations and transfers of care • Immunizations and response • Patient-provider secure messaging • Remote monitoring

31. Clinician Barriers to IT system implementation and change

32. Clinician Barriers to IT system implementation and change • Clinician prefer computer use for consultation but do not like data entry • Opposed to extra effort unless clear benefit • Do not like the inflexibility • Disrupts time for the clinician patient encounter • Clinician’s don’t like change Mcdonald et al 1992.

33. What do Clinicians Care About • Does it have the information we are used to having • What is it’s usability: • Learnability • Efficiency • Memorability • Minimization of Errors • Satisfaction Nielson 1993

34. IT Industry Response • More code devoted to Graphic User Interface • Understanding needs of different users • Understanding workflow • Budgets spent on usability increasing • Implementation budgets increasing

35. What do hospitals care about? • Cost reduction • Productivity enhancement • Quality Improvement • Competitive Advantage • Regulatory Compliance

36. 2008 HIMSS Leadership Survey

37. National Level • The Computer-Based Patient Record: An Essential Technology for Health Care -IOM report in 1991 and revised in 1997 • National commitment of 50 billion dollars over 5 years toward electronic health record for all? • IT czar in Washington • RHIO’s and Potential for a National Health Information Infrastructure (NHII)

38. NHII • Idea first raised in 2001 by the National Committee on Vital and Health Statistics • Distributed system of databases using standards for access • Benefits in: • Cost of Care • Compliance with national guidelines • Public health notification • Research

39. Physician Visit of the Future • Patient physician interaction is voice recognition recorded into standard history format • Physical exam is performed and commented on by device peripherals • Physician uses Tablet PC’s or PDA’s to review vitals, radiology, labs, and clinician notes, etc. • All physician orders are entered through the device and incorporated into note for plan • E and M billing recommendations made and verified • All this information could be viewed by itself and in aggregate from anywhere securely

40. What’s Happening at UCH • Evaluating use of a single vendor-Epic • Single database and interface system • CPOE • Decision support • Customized user views of patient information • CORHIO participation

41. References Barnett, GO. History of Medical Informatics: Proceedings of ACM conference on History of medical informatics .Bethesda, Maryland, United States, 43 – 49, 1987. Barnett, GO. Computers and Patient Care N. Eng. J. of Med.1968. 269: 1321-1327. Nielson 1993 Usability Engineering. Boston, Academic Press. Mcdonald, C.J. et al The Regenstrief medical record system: 20 years of experience in hospitals, clinics, and neighborhood health centers. MD Computing. 9 (1992) 206-217. Lin at al Applying human factors to the design of medical equipment. J. of Clin. Monitoring and Computing.14(4) 253-263.1998. van Ginnekan, AM. The computerized patient record: balancing effort and benefit. Int. J. of Med. Informatics. 65 (2002) 97-119. Shortliffe, EH (2006) Biomedical Informatics: Computer Applications in Health Care and Biomedicine 3rd Edition. New York. Springer