Chapter 20 Information Across the Health System

1. Chapter 20Information Across the Health System Yung-Fu Chen, Ph.D. Department of Health Services Administration, China Medical University

2. Outline • Emerging information and communications technologies, such as electronic health records (EHR) systems offer new ways of accessing health information and assisting clinicians and consumers in decision-making that improves the quality and safety of care delivery (Commonwealth of Australia, 2003c). These technologies create an awareness of the holistic needs of patients because information is readily available from multiple sources, across geographical boundaries and within flattening information silos. Using scenarios, this chapter draws together the discussion in previous chapters to illustrate information flows and to contrast the papers and automated record systems.

3. Introduction • Healthcare consumers have multiple entry and exit points in a complex system that support an increasingly transient community. • Reports of problems with paper health records are numerous with issues of illegibility and access well documented. Electronic health records (EHR) systems are thought to negate most of these problems and lead to more efficient, sale and cost-effective healthcare.

4. Information flows across care • Vera is a 72-year-old woman living alone. She felt unwell and visited her General Practitioner (GP) who drew blood for testing. She was given a script for angina medication and antibiotics, to be taken after meals but before her arthritis tabs. She is to return in two days for a check up and results of her tests. If current system A form is written and wrapped around the blood vials and secured with a rubber band. They are left on the bench (just washed, and still wet) awaiting the courier If automated system An electronic order is sent to the pathology lab. The plastic coated, bar coded vials are left on the bench (just washed, and still wet) awaiting the courier. • Vera goes home. She has heard of an acupuncturist who is also a herbalist and works “magic” with arthritis. Her arthritis is really bothering her so she makes an appointment for the next day. The acupuncturist has Vera’s EHR and full history, notes that she visited her GP yesterday and has had blood tests. Vera views her record and notes a mistake that is corrected by the acupuncturist in a new notation. Vera arrives for her session. Relates her history- what she can remember of it- and tells the acupuncturist about her symptoms, which he notes in a new paper chart.

5. Information flows across care • Vera has her treatment and her joints feel much improved, although she is still ‘off color’ The acupuncturist dispenses a herbal remedy after Vera recited her current medications. None were contra-indicated. The paper chart is filed. Whoops ... she forgot the little blue pill! The acupuncturist does not prescribe herbal medications because, according to the current medications list, the herbs are contra-indicated. The acupuncturist treatment is noted on the shared EHR • The next day Vera goes to the chemist to have her scripts filled (No hurry, she has plenty of old tablets In her cupboard [she just knew she would need them one day!] and she also has the new herbal remedy.) A locum pharmacist dispensed her estrogen as per his reading of the handwritten script from the GP An electronic prescription has been sent to Vera’s local pharmacist. A locum pharmacist checks her current medications list for contra- indications or alerts. The erythromycin was individually packaged and dispensed and she is handed a printout of instructions.

6. Information flows across care • Next day Vera returns to the GP (The receptionist knows she has filed Vera’s record... She is sure it started with V.) After reading the 1946 Readers Digest, Vera sees her GR. No results yet, the fax is ‘playing up’. Phone call to the pathologist: ‘V-e-r-a .... no, not Dora... Vera!.’ The results are read over the telephone. The GP jots them down on a note pad. After watching a health promotion video in the waiting room. Vera sees her GP. Her EHR is open on the desktop. The visit to the alternative therapist is noted. The test results are in the in- box and the current medications list shows that the correct medications have been dispensed. • Vera is to be admitted to hospital immediately The GP writes a quick note: Dear Dr... please admit this lovely woman ... who has been off color for a week. Vera’s GP sends a summary record to HealthConnect repository and provides her with printed information about diabetes from the practice computer’s knowledge database.

7. Information flows across care • The receptionist phones an ambulance. On the way to hospital Vera has ‘a turn’. The ambulance officers are unsure of the cause, her diagnosis is sketchy and she is not able to give them any information, They give her oxygen. monitor her and hope the traffic isn’t too heavy. Vera’s chart is downloaded to the ambulance’s mobile videoconferencing equipment and consultation begun between the emergency department (ED) specialist and ambulance. Real-time physiological monitoring data is available to the specialist. The ED is prepared for her arrival.

8. Information flows across care • Information technology (IT) has permanently transformed the way in which we communicate; however one ofthe constraints is the inadequacy of the mainly copper wire communications network. Sending large amounts of data through the existing network is painfully slow and largely ineffective • To provide broadband Internet access to GPs to ensure that all general practices and Aboriginal Community Controlled Health Services have access to high quality, secure broadband services. • IT also has the capacity to rein in the unacceptable levels of errors and adverse events resulting from illegible handwriting and mistakes in the prescribing and administration of medications. • Medications management is an ongoing concern in most countries with errors responsible for considerable morbidity. • The United States Institute of Medicine (2001) report that over 98000 deaths each year in America were related to medical error 40 per cent of outpatient prescriptions were unnecessary and patients receive only 55 per cent of recommended care. • In Australia, misuse, under-use, overuse and reactions to therapeutic drugs result in 140 000 hospital admissions ever year and cost approximately $380 million each year in the public hospital system alone (AIHW, 2002).

9. Information flows across care • The MediConnect trials demonstrated the benefits of improved provider and consumer access to medicines information and the usefulness of using technology to link patients, doctors, pharmacists and hospitals. • Access to more complete consumers’ medicines information improves quality and safety in prescribing, dispensing and managing medicines. This will help to reduce the incidence of duplicate prescriptions, and allergic or adverse reaction -both major problems and cost in the Australian health system.

10. Information flows across care • HealthConnect is expected to include a storage system that consists of three layers • a coordination layer representing the infrastructure, metadata and services needed to integrate HealthConnect into a common national network of records • a federated record system layer which comprises multiple nodes (potentially with a range of system owners), each of which has an independent records system servicing a defined user- population • the user layer comprised of the consumers’ and providers’ local information systems used to access HealthConnect

11. Information flows across care • Adaptable mobile computers and scalable, point-of-care devices that are easily integrated with a variety of wireless medical devices and healthcare sensors are available. They enable the rapid collection and transmission of vital patient data from the scene from the emergency response team. • Digital images and vital sign measurements are quickly captured and transmitted to the appropriate clinician, wherever that person might be situated. • Continuous vital signs monitoring coupled with high-speed digital network connections and interactive videoconferencing capabilities, enable the consultant and emergency personnel to discuss and monitor patient care en route. All care and interventions are accurately recorded and stored automatically in the patient’s EHR using voice recognition software.

12. Information flows across care • Vera arrives at the Emergency Department If current system Vera’s chart is ordered from Medical Records Department storage. She is resuscitated and sent to Intensive Care. A paper progress note is used to admit her and to document progress. It will be placed in her chart when it arrives. If automated system The current EHR is displayed on the point-of- care device and as Vera has been stabilized en route a routine admission follows. All clinicians have access to all information. Vera is transferred to the ward. Vera is admitted into a high dependency unit; her details are recorded (again). A medical student does a thorough admission as does the resident and the registrar repeats the dose. All ask about current medications and each documents a full past and present health history. Vera’s vague status is noted and yesterday’s tests are repeated (the former results are in the GP’s silo). A nursing assessment is also carried out and documented. The EHR is available in the ward and had been automatically updated. It includes Vera’s past and present health history and a list of current medications and dispensing dates. Yesterday’s and all previous test results are also in the EHR.

13. Information flows across care Vera is prescribed medications and the nursing staff makes sure that these are given at the right time, in the right dose. She is asked about allergies before being given the first dose of ampicillin. Vera is unsure, but after ingesting the medication remembers having ‘a funny turn’ some years ago after taking penicillin. Vera is due for her medications. She has a bar coded armband with all information - demographics, allergies etc. The bar code reader crosschecks this with her chart and an allergy alert is received. The antibiotic is changed.

14. Information flows across care • Next day Vera is sent for a chest x-ray A paper referral is sent to the x-ray department. Vera is x-rayed and waits for the quality to be checked. She returns to the ward. The film will be read, the results typed and a paper copy sent later. Some time later it is received but not glued into her chart, as it cannot be located. The result slip is placed in the filing box. The x-ray appointment is made electronically. A digital x-ray is taken, and uploaded into her EHR. The radiologist comments on the x-ray using voice recognition to populate the EHR. This is immediately available to all concerned in Vera’s care long before she returns to the ward. The physio referral was sent electronically and treatment began yesterday. He goes online and notes that Vera has returned to the ward. Treatment is completed and documented although three other clinicians are simultaneously using the record. The physio has received a referral slip sent yesterday. He has visited the ward twice to see Vera while she was still in the x-ray department.

15. Information flows across care • The Open Architecture Clinical Information System (OACIS) project in South Australia has demonstrated that improvements in information flow are possible in EHRs and that the provision of timely provider access to results makes duplicate pathology and radiology tests unnecessary • Benefits reported by the Toronto Electronic Child Health Network were also impressive and include reduced human and financial costs For repeat testing: better coordination of care; and the ability to inform clinical care by trending results over time • The Walsall study of EHRs (Orion Health, 2004), report a reduced number of appointments to effectively treat patients and that reviewing the record prior to consultations reduced the number of referrals to chiropody, physiotherapy and other areas. • Owens and Foord (2002) also report a reduction in time spent by clinicians chasing information For complex cases, with critical results being at band much faster than previously possible.

16. Information flows across care • Other benefits of EHR have been demonstrated, although it is premature to quantify these in most instances. • The fledgling Gloucester ERDIP project for example, points to major reductions in the average length of stay as well as significant savings on chemistry, haematology, transfusion and microbiology tests (Owens & Foord, 2002). • The national summary EHR (HealthConnect) should achieve similar results in Australia because it enables real-time downloading of current patient information at the point-of-care. It focuses on automating the capture, exchange, transmission and collection of health data • IT enables the sharing and storage of data not before possible with paper-based records and other current means of communication. In the United States of America for instance, 30 billion healthcare transactions are conducted electronically via mail, fax, or phone every year

17. Information flows across care • Vera is discharged If current system A discharge summary is written for the community nurse and given to Vera. It contains current medications and diagnosis. The resident forwards a letter to the GP with a brief reintroduction to Vera and her care. It should arrive in the next few days! weeks. One-month’s supply of medications is dispensed. Vera returns home and rings the Community Health Nurses for assistance, but she requires a referral. Her GP does not do this via telephone and it will have to wait until she see can see him. The first available appointment is next week. The community nurse makes an appointment to see Vera after that. Eventually. If automated system A clinical discharge summary is automatically uploaded into HealthConnect via a fast broadband connection. Her health team has immediate access to this All are aware of Vera’s medications and a sufficient supply has been pre packed and dispensed. Her GP will review her next week. An automatic referral is sent to the community nurse who makes an appointment with Vera the day after she returns home.

18. Information flows across care • Vera is seen by the community nurse The community nurse arrives a little late, as she was lost. She quizzes Vera about her past history and hospital stay and asks about her treatment and outcomes (unfortunately the discharge summary is still in the taxi). Vera does not seem to remember much. The nurse asks about medications. Vera produces an apple box containing medicines from 1956 to the latest supply from the hospital, oh ... and her herbs. She seems confused about which of the little red pills she should take. The community nurse arrives on time thanks to the GPS built into her Tablet PC. She has immediate access via a wireless network to Vera’s full history, current medications and care plan. Vera has surfed the net and has printouts about her condition that she wishes to discuss with the nurse. In future they will meet via a telehealth home link.

19. Information flows across care

20. Information flows across care • Mobile computing enables the collection and sharing of quality data to reduce errors, improve patient safety, and enhance service provision. However community healthcare providers also offer a range of services that have very specific obligatory reporting requirements. In such a diverse environment, data collection is potentially confusing and extremely complex. To overcome this, the Royal District Nursing Service introduced a data-mapping matrix that supports the use of quality data and information while enabling the organization to respond and comply with the many health-related minimum data sets (RDNS, 2005). • Telehealth in home healthcare is available in many forms and is transmitted in three basic forms - text data, audio, and images. However, home-based telehealth tools require the provider to exhibit cognitive and observational skills to assess patient status from a distance (Lisetti & LeRouge, 2004). Although physiological measurement and so forth can be effectively communicated using current telehealth systems, the often crucial affective state assessment provides a greater challenge. A system curreiitlv under development builds a model of user’s emotions (MOUE), while monitoring the patient using multi-sensory devices (Lisetti & LeRouge, 2004). These types of innovations will he a timely addition to the data and information available on a remotely monitored patient. • However, with the increasing transience of the population, the triangular model of health services between general practitioner; community nurse and hospital is dated and probably does not reflect healthcare of the future. Roggiero demonstrates the use of information technology in an isolated Aboriginal Community Health Centre and the necessity for a rethink about the way people engage with the health system.