A Bucket Full of Numbers?

1. A Bucket Full of Numbers? An Insight to Hemodialysis Data Management Systems Kevin Lyons Fresenius Medical Care, Bad Homburg / Germany

2. Evolution of Hemodialysis Data Management Systems Potential Pitfalls A case for automatic data acquisition The Current ‘State of the Art’ What should a modern IT system provide? What about the future? Topics

3. The early days…. Paper record. Only option available. Manual. Difficult to evaluate trends. Prone to tpyographical error. Very short term use. Limited contribution to patient care. Evolution…

4. Life Cycle of the Paper Record

5. Evolution over 25 years Adapted from Ronco C 2000

6. A dialysis unit may collect several GB of data per year Device & machine data Pressure, conductivities, flows, temperatures, physiological data Other treatment information Symptoms,access documentation, hospitalizations … Laboratory results Diagnosis Demographic information Drug prescription & intake Reference data (medications, diagnosis catalogues, …) It is hard to store/maintain this information without databases A case for a Database?

7. Downward pressure on healthcare costs Sheer Volume of data to manage Optimisation of Resources Desire to become paperless Steady increase in patient numbers Compliance to Standards E.g. DOQI Keeping abreast of technology Sharing & Exchange of information Driving Forces towards Data Management COMPUTERISE!

8. Industry Responds….. Sample for illustrative purposes only

9. Nurse Medical Manager Director Pleased with current system 41% 34% Need to add additional functions 75% 73% Need a new system 45% 55% Current system is very good at Patient care…. 37% 33% Current system is very good at Monitoring quality and outcomes 44% 38% Evaluation of Clinical Computing Systems as Used by DOPPS Participants Sargent J 1999

10. Purchasing system before needs are defined System does not meet the requirements Data collection and entry Management of collected data is complex Lack of a friendly interface Reporting not targeted to improving patient care levels Not upgradeable Lack of an ongoing training program / poor training Factors Limiting the Effectiveness of Computer Systems Adapted from Ronco C 2000

11. … modern dialysis machines are able to provide much more treatment information... T [°C] T [°C] Online plus™ System Online plus™ System 38 38 37 37 Tbody Tbody 36 36 Tven Tven 35 35 t[h] t[h] 0.0 0.5 1.0 1.5 2.0 0.0 0.5 1.0 1.5 2.0 E[kJ] E[kJ] 0 0 -100 -100 t[h] t[h] 0.0 0.5 1.0 1.5 0.0 0.5 1.0 2.0 1.5 2.0

12. Other Medical Devices Can Provide Information too… …in principle, any device with an RS 232 or similar interface can pass on its measured parameters

13. The Missing Link… Workstations File Servers Workstations

14. Manual -v- Automated Measurements (1) Table 1: Time needed to produce dialysis prescription using automated data acquisition compared to manual data entry Source: Rourke E et al. “Man or Machine”

15. Blood Pressure Pre-Finesse 150/90 140/92 150/110 150/80 140/90 150/90 202/100 150/90 150/90 150/85 Blood Pressure Post-Finesse 191/110 212/89 196/99 210/104 188/89 214/105 191/89 169/84 175/84 190/110 Manual -v- Automated Measurements (2) Table 2: Comparison of 10 Blood Pressure readings taken by a patient immediatelybefore the installation of Finesse and 10 automated readings produced immediatelyafter the installation of the system Source: Rourke E et al. “Man or Machine”

16. Manual -v- Automated Measurements (3) Figure 4 : Comparison of reported symptoms 3 months prior to, and 3 months after installation of Finesse Source: Rourke E et al. “Man or Machine”

17. Real time treatment information Accuracy of recorded data Patient reported Typographical Therapy given based upon patient status Burden of data collection greatly reduced Facilitates Audit and Analysis Benefits of a Data Acquisition System

18. Acquisition alone is not enough… It can only be successful when implemented with the ‘right’ database.

19. Functionality Data presentation & analysis Integration of dialysis machines & medical devices Advanced features (decision support, bio-feedback) Integration with other systems What Characterises an OutstandingData Management System?

20. Acceptance: The user likes to work with it, … Simplicity, usability and workflow Don’t have to drastically change their way of working Training Please Confirm F60 Where do I have to enter what?? Without workflow: The worker looks for the work With workflow: The work looks for the worker What Characterises an OutstandingData Management System?

21. Acceptance: Training is an ESSENTIAL element • NEVER underestimate the importance of training • Create local experts via the TTT concept • Ensure ALL relevant disciplines are involved • Bilateral responsibilities

22. Cost effectiveness Benefit from changing technologies and competition Scalability What Characterises an OutstandingData Management System?

23. Profit from competition, be independent of Platform (AS400, PC, SUN, …) Database (DB2, Oracle, MS-SQL, …) Operating System (OS400, NT, Win9x, Solaris, …) Profit from changing Telecoms market, choose LAN, Frame-Relay, Internet, Dial-up, … Profit from global developer community and use open and (license) free standards Java, HTML, XML, Servlet, Internet (www, ftp, …) Cost Effectiveness

24. THE data exchange format Non proprietary, widely supported (Microsoft, SUN, IBM, oracle, …) Standard also in the medical field (HL7) XML: Extended Mark-up Language XML <machine_data id="Fresenius_4008"> <patient id=Q1299817212 /> <row> <data name="time">15.02.2000 19:47:21</data> <data name="ven. pressure">1926</data> <data name="art. pressure ">9548</data> <data name="Temperature">7784</data> <data name="UF-Volume">4153</data> <data name="UF-Rate">1093</data> </row> <row> <data name="time">15.02.2000 19:47:26</data> <data name="Temperature">3529</data> <data name=“Dialysate-flow">681</data> <data name="UF-Volume">8225</data> <data name="UF-Rate">1808</data> </row> ... </machine_data> Standard-Interface 150220001947211926954877840000415300324331093de34ar153 150220001947260000000035290581822500deas01808de34ar154 ... Vendor specific Human readable

25. Cost Effectiveness: Scalability 1000+ PCs Technical Scope Disease state management 100 PCs Entire medical documentation 10 PCs Warehouse Functional Scope Workflow 1 PC Machine integration Dialysis unit Dialysis clinic Hospital Chain Single doctor National Healthcare

26. For the very first time in history we have: Option to share information and to communicate without any restrictions by borders and locations Send: text (letters), pictures (x-ray), movies (echo), sounds Discuss: chat-rooms, news-groups Retrieve information: on-line databases & journals Standardised technology Chance to share common data: consistent, non-redundant, without lavish interfaces, shared by larger community, e.g. Several clinics Affordable by nearly everybody Internet….. What’s so Special? • For the very first time in history we have: • Option to share information and to communicate without any restrictions by borders and locations • Send: text (letters), pictures (x-ray), movies (echo), sounds • Discuss: via chat-rooms, news-groups • Retrieve information: on-line databases & journals • Standardised technology • Chance to share common data: consistent, non-redundant, without lavish interfaces, shared by larger community, e.g. Several clinics • Affordable by nearly everybody State-of-the-art clinical IT systems have to utilize these opportunities!

27. Thank you for your attention Kevin Lyons Service & Training Manager Fresenius Medical Care Regional Office Middle East PO Box 3264 Dubai UAE Tel +9714 332 9317 Fax +971 332 9316 Mob +971506250443 E-mail: kevin_lyons@hotmail.com