Clinical Content Tracking System

1
Clinical Content Tracking System An Efficient
Request Tracking system via a Graphical User
Interface.

• Presented by Saif S. Khairat
• Advisor Dr. Chi-Ren Shyu
• Masters Defense

2
Overview

• Background
• CPOE systems
• CCTS
• Database Management System
• System Architecture
• Conclusion, Future work and Limitations
• System Demonstration

3
Background

• Between 44,000 to 98,000 Americans die each year
  due to medical errors, and about 1 million people
  are injured. (Institute of Medicine, 1999)
• Despite the desirability of implementing an
  efficient Computerized Physicians Order Entry
  (CPOE) system, only 9.6 of U.S. hospitals
  presently have CPOE completely available. (Ash,
  Gorman, 2002)
• Paper-based systems, especially in the Health
  Informatics field, tend to be error prone and
  inefficient.

4
What is a CPOE system in healthcare?

• A Computerized Physician Order Entry (CPOE)
  system is a process of electronic order entries
  for the treatment of patients under physicians
  care.
• Benefits
• Decreases delay in order completion
• Reduces errors related to handwriting
• Allows order entry at off site locations

5
Current CPOE systems

• The CPOE system has not yet proven its ability to
  fully eliminate medication errors.
• Current CPOE systems do not use programmable
  decision-support infrastructures, and most
  health-care institutions do not have centralized
  and encoded clinical databases. (Guilherme,
  Roberto, 2005)
• The cost of CPOE systems ranges from 3 million
  to 10 million, depending of hospital size and
  how well-built the IT infrastructure is.
  (Advisory Board Company, 2004)

6
What is CCTS and its role in the CPOE
implementation process?

• CCTS is a tool that helps physicians build
  clinical contents, in an electronic format, that
  will be then used in the CPOE system.
• CCTS develops new electronic order sets by modify
  existing paper order sets through a governed
  structure. An order set is the grouping of
  patient orders for a specific diagnosis or
  condition.
• The system delivers order sets that are less
  error prone to a CPOE system.

7
Why CCTS?

• The main motivation behind this research is to
  develop an adaptive system that can be configured
  or customized to meet the needs of various health
  institute.
• Our research emphasized the development a system
  that can be used by a large number of hospitals,
  regardless of their size or funds.
• CCTS has a decision-support system built within
  to ensure that the workflow is compatible with
  the original workflow in the hospitals.
• The system minimizes the use of free text by
  users to help eliminate errors.

8
System Information

• Average turn around time depends on the size of
  the hospital.
• Usually several months up to one year.
• Hospitals currently using the system
• Winnipeg Regional Health Authority
• Valley Baptist Medical Center
• About 500-600 Clinical Contents (CC) to load in
  the system at developing stage. Then, 3-5 CC per
  month (in a 350 bed hospital).

9
What our CCTS does

• Stores images of current-state paper order sets
  (in .PDF, .JPEG or .DOC form)
• Tracks various review-group decisions as these
  groups review all the existing order sets for
  electronic conversion and implementation into the
  Computerized Physician Order Entry system
• Allows requests for new order sets to be made by
  members in the system, which then go through the
  review process, too.
• Provides a versioning system for electronic order
  sets.

10
What our CCTS does (Cont)

• Creates electronic templates for existing order
  set review/modification requests and for new
  requests. Templates based on uploaded paper
  examples and review input.
• Tracks the decision of each group involved in
  reviewing and approving (or failing) the
  electronic templates, which are then handed off
  to the Clinical Information System (CIS)
  implementation team.

11
Sample of a template
Formulary Oral Antidiabetic agents Formulary Oral Antidiabetic agents Formulary Oral Antidiabetic agents Formulary Oral Antidiabetic agents Formulary Oral Antidiabetic agents Formulary Oral Antidiabetic agents
    Order Dose Route Frequency
?   Metformin (Glucophage) 500mg PO tid
?   Metformin (Glucophage) 850mg PO tid
?   Micronized Glyburide (Glynase) 3 mg PO tid
?   Glyburide (Micronase) 2.5mg PO tid
?   Glyburide (Micronase) 5 mg PO tid
?   Glypizide (Glucotrol) 5mg PO tid
?   Glypizide (Glucotrol) 10mg PO tid
?   Glypizide Extended Release (Glucotrol XL) 2.5mg PO tid
?   Glypizide Extended Release (Glucotrol XL) 5mg PO tid
?   Glypizide Extended Release (Glucotrol XL) 10mg PO tid
12
Database Management System

• CCTS is a database-driven system.
• Our research focuses on developing an adaptive
  Database Management System (DBMS) that allows for
  the grooming, reviewing and tracking of decision
  for clinical contents.
• The database design has been optimized and tuned
  several times in order to make the system as
  reliable and flexible as possible.

13
Old Entity-Relationship Diagram (1-2)
14
Old Entity-Relationship Diagram (2-2)
15
The ERD
16
Database Optimization and Tuning

• Several iterations of design were done to refine
  our database schema from 60 tables in the
  original design to roughly one third of the
  number of tables in the final design.
• The optimization process includes consolidations
  of contents from various tables and restructuring
  the design to a start-like architecture where
  Table Request plays as a heart of the entire
  database activities
• .
• The new design provides version tracking of
  templates for a certain request using Table
  E_template which gives an extra dimension of
  advantages over the paper-based process.

17
Database Optimization and Tuning (Cont.)

• To deal with M-N relationship, we add an extra
  table in between so that each table will have a
  one-to-many (1-M) relationship.

18
Database Optimization and Tuning (Cont.)
19
System Architecture
The system has eight modules. Each module has its
own members and functionalities.
20

• Work flow

21
Groups/roles (of users) involved -- 1 of 4

• CCTS has 8 typical groups/roles within hospitals
  that are involved in these processes. These are
  the main participant-users of this system
• Stakeholder anyone within the hospital that is
  allowed to make requests for order set reviews,
  amendments and new order sets. Who is allowed to
  do this would depend on hospital policy. Likely
  this would include head physicians and nurse
  managers within each program or service area.
• Content Board a small group of senior
  decision-makers from various programs and service
  areas who oversee all clinical content reviews,
  revision and updates for their hospital. If the
  Content Board approves a request, they assign a
  Facilitator and a Content Specialist.

22
Groups/roles (of users) involved -- 2 of 4

• Facilitator a higher level administrative
  assistant who assists the Content Board by
  creating templates
• Content Specialist every clinical program or
  service area would have at least one content
  specialist, if not more. These would be
  knowledgeable, experienced clinicians assigned by
  their program or service directors to participate
  in the ongoing content review and updating
  process.
• Peer Specialist every clinical program or
  service area would have a least one peer
  specialist, if not more. These would also be
  knowledgeable, experienced clinicians with whom
  the Content Specialist would confer on clinical
  content questions.

23
Groups/roles (of users) involved -- 3 of 4

• Clinical Program - this group comprises one
  person, likely the director or the directors
  designate, from each clinical program or service
  area. This is the senior in charge for that area
  who makes the final review decision on Templates
  for input into the CPOE-CIS and the final
  decision on the Working Product i.e. the
  computerized physician order entry order set
  within the new CPOE prior to CPOE go-live date.
• Clinical Content Design Team - this group
  comprises a small number of hospital IT people
  and informatics-savvy clinicians who will work
  with a consultant and the CIS implementation team
  to oversee the CIS implementation within their
  hospital.

24
Groups/roles (of users) involved -- 4 of 4

• System Analyst this is the person from the
  hospital IT department who is the primary liaison
  between the CCDT and the CIS Team. This person
  could be a member of the CCDT or it could be the
  hospital IT manager responsible for the CIS
  implementation.
• CIS Team this is not an entity or user within
  our system. This is a separate entity consisting
  of members of an implementation team from the CIS
  vendor for the CIS that the hospital has
  purchased. The CIS Team will build the CPOE
  system based on the Working Product that the
  System Analyst delivers.
• Administrator this is a designated hospital IT
  person responsible for the operation and
  maintenance of this CPOE system.

25
Outline of the work flow within CCTS - 1 of 3

• Stakeholder makes a request
• Content Board meets regularly as group to review
  requests
• - approves a request, assigns Facilitator,
  assigns Content Specialist
• - or fails request
• Content Specialist reviews the request
• - gathers and uploads scholarly articles to
  support her recommendations for clinical content
  changes
• - consults with Peer Specialist about
  recommendations
• - uploads .PDFs, JPEGs or .docs containing
  instructions on changes

26
Outline of the work flow within CCTS- 2 of 3

• Facilitator creates an electronic template from
  the materials the Content Specialist sent.
• Clinical Program Director (the director or a
  designate) from the related specialty (e.g.
  pediatrics, radiology) reviews the template
• - approves template
• - or fails template
• Clinical Content Design Team (CCDT) reviews the
  template
• - approves template
• - or fails template

27
Outline of the work flow within CCTS - 3 of 3

• Systems Analyst
• - works outside of this system with the CIS
  implementation team
• - creates a working product based on the
  approved template within the CPOE system

28
Screen shots from CCTS
29
Screen shots from CCTS
30
Screen shots from CCTS
31
Conclusion

• The need for electronic order sets in health
  institutes is growing rapidly for many reasons.
• This research proposed a system that will
  develop, review and track electronic order sets
  for CPOE systems to use.
• CCTS has a built-in request tracking feature and
  a versioning tool.
• It is essential to analyze our system against
  similar paper-based systems in order to evaluate
  our system.

32
Future work

• It is our goal in the future to create a library
  of all order set names, modules and line items
  entered in to the system through users.
• Create a Template via an Extensible Markup
  Language (XML) form with all the information in
  the library will be displayed to the user to
  choose from.
• The system will allow the storage, review
  decision-tracking and grooming of clinical
  content other than order sets e.g. medical logic
  modules and documentation templates.

33
Limitations

• Currently the system does not support searching
  through the literature collected in the system.
• Limitations of creating an XML library is that
  items inserted into the library might include
  errors.

34
Acknowledgments

• Thank you to Dr. Chi-Ren Shyu for all his efforts
  and support during my course of study.
• Thanks to Dr. Duan Ye and Dr. Guilherme DeSouza
  for their service as my thesis committee members
  .
• Thanks to everyone who gave up some of their time
  to attend my defense.

35
System Demonstration

• Click here

36
Questions?

• Thank you!