Clinical Informatics: 2000 and Beyond

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Clinical Informatics 2000 and Beyond

• R. Matthew Sailors, Ph.D.UTH Medical School
• Division of General Surgery
• Health Informatics Speakers Series
• November 1, 1999

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Role of Clinical Informatics

• Help clinicians

Make best use of time
Assimilate data from myriad of source
Make fast and effective decisions Make better
use of skills
3
How ?

• Make Best Use of Their Skills
• Make Best Use of Technology
• Automate Patient Care Process
• Information Presentation
• On-Line Reference Training

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Automate Patient Care Process
Charting
Open- and closed-loop protocols
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Charting

• Efficient Manual Data Entry
• Task-specific
• Real-time Validation
• Integrated Into Workflow
• Technology
• Low Tech
• High Tech

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Efficiency of Validation
Efficiency
Point Of Care
Database
7
Time Required to Validate
Time
Point Of Care
Database
8
Database Perception
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Data Used Without Validation
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Data Validation

• Completeness
• Consistent Calculations
• Ranges Checking
• Internal Consistency

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Example of Verification Validation Internal
Consistency
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Assuring Completeness at Point of Care
Force Entry of Data Allow Not Available Allow
Default Values
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Force Entry of Data
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Not Available

• Non-essential variables
• Values lost and confirmed
• No need to re-check

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Default Values

• Blank No
• Heparin? N
• Pre-fill with most likely answer
• Heart Failure? N
• Blank Normal, if variable not measured
• amylase 44
• Blank Hospital Average, if not measured
• Maximum WBC

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Different Calculations Units of Measurement

• CaO2
• Hgb (gm/dl) ? 1.39 ? (SaO2/100) PaO2 ? .0031
• (1.34 ??SaO2 ??Hgb)/100 PaO2 ? 0.003
• Systemic Vascular Resistance
• dynes sec cm-5
• wood units

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Data Not Within Valid Ranges
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Data set contains inconsistent values

• Future Dates
• Illogical value comparisons within the data
  record set
• VRset?????????VR Measured
• BPdiastolic?????????BPsystolic
• Dates not in a logical progression
• ICU Admit Date???????Hospital Admit Date

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Charting
PATIENT, IMA NMI 32232421 S224 I
10/29/96 C 40Y F
ÚÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄ ADULT VENTILATOR
MONITOR ÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄ ³Time of Tx
12/21/96.1613 Ventilator PB7200
Mode AC ³ ³ Settings
Patient Data Airway Management Calculated
Values ³ ³ VT 360 ml Ppeak
cmH2OLavageN ml ³ ³
Rate 35 bpm Pplat cmH2OSputumN
ml M Cor VTe ml ³ ³Pk flow 60 L/m
PEEP cmH2OAirway CareN Y/N
³ ³ Trig P F/P Int PEEP
cmH2OTube Data Comp ml/cmH2O³ ³
Sens- 0 cmH2O Pmean
cmH2OTypeNASOTRACH VT/kg 6.2 ml/kgBWP³ ³
O2 Set 80 IE 1
DescCUFFED ³ ³
PEEP 25 cmH2OTot Rate bpmSize 7.0
³ ³Waveform SQUARE
Tot Cor VE L/m Pos28.0
³ ³
Cuff Prs 0 cmH2ONotes ³ ³Ins
Paus 2.0 sec Circuit Data
Chng Per ProtN Y/N³ ³
O2 Meas Set temp35.0 C Adv
ReactionsN Y/N³ ³ Alarm Settings SpO2
Meas temp35.0 C ³ ³
Hi Pres 100 cmH2O ETCO2 Bag
MaskY Y/N Objectives ³ ³Low Pres 30
cmH2OPositn Circ changeN Y/N
Maintain Ven ³ ³Low PEEP 10 cmH2OCondtn
Suct changeN Y/N
³ ³ Low VT 250 ml Breath SoundsN Y/N HME
changeN Y/N ³ ³ Low VE 8.0
L/m SuctionedN Y/NCtube4.0
ml/cmH2ODuration 12 mins ³ ³ Hi Rate 40 bpm

³ ³Apnea Time20 sec Last Value
CommentsN
Y/N³ ÀÄÄÄÄÄÄÄÄÄÄÄÄÄÄF4-Save F10-Exit w/o saving
HOME-return to topÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÙ Enter the
mechanical tidal volume setting in
ml.--------------------------------
³Time of Tx 12/21/96.1613 Ventilator ³
Settings Patient Data ³ VT 360
ml Ppeak cmH2O ³ Rate 35 bpm
Pplat cmH2O ³Pk flow 60 L/m PEEP
cmH2O ³ Trig P F/P Int PEEP
cmH2O ³ Sens- 0 cmH2O Pmean cmH2O ³
O2 Set 80 IE 1 ³ PEEP 25
cmH2OTot Rate bpm ³Waveform SQUARE
Tot Cor VE L/m
Enter the mechanical tidal volume setting in ml.
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Charting

• Automated charting
• SpO2
• Vital signs
• IV infusion pumps
• Ventilator data ( experimental only )
• Technology
• MIB
• Proprietary interfaces

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Automated Ventilator Charting
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Medical Information Bus (MIB)
Bedside Communications Controller
Devices 1-3
Device 5
Device 4
Device 6
IEEE P1073 (MIB)
External Device Communication Controller
Device 7
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Information Presentation

• Provide information not just data
• Provided integrated data and information
• Make important items easy to identify

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Wisdom
Experience
Knowledge
Ability to use Information
Information
Meaning
Data
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InfoSense
Commonsense rules about Information
From InfoSense Turning Information into
Knowledge by Keith Devlin
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What is Information
What is information? How is it stored? And
what is required to turn information into
knowledge? Everyone thinks that they know the
answers to these questions until they are asked
to say what those answers are. At that point it
becomes clear that we have at best a vague idea
of what the words mean. Moreover, your vague
idea and mine may not be the same.
InfoSense Turning Information into Knowledge by
Keith Devlin
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What is Information
This is quite unlike the situation in
engineering. The engineers who produce our
buildings, bridges, automobiles, aircraft,
household appliances, and communications
technologies base their work on the solid
foundation of decades and even hundreds of years
of scientific progress in physics and other
sciences.
InfoSense Turning Information into Knowledge by
Keith Devlin
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What is Information
But the people who design and manage our
information systems have to work with much
shakier foundations. The fact is, when you
stop to compare the scientific foundations of
engineeriong with the theoretical understandings
on which we base the ways we handle information,
you realize that, when it comes to information
and knowledge, we are still innocents.
InfoSense Turning Information into Knowledge by
Keith Devlin
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What is Information
An yet, modern life depends heavily on
information and knowledge. If we handle it
poorly, because we do not really understand it,
then we will always be just a step away from
disaster. We need to learn how to handle this
stuff called information in a safe and
efficient manner. Our present information
innocence reminds me of Marie Curie who paid
for her scientific innocence with her life.
InfoSense Turning Information into Knowledge by
Keith Devlin
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Automated Ventilator Charting
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Blood Gas Interpretation
MAY 26 98 pH PCO2 HCO3 BE HB
CO/MT PO2 SO2 O2CT NORMAL HI 7.45
43.4 27.7 2.5 17.7 2/ 1 NORMAL LOW 7.35
30.0 17.4 -2.5 13.7 0/ 1 52 86
17.9
ÚÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄ
ÄÄÄÄÄÄÄÄÄÄ BLOOD GAS ÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄ
ÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄ ³ MAY 26 98
pH PCO2 HCO3 BE HB CO/MT PO2
SO2 O2CT O2 AVO2 VO2 C.O. A-a Qs/Qt
PK/ PL/PP MR/SR ³ ³ NORMAL HI 7.45 43.4
27.7 2.5 17.7 2/ 1
5.5 300 7.30 29 5
³ ³ NORMAL LOW 7.35 30.0 17.4 -2.5
13.7 0/ 1 52 86 17.9 3.0 200
2.90 0
³
BLOOD GAS
26 1425 A
7.42 34.6 22.2 -.9 13.1 1/ 1 71
92 17.0 40 127
SAMPLE
8,TEMP 37.0, BREATHING STATUS CPAP

NORMAL ARTERIAL ACID-BASE
CHEMISTRY

MILDLY REDUCED O2 CONTENT

PULSE
OXIMETER SO2 95.0




26 0406 V 11.7 2/
1 68 50
/ / 5 10/ 26 0400 A 7.43
34.3 22.6 -.4 11.7 2/ 0 68 93
15.4 50 190 / /
5 10/ End of data
for this time range




26 1425 A 7.42 34.6 22.2 -.9 13.1 1/
1 71 92 17.0 SAMPLE
8,TEMP 37.0, BREATHING STATUS CPAP
NORMAL ARTERIAL ACID-BASE CHEMISTRY
MILDLY REDUCED O2 CONTENT PULSE
OXIMETER SO2 95.0
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Metaphor Graphics
Wm. Cole, et al.
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GIFIC
Neurologic
Respiratory
Cardiac
Gastrointestinal
Dr. Michael Lesser GIFIC, Inc.
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Decision Support

• Open-Loop
• Do we trust the transducers?
• Simple
• Reminders Alerts
• Complex
• Diagnostic Therapeutic
• Explicit Rules

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Interpreting Guidelines
Not everyone interprets things in the same way!
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Decision Support

• ARDS ventilator management protocols
• Antibiotic Assistant
• DVT anti-coagulant therapy
• ABG Interpretation

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CPPV Oxygenation Protocols
Specific Instructions
Arterial PO2, SpO2, Mode, FiO2, PEEP, Ppeak
BP, HR
FiO2 PEEP Mode Wait Weaning
Ventilator
PATIENT
Accept Instruction
MD, RN, RT
Decline Instruction
Reason
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PUBLIC, JOHN Q. 2342123132 E907 I
03/18/86 C 47Y M ÉÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍ
ÍÍÍÍÍÍA R D S P R O T O C O L
SÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍ
º Patient
supported with HIGH stretch protocol.
BWP 59.062 º
ÚÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄEdit
options A to accept, R to reject, ltF7gt
displays past instuctionsÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄ
³ 03/18 0954.

³ ³ Change in
tidal volume(VT) since last ABG. New ABG required
to reassess patient status.
³ ³ 03/18 0954.

³ ³
Increase VT trial completed. User Cancellation.

³ ³ 1. Keep ventilator rate
(VR) at 29.0 bpm................................
....................................... A ³ ³
2. Keep tidal volume(VT) at 680.0
ml................................................
............................ A ³ ³ Set
peak flow to maintain an IE ratio between 11.8
and 12.8.
³ ³ Acknowledged YOUNG, JOE Q
Time03/18 0954.
³ ³ 03/18
0723.

³ ³ Change in tidal
volume(VT) since last ABG. New ABG required to
reassess patient status.
³ ³ 03/18 0513.

³ ³ Protocol
run from ABG drawn at 04/30 0511. PaO2 75.1,
pHa 7.4.
³ ³ Entering a VT trial for
assisting patient. This trial will attempt to
reduce the rate by increasing VT. ³ ³
Continue trial if patient is stable,
adequately sedated and medicated for pain.
Otherwise CANCEL the trial. ³ ³ 3.
Keep FIO2 at 50.0 .............................
..................................................
.......... A ³ ³

Page 1 of 2 ³ ³


³ ÀÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄ
ÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄ
ÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÄÙ


Please select 0 to 50 of
the above options
03/18 0954. Increase VT trial completed.
User Cancellation. 1. Keep ventilator rate
(VR) at 29.0 bpm.. A 2. Keep tidal
volume(VT) at 680.0 ml. ..... A Acknowledged
YOUNG, JOE Q Time03/18 0954.
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Antibiotic Assistant
ÉÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍ IHC ANTIBIOTIC ASSISTANT
ORDER PROGRAM ÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍ º xxxxxxxx
nnnnnnnnnnnnnnnnnnnn rrrr 83yr M DxVALVULAR
BACTERIAL ENDOCARDITº º Max 24hr WBC15.6 (18.2)
Admitmm/dd/yy.hhmm Max 24hr Temp36.6
(36.4) º º RENAL FUNCTION Impaired, CrCl 23,
Max 24hr Cr 2.1( 1.7) IBWeight 62kgº º
ANTIBIOTIC ALLERGIES None reported
º º CURRENT
ANTIBIOTICS
º º 1. 04/25/98.1213
NAFCILLIN (UNIPEN), VIAL 2000. Q
4 hrs º º IDENTIFIED PATHOGENS
SITE COLLECTED º º p
Staphylococcus aureus Wound
04/23/98.1000º º Staphylococcus
aureus Aortic
04/23/98.1536º º p Gram Positive Cocci
Aortic 04/23/98.1536º º
Staphylococcus aureus Sternum
04/23/98.1400º º THERAPEUTIC
SUGGESTION DOSAGE ROUTE INTERVAL
º º Vancomycin
1000mg IV q72h (infuse over 1hr)
º º Gentamicin 240mg IV
q48h (infuse over 1hr) º º Suggested
Antibiotic Duration 28 days
º º Adjusted based on
patient's renal function.
º º pPrelim Susceptibilities based on
antibiogram or same pathogen w/ suscept.
º ºPatient may qualify for hyperbaric oxygen
therapy, call 321-3623 or 321-1234 º º lt1gtMicro,
lt2gtOrganismSuscept, lt3gtDrug Info,
lt4gtExplainLogic, lt5gtEmpiric Abx, º º lt6gtAbx Hx,
lt7gtID Rnds, lt8gtLab/Abx Levels, lt9gtXray, lt10gtData
Input Screen, º º ltEscgtEXIT, ltF1gtHelp,
lt0gtUserInput, lt.gtOutpatientModels,
ltorF12gtChangePatientº ºORDERltgtSuggested Abx,
ltEntergtOther Abx, lt/gtD/C Abx, lt-gtModify Abx,
º º

º ÈÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍ
ÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍÍͼ
THERAPEUTIC SUGGESTION DOSAGE ROUTE INTERVAL
Vancomycin 1000mg IV q72h
(infuse over 1hr) Gentamicin 240mg
IV q48h (infuse over 1hr) Suggested
Antibiotic Duration 28 days
Adjusted based on patient's renal function.
pPrelim Susceptibilities based
on antibiogram or same pathogen w/
suscept.
ANTIBIOTIC ALLERGIES None reported
CURRENT ANTIBIOTICS
04/25/98.1213 NAFCILLIN (UNIPEN),
VIAL 2000. Q 4 hrs
IDENTIFIED PATHOGENS SITE
COLLECTED p Staphylococcus aureus Wound
04/23/98.1000 Staphylococcus aureus
Aortic 04/23/98.1536 p Gram Positive
Cocci Aortic 04/23/98.1536
Staphylococcus aureus Sternum
04/23/98.1400
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On-Line Reference and Training

• Reference lists
• formulary
• standard practices
• Texts
• Teaching examples
• Patient Simulations

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On-Line References

• Policies and Procedures
• isolation
• special equipment
• Quick Reference Cards
• Disease / Syndrome Profiles

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Emerging Technologies

• Virtual reality
• Augmented reality
• True 3D displays
• Artificial intelligence
• Closed-loop control ( made possible by better
  transducers )

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Information System Requirements

• Integrated Database (Clinical Data Repository)
• Clinical Lexicon
• Universal Presence
• Standards-Based

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Integrated Database
Radiology
Laboratory
Clinics
Clinical Data Repository
new / updated datarequests for data
requested datasynchronization data
ADT
Bedside
ICU
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Multiple Data Views
View by Clinician
Clinical Data Repository
View by Diagnosis
View by Patient
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Clinical Lexicon
Concept Text
Common Term
Synonyms
Concept ID
otitis media
otitis media ear infection
otitis media -inflammation of middle ear
09023
CDR
Clinician
Patient
ADT
Chief Complaint ear infection
otitis media
Patient has ear infection
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HELP System Integrated Database
Medical Knowledge
Pulse Oximeter
Ventilator
MIB
IV Pumps
Nurse
Nurse
Procedure
Care
MCC
Charting
Plans
Medication
Infectious
Schedule
Diseases
MIB data
Bedside Monitor
Physiologic
Data
Medical
Records
Surgery
PATIENT
Anesthesia
ECG Lab
DATA
Charting
BASE
X-Ray
Surgery
PTXT
Schedule
Blood
Gas Lab
Output
Laboratory
Respiratory
Pathology
Care
Admitting
Blood Bank
Catherterization
Lab
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Universal Presence

• Computer access at many locations
• library
• ward desk
• patient rooms
• ER
• OR
• procedure areas
• radiology
• cath lab

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Standards

• Consensus standards
• HL7
• ASTM
• IEEE
• ANSI
• ISO
• De facto standards
• operating systems
• development tools

• Communications
• HL7
• MIB (IEEE)
• Hardware
• ASTM / ANSI / ISO
• Software
• ANSI / ISO
• Knowledge
• Arden Syntax (HL7)

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Thanks to My Colleagues

• Cottonwood Hospital
• Thomas East, Ph.D.
• Laura Heermann, RN MS
• Richard Bradshaw, MS
• Don Hansen, BS
• Alejandra Lugo, BS
• Lewis Ershler, MS
• Gloria Poarch, RS

• Other IHC Facilities
• Reed Gardner, Ph.D.
• Scott Evans, Ph.D.
• Stan Pestotnik, R.Ph.
• Tom Oniki, Ph.D.
• Allan Pryor, Ph.D.
• Alan Morris, M.D.
• Joe Dalto, MS
• Debra Carlson, BS