A Bucket Full of Numbers

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A Bucket Full of Numbers?

• An Insight to Hemodialysis Data Management Systems

Kevin Lyons Fresenius Medical Care, Bad Homburg /
Germany
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Topics

• 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?

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Evolution

• 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.

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Life Cycle of the Paper Record
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Evolution over 25 years
Adapted from Ronco C 2000
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A case for a Database?

• 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

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Driving Forces towards Data Management
COMPUTERISE!
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Industry Responds..
Sample for illustrative purposes only
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Evaluation of Clinical Computing Systems as Used
by DOPPS Participants

• 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

Sargent J 1999
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Factors Limiting the Effectiveness of Computer
Systems

• 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

Adapted from Ronco C 2000
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modern dialysis machines are able to provide
much more treatment information...
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Other Medical Devices Can Provide Information too
in principle, any device with an RS 232 or
similar interface can pass on its measured
parameters
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The Missing Link
Workstations
File Servers
Workstations
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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
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Manual -v- Automated Measurements (2)

• 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

Table 2 Comparison of 10 Blood Pressure readings
taken by a patient immediately before the
installation of Finesse and 10 automated readings
produced immediately after the installation of
the system
Source Rourke E et al. Man or Machine
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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
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Benefits of a Data Acquisition System

• 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

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Computer Aided Dialysis Clinic Management
Outdoor clininc
Administration
Anamnesis
Insurance
Patient master data
Diagnosis
Accounting
Information
Nephro 7 Database
Laboratory data
Medication
Dialysis documentation
Dialysis regime
Laboratory
Quarterly updates
Dialysis prescription
Stored data
Dialysis monitoring
Hardware interfaces
Monitoring software
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Acquisition alone is not enough It can only be
successful when implemented with the right
database.
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What Characterises an OutstandingData Management
System?

• Functionality
• Data presentation analysis
• Integration of dialysis machines medical
  devices
• Advanced features (decision support,
  bio-feedback)
• Integration with other systems

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What Characterises an OutstandingData Management
System?

• Acceptance The user likes to work with it,
• Simplicity, usability and workflow
• Dont have to drastically change their way of
  working
• Training

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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

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What Characterises an OutstandingData Management
System?

• Cost effectiveness
• Benefit from changing technologies and
  competition
• Scalability

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Cost Effectiveness

• 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, )

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XML Extended Mark-up Language

• THE data exchange format
• Non proprietary, widely supported (Microsoft,
  SUN, IBM, oracle, )
• Standard also in the medical field (HL7)

XML ltmachine_data id"Fresenius_4008"gt ltpatient
idQ1299817212 /gt ltrowgt ltdata
name"time"gt15.02.2000 194721lt/datagt
ltdata name"ven. pressure"gt1926lt/datagt
ltdata name"art. pressure "gt9548lt/datagt
ltdata name"Temperature"gt7784lt/datagt
ltdata name"UF-Volume"gt4153lt/datagt ltdata
name"UF-Rate"gt1093lt/datagt lt/rowgt ltrowgt
ltdata name"time"gt15.02.2000
194726lt/datagt ltdata name"Temperature"gt3
529lt/datagt ltdata nameDialysate-flow"gt681
lt/datagt ltdata name"UF-Volume"gt8225lt/datagt
ltdata name"UF-Rate"gt1808lt/datagt
lt/rowgt ... lt/machine_datagt
Standard-Interface 1502200019472119269548778400004
15300324331093de34ar153 15022000194726000000003529
0581822500deas01808de34ar154 ...
Vendor specific
Human readable
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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
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Internet.. Whats 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 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

• 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!
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Thank you for your attention
Kevin Lyons Service Training Manager Fresenius
Medical Care Regional Office Middle East PO Box
3264 Dubai UAE
Tel [phone] Fax [phone] Mob
971506250443 E-mail kevin_lyons_at_hotmail.com