Chapter 17 Clinical Information Systems

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Chapter 17Clinical Information Systems

• Yung-Fu Chen, Ph.D.
• Department of Health Services Administration,
  China Medical University

Reference M. Conrick, Health Informatics with
Technology, Thomson Press, South Melborne,
Australia, 2006.
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Outline

• There is a plethora of challenges in dealing with
  clinical data, but once they are captured and
  identified they need to be stored in such a way
  as to allow efficient retrieval and their secure
  transmission to the appropriate clinician. This
  chapter discusses the development and
  implementation of clinical information system
  (CIS).

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Paper-based Clinical Records

• The paper-based records can only be read by only
  one person at a time they must have physical
  possession of the document
• Security is a problem with almost clinician able
  to access it regardless of their need to know
  status. Additionally, there is no method of
  tracking access
• Patient is frustrating to be continually
  repeating the same information to a number of
  different clinicians all asking the same or
  similar questions
• Since the communication has been so slow, it has
  often been the case that information is not in
  the right place at the right time

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Purpose of CIS

• To make information and knowledge available to
  healthcare providers during care delivery
• Purport to streamline clinical workflows and
  eliminate repetitive tasks that reduce
  productivity and lead to errors
• To achieve efficiency, healthcare facilities must
  integrate health data from a number of different
  sources

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Clinical Systems Architecture

• Using LAN, stand-alone desktop PC were linked
  creating a distributed computing environment.
  Sometimes information was only available to
  members of a particular department
• To overcome the above problem, client-server
  computing was developed that information can be
  shared between multiple smaller computers or
  clients that are all connected via a network to a
  powerful host computer, the server

• The most widely used form of client/server
  architecture is known as three-tiered
  architecture. It allows patient data to be stored
  across departments and facilities in database
  servers that can be integrated in a
  patient-centric format by the application server
• In many cases, this architecture uses thin client
  software, usually a browser, shift the data
  processing functions onto the server

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Figure 17.1 A mock-up of what a typical dumb
terminal character-based screen might look like
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Figure 17.2 A typical three-tier client/server
architecture. Most CIS now utilize this
architecture
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What are point-of-care clinical systems? (1)

• Simply CIS located adjacent to where care takes
  place, in most circumstances at the bedside
• Support clinical care by allowing easy input and
  retrieval of information.
• Examples Order entry, results reporting,
  clinical documentation, electronic decision
  support, medication management, online evidence
  retrieval, and telehealth systems
• The most common POC clinical systems include
  electronic prescribing, electronic order entry,
  and results viewing systems. These systems are
  referred to as e-ordering system, physician order
  entry (POE) or computerized physician order entry
  (CPOE),

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What are point-of-care clinical systems? (2)

• A major benefit of these e-ordering systems is
  their ability to augment clinical judgment via
  integrated clinical decision support system (DCS)
  
• The goals of any point-of-care system should be
  to
• reduce the amount of time spent documenting
  patient care
• Eliminate inaccuracies and data redundancy
• Enhance the timeliness of data communication
• Provide optimal access to information
• Improve the quality of care by providing
  clinicians with the best possible information on
  which to base clinician decisions

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Wireless Clinical Systems

• Most hospital clinicians are highly mobil and,
  consequently, software applications must allow
  them to quickly review and interact with patient
  information while they are on the move
• The development of wireless LANs over recent
  years has facilitated the move to mobile clinical
  computing solution
• The use of wireless technology has become
  widespread in healthcare settings

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Components of a CIS

• Clinical documentation systems
• Order entry
• Medication management
• Other systems
• Pharmacy
• Pathology
• Radiology
• Physiological monitoring systems
• Subsidiary systems

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Figure 17.3 A browser-based order entry system
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Figure 17.4 Once downloaded from the pathology
system, results are able to be cumulated and
graphed
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Figure 17.5 physiologic data presented in
Cerners PowerChart
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Chapter 5 Current and Emerging Use of Clinical
Information Systems

• Yung-Fu Chen, Ph.D.
• Department of Health Services Management, China
  Medical University

Reference Wager, Lee, Glaser, 2005
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Current and Emerging Use of Clinical Information
Systems

• Electronic medical record (EMR)
• Other Major Types of Health Care IS
• Computerized provider order entry (CPOE)
• Medication administration
• Telemedicine
• Telehealth
• Fitting Applications Together The EMR is the Hub
• Barrier to Adoption

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Electronic medical record (EMR)

• Five levels of computerization
• Automated medical record
• Although health-care organization may automate
  certain functions such as patient registration,
  scheduling, results reporting, and dictation,
  however, the paper-based medical record remains
  the primary source for patients clinical
  information
• Computerized medical record
• Digitizing the patients medical record through
  the use of a document imaging system
• Patients records are scanned and stored as
  images
• Does not allow the user to analyze or aggregate
  data for decision-making
• Is merely a digitized version of paper-based
  medical record

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Electronic medical record (EMR)

• Five levels of computerization
• Automated medical record
• Computerized medical record
• Electronic medical record
• Patient record as an active tool that can provide
  the clinician with decision support capabilities
  and access to knowledge resources, reminders, and
  alerts
• The EMR may trigger alert or notice to medication
  allergy, medication interaction, and
  examinations and tests
• Maintained by a single organization
• Electronic patient record
• Includes all healthcare-related information
  concerning the patient-gathered across two or
  more organization
• Brings together a central database all clinical
  information available on a patient
• Electronic patient record

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Electronic medical record (EMR)

• Five levels of computerization
• Automated medical record
• Computerized medical record
• Electronic medical record
• Electronic patient record
• Electronic patient record
• Is broader than the electronic patient record
• Includes wellness information (smoking habit,
  nutrition, level of exercise, dental health,
  alcohol use) and other information not maintained
  by health care organization
• Patient is at the center
• Is a longitudinal record and ultimately encompass
  a persons relevant health information from
  before birth to death

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Five Levels of Computerization of EMR
Level 5 Electronic Health Record (longitudinal,
comprehensive)
Level 4 Electronic Patient Record (spans across
organization)
Level 3 Electronic Medical Record (active tool,
organization level)
Level 2 Computerized Medical Record (document
imaging)
Level 1 Automated Medical Record (clinical info
systems)
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Computerized provider order entry (CPOE)

• To keep patients safe is one of the biggest
  concerns of health care organizations
• 98000 patients die each year in U.S. hospitals
  due to medical error (IOM, 2000, 2001)
• CPOE has the potential to reduce medication error
  adverse drug events (Bates Gawande 2003)
• CPOE is one of three changes that would most
  improve patient safety (Leapfrog Group 2004a)
• CPOE is a computer application that accepts
  physician orders electronically, replacing
  handwritten or verbal orders and prescriptions

• Current use of CPOE
• Approximately 5-13 of hospitals (Leapfrog group
  2002, First Consulting Group 2003, Brailer
  Terasawa 2003)
• Value of CPOE
• CPOE system can provide patient care, financial,
  and organizational benefits
• Potential to improve patient safety and reduce
  medication error
• Beneficial in ambulatory care setting (Johnston
  et al. 2003, 2004)
• The providers and patients are highly satisfied
  with their access to health care information ,
  their wait times, and the quality of care
  delivered (Johnston et al. 2003)

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Medication administration

• Barcode-enabled point of care (BPOC) has the
  potential to enhance productivity, improve
  patient safety such as those related to correctly
  identifying patients and medications, and
  ultimately improve quality of care (Low Belcher
  2002)
• Each patient receives a barcode wristband at the
  time of permission for identification
• The provider scan his or her bar-coded ID band to
  log into the medical administration system
• Provide an audit trail of who has accessed what
  systems at what time and for what information
• About half of medication errors occur during the
  ordering process, but errors also occur in
  dispensing, administrating, and monitoring
  medications (Kaushal Bates 2002)
• BPOC can be highly effectively in reducing all
  types of medication errors, yet only 1.1 of
  U.S. hospitals have bed-side scanners (Barlas
  2002)
• Only 35 of medications come from the
  manufacturer with bar-coded labels in 2003 ???
• RFID is replacing barcode in medication
  administration

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Telemedicine

• Use of telecommunication for the clinical care
  (diagnosing, treating, or following up) of
  patients at distant locations
• Current status of telemedicine programs
• 200 programs throughout the U.S. in 2004 (Brown)
• Univ. of Kansas provided clinical services to
  oncology patients and mental health services to
  patients in rural area and augmented school
  health services by giving school nurses to
  consult with physicians
• Univ. of Texas Medical Branch Provided services
  to inmates (400 patients a month)

• Primary delivery method
• Store and forward
• Is used to primarily for transferring digital
  images from one location to another by taking an
  image with a digital camera and stored on a
  server, and then sent to a health care provider
• Two-way interactive television
• Is used when a face-to-face consultation is
  necessary by giving patients living in rural
  communities access to providers in urban areas
  without traveling
• A number of devices can be linked to computers to
  aid in interactive examination
• Robotic equipment for telesurgery applications in
  battle fields

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Telehealth (1)

• Patients have increasingly turned to the Internet
  to obtain health care information and seek health
  care services, and are interested in
  communicating with their physicians directly on
  the line
• On-line communication from a patient may be
  everything from requesting an appointment to
  viewing a bill to refilling on prescriptions to
  seeking advice or a consultant via e-mail

• Current use of E-mail communication between
  physicians and patients
• Currently 25 physicians use Email to communicate
  with patients 90 of American adults would like
  to communicate with their physicians via Email
• Follow-up patient care, clarification on advice,
  prescription refills, and patient education

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Telehealth (2)

• Value of E-mail communication system
• Is asynchronous
• Decrease telephone hold time
• Is legible
• Can automatically document a conversation
• Does not increase physicians workload or
  decrease their productivity
• Reduces patient visits and telephone calls
• Reduces administrative tasks
• Allows more uninterrupted time for patients
  during office visits

• Critical considerations should be addressed when
  instituting an e-mail communication system
  between patients providers
• Complexity of infrastructure
• Degree of integration
• Message structure
• Cost
• Security
• reimbursement

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Fitting Applications Together The EMR is the Hub

• The data that eventually make up each patients
  record originate from a variety of sources
• Admission or registration systems
• Patient demographic information, health insurance
  or payer, providers name, date and reason for
  visit or encounter, and so forth
• Accounting systems
• Patient billing information
• Ancillary clinical (laboratory, radiology)
  systems
• Diagnostic tests, therapeutic procedures,
  results, and so on
• CPOE systems
• Physician orders, date, time and status, and so
  forth

• Medication administrative systems
• Medications ordered, dispensed, and
  administrated, and so forth
• Other clinical and administrative systems
• Nursing, physical therapy, and nutrition
  education documentation scheduling information
  and so forth
• Knowledge-based reference systems
• Access to MEDLINE, the latest research findings,
  practice guidelines, and so forth
• Telemedicine and telehealth systems
• Documentation of provision of health care
  services, on-line communication with patients and
  providers, and so forth

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EMR The Hub of Clinical Information Systems
Admission/ Administration
Other Clinical/AdministrativeSystem
Accounting

• ElectronicMedical Record
• Patient Identification
• Authentication

Pharmacy-Medication Distribution
LaboratoryResults
Interface
CPOE
Radiology
DecisionSupport
KnowledgeBase/Reference
TelemedicineTelehealth (for example,e-mail)
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Barrier to Adoption (1)

• Financial barriers
• EMR and related systems can be expensive to
  develop, implement, and support
• A significant amount of money invested and yet
  not realize a positive financial return even a
  return in term of quality
• Behavior barriers
• Physician acceptance to change in workflow to
  differences in state licensing regulations
• EMR requires that physicians respond to
  reminders, alerts, and other knowledge aids which
  lead to better patient care but may also require
  more time
• Most physicians receive no reimbursement or
  compensation for using EMR systems or for
  providing good-quality care
• Regarding telemedicine and telehealth
• Lack of hand-on interaction with patients
• Fear of litigation or missing important
  information

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Barrier to Adoption (2)

• Technical barriers standard and data definition
• Understanding how emerging technologies fit with
  existing technologies, and engaging in continuing
  development and refinement of standards and data
  definitions
• Following health care information standards is
  not an easy task
• Inadequate standards combined with rapid changing
  technologies can be a barrier to widespread EMR
  adoption and use
• Must have stable infrastructure to support
  clinical and administrative applications