Patient Care Information Systems

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Patient Care Information Systems

• Suzanne Bakken, RN, DNSc
• October 23, 2001

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Purpose

• To illustrate the manner in which information
  systems support the patient care process through
  the examples of computer-based patient records,
  other patient care systems and patient
  classification systems

3
Core Phenomena of Informatics

• Data
• Information
• Knowledge
• ...of relevance to x, e.g., patient care

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• What kinds of data, information, and knowledge do
  we require for patient care?

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Patient-Specific Data

• Demographics (age, gender, race, ethnicity,
  source of admission)
• Problems (diagnoses, symptoms, reasons for health
  care encounter)
• Severity of illness score (APACHE, Medis Groups,
  Nursing Severity Index)
• Interventions (risk assessments, procedures,
  medical interventions, nursing interventions,
  laboratory tests)
• Nursing care intensity
• Outcomes (mortality, morbidity, health services
  utilization, functional status, quality of life)

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Agency-Specific Data

• Medicare case mix
• Occupancy
• Hours per patient day
• Skill mix
• Utilization patterns
• Locally developed guidelines, standards of care,
  critical paths
• Raw and risk-adjusted outcomes
• Provider satisfaction
• Patient satisfaction

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Domain Information and Knowledge

• Synthesized evidence
• Bibliographic databases
• Decision support systems
• Standards of care, practice guidelines
• Comparative databases

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Patient Care Information Systems

• Computer-based patient record
• Ancillary (radiology, pharmacy, laboratory,
  dietary) - tied to CPR through order entry and
  results review
• Patient classification
• Patient monitoring

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• Example 1
• Computer-based Patient Record

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Computer-based Patient Record

• Definitions
• IOM Recommendations
• Attributes
• Barriers
• Status

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Computer-based Patient Record

• A primary patient record is used by healthcare
  professionals while providing patient care
  services to review patient data or document their
  own observations, actions, or instructions
• A secondary patient record is derived from the
  primary record and contains selected data
  elements to aid nonclinical users (ie., persons
  not involved in direct patient care) in
  supporting, evaluating, or advancing patient care

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Computer-based Patient Record

• A CPR is an electronic patient record that
  resides in a system specifically designed to
  support users by providing accessibility to
  complete and accurate data, alerts, reminders,
  clinical decision support systems, links to
  medical knowledge, and other aids

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IOM Recommendations

• Health care professionals and organizations
  should adopt the CPR as the standard for medical
  and all other records related to patient care
• To accomplish this the public and private sectors
  should join in establishing a CPR Institute
  (CPRI) to promote and facilitate development,
  implementation, and dissemination of the CPR

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IOM Recommendations

• Both the public and private sectors should expand
  support for the CPR and CPR system implementation
  through research, development, and demonstration
  projects
• The CPRI should promulgate uniform national
  standards for data and security to facilitate the
  implementation of the CPR and its secondary data
  bases

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IOM Recommendations

• The CPRI should review federal and state laws and
  regulations for the purpose of proposing and
  promulgating model legislation and regulations to
  facilitate the implementation and dissemination
  of the CPR and its secondary data bases and to
  streamline the CPR and CPR systems

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IOM Recommendations

• The costs of CPR system should be shared by those
  who benefit from the value of the CPR
• Full costs of implementing and operating CPRs and
  CPR systems should be factored into reimbursement
  levels or payment schedules of both public and
  private sector third-party payers
• Users of secondary databases should support the
  costs of creating such data bases

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IOM Recommendations

• Heathcare professional schools and organizations
  should enhance educational programs for students
  and practitioners in the use of computers, CPRs,
  and CPR systems for patient care, education, and
  research

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Attributes of CPRs and CPR Systems

• The CPR contains a problem list that clearly
  delineates the patients clinical problems and
  the current status of each (e.g., the primary
  illness is worsening, stable, or improving)
• The CPR encourages and supports the systematic
  measurement and recording of the patients health
  status and functional level to promote more
  precise and routine assessment of the outcomes of
  patient care

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Attributes of CPRs and CPR Systems

• The CPR state the logical basis for all diagnoses
  or conclusions as a means of documenting the
  clinical rationale for decisions about the
  management of the patients care. This
  documentation should enhance use of a scientific
  approach in clinical practice and assist the
  evolution of a firmer foundation for clinical
  knowledge

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Attributes of CPRs and CPR Systems

• The CPR system addresses patient data
  confidentiality comprehensively--in particular
  ensuring that the CPR is accessible only to
  authorized individuals
• The CPR is accessible for use in a timely way at
  any and all times by authorized individuals
  involved in direct patient care. Simultaneous
  and remote access to the CPR is possible

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Attributes of CPRs and CPR Systems

• The CPR system allows selective retrieval and
  formatting of information by users. It can
  provide custom-tailored views of the same
  information
• The CPR can be linked to both local and remote
  knowledge, literature, bibliographic, or
  administrative databases and systems (including
  those containing clinical practice guidelines or
  clinical decision support capabilities) so that
  such information is readily available to assist
  practitioners in decision making

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Attributes of CPRs and CPR Systems

• The CPR can assist, and in some instances, guide
  the process of clinical problem solving by
  providing clinicians with decision analysis
  tools, clinical reminders, prognostic risk
  assessment, and other clinical aids
• The CPR supports structured data collection and
  stores information using a defined vocabulary.
  It adequately supports direct data entry by
  practitioners

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Attributes of CPRs and CPR Systems

• The CPR can help individual practitioners and
  healthcare provider institutions manage and
  evaluate the quality and costs of care
• The CPR is sufficiently flexible and expandable
  to support not only todays basic information
  needs but also the evolving needs of each
  clinical specialty and subspecialty

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Attributes of CPRs and CPR Systems

• The CPR can be linked with other clinical records
  of a patient--from various settings and time
  periods--to provide a longitudinal (lifelong)
  record of events that may have influenced a
  persons health

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Technological Building Blocks

• Data exchange and vocabulary standards
• Systems communications and network infrastructure
• System reliability and security
• Linkages to secondary databases

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Technological Building Blocks

• Databases and database management systems
• Workstations
• Data acquisition and retrieval
• Text processing
• Image processing and storage

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Technological Barriers

• Human interface and system performance
• Text processing
• Confidentiality and security
• Health data-exchange standards

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Nontechnological Barriers

• Unpredictable user behavior
• Lack of leadership for resolving CPR issues
• Lack of training for developers
• Lack of consensus on the content of the CPR
• Development costs
• Disaggregated health care environment

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Status of Issues Related to CPRs

• CPRI formed
• Healthcare Information Portability and
  Accountability Act (K2)
• IOM report on confidentiality and security
• Health data-exchange standards

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Status of Attributes

• Problem list and status
• Functional status
• Logical basis of diagnosis and clinical rationale
  for treatment
• Accessibility
• Confidentiality
• Linkages to local and remote sources of knowledge

• Tailored views
• Structured data entry by providers
• Storage in standardized vocabulary
• Decision analysis and decision support aids
• Manage cost and quality
• Longitudinal record

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44

• Example 2
• Patient Classification

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Patient Classification

• Patient dependency predict nursing care
  requirements (aka acuity, nursing care intensity,
  workload)
• Severity of illness predict mortality
• Diagnosis-related groups predict resource use,
  e.g., cost of care, length of stay

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Essential Elements of Patient Classification Tool
for Nursing Care Requirements

• Tool to predict nursing care requirements for
  individual patients
• Sound method of validating the amount of care
  given to each category of type of patient on each
  unit and shift
• Sound method of evaluating the patterns of care
  delivery by each unit, shift, and staff level
• Mechanism of revalidating the amount of care by
  patient category and patterns of care delivery on
  a periodic basis
• Method of relating nursing care requirements to
  staff resource allocation on a shift-by-shift and
  unit-by-unit basis
• Method of monitoring the reliability of patient
  classification over time
  (deGroot, 1989)

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Examples

• Medicus
• 37 indicators (e.g., unconscious, bath with
  assistance, invasive monitoring, patient
  education)
• THC RV X TH
• THC total hours of care per patient per day
• RV relative value per level of care (standard)
• TH target hours per unit of workload
  (institution or unit-specific)
• Type I 0-3 hours/24 and Type V 18-24 hours/24

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Examples

• GRASP
• Variable indicators, typically gt45 (e.g.,
  emotional status, complexity of clinical
  judgments, activities of daily living
• Indicators are unit-specific
• Time standards are unit-specific

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Severity of Illness Measures

• Focus on clinical stability and probability of
  death
• Uses
• Provision of care
• Determination of potentially ineffective care
• Risk-adjustment of outcomes for benchmarking

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Adjusting Risk

• Var(O) Var (V) Var (SE) Var (RE)
• Var (O) is the observed variability in patient
  outcomes across providers
• Var(V) is the part of Var(O) validly
  attributable to quality of care differences among
  providers
• Var(SE) is the systematic error related to
  differences in patient-specific characteristics
  among providers
• Var(RE) is the random error related to residual
  variability caused by unknown or unmeasured
  factors.

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Dimensions of Risk

• Age
• Gender
• Acute clinical stability
• Principal diagnosis
• Severity of principal diagnosis
• Extent and severity of comorbidities
• Physical functional status

• Psychological, cognitive, and psychosocial
  functioning
• Cultural, ethnic, and socioeconomic attributes
  and behaviors
• Health status and quality of life
• Patient attitudes and preferences for outcomes

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An Example Comparing Risk Adjustment Strategies
in HIV/AIDS

• Quality of nursing care of persons with AIDS
  link interventions with outcomes
• Predictors
• Apache Acute Physiology scores (APS)
• Nursing Severity Index scores (NSI)
• Quality Audit Marker (QAM)
• Outcomes
• Mortality
• Length of stay

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APACHE System

• Acute Physiologic Score (APS) - primarily vital
  signs and laboratory values (e.g., BUN)
• Range of possible scores on 14/17 variables
  0-211
• No data on creatinine, urine output, or bilirubin
• Chronic Health Evaluation - presence or absence
  of specific medical diagnoses
• Comparative database for benchmarking

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Nursing Severity Index

• 34 items (range of score 0-34)
• Significant predictor of mortality and length of
  stay
• Nursing diagnosis-based (28/34 NANDA)
• Nutrition and metabolism (n7)
• Urinary and fecal elimination (n5)
• Activity and exercise (n8)
• Underlying management issues (n5)
• Psychosocial issues (n9)

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Quality Audit Marker

• Developed to measure functional status in
  HIV/AIDS
• QAM ambulation 2 items
• QAM self-care 6 items

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Descriptive Statistics
Predictors Mean(SD)
Apache APS 34.4(5.9)
Nursing Severity Index 3.1(1.8)
QAM ambulation 7.0(1.5)
QAM self-care 19.6(4.9)
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Significant predictors

• Apache APS
• Significant predictor of mortality
• During hospitalization
• 3 month
• 6 month
• Nursing Severity Index
• Did not significantly predict mortality or length
  of stay
• QAM self-care
• Did not significantly predict mortality or length
  of stay
• QAM ambulation
• Significant predictor of length of stay
• Significant predictor of mortality during
  hospitalization
• Model with 4 predictors better than only Apache
  APS at all points in time

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• Discussion and Questions