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Overview
• Review the Computer Based Patient Record
• Describe the UI CBPR Project• INFORMM Patient Record
Topics of Discussion
• What is a Computer Based Patient Record?
• What are the Components?
• What are the Main Issues?
• Who are the Major Players?
• What is the Value?
What is a CBPR?
• Documentation (e.g., Medical Record)
• Workflow
• Clinical quality improvement
• Outcomes data
• http://www.cpri.org/what.html
• http://www.cpri.org/docs/docs.html
What are the Components?
• Summary Documentation– Problem List/ Allergies Medications
• Encounter Documentation– CC/HPI/PFSH/ROS/PE/Imp/Plan/Procedure– Orders/Results
• Rules / Guidelines
• Tabular Information (Formularies etc..)– Formularies / Lexicon
• Process Flow
Components (cont’d)
• Outcomes Tracking– Health Status Indicators– Problem Episode Tracking– Randomized Impact Studies
What are the Main Issues
• Text versus Structured & Coded
• Security versus Access
• Buy versus Build
• Human Interface– GUI / Voice / Wearable
• Human Acceptance
Text versus Structured & Coded
• Structured & Coded– What does a given [response] mean?– If [response] then do [whatever]– When or how many of a given [response] ?
• Text– Extemporaneous– Context Imbedded– Tells a story
Transitioning: Text to Coded
• Incomplete Vocabularies– In six defined vocabularies find only 60-80%
• Validity depends on context
• Context may be implicit for the educated– nursing documentation– physical exam– test and therapy orders
In the Meanwhile:
• Text is necessary
• What can we do with it?– Categorize it
• structured dictation
– Encapsulate it• disallow it wherever possible
– Extract from it• lexigraphical analyses have limited success
Security versus Access
• Security– Who are you (authentication)– What are your information rights (authorization)– What did you do (audit trail)– How can we ensure integrity of communication
• Access– Intuitive Design– Online Intelligent Assistance
Buy versus Build
• Buy– Turn-key versus Customizable– Cost-sharing versus Cost-shifting– Support versus Holding-the-Bag
• Build– Personal Relationship with the Customer– Talent Pool Stability
Human Interface
• GUI– layout itself communicates information– pointing supported
• Voice – ready for prime time?
• Wearable
• Virtual
Human Acceptance
• Acceptable Interface
• Workflow Makes Sense
• Problems - More Solved than Created
Who Are the Major Players
• Non-profit Organizations– Academies / Societies / CPRI
• Government Institutions– NLM, ASTM
• Academic & Medical Institutions– LDS/IMHC / Brigham / Columbia / Stanford– http://ucsub.colorado.edu/~gorman/thesis/EMR.html
• Commercial Product Vendors
Processes
• Macro– Birth to Death– Induction to Discharge
• Micro– Check-in to Check-out– Chief Complaint to Episode Resolution
Birth to Death Record
• Universal Identifier
• Data Model
• Vocabulary
• Data Exchange
• Security
• Policy
Micro Process
• Patient Seeks Attention
• Patient Responds to Questions
• Provider Examines
• Impression and Plan Formed
• Plan Executed
• Outcome Assessed
Patient Seeks Attention
• Now– Patient Calls or Drops In
• Some Enhancements in Progress– System Proactively Advises Patient– Patient Seeks Online Information
Patient Responds to Questions
• Now– Provider Assisted– Mostly Text, Some Coded
• Some Enhancements in Progress– Coded Questions and Responses– Context-sensitive Branching– Automated Capture of Information– Automated Intelligent Assessment
Provider Examines
• Now– Provider Documents After the Fact– Mostly Text, Some Coded
• Some Enhancements in Progress– Coded Questions and Responses– Context-sensitive Branching– Automated Capture of Information
Impression and Plan Formed
• Now– Information Reviewed (Hx, PE, Results)– Mostly Narrative
• Some Enhancements in Progress– Assisted Differential Diagnosis– Guidelines
• Evidence Based Medicine
– Critical Path
Plan Executed
• Now– Orders Written– Procedures Performed– Tests Done
• Some Enhancements in Progress– Orders Captured Online with Problem– Plan Process Tracked
Outcome Assessed
• Now– Follow Up Visit Narrative– A Few Objective Outcomes are Tracked
• Some Enhancements in Progress – Episode Tracking
• CC to Assessment to Treatment to Resolution
• Beyond the Single Encounter
– Outcome Classification• Health Status per Patient Report
Rules Span the Entire Process
• If Event Detected– Demographics– History– Result– Order
• Then Response– Communicate to Patient / Provider– Execute a Plan
University of Iowa CBPR Project
• Phase I• Health Resume and Guidelines• Document System
• Phase II• Outpatient Contact Summary
– Templates, Coding, Ordering
• Phase III• Inpatient Contact Summary
– Templates, Coding, Ordering, Guidelines
• Images
Lessons Learned from Experiments
• Passive Information Increases Utilization
• In-your-face Information Decreases It
• If Seen, Information Changes Outcome– second-vaccine ordering– no vaccine ordering– prescription drug ordering