Академический Документы
Профессиональный Документы
Культура Документы
* van Bemmel JH, Musen MA (eds). Handbook of Medical Informatics. Heidelberg: Spinger-Verlag. 1997.
** Greenes RA, Shortliffe EH. Medical informatics. An emerging academic discipline and institutional priority. JAMA. 1999;263:1114-1120
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A Patient Scenario from the ED A Patient Scenario from the ED
A pt comes to the ED with crushing chest pain. MDs at this ED have access to a computerized
He was very ill and unable to provide a patient record, aggregated from all the EDs in
medical history. Indy.
The physicians were concerned about his chest The EHR data showed that this pt had been
treated at a nearby hospital for a head injury
pain and thought he may be having a heart just 3 weeks prior.
attack.
Giving anticoagulants would have increased
Standard treatment for this is to give bleeding in his brain, forcing an unnecessary
anticoagulants, to return blood flow back to head surgery and an injury that easily could
the injured area. have killed him.
• McDonald CJ. Protocol-based computer reminders, the quality of care and the non-perfectability of man. N Engl J Med 1976;295(24):1351-5.
• Tierney WM. Improving clinical decisions and outcomes with information: a review. Int J Med Inf. 2001;62:1-9. • Tierney WM, McDonald CJ, Martin DK et al. Computerized display of past test results – Effect on outpatient testing. Ann Int Med. 1987;107(4) 569-574.
• McDonald CJ. Protocol-based computer reminders, the quality of care and the non-perfectability of man. N Engl J Med 1976;295(24):1351-5.
• Lopopolo RB. Hospital restructuring and the changing nature of the physical therapist’s role. Phys Ther. 1999;79(2) 171-185. • Jette DU, Grover L, Keck CP. A qualitative study of clinical decision making in recommending discharge placement from the acute care setting. Phys Ther. 2003;83(3):224-236.
• American Physical Therapy Association. Reported Productivity Expectations of PTs 1999-2002. Available from http://apta.org • Smith PC, Araya-Guerra R, Bublitz C et al. Missing clinical information during primary care visits. JAMA. 2005;293(5):565-571.
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Types of Data That May Be Generated From a Patient/Client History
General Demographics Medical/Surgical History Current Condition/Chief Complaint
Clinical Decision Making
•
•
Age
Sex
•
•
Cardiovascular
Endocrine/metabolic
•
•
Concerns that led the patient/client to seek the
services of a PT
Concerns or needs of patient/client who requires the
How Can Computers Help?
• Race/Ethnicity • Gastrointestinal
services of a PT
• Primary Language • Genitourinary
• Current therapeutic intervention(s)
• Education •
•
Gynecological
Integumentary
• Mechanisms of injury or disease, including date of
onset and course of events
• Eliminating the logistic problems of the paper record
Social History • Onset and pattern of symptoms
• Musculoskeletal
• Cultural believes and behaviors
• Neuromuscular • Patient/client, family, significant other, and caregiver
•
•
Family/Caregiver resources
Social interactions, activities, and support systems
• Obstetrical
expectations and goals for the therapeutic
intervention 1. Simultaneous, remote access to patient data
• Prior hospitalizations, surgeries, and pre-
• Patient/client, family, significant other, and caregiver
Employment/Work existing medical and health conditions
perceptions of patient/client emotional response to
2. Legibility of record
• Psychological the current clinical situation
• Current and prior work, community, and leisure
actions, tasks, or activities • Pulmonary • Previous occurrence of chief complaint
•
•
Devices and equipment
Living environment and community characteristics
• Current and prior functional status in work,
community, and leisure actions, tasks, or activities 5. Flexible data layout
• Projected discharge desirations
Medications
General Health Status • Medications for current condition
6. Integrated information from multiple sources
• General health perceptions • Medications previously taken for current condition
• Physical function • Medications for other conditions 7. Enhanced search capabilities
• Psychological function
•
•
Role function
Social function
Other Clinical Tests 8. Enhanced output capabilities
• Laboratory and diagnostic tests
Social/Health Habits
• Behavioral health risks
•
•
Review of available records
Review of other clinical findings
9. Real-time access to information
• Level of physical fitness
– Computers are tireless data processors 1 Paralysis, paresis, or recent plaster immobilization of the LE’s
1 Recently bedridden for >3 d or major surgery w/in 4 wk
– Computerized reminders informed by
1 Localized tenderness along distribution of the deep venous
electronic data can improve care system
• Convincingly demonstrated in medical 1 Calf swelling > 3 cm when compared with asymptomatic LE
Childs JD, Cleland JA. Development and Application of Clinical Predictions Rules to Improve Decision Making in Physical Therapist Practice. Phys Ther. 2006;86(1):122-131.
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Consumerism Consumerism
How Can Computers Help?
• Empowered patients with changing expectations
• Integrate information from multiple sources across
the life-span, but with challenges:
• Technology-enabled experiences
– Care and information are fragmented [reconciliation]
– Rapid, multi-modal communication
• Explosion of health information available on the WWW
– Large portions of record are not captured electronically
– E-commerce – Issues of identity, security, privacy, and trust
– Online banking • Consumers view computerization as ‘state-of-the-art’
• Consumers (patients) are demanding – Can promote a perception of high quality
– Speed • Repositories can be the information source for
– Convenience customizing healthcare delivery and resource
– Customized service and tools distribution
• Patient and condition-specific • Computers/repositories can enable process and
– Security, confidentiality system integration to improve the consumer
experience
– Customer Relationship Management solutions
– Online scheduling, tracking, communication, etc…
Kaplan B, Brennan PF. Consumer informatics supporting patients as co-producers of quality. JAMIA. 2001;8(4):309-316.
Kaplan B, Brennan PF. Consumer informatics supporting patients as co-producers of quality. JAMIA. 2001;8(4):309-316.
• Tierney WM, McDonald CJ. Practice databases and their uses in clinical research. Stat Med. 1991;10(4):541-557.
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Cost of Care EBP and Quality of Care
How Can Computers Help?
• Estimates of saving $140 billion annually “The conscientious, explicit, and judicious
• How? use of current best evidence in making
– Improved information sharing decisions about the care of individual
– Improved care coordination patients. The practice of EBM means
– Reduced redundancy integrating individual clinical expertise
– Reduced medical errors with the best available external
• The challenge remains that mere evidence from systematic research.”
adoption won’t produce savings
• Real process change (transformation)
must occur
Hillestad R, Bigelow J, Bower A, et al. Can electronic medical record systems transform health care? Potential health benefits, savings and costs. Health Affairs. 2005;24(5):1103-1117.
* Sackett DL, Rosenberg WM, et al. Evidence based medicine: what it is and what it isn’t. BMJ 1996;312(13):71-72
• Institute of Medicine. Crossing the quality chasm: A new health system from the 21st century. Washington, DC, National Academy Press 2001.
on clinical details, not just claims data • Lack of time was the greatest reported barrier
• Sackett DL, Rosenberg WM, et al. Evidence based medicine: what it is and what it isn’t. BMJ 1996;312(13):71-72
Jette DU, Bacon K, et al. Evidence-based practice: beliefs, attitudes, kowledge, and behaviors of physical therapists. Phys Ther. 2003;83(9):786-805.
• Jette DU, Bacon K, et al. Evidence-based practice: beliefs, attitudes, kowledge, and behaviors of physical therapists. Phys Ther. 2003;83(9):786-805.
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Barriers to EBP PT’s Literature Access and Availability
• Jette DU, Bacon K, et al. Evidence-based practice: beliefs, attitudes, knowledge, and behaviors of physical therapists. Phys Ther. 2003;83(9):786-805.
Jette DU, Bacon K, et al. Evidence-based practice: beliefs, attitudes, kowledge, and behaviors of physical therapists. Phys Ther. 2003;83(9):786-805.
Why Informatics?
• All of these forces
– Clinical decision making
– Consumerism
– Expanded uses of health information
– EBM
– Quality of care
are converging on the need to effectively The Field of Medical Informatics
manage health information
• Inadequacy of our current paper-based
health information system
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Training in Medical Informatics Training in Medical Informatics
From undergraduate to PhD and post-doctoral fellowships
• Fellowships
– 19 National Library of Medicine-sponsored
programs and also through the VA
– For doctorally-prepared candidates (MDs, PhDs,
DPTs) with relevant computer experience
– Regenstrief Institute
• Intensely pragmatic
Big Picture
What is the Role of EHRs?
• Institute of Medicine (U.S.). Committee on Data Standards for Patient Safety. Board on Health Care Services. Key Capabilities of an Electronic Health Record System. • Institute of Medicine (U.S.). Committee on Data Standards for Patient Safety. Board on Health Care Services. Key Capabilities of an Electronic Health Record System.
Washington, DC: National Academy Press; 2003. Washington, DC: National Academy Press; 2003.
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The EHR The Scientific Side of Clinical Informatics
Myriad Sources and Uses19
19. Institute of Medicine (U.S.). Committee on Data Standards for Patient Safety. Board on Health Care Services. Key Capabilities of an Electronic Health Record System. Washington, DC: National Academy Press; 2003.
Thompson TG, Brailer DJ. The decade of health information technology: delivering
consumer-centric and information-rich health care. Framework for Strategic Action. July
21, 2004. Available: http://www.os.dhhs.gov/healthit/documents/hitframework.pdf
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The Decade of Health Information Technology
Information Technology –
–
Less wasteful care
Fewer variations in care
– Patient-centered care
Delivering Consumer-centric and Information-rich Health Care
– Clinicians with more time for patient care
– Employers will gain productivity and competitive edge from
reduced spending
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A Quick Org Chart
Strategic Framework
Offices Agencies
• Office of the National Coordinator • AHRQ
The Decade of Health for Health Information Technology
• Office of the Inspector General
• NIH
– NLM
The Decade of Health Information Technology The Decade of Health Information Technology
The Decade of Health Information Technology The Decade of Health Information Technology
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The Decade of Health Information Technology The Decade of Health Information Technology
The Decade of Health Information Technology The Decade of Health Information Technology
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Agency for Healthcare Research and Quality Centers for Medicare & Medicaid Services
Medicare Payment Advisory Commission Centers for Medicare & Medicaid Services
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The Regenstrief Institute
• Endowed by Sam Regenstrief
– Inventor of the low-cost dishwasher
– Obsessed with process improvement
• Created the Institute in 1972
• A healthcare improvement “skunkworks”
• A community of scholars
The Indiana Network for Patient Care – Informatics unit has published more
controlled trials than any other U.S. center
a working example of interoperable health information exchange – A “benchmark” institution
• BIondich PG, Grannis SJ. The Indiana Network for Patient Care: An integrated clinical information system informed by over thirty years of experience. J Public Health
Management Practice 2004 (Nov Suppl):S81-S86.
• McDonald CJ, Overhage JM, Barnes M, et al. The Indiana Network for Patient Care: A working Local Health Information Infrastructure. Health Affairs. 2005;24(5):1214-1220.
• McDonald CJ. Protocol-based computer reminders, the quality of care and the non-perfectability of man. N Engl J Med 1976;295(24):1351-5.
• Tierney WM, et al. Physician inpatient order writing on microcomputer workstations: effects on resource utilization. JAMA. 1993;263(3):379-383.
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Indy ED Registration Crossover
Hospital Systems Percent Overlap
One 40%
Two 39%
Three 18%
Four 3%
Five <1%
RHII
= LHII
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Indiana Network for Patient Care
Identifying Patients and Providers
Referral
Laboratories, etc
• ‘Global patient registry’ creates virtual record
– Sophisticated mechanisms “link” data
St. Vincent IUMG
– Based on fuzzy matching algorithms
– Clinician has the final say in whether to merge the
data for viewing or not
Global Patient Concept Global Provider State/County • A similar mechanism matches providers across
St. Francis Index Dictionary Index
Health Departments
institutions
– INPC doesn’t “create” access
– It only makes it easier to use
– Approved access uses is evolving
Clarian Community
Wishard Memorial
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A Related Organization
• Indiana Health Information Exchange (IHIE)
– Non-profit organization created in 2004
– Goal is to support the INPC infrastructure by creating a
–
sustainable business model
IHIE Board
Clinical Uses of the INPC
• Mayor’s office, BioCrossroads, Marion County and IN State
Public health departments, state and county medical societies, Database and the
Associated Tools
CEOs of the major hospital systems, other leaders
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EKG Tracing Radiology Reports
• Patient Abstracts
– Outpatient views
– Customized for clinical location
• ER vs newborn vs pediatrics
• Encounter Forms
– A form for clinicians to document care
– Can contain computer-generated
reminders, alerts, etc
• Tailored Documents
– “Pocket Rounds”
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The Medical Gopher The Medical Gopher
Clinical Work Station Application Clinical Work Station Application
• A work station application at Wishard • Informed by 30 years of clinical data
Memorial Hospital and Clinics • Extensive Clinical Decision Support
• Capabilities for – Contraindicated meds
– Prescriptions, Orders, Problems, Clinical notes – Allergies
• In return – Reminders for vaccinations, etc
– Hints / Reminders – Prevents errors of omission with order sets
– Alerts • Auto-generates corollary orders for monitoring
– Secure email
– Rapid access to relevant information
• Patient specific
• A “mini library”
– Formulary info
– Directories
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Child Health Improvement through Child Health Improvement through
Computer Automation (CHICA) Computer Automation (CHICA)
Sample Sample
Screening
Form (PSF) Physician
Worksheet
Form
Physician’s Worksheet
(PWS)
Care
Reminders
Physician’s Worksheet
(PWS)
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Screening Identifying More PWS
Form (PSF) Risk Factors Features
• Physical exam
“coding”
• Also duplex..
E-mail
Summary
Abnormal flag,
Realtime Compare to Dwyer Organism name Daily Batch
Table I content in Dwyer II, or
(LOINC codes) Value above To Public
threshold Health
Reportable
Potentially Reportable Conditions
Reportable Condition Databases
To Infection
Control
Record Count
as denominator
Print
Reports
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Biosurveillance Clinical Research Usage
• In process of building a network to capture chief • Over 2,000 active studies at IU use INPC data
complaint data from all 140 hospital ERs in IN
• Electronic Tools
• Chief complaint data fed into algorithms to detect
– Fast Retrieval for “quick answers” and “first looks”
and monitor for bioterrorism and outbreak detection
– Shared Pathology Informatics Network (SPIN)
• More than 60 hospitals are now connected
• Links pathology specimens with clinical data
• Tools for conducting de-identified research
Event: Time • Epidemiologic Studies
Weekly ED Gastrointestinal Syndromes
– Association of erythromycin and pyloric stenosis
among newborns
Signal: Alarm
Alarmthreshold
Threshold
27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46
Week
• Mahon BE, Rosenman MB, Leinman MB. Maternal and infant use of erythromeycin and macrolide antibiotics as risk factos for infantile hypertrophic pyloric stenosis. Journal of Pediatrics. 2001;139(3):380-384.
Lessons Learned
• Start with things that add value/information
• Recognize that different data sources require
different standardization efforts
Keys to Success and • Commitment to standards
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Current Related APTA Initiatives
• Hooked On Evidence
– Online database of article summaries relevant to
interventions used by physical therapists Proposed Competencies and
– Accuracy?
Clinical Informatics
• APTA CONNECT Educational Content for
– a point-of-care, computerized patient record
system designed specifically for physical therapists
Physical Therapy
– Includes the ability to collect outcomes measures
that will be used to generate a national database
• OPTIMAL, SF-36, Oswestry, etc
Lobach DF. Clinical informatics: Supporting the use of evidence in practice and relevance
– For outpatient, PT-only practices to physical therapy education. J Phys Ther Educ. 2004;18(4):24-34.
Content for Physical Therapy Education Content for Physical Therapy Education
Computer Literacy •Skill with office productivity software
•Email
• Discussion of Lobach paper •Internet use for various applications + searching for health info
•PDA use
Information Retrieval •Develop and use search strategies for accessing professional literature
•Access and use online textbooks
•Organize electronic information for future access
Information Management •Familiarity with data modeling and data flow concepts
•Database principles and use for health information
•Awareness of data warehousing and data mining concepts
•Use of aggregate data for quality assessment and population health
•Understand issues related to data security
Clinical Decision Support Systems •Understanding of various approaches to using information systems for decision support
•Awareness of the role of information systems in decision making
•Understand the value of information systems to support EBP
Resources
• Office of the National Coordinator for Health
Information Technology (ONCHIT).
http://www.os.dhhs.gov/healthit/
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