Physician Reminder System (PRS) Herbert Diamond, West Penn Hospital John Engberg Michael Johnson Rema Padman The Heinz School

Project A prototype reminder system for Western Pennsylvania Hospital’s Internal Medicine clinic (Medical Ambulatory Care Clinic - MACC) to support the practice of evidence- based medicine and preventive care management.

Evidence-Based Medicine “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients..[by] integrating individual clinical expertise with the best available external clinical evidence from systematic research” [Sackett et al. 1996] - Our computer application uses clinical practice guidelines to present evidence in the form of rules and suggestions

Background Errors in outpatient environment caused by: Intermittent care Missed results Possible improper drug usage Patient misinformation Poor transfer of clinical information

Examples 20% of Type 1 diabetic patients do not see a physician once a year 40% are not tested regularly for glycohemoglobin levels 41% do not have annual retinal exams …… (NEJM, April, 1999) How should these patients be managed such that patient outcomes are better and compliance with practice guidelines are improved?

Challenges to the “ideal” office visit Difficulty of tracking patient’s medical history Difficulty of maintaining or extracting patient records Possibility of busy physicians overlooking critical examinations

Motivation Proactive patient management Just-in-time physician reminders Compliance with practice guidelines These actions improve patient outcomes and reduce variation in care

Reminder System Project Details Client: Department of Medicine and Medical Ambulatory Care Clinic, Western Pennsylvania Hospital Developers: MISM and MSPPM students at the Heinz School plus faculty advisors and advisory board members Medical Domain: –Chronic diseases: hyperlipidemia, diabetes, low back pain –Preventive care categories: cervical cancer, breast cancer, pneumonia, influenza, cortico steroid-induced osteoporosis Project Success Measures: –Increased physician/staff productivity –Improved compliance with medical guidelines (shorter-term) –Improved population health outcomes (longer-term) –System that is scaleable,generalizeable, interoperable and user-friendly

Model Management System MODEL BASE Architecture for Reminder System Database Management System Clinical Guidelines Repository Evidence- Based Medicine Cues Dialogue Management System REMINDERS REPORTS User Interface

IS Project Methodology Feasibility Analysis Requirements Analysis System Design & Specification System Implementation Query clients on the best medical practices, the cueing methodology, and information requirements for efficient decision making Map client requirements into system functionality requirements Create preliminary design and specification for the system to be developed Develop system and integrate with the client’s current business process

Data Sources Demographic data from patient registration system Diagnosis, visit, procedure and test results data from billing and laboratory systems Screening data from staff Specific clinical data entered by physicians

Algorithms Derived from federal or major national organization consensus standards Based upon best available data Specific guidelines for each type of preventive care and each disease management program

Users Physicians: Reminders or suggestions for preventive care, treatment changes or referrals, patient education at time of visit Patients: Reminders regarding appointments and compliance Office Staff: Reminders of actions during current appointment and of future appointments

System Implementation Database: –Data standards: CPT-4 for medical procedures and ICD-9-CM for diagnoses –Platform: Oracle 8i, to accommodate multiple users, large datasets, Web- enabling –Test data: 30 dummy records Reminders: –SQL code for procedures: Triggers, invoked by updates to other tables Stored procedures, invoked by the application program Packages: storage of related programs, e.g. time-driven cues/visit-driven cues –Key parameters are hard-coded  application maintenance not trivial Interface: –Platform: Visual Basic 6.0 –Low-level design: flow diagrams, interface-table mapping –Application security: enable system administration functionality –Connection with Oracle: Active X Data Object controls

Interface Forms

Other Features Security and Privacy/confidentiality features to ensure that patient data cannot be accessed by unauthorized users –Three-level security functions: DBA, Administrator, Clinic Staff –Audit trail –Password management functions (time-out, expiry,reuse, complexity…)

Other Features Reporting capabilities: –summaries of treatment recommendations –elementary outcomes evaluations –automated reminder letters to patients Integration with West Penn hospital information system, patient scheduling and other information systems so that data stores can be updated automatically

Next Steps Automated archiving and data retrieval capabilities Expand to include one or more new diseases Web-enabling Develop tools to extract data on an as-needed basis and to determine outcomes that deviate from norms and/or optimal clinical pathways Develop a graphical interface that allows the user to compare sub-population outcomes with population characteristics