1. Computer Based Patient Records

2. Overview Review the Computer Based Patient Record Describe the UI CBPR Project INFORMM Patient Record

3. 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?

4. 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

5. 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

6. Components (cont’d) Outcomes Tracking –Health Status Indicators –Problem Episode Tracking –Randomized Impact Studies

7. What are the Main Issues Text versus Structured & Coded Security versus Access Buy versus Build Human Interface –GUI / Voice / Wearable Human Acceptance

8. 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

9. Structured and Coded Context –Validity Question and Response –Lexicon –Metathesaurus

10. 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

11. 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

12. 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

13. 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

14. Human Interface GUI –layout itself communicates information –pointing supported Voice –ready for prime time? Wearable Virtual

15. Human Acceptance Acceptable Interface Workflow Makes Sense Problems - More Solved than Created

16. 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

17. http:\\www.telemedical.com/ Telemedical/Products/emr.html

18. Processes Macro –Birth to Death –Induction to Discharge Micro –Check-in to Check-out –Chief Complaint to Episode Resolution

19. Macro Process

20. Birth to Death Record Universal Identifier Data Model Vocabulary Data Exchange Security Policy

21. Micro Process Patient Seeks Attention Patient Responds to Questions Provider Examines Impression and Plan Formed Plan Executed Outcome Assessed

22. Patient Seeks Attention Now –Patient Calls or Drops In Some Enhancements in Progress –System Proactively Advises Patient –Patient Seeks Online Information

23. 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

24. 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

25. 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

26. Plan Executed Now –Orders Written –Procedures Performed –Tests Done Some Enhancements in Progress –Orders Captured Online with Problem –Plan Process Tracked

27. 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

28. Rules Span the Entire Process If Event Detected –Demographics –History –Result –Order Then Response –Communicate to Patient / Provider –Execute a Plan

29. 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

30. INFORMM Patient Record

31. Patient Text Document System

32. Health Resume

33. Allergies & Adverse Reactions

34. Prescribing: Pre-written Orders

35. Online Guidelines

37. Immunization: Hx, Reminders, Orders & Charting

38. Immunization: Adults

39. Immunization: Travel Vaccines

40. Online Clinical Help

41. Contact Summary: CC to Billing

42. Template Input: Large Format, Touch Screen, Branching

43. Problem List (Coded)

44. Orders: Tracking by Problem

45. Teaching Documentation Compliance

46. Billing Code Documentation

47. Online Impact Assessment

48. 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

49. University of Iowa CBPR Project INFORMM Patient Record