Chapter 20 Information Across the Health System

1
Chapter 20Information Across the Health System

• Yung-Fu Chen, Ph.D.
• Department of Health Services Administration,
  China Medical University

2
Outline

• Emerging information and communications
  technologies, such as electronic health records
  (EHR) systems offer new ways of accessing health
  information and assisting clinicians and
  consumers in decision-making that improves the
  quality and safety of care delivery (Commonwealth
  of Australia, 2003c). These technologies create
  an awareness of the holistic needs of patients
  because information is readily available from
  multiple sources, across geographical boundaries
  and within flattening information silos. Using
  scenarios, this chapter draws together the
  discussion in previous chapters to illustrate
  information flows and to contrast the papers and
  automated record systems.

3
Introduction

• Healthcare consumers have multiple entry and exit
  points in a complex system that support an
  increasingly transient community.
• Reports of problems with paper health records are
  numerous with issues of illegibility and access
  well documented. Electronic health records (EHR)
  systems are thought to negate most of these
  problems and lead to more efficient, sale and
  cost-effective healthcare.

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Information flows across care

• Vera is a 72-year-old woman living alone. She
  felt unwell and visited her General Practitioner
  (GP) who drew blood for testing. She was given a
  script for angina medication and antibiotics, to
  be taken after meals but before her arthritis
  tabs. She is to return in two days for a check up
  and results of her tests.

If current system A form is written and wrapped
around the blood vials and secured with a rubber
band. They are left on the bench (just washed,
and still wet) awaiting the courier
If automated system An electronic order is sent
to the pathology lab. The plastic coated, bar
coded vials are left on the bench (just washed,
and still wet) awaiting the courier.

• Vera goes home. She has heard of an acupuncturist
  who is also a herbalist and works magic with
  arthritis. Her arthritis is really bothering her
  so she makes an appointment for the next day.

The acupuncturist has Veras EHR and full
history, notes that she visited her GP yesterday
and has had blood tests. Vera views her record
and notes a mistake that is corrected by the
acupuncturist in a new notation.
Vera arrives for her session. Relates her
history- what she can remember of it- and tells
the acupuncturist about her symptoms, which he
notes in a new paper chart.
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Information flows across care

• Vera has her treatment and her joints feel much
  improved, although she is still off color

The acupuncturist dispenses a herbal remedy after
Vera recited her current medications. None were
contra-indicated. The paper chart is filed.
Whoops ... she forgot the little blue pill!
The acupuncturist does not prescribe herbal
medications because, according to the current
medications list, the herbs are contra-indicated.
The acupuncturist treatment is noted on the
shared EHR

• The next day Vera goes to the chemist to have her
  scripts filled

(No hurry, she has plenty of old tablets In her
cupboard she just knew she would need them one
day! and she also has the new herbal remedy.) A
locum pharmacist dispensed her estrogen as per
his reading of the handwritten script from the GP
An electronic prescription has been sent to
Veras local pharmacist. A locum pharmacist
checks her current medications list for contra-
indications or alerts. The erythromycin was
individually packaged and dispensed and she is
handed a printout of instructions.
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Information flows across care

• Next day Vera returns to the GP

(The receptionist knows she has filed Veras
record... She is sure it started with V.) After
reading the 1946 Readers Digest, Vera sees her
GR. No results yet, the fax is playing up.
Phone call to the pathologist V-e-r-a .... no,
not Dora... Vera!. The results are read over the
telephone. The GP jots them down on a note pad.
After watching a health promotion video in the
waiting room. Vera sees her GP. Her EHR is open
on the desktop. The visit to the alternative
therapist is noted. The test results are in the
in- box and the current medications list shows
that the correct medications have been dispensed.

• Vera is to be admitted to hospital immediately

The GP writes a quick note Dear Dr... please
admit this lovely woman ... who has been off
color for a week.
Veras GP sends a summary record to HealthConnect
repository and provides her with printed
information about diabetes from the practice
computers knowledge database.
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Information flows across care

• The receptionist phones an ambulance. On the way
  to hospital Vera has a turn.

The ambulance officers are unsure of the cause,
her diagnosis is sketchy and she is not able to
give them any information, They give her oxygen.
monitor her and hope the traffic isnt too heavy.
Veras chart is downloaded to the ambulances
mobile videoconferencing equipment and
consultation begun between the emergency
department (ED) specialist and ambulance.
Real-time physiological monitoring data is
available to the specialist. The ED is prepared
for her arrival.
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Information flows across care

• Information technology (IT) has permanently
  transformed the way in which we communicate
  however one of the constraints is the inadequacy
  of the mainly copper wire communications network.
  Sending large amounts of data through the
  existing network is painfully slow and largely
  ineffective
• To provide broadband Internet access to GPs to
  ensure that all general practices and Aboriginal
  Community Controlled Health Services have access
  to high quality, secure broadband services.
• IT also has the capacity to rein in the
  unacceptable levels of errors and adverse events
  resulting from illegible handwriting and mistakes
  in the prescribing and administration of
  medications.
• Medications management is an ongoing concern in
  most countries with errors responsible for
  considerable morbidity.
• The United States Institute of Medicine (2001)
  report that over 98000 deaths each year in
  America were related to medical error 40 per cent
  of outpatient prescriptions were unnecessary and
  patients receive only 55 per cent of recommended
  care.
• In Australia, misuse, under-use, overuse and
  reactions to therapeutic drugs result in 140 000
  hospital admissions ever year and cost
  approximately 380 million each year in the
  public hospital system alone (AIHW, 2002).

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Information flows across care

• The MediConnect trials demonstrated the benefits
  of improved provider and consumer access to
  medicines information and the usefulness of using
  technology to link patients, doctors, pharmacists
  and hospitals.
• Access to more complete consumers medicines
  information improves quality and safety in
  prescribing, dispensing and managing medicines.
  This will help to reduce the incidence of
  duplicate prescriptions, and allergic or adverse
  reaction -both major problems and cost in the
  Australian health system.

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Information flows across care

• HealthConnect is expected to include a storage
  system that consists of three layers
• a coordination layer representing the
  infrastructure, metadata and services needed to
  integrate HealthConnect into a common national
  network of records
• a federated record system layer which comprises
  multiple nodes (potentially with a range of
  system owners), each of which has an independent
  records system servicing a defined user-
  population
• the user layer comprised of the consumers and
  providers local information systems used to
  access HealthConnect

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Information flows across care

• Adaptable mobile computers and scalable,
  point-of-care devices that are easily integrated
  with a variety of wireless medical devices and
  healthcare sensors are available. They enable the
  rapid collection and transmission of vital
  patient data from the scene from the emergency
  response team.
• Digital images and vital sign measurements are
  quickly captured and transmitted to the
  appropriate clinician, wherever that person might
  be situated.
• Continuous vital signs monitoring coupled with
  high-speed digital network connections and
  interactive videoconferencing capabilities,
  enable the consultant and emergency personnel to
  discuss and monitor patient care en route. All
  care and interventions are accurately recorded
  and stored automatically in the patients EHR
  using voice recognition software.

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Information flows across care

• Vera arrives at the Emergency Department

If current system Veras chart is ordered from
Medical Records Department storage. She is
resuscitated and sent to Intensive Care. A paper
progress note is used to admit her and to
document progress. It will be placed in her chart
when it arrives.
If automated system The current EHR is displayed
on the point-of- care device and as Vera has been
stabilized en route a routine admission follows.
All clinicians have access to all information.
Vera is transferred to the ward.
Vera is admitted into a high dependency unit her
details are recorded (again). A medical student
does a thorough admission as does the resident
and the registrar repeats the dose. All ask about
current medications and each documents a full
past and present health history. Veras vague
status is noted and yesterdays tests are
repeated (the former results are in the GPs
silo). A nursing assessment is also carried out
and documented.
The EHR is available in the ward and had been
automatically updated. It includes Veras past
and present health history and a list of current
medications and dispensing dates. Yesterdays and
all previous test results are also in the EHR.
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Information flows across care
Vera is prescribed medications and the nursing
staff makes sure that these are given at the
right time, in the right dose. She is asked about
allergies before being given the first dose of
ampicillin. Vera is unsure, but after ingesting
the medication remembers having a funny turn
some years ago after taking penicillin.
Vera is due for her medications. She has a bar
coded armband with all information -
demographics, allergies etc. The bar code reader
crosschecks this with her chart and an allergy
alert is received. The antibiotic is changed.
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Information flows across care

• Next day Vera is sent for a chest x-ray

A paper referral is sent to the x-ray department.
Vera is x-rayed and waits for the quality to be
checked. She returns to the ward. The film will
be read, the results typed and a paper copy sent
later. Some time later it is received but not
glued into her chart, as it cannot be located.
The result slip is placed in the filing box.
The x-ray appointment is made electronically. A
digital x-ray is taken, and uploaded into her
EHR. The radiologist comments on the x-ray using
voice recognition to populate the EHR. This is
immediately available to all concerned in Veras
care long before she returns to the ward.
The physio referral was sent electronically and
treatment began yesterday. He goes online and
notes that Vera has returned to the ward.
Treatment is completed and documented although
three other clinicians are simultaneously using
the record.
The physio has received a referral slip sent
yesterday. He has visited the ward twice to see
Vera while she was still in the x-ray department.
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Information flows across care

• The Open Architecture Clinical Information System
  (OACIS) project in South Australia has
  demonstrated that improvements in information
  flow are possible in EHRs and that the provision
  of timely provider access to results makes
  duplicate pathology and radiology tests
  unnecessary
• Benefits reported by the Toronto Electronic Child
  Health Network were also impressive and include
  reduced human and financial costs For repeat
  testing better coordination of care and the
  ability to inform clinical care by trending
  results over time
• The Walsall study of EHRs (Orion Health, 2004),
  report a reduced number of appointments to
  effectively treat patients and that reviewing the
  record prior to consultations reduced the number
  of referrals to chiropody, physiotherapy and
  other areas.
• Owens and Foord (2002) also report a reduction in
  time spent by clinicians chasing information For
  complex cases, with critical results being at
  band much faster than previously possible.

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Information flows across care

• Other benefits of EHR have been demonstrated,
  although it is premature to quantify these in
  most instances.
• The fledgling Gloucester ERDIP project for
  example, points to major reductions in the
  average length of stay as well as significant
  savings on chemistry, haematology, transfusion
  and microbiology tests (Owens Foord, 2002).
• The national summary EHR (HealthConnect) should
  achieve similar results in Australia because it
  enables real-time downloading of current patient
  information at the point-of-care. It focuses on
  automating the capture, exchange, transmission
  and collection of health data
• IT enables the sharing and storage of data not
  before possible with paper-based records and
  other current means of communication. In the
  United States of America for instance, 30 billion
  healthcare transactions are conducted
  electronically via mail, fax, or phone every year

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Information flows across care

• Vera is discharged

If current system A discharge summary is written
for the community nurse and given to Vera. It
contains current medications and diagnosis. The
resident forwards a letter to the GP with a brief
reintroduction to Vera and her care. It should
arrive in the next few days! weeks. One-months
supply of medications is dispensed. Vera returns
home and rings the Community Health Nurses for
assistance, but she requires a referral. Her GP
does not do this via telephone and it will have
to wait until she see can see him. The first
available appointment is next week. The community
nurse makes an appointment to see Vera after
that. Eventually.
If automated system A clinical discharge summary
is automatically uploaded into HealthConnect via
a fast broadband connection. Her health team has
immediate access to this All are aware of Veras
medications and a sufficient supply has been pre
packed and dispensed. Her GP will review her next
week. An automatic referral is sent to the
community nurse who makes an appointment with
Vera the day after she returns home.
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Information flows across care

• Vera is seen by the community nurse

The community nurse arrives a little late, as she
was lost. She quizzes Vera about her past history
and hospital stay and asks about her treatment
and outcomes (unfortunately the discharge summary
is still in the taxi). Vera does not seem to
remember much. The nurse asks about medications.
Vera produces an apple box containing medicines
from 1956 to the latest supply from the hospital,
oh ... and her herbs. She seems confused about
which of the little red pills she should take.
The community nurse arrives on time thanks to the
GPS built into her Tablet PC. She has immediate
access via a wireless network to Veras full
history, current medications and care plan. Vera
has surfed the net and has printouts about her
condition that she wishes to discuss with the
nurse. In future they will meet via a telehealth
home link.
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Information flows across care
20
Information flows across care

• Mobile computing enables the collection and
  sharing of quality data to reduce errors, improve
  patient safety, and enhance service provision.
  However community healthcare providers also offer
  a range of services that have very specific
  obligatory reporting requirements. In such a
  diverse environment, data collection is
  potentially confusing and extremely complex. To
  overcome this, the Royal District Nursing Service
  introduced a data-mapping matrix that supports
  the use of quality data and information while
  enabling the organization to respond and comply
  with the many health-related minimum data sets
  (RDNS, 2005).
• Telehealth in home healthcare is available in
  many forms and is transmitted in three basic
  forms - text data, audio, and images. However,
  home-based telehealth tools require the provider
  to exhibit cognitive and observational skills to
  assess patient status from a distance (Lisetti
  LeRouge, 2004). Although physiological
  measurement and so forth can be effectively
  communicated using current telehealth systems,
  the often crucial affective state assessment
  provides a greater challenge. A system curreiitlv
  under development builds a model of users
  emotions (MOUE), while monitoring the patient
  using multi-sensory devices (Lisetti LeRouge,
  2004). These types of innovations will he a
  timely addition to the data and information
  available on a remotely monitored patient.
• However, with the increasing transience of the
  population, the triangular model of health
  services between general practitioner community
  nurse and hospital is dated and probably does not
  reflect healthcare of the future. Roggiero
  demonstrates the use of information technology in
  an isolated Aboriginal Community Health Centre
  and the necessity for a rethink about the way
  people engage with the health system.