Health IT

Dear Joaquin, this is a signficant personal honour to be invited to contribute to GHDonline. In this reply my introductory text is added. In the emails to follow are the 3 secondary files that I have used to support my submission. I confirm that the patient has provided permission to submit her record with I hope complete deidentification of her. The photo would not permit personal identification because of the angioedema.
A/Prof. Terry Hannan,

It is a great pleasure to be invited to GHDonline’s Member Spotlight.

I am a practicing Hospital Specialist in General Internal Medicine in Tasmania, Australia and a Clinical Health Informatician. Tasmania is the apple shaped island state of the southern coast of Australia.
From 1984-1992 I was the Medical Manager of the project to install the Johns Hopkins Oncology System (OCIS) in an Australian hospital. This was one of the first ‘successful’ international transfers of a complex e-Health Clinical Information System. [ Enterline J.P., L.J.R.E., Blum B.I., A Clinical Information System for Oncology. Computers in Medicine. 1989, New York: Springer-Verlag.]. This system remains in extensive use in the Johns Hopkins Oncology Centre and was functional in the Australian hospital until ...

Dear Joaquin, this is a signficant personal honour to be invited to contribute to GHDonline. In this reply my introductory text is added. In the emails to follow are the 3 secondary files that I have used to support my submission. I confirm that the patient has provided permission to submit her record with I hope complete deidentification of her. The photo would not permit personal identification because of the angioedema.
A/Prof. Terry Hannan,

It is a great pleasure to be invited to GHDonline’s Member Spotlight.

I am a practicing Hospital Specialist in General Internal Medicine in Tasmania, Australia and a Clinical Health Informatician. Tasmania is the apple shaped island state of the southern coast of Australia.
From 1984-1992 I was the Medical Manager of the project to install the Johns Hopkins Oncology System (OCIS) in an Australian hospital. This was one of the first ‘successful’ international transfers of a complex e-Health Clinical Information System. [ Enterline J.P., L.J.R.E., Blum B.I., A Clinical Information System for Oncology. Computers in Medicine. 1989, New York: Springer-Verlag.]. This system remains in extensive use in the Johns Hopkins Oncology Centre and was functional in the Australian hospital until 2010.

The OCIS project led me to be invited by Bill Tierney of Regenstrief to help co-found the Mosoriot Medical Record System (MMRS) in Eldoret, Kenya the precursor to the AMPATH/OpenMRS project. The evolution and measured effectiveness of this system is well documented in papers such as these.

Braitstein, P., et al., "Talkin' about a revolution": How electronic health records can facilitate the scale-up of HIV care and treatment and catalyze primary care in resource-constrained settings. J Acquir Immune Defic Syndr, 2009. 52 Suppl 1: p. S54-7.

Tierney, W.M., et al., The AMPATH medical record system: creating, implementing, and sustaining an electronic medical record system to support HIV/AIDS care in western Kenya. Stud Health Technol Inform, 2007. 129(Pt 1): p. 372-6.

Though I know the power of health informatics, in my clinical practice I sometimes have had to resort to low-cost technologies to provide a form of Summary Patient Record (SPR) for my patients. The format of my SPR has evolved over 5-10 years as I learn how to synchronise the core record with ancillary databases (Labs, Radiology) and knowledge resources (e.g. Google, Medline), for my CDS and the individual patients. The design is evolutionary based on my needs and feedback from nursing staff and patients.

Functionalities of the SPR.

--It is primarily a communication tool between me and my patients and care associated clinicians. All of my patients receive a copy (e-format or printed) of their record and its sequential updates with additional copies going to all authorised persons involved in the patient’s care.

--It provides me with timely access to longitudinal data and information on a patient.

--It is timely. 10-15 minutes to construct a full record depending on content. Less than 5 mins to update new encounters (Follow Up). All notations entered by me are evaluated by the patient during the encounter OR all email communications are Cut and Pasted into the record with date and time. This is beneficial for medication list verification and patient comprehension of management. Many patients live in remote areas of northern Tasmania so access to care is difficult and costly (ambulance, car, light aeroplane). Many patients use direct email communications with me as their clinical support and this has many benefits including reduced visits to the hospital and real time management of blood glucose control and blood pressure.

--Linkage in seconds to ancillary databases is direct via the Hyperlink function and IF required Cut and Paste functions insert data into the SPR.

--When available external reports on procedures are available (e-PDFs, scanned) are stored in a specified directory also accessible by Hyperlinks.

--I do not require paper records on my patients in clinic encounters and in-hospital records are the source of the initial SPR for admitted patients.

--My patient load is not large 10-15 new patients per week although this has been up to 50 patients per week. I usually have anywhere from 5-20 patients in my care at any one time and a total of 2,300 records (6 years). In my previous private practice I managed ~ 6,000 patient records.

--Access to the in-hospital secure storage site for the SPR is possible from any Internet access point in the world using a system called Cisco VPN. This system has a license which my hospital has, but other storage systems could be used as was described in this discussion. http://www.ghdonline.org/tech/discussion/secure-document-storage-and-sharing/...

For the benefit of this discussion theme I have attached the Blank Template [with comments] of the SPR and have included with permissions the record of a patient who lives remotely (>80Km) and is on welfare with major social issues. Use of her SPR with email has eliminated her recurrent admissions with angioedema for 2 years. The photograph in her record taken during an angioedema episode was provided by her from her mobile phone to my iPhone for insertion in the record. Her consent to display this information is recorded in her email communication –see italics, underlined text.]

The third file is the Excel Template for blood glucose monitoring which can be emailed to me for home based diabetic care.

I believe that this type of system could be used in other settings with patients in remote sites that have internet or telephone access, perhaps even using the same type of SPR shown here. I know that Summarisation is used in many advanced e-systems such as Regenstrief the OCIS project and AMPATH. The Australian GP network has a referral summary format for inter-professional communication. This is sent in complex text laden, printed format only. The evaluation of this as a communication tool has not been documented.

As I mentioned, this system is complementary to an EMR such as OpenMRS, but could see how in the future OpenMRS could have the functionality to have patients enter information or perhaps connect with a personal health record to exchange information. This would be particularly relevant to medication verifications. The SPR in my clinical practice can be transmitted (use is increasing) to Primary Care e-systems in Word or PDF formats and saved as a report file in their system. In my institution no other clinicians’ use e-patient communications.

It is truly an honour for us to have you with us,Tarry.
I would love to learn from you as to how the system can be adopted for remote areas where patients are seen both in the clinic and in the field(where camps are held) and in their huts.I often feel the need for a small hand held device which can record brief data of a large number of patients.Many such areas do not have mobile network also.

I'm uploading the sample Summary Patient Record (SPR) that Terry mentions.

I'm uploading the Sample Blood Suger Level form that Terry mentioned.

This is the sample lab and tests form from Terry.

Lastly, the sample follow up form from the Summary Patient Record (SPR).

Readers, I note that the Excel BSL graph if the data does not display as a graph when the file is opened on my iPad. I am not sure of the reason for this. It shows the time sequence drop in the sugar level as this patient decreased his weight from 130kg to 105kg and came off all diabetic medications including insulin. The graphical display was a motivator for dietary control. Terry Hannan

Sandeep, I will make some points about ‘expandability and mobility of the record. You will notice the subtle change in Template format from the actual patient’s record to the current blank Template. This is because I am trying to constantly make the SPR meet the patient’s needs and my own. Once the original SPR is created the only changes are for Follow Up data capture, Medication updates, Diagnoses and Procedures. For this I only require a Follow Up Template that prompts me to organise my assessment and management by date, purpose of review, new history, system review, examination, investigations and then management. Once updated this SPR version replaces all previous copies of the file.

I have tried to do this on my iPhone and iPad but the ability to complete the Templates on the Apple device is cumbersome and not easily achieved. The WordR Templates may be easier to manage on non-Apple mobile devices. I can load the SPR into the DocToGo App for reading (i.e. carry the record with me). For updates I can use the Notes App on the iPhone and email that text to myself for insertion in the record at a later date ...

Sandeep, I will make some points about ‘expandability and mobility of the record. You will notice the subtle change in Template format from the actual patient’s record to the current blank Template. This is because I am trying to constantly make the SPR meet the patient’s needs and my own. Once the original SPR is created the only changes are for Follow Up data capture, Medication updates, Diagnoses and Procedures. For this I only require a Follow Up Template that prompts me to organise my assessment and management by date, purpose of review, new history, system review, examination, investigations and then management. Once updated this SPR version replaces all previous copies of the file.

I have tried to do this on my iPhone and iPad but the ability to complete the Templates on the Apple device is cumbersome and not easily achieved. The WordR Templates may be easier to manage on non-Apple mobile devices. I can load the SPR into the DocToGo App for reading (i.e. carry the record with me). For updates I can use the Notes App on the iPhone and email that text to myself for insertion in the record at a later date. I find this very useful during Ward Rounds when I may get distracted by teaching or patient complexity and later recall an important issue I need to document of a patient.

I know of other ways to do this Dragon voice input (does not fit in the information flow easily) and another App used by my junior staff with their extended in patient lists. They then email their ward round assessments to me for inclusion in the SPR.

There is another very useful trick I use for standard treatment regimens. I have created “protocols” for certain clinical states e.g. Clexane management for long distance travel, guidelines for insulin adjustment, chronic pain management and other scenarios and these are inserted directly into the record for the patient and others who use it. I can send you copies if you think they may help.

I have always been concerned that this SPR is not a data capture tool and have in the past created an MSAccess database Hyperlinked to the SPR. This was useful when I was in private practice but the dynamics of the IT implementations in my institution do not make this a worthwhile undertaking.

Another method of data capture I am experimenting with is the use of PDF forms. [I can send examples] where the completed form is saved and there is an automatic export of the captured data in an XMAL file. This was very successful for the management of peritonitis in peritoneal dialysis patients. The first iteration of that form ‘replaced to handwritten orders’ in ½ day. After 18 months of use and refinement of format with the dialysis nurses the “Forms Police” prevented it use as the form did not have an official number code! This is despite the nursing staff using the PDF data capture forms with e-exporting of the data to an XML directory.

Terry,
I had a couple of questions about this system. The first how come you are doing this via word and excel documents and not directly in your EMR, because I believe you mentioned that you do have internet access.

Also, is there reimbursement for your time doing this and how many clinicians at your hospital use this system?

Thanks,

Joaquin

Sent from my Android phone using TouchDown (www.nitrodesk.com)

Joaquin, here are my responses to your enquiry.
o We do not have an EMR or a partial EMR in our institution.
o A small number of clinicians would like an EMR but most remain of the belief that they can do their work as good as or better than any e-system. Part of this attitude is because there is no clinician involvement in e-Health projects in our institution as well as the poor quality systems that have been tried and have established separate non communicating entities, with some costing millions of dollars and others representing million of dollars and are lying in the dust of history.
o In my hospital we have e-labs, e-Radiology, e-Patient management and maybe some other systems that store or generate patient care generated data. None of these are connected (interoperable) or standardised.
o When logged in as a user each system demands a separate log on and have different patient ID numbers, even though it is with the same user ID and password. Log on times can be 1- 2 minutes per application.
o System response times are slow but ‘acceptable’ because the paper trail is even slower.
o Coordination of data from ancillary ...

Joaquin, here are my responses to your enquiry.
o We do not have an EMR or a partial EMR in our institution.
o A small number of clinicians would like an EMR but most remain of the belief that they can do their work as good as or better than any e-system. Part of this attitude is because there is no clinician involvement in e-Health projects in our institution as well as the poor quality systems that have been tried and have established separate non communicating entities, with some costing millions of dollars and others representing million of dollars and are lying in the dust of history.
o In my hospital we have e-labs, e-Radiology, e-Patient management and maybe some other systems that store or generate patient care generated data. None of these are connected (interoperable) or standardised.
o When logged in as a user each system demands a separate log on and have different patient ID numbers, even though it is with the same user ID and password. Log on times can be 1- 2 minutes per application.
o System response times are slow but ‘acceptable’ because the paper trail is even slower.
o Coordination of data from ancillary systems is often Cut and Pasted into printed summary sheets for the House Officers for Ward Round summaries.
o Therefore the use of WordR / ExcelR allows me to create my user designed “interface” with my patient record data which is Hyperlinked to these resources while I am working within my record. The same Hyperlink function is the single click for access to Labs and Radiology and the web page “back arrow button” takes me directly back to the SPR which remains open while I access these remote systems.
o The Internet access is both an Intranet and Internet provides me with access to my secure directory on the hospital’s network that only I can access. The files are stored daily in the secure hospital data back up procedures.
o I am aware that some clinicians are surreptitiously ‘using’ my SPR (a copy is in the paper chart) when patients are being readmitted. Feedback is that they find them very useful but are unable to influence policy change for use of this type of record in this area at the moment.
o Re reimbursement. The first comment is that I receive no reimbursement for the use of these records and no other clinician uses an e-record in our institution. My SPR is used because my experiences have shown that this form of clinician-patient (-other clinicians) communication improves care through a variety of mechanisms. I live in a dispersed remote community where patients require costly and inefficient access to care and in particular my regional secondary care hospital. The Primary Care (General Practitioners) clinicians have very long waiting times or closed lists and therefore the hospital becomes the bus stop for all levels of care. I am of the belief, unproven, that an integrated SPR tool can be tested as an adequate tool for clinician-patient communication on which a reimbursement model can be built.

Thanks Terry, and I'm sorry to hear about the failed eHealth initiatives, though I'm sure you know that this, unfortunately, is more the norm than the exception, as is the jungle of unconnected systems.



Do you see a simple EMR (that is accessible by all users) being built similar to this SPR as a better solution? i.e. do you see this SPR experience as being a good step towards an EMR implementation?



Joaquin



___________________________________________________________________

Chief Technology Officer, eHealth Systems Chile

Research Fellow, Harvard Medical School/Partners In Health

Moderator, GHDOnline.org

Joaquin, here are my responses to your question.
o The simplest answer to your questions is yes.
Here are some of the reasons I respond in the affirmative.
o This SPR is a model of Summarisation that has been designed using established models in a variety of clinical domains and these have also been shown to improve communication in care from doctor to patient and doctor to doctor. (Fries. J. 1984Whiting-O’Keefe 1980, Bart 2007), within hospitals (Blum 1990, Regenstrief 1995, Kripalani 2007).
o In our hospital as well as others I have visited, junior house staff is daily compiling “summary formats” of their inpatients with basic Cut and Paste word processing tasks, with the information being taken from electronic resources such as laboratories then being printed. This behaviour reflects a desire to summarise their patients’ longitudinal clinical data. Of course they ‘select what they need’ and may not reflect what information they also need but ‘overlook’. In our hospital several of the junior medical staff have found ways to link their portable devices, (m-phones, iPads, iPhones, etc) to the Lab results and also save their summary notes on these devices. To me this confirms the rapid behavioural adaptation of ...

Joaquin, here are my responses to your question.
o The simplest answer to your questions is yes.
Here are some of the reasons I respond in the affirmative.
o This SPR is a model of Summarisation that has been designed using established models in a variety of clinical domains and these have also been shown to improve communication in care from doctor to patient and doctor to doctor. (Fries. J. 1984Whiting-O’Keefe 1980, Bart 2007), within hospitals (Blum 1990, Regenstrief 1995, Kripalani 2007).
o In our hospital as well as others I have visited, junior house staff is daily compiling “summary formats” of their inpatients with basic Cut and Paste word processing tasks, with the information being taken from electronic resources such as laboratories then being printed. This behaviour reflects a desire to summarise their patients’ longitudinal clinical data. Of course they ‘select what they need’ and may not reflect what information they also need but ‘overlook’. In our hospital several of the junior medical staff have found ways to link their portable devices, (m-phones, iPads, iPhones, etc) to the Lab results and also save their summary notes on these devices. To me this confirms the rapid behavioural adaptation of their behaviour to the available technologies. It is of interest that some of these linkages are not clearly “authorised” by the hospital wide network policies!
o The question you ask re this SPR being a “good step” focuses is a critical issue with all EMR implementations. The approach must be incremental as we know an all-in-one approach is almost a guarantee for failure (Hannan 1994 and 2003, Kolodoner 2007). The need for incremental change is because the technology changes behaviour and often the resistance comes from those who need it most-clinicians (Leape 2005). In addition to the clinical cultural challenges another major barrier to successful implementations of EMRs and their components is by governmental departments that predominantly focus on administrative functionalities-the pure “business model”.
o My thoughts on the adaptability of incremental implementations are best summed up by words from Dr. Andrew Kanter of the MVP project this week. In a response to a Médecins sans frontiers enquiry Andy reply included “we are using OpenMRS in all 10 African countries, with different applications for different users at the front end. Our Community Health Workers use ChildCount+ (RapidSMS) and this feeds into OpenMRS”. This indicates to me that with an effective adaptable infrastructure users can adapt the EMR (SPR) to their needs. A practical example is that shown by Evelyn Castle in Nigeria. http://www.youtube.com/watch?v=UIpqE5WoufE

I wanted to thank Terry for taking the time to do this Member Spotlight and for providing such comprehensive responses. Terry has informed us that he has received requests to write an article on this experience in a journal, which is a great side benefit of being on GHDonline.

Thanks again Terry,

Joaquin