EMR Challenges & Evolutions VUB Fac Geneeskunde
Rudi Van de Velde
Agenda Setting the scene
We need a medical record Intelligent
Hollistic
Dynamic
Patient Engagement Mobility Towards EMR Implementation 2
Two core problems to solve “when demand for resources and supply diverge”
Sustainability Demand Sustainibility gap
Health services
Inferential Resources available
gap
Time
LEFT
20% of Population Generates 80% of the Cost
Health Status
Healthy / Low Risk
At-Risk
Value
High Risk
Chronic Disease Early stage
Chronic Disease Progression
End of Life Care
Acute Stage
Cost 4
Dgigital penetration
Digital Immigrants 24/04/2014
Digital is the norm Time
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ICT related harm
ICT associated patient harm
24/04/2014
Opportunity for harm
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We need a medical record that is … • Dynamic
– Misrepresenting collective, interactive work as a –
linear, clear-cut and predictable workflow Provider collaboration & productivity under continuous time pressure and in constant interaction
• Understandable & holistic – –
Interface not suitable for highly interruptive context. Fit the ecology of the workplace Cognitive overload due to overly structured information entry and complete information
• Value for the money – –
24/04/2014
Misrepresenting communication as information transfer. Increasing mismatch between information overload and ability to manage 7
CDSS
EMR Repository
Workflow
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UZBrussel Flow CPOE
Plan 12.000/day 5.000/day
CP EMR
50.000 QUERIES/DAY
10.000/day
ADT Billing 2.000/day R. Van de Velde
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2.000.000 1.800.000 1.600.000 1.400.000 1.200.000 1.000.000 800.000 600.000
Processen Taken
400.000 200.000 0 2007
2008
2009
2010
2011
Clinical workflow & CDSS A Mutual Relationship R. Van de Velde
2012
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Protocols : Radiotherapy Planniing
R. Van de Velde
Notify the Appropriate Person • Need to know who • Reminders for non-life threatening events must not interrupt clinician • Escalation procedure • Notification modalities – Active – Passive • Notify at network or application logon • Print on a face sheet at time of visit 12
The Medical Organizer
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CDSS
EMR Repository
Workflow
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Data mapping
Crossing Boundaries
Rule extraction
Separation of concerns
Exception Model verification handling semantic interoperability Process Maintenance modeling
Expressivity
Flexibility and adaptibility
Timeline
Temporal abstraction Tooling User interface & Usability
Discrepancy
Execution
Visualization
System architecture
Complexity
Goal modelingInformation/
Localization
Clinical implementation
Clinician attitude
Barriers to the Introduction of CP
Organizational change Organizational modeling
R. Van de Velde
Guideline translation
UZBrussel Case : Task Network Model
Then the demands of increasingly advanced technology will drive paradigm changes in how we view and manage data 1970’s era single slice CT
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CT during the early 1990s (160 slices)
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2006 cardiac CT (4000 slices)
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• Lots of Clincal data going online • Lots of Genetic data coming • Lots of personal data coming 20
Sort by: Relevant Important (Mass)-Personalized Other Points of View AND…Simple
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A Strange Phenomenon User Satisfaction Consumer Tech
Business Hospitals
Time
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OUTCOME
= EXPECTED
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CDSS
EMR Repository
Workflow
Quality Cost R. Van de Velde
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Access
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Interactions : Antibiotics
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Interactions :Pregnancy
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Context Sensitive Input
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*
Order Sets
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Protocols : Radiotherapy Planniing
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Empowering Knowledge Analytics The secondary use of EMR …..just couriers, bringing our records from one doctor to another without understanding what’s in them….. *
Full text search Text data
Clinical Data Ware House
Smart Indexing
Structured data
Unstructured data
Motivation
There is a significant need to conduct full-text search
Very few electronic health records (EMR) Have full-text search functionality (Natarajan et al., IJMI 2010)
Improved understanding of end-user search behavior will help design.
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24/04/201 4
IBM Watson brings together a set of transformational technologies to drive optimized outcomes
2 1 Understands natural language and human speech
Generates and evaluates hypothesis for better outcomes 99% 60% 10%
3 Adapts and Learns from user selections and responses
…built on a massively parallel probabilistic evidence-based architecture optimized for POWER7
Agenda Setting the scene
We need a medical record Intelligent
Hollistic
Dynamic
Patient Engagement Mobility Towards EMR Implementation
43
24/04/2014
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24/04/2014
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SECURITY Therapeutic Relation
Therapeutische Relatie (4/4) Secretar. Nurse A
Dr. X
Patiënt
TR Soc. Verpl.
Dr. Y
Dr. Z
Dr. W
Spec A
Spec A
Spec A
Nurse B
Duur = 3 maand
Nurse C Opname
Circles of trust
Secretariaat Sociaal verplegenden (nota, brief,e.a. ….)
Agenda Setting the scene
We need a medical record Intelligent
Hollistic
Dynamic
Patient Engagement Mobility Towards EMR Implementation
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Mobility – Agressive Momentum
Be able to do your work wherever
In all locations At the Patient At home On the road …
Be able to do your at any time
Be able to do your work on any device
On any computer On your tablet On your smarthphone …
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24/04/2014
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What to buy? DESKTOP OS
Windows Mac OSX Linux BSD
MOBILE OS
Windows Phone iOS Android BlackBerry
Different Challenges
Customizable Fully manageable
Closed More secure Limited management possibilities 59
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Kaiser Permanente 61
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eHealth-platform In de praktijk
De patiënt raadpleegt zijn geneesheer
Administratieve voordelen
Mogelijkheid om therapeutische relaties en geïnformeerde toestemming te registreren
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eHealth-platform In de praktijk
Opzoeken voorgeschiedenis via de SumEHR
Medicatieschema
Raadplegen van laboresultaten
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Online advies en guidelines
Medische voordelen
Elektronische voorschriften
Elektronische verwijsbrief
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Ziekenhuizen naar Artsen Dossier per instelling Niet-geadresseerd Ontslagbrieven Resultaten Beelden
HUBS
Samenwerking in zorgteam Dossier per patiënt Niet-geadresseerd
VITALINK INTERMED
Medicatieschema Sumehr Vaccinaties …
Gegevens delen ⬆ Verzenden ⬇ Voorschriften: geneesmiddelen kinesitherapie verpleging
Niet-geadresseerd Voorschriften Verwijsbrieven
RECIP-E
eHBOX
Brieven Formulieren Medische gegevens
Geadresseerd Eén-op-één communicatie 66
RECIP-E
© APB 2009
Agenda Setting the scene
We need a medical record Intelligent
Hollistic
Dynamic
Patient Engagement Mobility Towards EMR Implementation
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“EPD is een werkwoord” Geen IT project Proces kennis is cruciaal!
Gartner
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Difficulties involved with EMR
Physician Online Documentation
Difficulty to Achieve Success
High Clinical Decision Support Computerized Physician Order Entry Results Review
Pharmacy Laboratory PACS
High Low
Reliance on Physicians for Execution R. Van de Velde
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ICT-landschappen verbinden Samenwerkingsvormen: • tussen gelijken? Zijn de partijen gelijkwaardig qua omvang, kennisniveau en volwassenheid? • ad hoc, tijdelijk of permanent of blijven de partijen autonoom? • op alle vlakken of alleen op bepaalde gebieden? • Gaat men bepaalde taken uitbesteden? • Is er sprake van uniformering van ICT-infrastructuur, van applicaties of zelfs van diensten en bedrijfsprocessen? • Ligt de regie bij een van de alle partijen, bij … of daarbuiten? R. Van de Velde
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Functionaliteit
Implementatie Opties Best of breed
Modulair
Massa Personalisatie
Monoliet In house Flexibiliteit
Integratie
Integratie
Diensten die uitbesteed kunnen • •
Incident, problem, change & release management Security Management – – –
• •
Capacity and performance management Availability – – –
•
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Backup and restore services: Redundancy Level (Tier1-2-3) Archiving LT-MT storage Disaster Recovery Services
Service Level management (24/7?) – – – – –
•
Physical Logical Network security & antivirus-antispam
Monitoring, operations,...high availability management Response and resolution SLA’s Availability SLA’s Performance SLA’s Disaster Recovery SLA’s
Governance – – –
Financial Contract management Architceture & Innovation board
24-Apr-14
• The Flip is about to happen – We are “Half way “
• ICT associated Harm! • No platform, form factor or technology will dominate (“Post-PC “era) • We need …. 24/04/2014
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Thank You
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