copyright ©, 1999, alan s. tonnesen implementation of an electronic medical record theoretical...
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Copyright ©, 1999, Alan S. Tonnesen
Implementation of an Electronic Medical Record
Theoretical Model meets the Real World
Alan S. Tonnesen, MD
Copyright ©, 1999, Alan S. Tonnesen
Basic ModelData collection
Compare to Goal
Problem / Diagnosis
ActionClinical Data Repository
Copyright ©, 1999, Alan S. Tonnesen
Data CollectionData collection
Compare to Goal
Problem / Diagnosis
ActionClinical Data Repository
SymptomsPhysical ExamROSPast historyFamily historyTest resultsTherapy
Copyright ©, 1999, Alan S. Tonnesen
Data CollectionData collection
Compare to Goal
Problem / Diagnosis
ActionClinical Data Repository
SymptomsPhysical ExamROSPast historyFamily historyTest resultsTherapy
•Providing a real-time data entry tool has been a challenge. Dictated notes depend on a transcription company - problems.•Structured documentation is very intrusive.•Typing is difficult for some. •Handwriting recognition programs are poor•Speech recognition programs are not yet acceptable.
Copyright ©, 1999, Alan S. Tonnesen
GoalsData collection
Compare to Goal
Problem / Diagnosis
ActionClinical Data Repository
Patient GoalsMedical Goals
KnowledgeResources
Copyright ©, 1999, Alan S. Tonnesen
GoalsData collection
Compare to Goal
Problem / Diagnosis
ActionClinical Data Repository
Patient GoalsMedical Goals
KnowledgeResources
•Knowledge resources are not well organized on the WWW.•Who decides which resources are authoritative enough to get “institutional blessing”.
Copyright ©, 1999, Alan S. Tonnesen
Patient / Medical Goals:Outcomes
• Patient Goals– longevity– absence of pain– functionality
• Medical Goals– prevent disease– cure disease– control disease– reduce symptoms
Copyright ©, 1999, Alan S. Tonnesen
Problem List
• Suppportable statement of abnormality– Requires current or periodic diagnostic or
therapeutic action– Stated at supportable level of
understanding
Copyright ©, 1999, Alan S. Tonnesen
Problems & Diagnoses Data collection
Compare to Goal
Problem / Diagnosis
ActionClinical Data Repository
Supportable statement of abnormality
•Whose problem is it? Doctor?, Nurse? Billing office?•Does it conflict with medical records coding for billing purposes?•Who enters it?•Do we want to assign a “responsible provider”?•Can a nurse be a “provider”?
Copyright ©, 1999, Alan S. Tonnesen
Actions (Plans / Orders)Data collection
Compare to Goal
Problem / Diagnosis
ActionClinical Data Repository
DiagnosticTherapeuticInformationalEducational
LocalResources
•Physician order entry is the goal, but current systems are incredibly inflexible.•Overhead for entering an order is much greater in an electronic system.
Copyright ©, 1999, Alan S. Tonnesen
Test Results
• Laboratory
• Radiology
• Cardiology
• Neurophysiology
Copyright ©, 1999, Alan S. Tonnesen
Test Results
• Laboratory
• Radiology
• Cardiology
• Neurophysiology
•How do we convince external laboratories to send us their data electronically?•How do we convert the current paper-based system of reporting of test interpretations to electronic format?•Who “owns” the format of a specific report?
Copyright ©, 1999, Alan S. Tonnesen
Therapeutic Categories
• Diet• Drugs• Exercise• Physical Rx• Psychotherapy• Radiation
• Hygiene• Immune• Thermal• Surgery• Transplantation• Biomedical device
Copyright ©, 1999, Alan S. Tonnesen
History & Physical
• Text blob• Discrete data
– symptoms– signs– family history– social history– review of systems
Copyright ©, 1999, Alan S. Tonnesen
Decision SupportData collection
Compare to Goal
Problem / Diagnosis
ActionClinical Data Repository
Data collection aids
Diagnostic support
Dx & Rx suggestions
Interactions, costs, etc
Copyright ©, 1999, Alan S. Tonnesen
Decision Support: data collection Data collection
Compare to Goal
Problem / Diagnosis
ActionClinical Data Repository
Ensure data quality: - complete- correct- current
Copyright ©, 1999, Alan S. Tonnesen
Decision Support: Diagnostic Data collection
Compare to Goal
Problem / Diagnosis
ActionClinical Data Repository
- Formulate differential diagnosis- Identify trends and outliers
Copyright ©, 1999, Alan S. Tonnesen
Decision Support: Planning Data collection
Compare to Goal
Problem / Diagnosis
ActionClinical Data Repository
- Suggest data collection- Suggest therapy- Implement practice guidelines
Copyright ©, 1999, Alan S. Tonnesen
Decision Support: Planning Data collection
Compare to Goal
Problem / Diagnosis
ActionClinical Data Repository
- Suggest data collection- Suggest therapy- Implement practice guidelines
•Decision support depends on data being available.•You must deliver the message to the decision-maker, not a transcriptionist.•The message needs to be highly important.•The message needs to be timely.•The message needs to be non-threatening and accompanied by a suggested “way-out”.
Copyright ©, 1999, Alan S. Tonnesen
Decision Support: Order ImprovementData collection
Compare to Goal
Problem / Diagnosis
ActionClinical Data Repository
- Interactions- Costs- Redundant Dx or Rx
Copyright ©, 1999, Alan S. Tonnesen
Decision Support: Order ImprovementData collection
Compare to Goal
Problem / Diagnosis
ActionClinical Data Repository
- Interactions- Costs- Redundant Dx or Rx
•Pharmacy decision support has great value.•The pharmacy system is not interfaced with the EMR.•The system will choose a pharmacy system based on many factors, only one of which is the EMR.•If the new pharmacy system is not integrated, with the EMR, then we can not implement useful drug decision support.
Copyright ©, 1999, Alan S. Tonnesen
Population Model
Data collection
Compare to Goal
Problem / Diagnosis
Action Clinical Data Repository
Data collection
Compare to Goal
Problem / Diagnosis
Action Clinical Data Repository
Data collection
Compare to Goal
Problem / Diagnosis
Action Clinical Data RepositoryData collection
Compare to Goal
Problem / Diagnosis
Action Clinical Data Repository
Data collection
Population Problems
Action Population Data Repository Populatoin Goals
Copyright ©, 1999, Alan S. Tonnesen
Population Repository
Data collection
Action Population Data Repository
Population Goals
Population Problems
Copyright ©, 1999, Alan S. Tonnesen
Persons in Database
0
500000
1000000
1500000
2000000
2500000
0 100 200 300 400 500 600 700 800
Time (days since inception)
Num
ber
Table Row s Persons grow th rate / day
Copyright ©, 1999, Alan S. Tonnesen
Results in Database
0
2000000
4000000
6000000
8000000
10000000
12000000
14000000
16000000
18000000
0 100 200 300 400 500 600 700 800
Days since inception
Nu
mb
er
table rows Unique results
Copyright ©, 1999, Alan S. Tonnesen
HIN DowntimeRecord continuous up-time 12/16/98 - 1/17/99 = 37 Days
Restart the uptime clock1/31/99 @ 13:00: 59 hoursContinuous up-time as of 2/9/99 = 9 days
0
500
1000
1500
2000
2500
12/1
/98
12/8
/98
12/1
5/98
12/2
2/98
12/2
9/98
1/5/
99
1/12
/99
1/19
/99
1/26
/99
2/2/
99
2/9/
99
Date
Min
ute
s
Day time Night time
Copyright ©, 1999, Alan S. Tonnesen
Number of Trainees by Date
489588 607 607
0 0 0 0
275
500536 536
0 0 0 00
200
400
600
800
1000
1200
1400
Jun-98 Jul-98 Aug-98 Sep-98 Oct-98 Nov-98 Dec-98 Jan-99 Feb-99 Mar-99 Apr-99 May-99 Jun-99
Date
Nu
mb
er
Physicians Others
Copyright ©, 1999, Alan S. Tonnesen
Thank you!
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