copyright ©, 1999, alan s. tonnesen implementation of an electronic medical record theoretical...

Copyright ©, 1999, Alan S. Tonnesen

Implementation of an Electronic Medical Record

Theoretical Model meets the Real World

Alan S. Tonnesen, MD


Basic ModelData collection

Compare to Goal

Problem / Diagnosis

ActionClinical Data Repository


Data CollectionData collection

Compare to Goal

Problem / Diagnosis


SymptomsPhysical ExamROSPast historyFamily historyTest resultsTherapy


Data CollectionData collection

Compare to Goal

Problem / Diagnosis


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.


GoalsData collection

Compare to Goal

Problem / Diagnosis


Patient GoalsMedical Goals

KnowledgeResources


GoalsData collection

Compare to Goal

Problem / Diagnosis


Patient GoalsMedical Goals

KnowledgeResources

•Knowledge resources are not well organized on the WWW.•Who decides which resources are authoritative enough to get “institutional blessing”.


Patient / Medical Goals:Outcomes

• Patient Goals– longevity– absence of pain– functionality

• Medical Goals– prevent disease– cure disease– control disease– reduce symptoms


Problem List

• Suppportable statement of abnormality– Requires current or periodic diagnostic or

therapeutic action– Stated at supportable level of

understanding


Problems & Diagnoses Data collection

Compare to Goal

Problem / Diagnosis


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”?


Actions (Plans / Orders)Data collection

Compare to Goal

Problem / Diagnosis


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.


Test Results

• Laboratory

• Radiology

• Cardiology

• Neurophysiology


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?


Therapeutic Categories

• Diet• Drugs• Exercise• Physical Rx• Psychotherapy• Radiation

• Hygiene• Immune• Thermal• Surgery• Transplantation• Biomedical device


History & Physical

• Text blob• Discrete data

– symptoms– signs– family history– social history– review of systems


Decision SupportData collection

Compare to Goal

Problem / Diagnosis


Data collection aids

Diagnostic support

Dx & Rx suggestions

Interactions, costs, etc


Decision Support: data collection Data collection

Compare to Goal

Problem / Diagnosis


Ensure data quality: - complete- correct- current


Decision Support: Diagnostic Data collection

Compare to Goal

Problem / Diagnosis


- Formulate differential diagnosis- Identify trends and outliers


Decision Support: Planning Data collection

Compare to Goal

Problem / Diagnosis


- Suggest data collection- Suggest therapy- Implement practice guidelines


Decision Support: Planning Data collection

Compare to Goal

Problem / Diagnosis


- 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”.


Decision Support: Order ImprovementData collection

Compare to Goal

Problem / Diagnosis


- Interactions- Costs- Redundant Dx or Rx


Decision Support: Order ImprovementData collection

Compare to Goal

Problem / Diagnosis


- 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.


Population Model

Data collection

Compare to Goal

Problem / Diagnosis

Action Clinical Data Repository

Data collection

Compare to Goal

Problem / Diagnosis


Data collection

Compare to Goal

Problem / Diagnosis

Action Clinical Data RepositoryData collection

Compare to Goal

Problem / Diagnosis


Data collection

Population Problems

Action Population Data Repository Populatoin Goals


Population Repository

Data collection

Action Population Data Repository

Population Goals

Population Problems


Persons in Database

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Time (days since inception)

Num

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Table Row s Persons grow th rate / day


Results in Database

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0 100 200 300 400 500 600 700 800

Days since inception

Nu

mb

er

table rows Unique results


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

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12/1

/98

12/8

/98

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5/98

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2/98

12/2

9/98

1/5/

99

1/12

/99

1/19

/99

1/26

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2/2/

99

2/9/

99

Date

Min

ute

s

Day time Night time


Number of Trainees by Date

489588 607 607

0 0 0 0

275

500536 536

0 0 0 00

200

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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


Thank you!

copyright ©, 1999, alan s. tonnesen implementation of an electronic medical record theoretical...

Documents

ordersdata collectioncompare

realtime data entry

electronic system

electronic format

current systems

patient medical goals

medical records coding

therapeutic actionstated