in Critical Care Stephen Lapinsky Mount Sinai Hospital
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1 Electronic Patient Record in Critical Care Stephen Lapinsky Mount Sinai Hospital Toronto
2 Outline Terminology How can IT improve care The ICU Clinical Information System Drivers and barriers to a CIS Clinical Decision Support
3 Terminology A hospital-based information system designed to collect, organize and Clinical Information System CIS present data relating exclusively to clinical information about the care of a patient. Electronic Medical Record EMR Electronic Health Record EHR A computer-based record of healthcare information about a patient, for ongoing healthcare provision. A computer-based longitudinal lifetime record of a patient, generated from various encounters within the healthcare system
4 Terminology Patient Hosp A Hosp B Family doc A B C D E Radiol CIS EMR EMR EMR EHR EMR EMR?? EMR EMR Pharm Lab
5 How can IT help in the ICU? One ICU patient generates up to 236 variable categories Morris, Crit Care Clin 1999, 15:523 Humans capable of managing p g g 5 to 9 variables adequately Miller, Psychol Rev 1956, 63:81
6 The technology is out there
7 How I.T. can improve healthcare Improve communication Make data and knowledge accessible Decision support Facilitate t rapid responses Reduce errors Track compliance with guidelines Remote access, multiple users Avoid handwriting errors, abbreviations
8 How I.T. can improve healthcare Track compliance with guidelines 19 Michigan ICU s Clinical information technology index CRBSI rate pre-/post- implementation of change Amarasingham et al, J Am Med Inform Assoc. 2007;14:
9 Critical Care Clinical Information System COMPONENTS Labs and imaging RN & MD documentation CPOE & tasks emar, medication safety Connectivity with bedside devices Decision support & alerts
10
11 Critical Care Clinical Information System COMMERCIAL PRODUCTS Cerner inet Drager Infinity Phillips Intellivue Picis Caresuite Spacelabs Ultraview Siemens Axiom Sensis GE QS Critical Care imdsoft MetaVision
12 Critical Care Clinical Information System DECISION SUPPORT Simplest: Passive link to data
13 Critical Care Clinical Information System DECISION SUPPORT Simplest: Passive link to data
14 Critical Care Clinical Information System DECISION SUPPORT Active: Interacts with workflow Intervenes at opportune times Reduce errors of Commission Omission Drug dosing -out of range -renal failure -interactions -policy related
15 Critical Care Clinical Information System DECISION SUPPORT Active: Interacts with workflow Intervenes at opportune times Reduce errors of Commission Omission Reminders: - DVT prophylaxis - Check drug levels - avoid trivial, repetitive alerts
16 Critical Care Clinical Information System DECISION SUPPORT Sophisticated: Antibiotic prescribing based on current resistance patterns Evans et al, N Engl J Med. 1998;338:232-8 LDS Hospital, Salt Lake City McKinley et al, J Trauma. 2001;50:415-24;
17 Critical Care Clinical Information System DECISION SUPPORT Sophisticated: Antibiotic prescribing based on current resistance patterns Evans et al, N Engl J Med. 998;338:232-8 LDS Hospital, Salt Lake City McKinley et al, J Trauma. 2001;50:415-24;
18 Drivers for implementing a CIS Improving patient safety Consumer needs & expectations National initiatives Regional data sharing initiatives Improved technology
19 Barriers to implementing a CIS Financial limitations Interoperability between systems Clinician resistance to change Variation in systems used in Ontario survey Unmet of ICU s expectations: in the province time, of Ontario workload 15 different CIS vendors Usability, workflow, accessibility 8 different PACS vendors Data security Lapinsky et al. BMC Med Inform Decis Mak. 2008; 8:5 Presence of pre-existing existing poor practices
20 Barriers to implementing a CIS Financial limitations Interoperability between systems Clinician resistance to change Unmet expectations: time, workload Usability, workflow, accessibility Data security Presence of pre-existing existing poor practices
21 Adverse effects of ICU Clinical Information systems Facilitation ti of new errors Koppel et al, JAMA 2005;293:1197 Change in interactions on ward rounds Alteration to usual workflow Morrison et al et al, Crit Care 2008; 12:R148
22 Adverse effects of ICU Clinical Information systems Facilitation ti of new errors University of Pennsylvania Eclipsys System Koppel et al, JAMA 2005;293:1197 Change in interactions on ward rounds incorrect dosing (based on warehousing, not clinical data) discontinuation failures (due to multiple l screens) fragmented displays (routine v. stat v. prn meds) allergy alerts shift responsibility patient/medication selection errors delayed tomorrow orders Alteration to usual workflow Morrison et al et al, Crit Care 2008; 12:R148
23 Adverse effects of ICU Clinical Information systems Facilitation ti of new errors Koppel et al, JAMA 2005;293:1197 Change in interactions on ward rounds Alteration to usual workflow Morrison et al et al, Crit Care 2008; 12:R148
24 Adverse effects of ICU Clinical Information systems Facilitation ti of new errors Koppel et al, JAMA 2005;293:1197 Change in interactions on ward rounds Alteration to usual workflow Morrison et al et al, Crit Care 2008; 12:R148
25 Adverse effects of ICU Clinical Information systems Facilitation ti of new errors Koppel et al, JAMA 2005;293:1197 Change in interactions on ward rounds Alteration to usual workflow Morrison et al et al, Crit Care 2008; 12:R148
26 Implementation of ICU CIS Include all key stakeholders: MD, RN, others Ensure physician and nursing leadership support Understand and improve clinical processes Ongoing training and support Demonstrate and provide benefits: More rapid access to information Point-of-need information access Decision support
27 The Cedars Sinai debacle Slow, inefficient system Physicians not involved in development Interfering alerts Shelved system after 3 months, in 2002
28 10 Commandements for Implementation 1. Speed is everything. 2. Realize that doctors won't wait for the computer's pearls. 3. Deliver just-in-time information. 4. Fit into the user's workflow. 5. Respect physicians' sense of autonomy. 6. Monitor implementation in real time and respond right now. 7. Beware of unintended consequences. 8. Be wary of uncovering long-standing process flaws. 9. Don't disrupt magic nursing glue. 10. Speed is everything. Conclusion Shabot. Proc (Bayl Univ Med Cent). 2004; 17:
29 5 second 2 second 1 second 0.5 second
30 5 second 2 second 1 second 0.5 second
31 5 second 2 second 1 second 0.5 second
32 5 second 2 second 1 second 0.5 second
33 Conclusion Potential to improve patient care Standardize care Process control Reduce errors Requires a critical mass to be effective Integration of clinical, laboratory, PACS Clinical decision support Requires administrative commitment and financial support
34 Doctors can be sceptical and slow adopters That it will ever come into general use, notwithstanding its value, is extremely doubtful because its beneficial application requires much time and gives a good bit of trouble, both to the patient and to the practitioner.
35 Doctors can be sceptical and slow adopters That it will ever come into general use, notwithstanding its value, is extremely doubtful because its beneficial application requires much time and gives a good bit of trouble, both to the patient and to the practitioner. London Times, about the stethoscope
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