How computers help make efficient...
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This document summarizes an article about how clinical informatics tools can help make patient consultations more efficient. It discusses how computers can help clinicians obtain relevant patient information, assess the patient's status, and take effective management steps. It also explains how recording consultation data can produce useful information to improve local healthcare services and inform broader health system policies. The document provides a flow chart outlining the acute asthma management process in emergency departments for children over 5 years old.
How computers help make efficient...
- 1. Clinical review ABC of health informatics How computers help make efficient use of consultations Frank Sullivan, Jeremy C Wyatt Efficient consultations deal with patients’ problems promptly This is the seventh in a series of 12 articles and effectively while taking into account other relevant A glossary of terms is available at http://bmj.com/cgi/ circumstances. Sometimes the relevant circumstance is another content/full/331/7516/566/DC1 health problem in the patient or their family, or it could be an issue affecting society at large, such as resource constraints. The immediate role of the team caring for Patrick Murphy (see box opposite) is to deal with his severe asthma. Patrick Murphy is a 5 year old boy who has been To do so the team needs information on the current brought to the accident and emergency department with problem, which is quickly obtained from Patrick’s mother (who status asthmaticus. He is cyanosed with a poor respiratory accompanied him in the ambulance) and background details effort from her or from his medical records. They also need to assess Patrick’s physical status using clinical examination and other diagnostic methods. The information obtained enables the clinicians caring for Patrick to take the most effective Assess asthma severity management steps. In the longer term, data from the Moderate exacerbation Severe exacerbation Life threatening asthma consultation may be used to redesign the service locally, or at • SpO2 ≥92% • SpO2 <92% • SpO2 <92% • Peak expiratory flow ≥50% best or • Peak expiratory flow <50% best or • Peak expiratory flow <33% best or the level of the health system. This article shows how predicted predicted predicted • No clinical features of severe asthma • Heart rate >120/min • Silent chest informatics tools can make it easier to record important data, NB: If a patient has signs and • Respiratory rate >30/min • Poor respiratory effort symptoms across categories, always • Use of accessory neck muscles • Altered consciousness and that this processing can produce useful information for a treat according to their most severe • Cyanosis features low cost. • Give nebulised β2 agonist: Most doctors focus on assessing the patient and carrying • β2 agonist 2-10 puffs via spacer salbutamol 2.5 mg or terbutaline 5 mg with oxygen as • Reassess after 15 minutes driving gas out immediate management steps. Some clinicians see the • Continue O2 via face mask/nasal prongs • Give soluble prednisolone 30-40 mg recording of what happened and why as a necessary evil to be or intravenous hydrocortisone 100 mg done in the minimum time, with the least effort. Legal Responding Not responding If life threatening features present responsibilities ensure that most encounters are recorded, but • Continue inhaled β2 agonist 1-4 hourly • Repeat inhaled β2 agonist • Add 30-40 mg soluble oral Discuss with senior clinician, paediatric intensive care unit team, or paediatrician the quality of data is often constrained, partly because so much • Add 30-40 mg soluble oral prednisolone prednisolone Arrange admission Consider: • Chest x ray and blood gases data are required. (lower threshold if concern over social circumstances) • Bolus intravenous salbutamol 15 µg/kg of 200 µg/ml solution over 10 minutes • Repeat nebulised β2 agonist Plus: Discharge plan • Ipratropium bromide 0.25 mg Data to be recorded for acute medical admissions • Continue β2 agonist 4 hourly nebulised • Consider prednisolone 30-40 mg daily for up to 3 days x Patient’s registered general practice details • Advise to contact GP if not controlled on above treatment • Provide a written asthma action plan Arrange immediate transfer to paediatric intensive care unit/ x Admission details (administrative) • Review regular treatment high dependency unit if poor response to treatment • Check inhaler technique Admit all cases if features of severe exacerbation persist after x Reason for clinical encounter • Arrange GP follow-up initial treatment x Presenting problem x History of presenting problem Acute asthma management flow chart for children >5 years in accident and x Current diagnoses, problems emergency department. Adapted from Scottish Intercollegiate Guidelines x Drugs, allergies, and diets Network, guideline 63 (www.sign.ac.uk/guidelines/fulltext/63/index.html) x Past illnesses, procedures, and investigations x Social circumstances x Functional state x Family history Clinical data x Systems review Results of care-based and cohort audit x Examination results Health needs assessment x Results of investigations External data (eg national comparators) x Overall assessment and problem list Information x Management plan Evidence including research x Intended outcomes Guidelines x Information given to patient and carers Experience External comparison Textbooks Knowledge Protocols Write once, read many Formularies Reminders Other tasks in the emergency consultation include gathering Feedback on performance Commissioning and recording information that may be useful to Patrick or Change other patients in the future. Paper or electronic records, or Clinical effectiveness other information tools, may make it easier to record items of Cost effectiveness data that can be aggregated and analysed after the event. The Clinical governance Outcomes audit data can improve efficiency when they are entered into clinical Improved outcomes records and made available to other members of the clinical team. Wireless networks allow data to be transmitted to and from handheld computers, laptops, or desktop computers. This Turning clinical data into improved patient outcomes 1010 BMJ VOLUME 331 29 OCTOBER 2005 bmj.com
- 2. Clinical review enables data to be shared early. An improved standard of record keeping probably means better data in the electronic patient record, which increases knowledge about the range of problems seen in clinical practice. This new knowledge informs decisions made at several levels, and contributes to better outcomes for Classification, coding, and nomenclature patients. x Classification is a method for systematically grouping something—for example, diseases. In most classifications, classes are designated by codes, which allow aspects of the things to be captured (a systematic arrangement of similar entities on the basis Structured recording of data of certain characteristics) x A code is usually a unique numeric or alphabetic representation of Although modern computers have massive processing and items in a classification storage capacity, data needs to be recorded in code to be x Nomenclature is a system of naming used in a branch of “understood” by computers. The computer processes and knowledge. Medical nomenclature attempts to standardise the analyses the data to add meaning. Free text notes are too names used for patient findings, diseases, interventions, and difficult for computers to process so that clinicians and outcomes policymakers can carry out analyses on them. Although there are many coding and classification systems, according to Gardner, one system aims to “create a new world standard for computerising medical terminology.” It is called the Secondary uses of data captured during consultations systematised nomenclature of medicine and clinical terms (SNOMED-CT) system. This coding system will be used in the x Reminders and decision support x Communication of clinical data between healthcare workers—for NHS. It is a detailed, coded classification of medical terms and example, discharge summaries, referrals, ordering, and requests concepts, and has more than 150 000 terms and codes that are x Identifying and monitoring the health needs of a population organised into 11 linked, hierarchical modules. Doctors will not x Reducing bureaucracy while managing and funding care delivery see, and do not have to remember, all these codes. They use the x Enabling reporting of externally specified health statistics—for interface provided by their clinical system, which is intuitive and example, for infection control carries out all the necessary translation to and from English. x Effective and efficient resource allocation and healthcare To realise all potential efficiencies, the electronic record management x Research must comply with several requirements. The variables to be x Education collected and their format may be agreed at different levels: x Local clinical audit and governance hospital, region, organisation, or country. The electronic records should also be shared appropriately among different organisational units using standard communications procedures, and they must be subject to security and Lateral view Medial view confidentiality protocols. Computer systems designed with sharing in mind are called “open.” They can run programs that A Posterior Malleolar zone B Posterior edge or tip edge or tip connect with systems of the same type, and can accept of lateral Midfoot zone of medial programs or connections from other sources. malleolus 6 cm 6 cm malleolus D Navicular C Base Rapid decisions and the human brain of 5th metatarsal In Patrick Murphy’s case, effective use of consultation data may An ankle x ray series is required only if A foot x ray series is required only if not require a computer. Most clinical decision making is done there is any pain in malleolar zone and there is any pain in midfoot zone and faster than current computer technologies can manage. any of these findings: any of these findings: • Bone tenderness at A • Bone tenderness at C • Bone tenderness at B • Bone tenderness at D • Inability to bear weight both • Inability to bear weight both Clinical prediction rules immediately and in emergency department immediately and in emergency department A clinical prediction rule, sometimes called a clinical decision rule, is a method that quantifies the individual contributions Ottawa ankle rules for use of radiography in acute ankle injuries. Adapted made by various components of the history, examination, and from Stiell IG, et al. JAMA 1994;271:827-32 basic laboratory results towards the diagnosis, prognosis, or likely response to treatment in a specific patient. Clinical prediction rules increase the accuracy of clinicians’ diagnostic and prognostic assessments. They have been developed to help Factors predicting a future risk of developing near-fatal or diagnose and manage patients with a wide range of diseases fatal asthma and in different settings. They reduce the uncertainty inherent x Socioeconomic deprivation in medical practice by defining how to use clinical findings to x Previous near fatal asthma—for example, previous ventilation or make predictions. respiratory acidosis Every rule should assist the doctor in making a decision, and x Previous admission for asthma, especially if in past year each one is based on factors drawn from a patient’s history, x Requiring three or more classes of asthma medication physical examination, or diagnostic tests. The Ottawa ankle rule x Overuse of ß2 agonist x Repeated attendance at accident and emergency department for is often used. The Ottawa Health Research Institute keeps an asthma care, especially if in past year inventory of clinical prediction rules. In August 2004 it x Brittle asthma recorded 523 prediction rules, 337 of which were validated x Poor adherence to drug regimen using Cochrane methods. BMJ VOLUME 331 29 OCTOBER 2005 bmj.com 1011
- 3. Clinical review After decisions about how to manage a clinical problem have been made, admissions that are potentially avoidable Continuity of care* should be considered. Using data to stratify the risk of For patients and their families the experience of continuity is the recurrence may enable doctors to vary the level of follow-up perception that providers know what has happened before, that and to tailor treatment depending on the risk—for example, the different providers agree on a management plan, and that a provider who knows them will care for them in the future. For providers, the risk of Patrick’s asthma recurring. experience of continuity relates to their perception that they have sufficient knowledge and information about a patient to best apply their professional competence, and they have the confidence that Establishing trust their care inputs will be recognised and pursued by other providers. An effective consultation instils trust and develops the *From Haggerty JL, Reid RJ, Freeman, GK, Starfield BH, Adair, CE, McKendry relationship between doctor and patient. In Patrick’s case, his R. Continuity of care: a multidisciplinary review. BMJ 2003;327:1219-21 family will probably consider returning to the team who dealt with his problems on this occasion for further care. When a patient sees the same doctor over time in a general practice surgery or outpatient clinic, it makes the consultation more Useful material on websites efficient for both parties. The patient’s story need not be repeated, and clinical examinations provide data that are x To read about the information strategy of the UK NHS see comparable. When personal continuity of care is not possible, www.nhsia.nhs.uk/def/pages/info4health/contents.asp x Background reading and justification on proposed record keeping the electronic patient record provides some organisational standards can be found at http://hiu.rcplondon.ac.uk/ continuity. Complete and accurate recording of data by clinicalstandards/recordsstandards/index.asp clinicians becomes more important when a different member of x The Ottawa Health Research Institute inventory of validated the healthcare team needs to know what information is already decision rules can be accessed at www.ohri.ca/programs/ known, or deduced, about the patient. clinical_epidemiology/OHDEC/clinical.asp Efficient use of consultation time The time available during consultations is often constrained, and doctors may need to select the most important problems to Further reading deal with. In a case like Patrick’s, this is simple: the severity of his x Berwick DM. A primer on leading the improvement of systems. physical disease means that his acute respiratory problem must BMJ 1996;312:619-22 be managed. On a later occasion (for example, at the next x Gardner M. Why clinical information standards matter. BMJ 2003;326:1101-2 outpatient visit) discussing parental smoking or pets in the x Wasson JH, Sox HC. Clinical prediction rules: have they come of house may be the best use of time. Looking over the patient’s age? JAMA 1996;275:641-2 records before a consultation may alert the doctor to x Wyatt JC, Altman DG. Prognostic models: clinically useful, or opportunities for efficient use of time. Patients often forget quickly forgotten? BMJ 1995;311:1539-41 much of what is said during a consultation, and giving them an x Schatz M, Cook EF, Joshua A, Petitti D. Risk factors for asthma audio recording of consultations is an easy and cheap way for hospitalizations in a managed care organization: development of a clinical prediction rule. Am J Manag Care 2003;9:538-47 patients to listen to the advice provided after their visit is x Guthrie B, Wyke S. Does continuity in general practice really over. Providing patients with a written leaflet or advice about matter? BMJ 2000;321:734-6 a self help organisation with materials on its website is also x Bates DW, Kuperman GJ, Wang S, Gandhi T, Kittler A, Volk L, et al. useful. Ten commandments for effective clinical decision support: making the practice of evidence-based medicine a reality. J Am Med Inform Assoc 2003;10:523-30 Summary The strengths of human thought processes may be complemented by the strengths of electronic tools. The initial costs of developing and implementing new information systems Frank Sullivan is NHS Tayside professor of research and development may be high, but the costs thereafter can be lower than the in general practice and primary care, and Jeremy C Wyatt is professor non-electronic source that is being replaced. In 2003, American of health informatics, University of Dundee. policymakers said that $120 billion a year could be saved by The series will be published as a book by Blackwell Publishing in using information systems. Well designed, new, informatics tools spring 2006. typically improve effectiveness by 10-15%. Lower costs and Competing interests: None declared. better outcomes mean that informatics tools are moving from an era of hype to one in which real benefits are seen. BMJ 2005;331:1010–2 1012 BMJ VOLUME 331 29 OCTOBER 2005 bmj.com