SlideShare.

net/Nawanan

HHealth
lth IInformatics:
f ti
The Next ““Stethoscope””
p in Healthcare
Nawanan Theera-Ampornpunt, MD, MS
Healthcare &
H lth IT
Health
Manufacturingg

Source: Guardian.co.uk
Bankingg

Source: Cablephet.com
Healthcare

Source: nj.com
Why Healthcare Isn’’t Like Any Others?
• Life-or-Death
• Many & varied stakeholders
• Strong professional values
• Evolving standards of care
• Fragmented poorly-coordinated
Fragmented, poorly coordinated systems
• Large, ever-growing & changing body of knowledge
• High volume, low resources, little time

Source: nj.com
Why Healthcare Isn’’t Like Any Others?
• Large
g variations & contextual dependence
p

Input Process Output

Patient
Patient DecisionͲ
Decision Biological
Biological
Presentation Making Responses

Source: nj.com
But...Are We That Different?
Banking

Input Process Output

Transfer

Location A
LocationA Location B
LocationB
ValueͲAdd
Ͳ Security
Ͳ Convenience
C i
Ͳ CustomerService
But...Are We That Different?
Manufacturing

Input Process Output

Raw
Raw Assembling Finished
Finished
Materials Goods

ValueͲAdd
Ͳ Innovation
Ͳ Skills
Ͳ QA
But...Are We That Different?
Healthcare

Input Process Output

SickPatient PatientCare WellPatient

ValueͲAdd
Ͳ Medicaltechnology&medications
g
Ͳ Clinicalknowledge&skills
Ͳ Qualityofcare;processimprovement
Ͳ Information
Information is Everywhere
y
 Various Forms of Health IT

Hospital Information System (HIS) Computerized Provider Order Entry (CPOE)

Electronic
Health
Records Picture Archiving
g and
(EHRs) Communication System
(PACS)
Still Many Other Forms of Health IT

Health Information
Exchangeg ((HIE))

m Health
m-Health

Biosurveillance

Personal Health Records

(PHRs)

Telemedicine &
Information Retrieval Telehealth

ImagesfromAppleInc.,Geekzone.co.nz,Google,PubMed.gov,andAmericanTelecare,Inc.
Why Adopting Health IT?
“Go
Go paperless”
paperless “Computerize”
Computerize

“Get a HIS”
“Digital
Digital Hospital”
Hospital

“H
“Have EMR
EMRs””
“Modernize”

“Share
Share data”
data
 Some Quotes
• ““Don’’t
Don t implement technology just for technology
technology’’ss sake.
sake ””
• ““Don’’t make use of excellent technology.
Make excellent use of technology.””
(Tangwongsan, Supachai. Personal communication, 2005.)
• ““Health care IT is not a panacea for all that ails medicine.””
(Hersh, 2004)
• ““We worry, however, that [electronic records] are being
touted as a panacea for nearly all the ills of modern
medicine.””
(Hartzband & Groopman, 2008)
Health IT: What’’s In A Word?

Health Goal

Information
f Value-Add

Technology Tools
Dimensions of Quality Healthcare
• Safety
• Timeliness
• Effectiveness
• Efficiency
• E it
Equity
• Patient-centeredness
at e t ce te ed ess

(IOM, 2001)
Value of Health IT
• GGuideline
ideline adherence
• Better documentation
• Practitioner decision making or process of care
• Medication safety
• Patient surveillance & monitoring
• Patient education/reminder
ed cation/reminder
Fundamental Theorem of Informatics

(Friedman, 2009)
Is There A Role for Health IT?

(IOM, 2000)
Landmark IOM Reports

(IOM, 2000) (IOM, 2001)

Landmark IOM Reports: Summary
• Humans are not pperfect and are bound to make errors
• High-light problems in the U.S. health care system that
systematically contributes to medical errors and poor
quality
• Recommends reform that would change how health
care works and how technology innovations can help
improve quality/safety
 Why We Need Health IT
• Health care is very complex (and inefficient)
• Health care is information-rich
• Quality of care depends on timely availability &
quality of information
• Clinical knowledge body is too large
• Short time during a visit
• Practice guidelines are put ““on-the-shelf””
• ““To err is human””
To Err Is Human
• Perception errors

Source: interaction-dynamics.com
To Err Is Human
• Lack of Attention

Source: aafp.org
To Err Is Human
• Decoy Pricing
# of
The Economist Purchase Options People

• Economist.com subscription $59 16

• Print subscription $125 0
• Print & web subscription $125 84

# of
The Economist Purchase Options People

• Economist.com
Economist com subscription $59 68
• Print & web subscription $125 32
(Ariely, 2008)
What If This Happens in Healthcare?

• It already
l d hhappens....
(Mamede et al., 2010; Croskerry, 2003; Klein, 2005)

• What if health IT can help?

 U.S.’’s Efforts on Health IT Adoption

““...We
We will make wider use of electronic records and
other health information technology, to help control
costs and reduce dangerous medical errors.””
President George W. Bush
Sixth State of the Union Address, January 31, 2006
Source: Wikisource.org Image Source: Wikipedia.org
Public Policy in Informatics: A US’’s Case

1991: IOM’’sCPRReportpublished
1991:IOM s CPR Report published

1996:HIPAA enacted

2000Ͳ2001:IOM’’sToErrIsHuman&
CrossingtheQualityChasmpublished

2004:GeorgeW.Bush’’sExecutiveOrder
establishingONCHIT (ONC)

2009Ͳ2010:ARRA/HITECH Act&
““Meaningful
Meaningfuluse
use””regulations
regulations
U.S. Adoption of Health IT
Ambulatory (Hsiao et al, 2009) Hospitals (Jha et al, 2009)

Basic EHRs w/ notes 7.6%

Comprehensive
p EHRs 1.5%
CPOE 17%

•• U.S. lags behind other Western countries

(Schoen et al, 2006;Jha et al, 2008)
•• Money and misalignment of benefits is the biggest
reason
We Need ““Change””

“...we need to upgrade our medical

records byy switching
g from a p
paper
p to
an electronic system of record
keeping...”
P id t Barack
President B k Obama
Ob
June 15, 2009
 The Birth of ““Meaningful Use””

““...Ourrecoveryplanwillinvestin
yp
electronichealthrecords andnewtechnology
thatwillreduceerrors,bringdowncosts,
ensure privacy and save lives ””
ensureprivacy,andsavelives.
PresidentBarackObama
Address to Joint Session of Congress
AddresstoJointSessionofCongress
February24,2009
Source: WhiteHouse.gov
American Recovery & Reinvestment Act

• Contains HITECH Act

((Health Information Technology
gy for Economic and
Clinical Health Act)

• ~ 20 billion dollars for Health IT investments

• Incentives & penalties for providers

National Leadership
€ Office
Offi off the
th National
N ti l Coordinator
C di t for f Health
H lth Information
If ti
Technology (ONC -- formerly ONCHIT)

David Blumenthal, MD, MPP

National Coordinator for
Health Information Technology
(2009 - Present)

Photo courtesy of U.S. Department of Health & Human Services

What is in the HITECH Act?

(Blumenthal, 2010)
““Meaningful
g Use””

Pumpkin ““Meaningful Use””

of a Pumpkin

Image Source & Idea Courtesy of Pat Wise at HIMSS, Oct. 2009
““Meaningful
g Use”” of Health IT

Stage1
Stage 1
Ͳ Electroniccaptureof Better
healthinformation
Ͳ Informationsharing
St
Stage3
3
Health
Ͳ Datareporting
Stage2
Useof
EHRs to
to
UseofEHRs improve
toimprove outcomes
processesof
care

(Blumenthal, 2010)
 Health IT
A li ti
Applications
Enterprise-wide Hospital IT
• Master Patient Index (MPI)
• Admit-Discharge-Transfer (ADT)
• Electronic Health Records (EHRs)
• Computerized
C t i d PhPhysician
i i OOrder
d EEntry
t (CPOE)
• Clinical Decision Support
pp Systems
y (CDSSs)
• Picture Archiving and Communication System (PACS)
• Nursing applications
• Enterprise Resource Planning
l ((ERP))
Departmental IT
• Pharmacyy applications
pp
• Laboratory Information System (LIS)
• Specialized applications (ER, OR, LR, Anesthesia,
Critical Care, Dietary Services, Blood Bank)
• Incident management & reporting system
EHRs & HIS
TheChallengeͲ KnowingWhatItMeans

ElectronicHealth
Records(EHRs)
HospitalInformation
Hospital Information
System(HIS)
ElectronicMedical
Records (EMRs)
Records(EMRs)

ElectronicPatient
Records(EPRs)
ClinicalInformation
System(CIS)
PersonalHealth
ComputerͲBased
C B d Records(PHRs)
PatientRecords
(CPRs)
 EHR Systems
Just electronic documentation?

History DiagͲ TreatͲ

...
&PE nosis ments

O do
Or d they
th have
h other
th values?
l ?
Functions that Should Be Part of EHR Systems
• Computerized Medication Order Entry
• Computerized Laboratory Order Entry
• Computerized
p Laboratoryy Results
• Physician Notes
• P ti t Demographics
Patient D hi
• Problem Lists
• Medication Lists
• Discharge Summaries
• Diagnostic Test Results
• Radiologic Reports
(IOM, 2003; Blumenthal et al, 2006)
Computerized Physician Order Entry
Values
• No handwriting!!!
• Structured data entry: Completeness,
Completeness clarity,
clarity
fewer mistakes (?)
• No transcription errors!
• Entry
E point i ffor CDSSs
CDSS
• Streamlines workflow, increases efficiency
Clinical Decision Support Systems (CDSSs)
• The real place where most of the values of health IT can be achieved
– Expert systems
• Based on artificial intelligence, machine learning, rules, or statistics
• Examples: differential diagnoses, treatment options
– Alerts & reminders
• Based on specified logical conditions
• Examples: drug-allergy checks, drug-drug interaction checks,
reminders for preventive services or certain actions (e.g. smoking
cessation), clinical practice guideline integration
– Evidence-based knowledge sources e.g. drug database, literature
– Simple UI designed to help clinical decision making
Clinical Decision Support Systems (CDSSs)
PATIENT

Perception
CLINICIAN

Attention

Long Term Memory External Memory

Working
Memory
Knowledge Data Knowledge Data

Inference

DECISION
FromateachingslidebyDonConnelly,2006
Clinical Decision Support Systems (CDSSs)
PATIENT

Perception
CLINICIAN
Abnormal lab
Attention highlights

Long Term Memory External Memory

Working
Memory
Knowledge Data Knowledge Data

Inference

DECISION
Clinical Decision Support Systems (CDSSs)
PATIENT

Perception
CLINICIAN
Drug-Allergy
Attention Checks

Long Term Memory External Memory

Working
Memory
Knowledge Data Knowledge Data

Inference

DECISION
Clinical Decision Support Systems (CDSSs)
PATIENT

Drug-Drug
Perception Interaction
CLINICIAN
Checks
Attention

Long Term Memory External Memory

Working
Memory
Knowledge Data Knowledge Data

Inference

DECISION
Clinical Decision Support Systems (CDSSs)
PATIENT

Perception Clinical
CLINICIAN Practice
Guideline
Attention Reminders

Long Term Memory External Memory

Working
Memory
Knowledge Data Knowledge Data

Inference

DECISION
Clinical Decision Support Systems (CDSSs)
PATIENT

Perception
CLINICIAN

Attention

Long Term Memory External Memory

Working
Memory
Knowledge Data Knowledge Data

Inference Diagnostic/Treatment
Expert Systems

DECISION
Clinical Decision Support Systems (CDSSs)
• CDSS as a supplement or replacement of clinicians?
– The demise of the ““Greek Oracle”” model (Miller & Masarie, 1990)

The “Greek Oracle” Model

The “Fundamental Theorem”

(Friedman, 2009)
Clinical Decision Support Systems (CDSSs)
Somerisks
• Alertfatigue
Workarounds
Health IT for Medication Safety

Orderingg Transcription
p Dispensing
p g Administration

Automatic Electronic
C O
CPOE
Medication Medication
Dispensing Administration
Records
(e-MAR)
Barcoded
Medication Barcoded
Di
Dispensing
i Medication
Administration
Health Information Exchange (HIE)

Government

Hospital A Hospital B

Clinic C
L b
Lab P ti t att Home
Patient H
4 Quadrants of Health IT
Strategic

Business
Intelligence
g HIE

CDSS

CPOE

Administrative Clinical
VMI EHRs
ERP LIS

ADT

Operational (Theera-Ampornpunt [unpublished], 2010)

Health Informatics
As A Field
Biomedical/Health Informatics
• ““[T]he field that is concerned with the optimal use of
information, often aided by the use of technology, to
improve individual health,
health health care,
care public health,
health
and biomedical research”” (Hersh, 2009)
• ““[T]he application of the science of information as
d t plus
data l meaning i tot problems
bl off biomedical
bi di l
interest”” (Bernstam et al, 2010)
Data-Information-Knowledge-Wisdom Pyramid

Wisdom

Knowledge

Information

Data
Task-Oriented View

Collection Processing Utilization

Communication/
Storage Dissemination/
Presentation
M/B/H Informatics As A Field

(Shortliffe, 2002)
M/B/H Informatics and Other Fields
SocialSciences
(Psychology
(Psychology, Statistics&
Statistics &
Sociology, Research
Linguistics,Law Methods
Cognitive& &Ethics) Medical
Decision
Decision Sciences &
Sciences&
Science PublicHealth

Engineering Management

Computer&
Computer & Biomedical/ LibraryScience,
Library Science,
Information Health Information
Science Informatics Retrieval,KM

And More!
Balanced Focus of Informatics

People

TechnoͲ
Process logy
Informatics & Engineering
Process-focus
Process focus
• Industrial Engineering
g g / Operations
p Research
& Management / Business Process Reengineering
Technology-focus
• Computer & Software Engineering
• Biomedical Engineering
• Electrical Engineering
Summary
• Healthcare will benefit from health IT through
– Information deliveryy
– Process improvement
• The world is moving toward health IT
• Health
H lth iinformatics
f ti needsd expertise
ti ffrom engineering
i i &
other fields
• Health informatics will be crucial to future’’s healthcare
 Let s Build The
Let’’s
Next Generation’’s
H lth !
Healthcare!
References
• Bernstam EV,SmithJW,JohnsonTR.Whatisbiomedicalinformatics?JBiomedInform.2010
Feb;43(1):104Ͳ10.
• BlumenthalD.LaunchingHITECH.NEngl JMed.2010Feb4;362(5):382Ͳ5.
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[Internet].Princeton(NJ):RobertWoodJohnsonFoundation;2006
• Croskerry P.Theimportanceofcognitiveerrorsindiagnosisandstrategiestominimizethem.
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emr_ehr.pdf
References
• InstituteofMedicine,BoardonHealthCareServices,CommitteeonDataStandardsfor
PatientSafety.KeyCapabilitiesofanelectronichealthrecordsystem:letterreport[Internet].
f bl f l h lh d l [ ]
Washington,DC:NationalAcademyofSciences;2003.
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AK DesRoches CM,CampbellEG,Donelan
CM Campbell EG Donelan K,RaoK Rao SR,FerrisTG,ShieldsA,RosenbaumS,
SR Ferris TG Shields A Rosenbaum S
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• Jha AK,Doolan
, D,Grandt
, D,ScottT,BatesDW.Theuseofhealthinformationtechnologyin
, , gy
sevennations.Int JMedInform.2008;77(12):848Ͳ54.
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2;330(7494):781Ͳ3.
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medicineresidents.JAMA.2010Sep15:304(11):1198Ͳ203.
• Mill RA M
MillerRA,Masarie i FE.Thedemiseofthe"GreekOracle"modelformedicaldiagnostic
FE Th d i f h "G k O l " d lf di l di i
systems.MethodsInf Med.1990Jan;29(1):1Ͳ2.
• SchoenC,OsbornR,HuynhPT,DotyM,Puegh J,Zapert K.Onthefrontlinesofcare:primary
care doctors’’officesystems,experiences,andviewsinsevencountries.HealthAff
caredoctors office systems experiences and views in seven countries Health Aff
(Millwood).2006;25(6):w555Ͳ71.
• Shortliffe EH.JBI statusreport.JournalofBiomedicalInformatics.2002Oct;35(5Ͳ6):279Ͳ80.