Using the NII to Coordinate Health Care

1. Using the NII to Coordinate Health Care 1. Applied Informatics 2. WebCIS 3. Home PFT

2. Applied Informatics George Hripcsak Nilesh Jain Charles Knirsch Ariel Pablos-Mendez

3. What • overall • use the National Information Infrastructure (NII) to coordinate care for patients across multiple encounters, providers, and settings • clinical area • begin with treatment of tuberculosis • then extend technology to all patients

4. Who • Columbia-Presbyterian Medical Center • out- and inpatient • New York City Department of Health • tuberculosis clinics • Visiting Nurse Service of New York • patient’s homes

5. Why - goals • coordinate (TB) care among providers • respond to patient needs • reduce variance in care via TB protocols • reduce treatment failure, resistance, spread • demonstrate privacy and security

6. How - components • connectivity • linking electronic medical records • automated clinical protocols • information resources • wireless pen-based computing • security

7. Schematic CPMC VNS registration TB isolation visit data DOHclinics kiosk casereporting clinicaldata mobile computing kiosk mobile computing DOH home

8. Connectivity • Internet • CPMC-VNS via linked frame relay • CPMC-DOH via dial-up phone line

9. TB patient resources • patient education critical in TB • patients do not have Web access • clinic kiosk • Web browser • touch screen monitor • HTML with large buttons, discrete screens • statistics gathering

10. TB patient resources • patient information • 4 TB pamphlets, 2 in Spanish • 62 English pages, 31 Spanish pages

11. TB patient resources ...cuando las defensas del cuerpo estan debiles, las bacterias inactivas de la tuberculosis se reactivan y se salen de las paredes

12. TB patient resources • utilization (8/95-1/96) • 275 pages (44 doc) per clinic day • 40% Spanish • (100 repeat visits, 2 new visits per day) • clinic director • addressed language barriers • patients asked better questions • only once personnel encouraged patients

13. TB Web resources • on Internet • patient pamphlets • DOH’s TB protocols (100 pages) • links to other sites • utilization • 25,000 files per month • 2000 unique computers • 12% outside US

14. TB resources • well-used • need to prove kiosk effect • how to address clinical questions from Web users

15. Mobile computing • home care nurses • isolation • patient information and changes • carry manuals • use wirless mobile computing

16. Mobile computing • pen-based tablet (Fujitsu) • 2.5 lbs, 50 MHz 486, 170 MB disk • CDPD wireless telecommunications • 90% connection, rest store and forward • applications • work lists, initial visit • data forwarded to CPMC • information resources (care plan, policies)

17. Mobile computing • 8 nurses for 3 months • enthusiastic • increase in information (contacts) • less need to carry manuals • empowerment (contact with CPMC nurses) • but no paperwork reduction • did not automate everything • coordination: MDs do not have devices

18. TB detection & reporting • automatically report CPMC tuberculosis cases to DOH • clinical event monitor • countable: TB culture • suspicious: AFB smear, lab tests, CXR, medications • natural language processing

19. TB detection & reporting • improved timeliness (2 weeks) • could not automate entirely • lack of electronic clinical information(clinical improvement, PPD) • difficulty automating complex judgments(lab errors)

20. TB isolation • 4% of new TB pts infected in hospital • respiratory isolation • surveillance and enforcement is difficult • automated detection of patients • at high risk for TB • not in isolation room

21. TB isolation • alerts based on electronic patient data • “The patient's chest X-ray (on 12 Oct 1995 at 12:11) shows specific evidence for tuberculosis disease. The patient is in the hospital, NOT in an isolation room.” • alerts are sent to • hospital epidemiologist • clinician (via electronic medical record)

22. TB isolation • 43 patients proven TB (7/95 to 7/96) • 13 (30%) not isolated by MD • 5 (38% of 13) caught by system • 2 of 30 taken off isolation too soon,system recommended re-isolation • 15 FP for every 1 TP (PPV 6%)

23. TB discussion • only critical tasks are achieved • largely intra-organizational gains • security • standards • difficult to evaluate a diffuse project

24. TB discussion • cost benefit • TB detection & isolation save $10,000/year • only pays incremental costs • entertainment, commerce drive Web

25. WebCIS James Cimino George Hripcsak Soumitra Sengupta Socrates Socratous

26. WebCIS • Web-based clinical user interface • three-tiered architecture • mainframe (DB2) clinical repository • TCPIP socket interface • UNIX Web server • CGIs in C • Web browser • HTML and Java Script

27. WebCIS • Medical Entities Dictionary • translation of codes • design of displays • based on MED classes and slots • security • time out • back in history • Secure ID cards

36. WebCIS • benefits of Web development • quick prototyping and development • improved access • easier deployment and maintanence • multimedia • hypertext links • security

37. WebCIS • challenges of Web development • CGIs stateless • moving target • security

38. Home PFT Joseph Finkelstein George Hripcsak Manny Cabrera

39. Home PFT • monitor asthma severity in patients’ homes • current technology • symptom reports • peak flow • poor predictive power and reliability

40. Home PFT • components • portable spirometer • handheld computer with data entry(or desktop with Web browser) • wireless or landline communications • clinical repository with decision support • Web server

42. Home PFT • results (7 normal, 3 patients) • able to perform PFT • able to run computer interface • 1 (land) to 8 (RAM) minute upload delay • current equipment fragile • clinical annecdotes • intervene for morning exacerbation • normal peak flow with poor terminal flow

43. Home PFT • benefits • full flow-volume curve (with FVC) • portable • can check compliance • immediately available to physician • automated decision support

44. Home PFT • questions • what parameters best predict exacerbation and is it preventable • optimize user interface and communication • what can be automated

45. Overall conclusions • enormous potential • not just the Web • clinical repository • automated decision support • vocabulary tools • kiosks, wireless • will be driven by other forces