5. Reasons to Develop an
Automated Patient Medical Record

5.1 Project Context: Determining Project Objectives From Organizational Objectives

The reason for doing a project within an organization is to improve the organization. In order to justify spending a lot of money to do a costly project, an organization must identify the reasons for doing the project, comparing these reasons and resulting benefits against the costs. Further, the organization must choose between projects and pick the proper mix of projects to select a mix with the greatest overall benefits to the organization at the lowest overall cost.

One way an organization can evaluate, select and compare projects is to determine the reasons for doing each project, the project objectives, and compare these project objectives against organizational objectives, desired future positions of the organization, as projects must support organizational objectives. See figure 5.1.

Since all projects, and thus all project objectives, must support organizational objectives, a method for determining project objectives is to look at each organizational objective to determine if the project would positively impact the organizational objective. If so, a project objective can be determined from the organizational objective.

For example, one “organizational objective” may be to “decrease healthcare organization costs without impacting patient care”. Two projects may each support this organizational objective: An automated patient medical record system will “reduce or eliminate the costs of transporting, finding, copying, storing, filing, and organizing the patient medical record”, while a new membership system will “reduce the costs of collecting capitation fees”. Another organizational objective might be to “improve patient care”. Of the two projects, only the automated patient medical record project supports this organizational objective; it improves patient care by “making the patient medical record always available”.

Once a project is completed, its project objectives can be used to measure its failure or success: a project can be considered successful if it meets its project objectives, enhancing the organizational objectives. Because a project objective is usually not directly measurable, a goal that can be measured should be set up to evaluate whether or not the project objective has been reached. For example, a project objective to “create an always available patient medical record” might have a measurable goal at the end of the project of “observing patient visits with physicians, an analyst must verify that for 99.5% of visits that the patient’s medical record is immediately available on-line to the physician”. This could be done statistically with the analyst visiting various medical locations and observing various physicians giving care, observing whether or not the patient’s medical record is available on-line.

Because the objectives are likely to take a long time to achieve, measurable goals may also be established at many different points during the project that can be used to measure the progress of the project towards the objective—An intermediate goal might be that “40% of HMO patient records will be automated after 3 years from the start of the project”.

Figure 5.8 lists project objectives for our project to automate the patient medical record derived from HMO organizational objectives. In the early stages of a project, project objectives can be used to determine an initial set of business requirements for the project. A business requirement is a required characteristic of the organization at the end of the project. The total set of business requirements for the project, determined as the project progresses, describe the expected project effects upon the organization.

From these initial business requirements, an initial description of products of the project can be determined—In our case the product is an automated patient medical record. These products can be described by a model of them, referred to here as a conceptual view. Section 5.6 presents an initial conceptual view of the automated patient medical record system. More refined conceptual views can later be developed as the project is defined further, as additional business requirements are determined.

But again, before a project is started, it must be selected among many potential projects that might benefit the organization. The next section describes an approach that could be used by an organization to select and evaluate projects.

5.2 Organization and Project Objectives Strategies, and Goals

An approach for selecting and evaluating projects within an organization is presented in reference [1]. It uses the following terminology, which is related to the overall organization rather than to a project:

· Mission: the business the organization is in.

· Objectives: desired future positions of an organization.

· Strategy: the general direction in which the objectives are to be pursued.

· Goals: specific targets to be sought at specified points in time.

· Projects: resource-consuming sets of activities through which strategies are implemented and goals are pursued.

Figure 5.2 shows the relationship between these elements together with an example for an HMO.

The company has a specific mission. Based upon this mission and the market, the company defines objectives for the future for the company to enable the company to improve and advance. Strategies for achieving these objectives are determined. Goals, ways to measure the organizational objectives, are established.

Appropriate projects to fulfill the goals and objectives are picked. Projects themselves have project objectives. Projects are picked whose project objectives most closely match the organizational objectives taking into consideration constraints on the project, including availability of resources (money, time, people) necessary to do the project, the availability of technology to successfully accomplish the project, and other obstacles that might hinder accomplishment of the project.

After a project is picked, goals to measure project objectives during the course of the project are determined. Strategies for doing the project are later determined as part of the project plan.

5.3 Possible Objectives for an HMO

The following are a set of organizational objectives of our example HMO that enhance the HMO’s organizational mission of “providing quality healthcare at a reasonable cost”:

1. quality medical care is provided to HMO members

2. medical care is provided at a reasonable cost to members or to members’ employers paying for the care

3. the HMO makes money

4. members are highly satisfied with the HMO and medical care

5. HMO employees are productive and happy in doing their jobs

6. the HMO can predict and handle future growth, or non-growth.

The above is a typical mission of an HMO and are typical organizational objectives for an HMO.

5.4 Derived Objectives for a Project

Project objectives can be determined from organizational objectives as follows: (1) Each organizational objective must be evaluated as to how the project would effect it. (2) If the project has a positive effect on the organizational objective, then some aspect of that HMO organizational objective should be a project objective. So let us consider these organizational objectives one by one and how they are positively effected by our project to automate the patient medical record.

(Note that negative effects of the project will be considered later on.)

5.4.1 Quality Medical Care

Automating the patient medical record could have a positive effect on patient care within an HMO.

5.4.1.1 Reengineering to Improve the Quality of Patient Care

An automated patient medical record system effects the entire clinical workflow. Patient care is a joint effort of many people, including medical personnel and non-medical support personnel. Patient care is the result of interactions between many different departments inside and outside the HMO. The automated patient medical record system would support all these people and all departments that influence patient care.

Changing and improving the way an organization works is called “reengineering”. Reengineering involves looking at and possibly changing the workflows of employees in the HMO to improve the workflows. Creation of an automated patient medical record system provides an excellent opportunity to make patient care better for both patients and employees through reengineering.

In the creation of an automated patient medical record system, the entire clinical workflow of the HMO must be re-evaluated to completely eliminate unnecessary steps and to restructure non-productive steps. At the same time, healthcare organization employees must be insured that the automated patient medical record system improves patient care while not creating additional employee stress. Each step must be evaluated on how it positively or negatively affects both patients and employees, with significant employee and patient input into changes in the care process. Through this reengineering process, the quality of medical care at the HMO would be improved.

5.4.1.2 A Complete, Always Available, Patient Medical Record

With automation of the patient medical record, there is the potential of having a complete patient medical record, containing information from both inside and outside the HMO (a “longitudinal” or “life time” patient medical record) that is available at any time to authorized caregivers both inside and outside the HMO. Whereas, the current (paper) patient chart may be only at one location at a time with transportation time between locations, and might even be temporarily misplaced, the automated patient medical record would be immediately available to all caregivers who needed it.

The fragmentation of the patient medical record described in section 4.7 and shown in figure 5.3 should no longer occur.

Patient care, as a result, could be changed in a positive way in many ways, including the following:

· There would be fewer gaps in medical information.

· Critical medical information, such as allergies to medications, advance directives, a complete list of medications the patient is taking, and an up-to-date patient and family history is likely to be immediately available. This information is especially important in the emergency department and the inpatient setting.

· There would be no delay between closely occurring visits to transport over the chart.

· A caregiver can telephone a patient when needed instead of having to first wait for the arrival of the chart.

· A patient can contact a physician by telephone and immediately receive informed advice because the physician will have the (automated) patient medical record in hand.

· The patient medical record would now be available to advice nurses at the time a patient calls in for advice.

· Multiple caregivers can view and/or update the patient medical record concurrently, even at two different geographic locations.

With simultaneous caregiver access to the patient medical record, telemedicine becomes more feasible—especially when a nurse is co-located with the patient and the physician is at a remote location, or when physicians at different locations are working in consultation with each other.

Telemedicine [2,3] uses telecommunications, from phones, teleconferencing to teleinstrumentation, together with computing technology to facilitate caregiver/patient and caregiver/caregiver interactions, remote diagnosis and treatment, and the transmission of medical data and images (from photographs to MRI to audiovisual). Telecommunication interactions fall into the following categories :

· Telementoring: fostering a mentoring relationship between a specialist and primary care physician, between a physician and a nurse practitioner, etc.

· Teleconsultation: fostering consultations between physicians, usually in very different locations, for time critical care or care requiring a second opinion.

· Telediagnosis: the provision of diagnostic services to remote locations without the expertise.

Concurrent access to the patient’s medical record would certainly assist the first two situations where caregivers all have the authority to access and update the patient medical record.

Telemedicine with a mutually available patient medical record fosters interactive communication between caregivers located remotely. Remote instrumentation, using medical instruments remotely located with the patient, where results can be immediately included as values, graphics or images in the patient medical record can further foster this communication.

At least the following medical instruments which can be used remotely currently have defined ANSI interface standards [4]: dermscope (for images of skin), ophthalmoscope (for images on the interior of the eye), otoscope (for images of the middle ear), laparoscope (for structures within the abdominal cavity), nasopharyngoscope (for examination of the sinus cavity and nasopharynx), intraoral scope (for inside the month, usually for dentistry), bronchoscope (for examination of the bronchi), sigmoidscope (for examination of the rectum and sigmoid colon with attachments to allow biopsy), and stethoscope (for heart and lung sounds), with the potential of significant results automatically being recorded in the automated patient medical record. Other currently existing remote instrumentation, without ANSI standards also exist (e.g., tele-ultrasound for OB/GYN and real-time interactive digital diagnostic quality transmission of Echocardiograms [5]).

5.4.1.3 Organization So Clinical Information can be Easily Found

If relevant information cannot be found in the patient medical record, then it is essentially equivalent to the information not being there. Patient care can be improved by making it easier to find clinical information in the patient medical record by “organizing” it.

Unlike the paper patient medical record which can be organized in a limited number of ways, the automated patient medical record can be electronically organized in an unlimited number of ways, for example by encounter, significant health problem or type of caregiver.

An “encounter” will be used here to mean a face-to-face interaction between a patient and a healthcare provider or other direct communication that substitutes for a face-to-face interaction, such as some phone calls. Examples of encounters are an inpatient stay, outpatient visit, emergency department visit, advice nurse call, a phone call between a patient and a physician, a home health visit, or a skilled nursing facility (SNF) stay. A “significant health problem” is any significant medical condition or disease.

For example, four methods that can be employed to organize the patient medical record and enable a caregiver to find relevant information are the following:

· Summaries: Lists can be produced summarizing clinical information for a patient, including past encounters, current medications taken by the patient, significant health problems, immunizations.

· Drill down: Patient clinical information can be organized in a hierarchical fashion, including by encounter and significant health problem, so drill down is possible to relevant documents containing that information (e.g., drill down from an encounter, perhaps after selection from a list of encounters, to a list of the medical record documents for the encounter, and drill down after selection of the document on the list to the document contents).

· Organize by type of caregiver: Categorize parts of the patient medical record so the parts relevant to a particular type of caregiver can be found (e.g., an ophthalmologist is interested in all eye problems)

· Synopses: Display a shortened, summarized, version of what happened during an encounter.

Reference [6] gives examples of possible useful ways to organize a patient medical record in a teaching hospital:

· The general internist wants a view that will help him or her manage the medical aspects of the case.

· The subspecialist’s view must contain additional details relevant to his or her special duties in a case.

· The chief resident needs additional details to support teaching during rounds.

· The intensive care nurse needs a view that embraces the care and management of the patient to whom he or she is assigned.

· The pharmacy’s view supports patient medication, including medication history and patient response to drugs.

· The dietitian requires a view to support diet and nutrition control for the patient.

· The security department’s view identifies security risks or hazardous patients.

· The accounting department has a view relating to what should be charged.

· Multiple reporting views are required to prepare internal or external reports for policymakers as appropriate.

Even when clinical information in an automated patient medical record is not organized (e.g., in free text progress notes), it still can be found by information retrieval (IR). Searches for related information scattered throughout the Internet, produced by different organizations and individuals, use this approach.

5.4.1.4 Continuity and Coordination of Patient Care Among Caregivers

Patient care can be improved by a patient medical record that assists caregivers in the coordination of caregivers who see the patient. There are at least two types of continuity of care: (1) continuity of care across encounters or (2) continuity of care within an encounter.

Continuity of Care Across Encounters

Continuity of care across encounters in an HMO is generally accomplished by having each HMO member pick a primary care physician and by assignment of the patient with a care team. When the patient comes in for care, he will usually be appointed with the primary care physician or a member of the care team.

Independent of whether the patient primarily sees one caregiver, sees a care team, or sees many unaffiliated caregivers, patient care can be improved if there is better communication between the many or even the same caregiver as the caregiver(s) treat the patient across many visits and/or hospital stays. The automated patient medical record is one vehicle for improving this communication.

This requires a way of identifying all encounters that are part of the same treatment plan. Possible ways of doing this are relating encounters in the patient medical record by use of case management techniques or use of clinical pathways.

Case management involves assignment of a case manager for a set of encounters either (1) for a particular medical condition for a patient or (2) for all encounters for a high-risk patient.

A clinical pathway is a structured way to identify care activities and caregiver workflow needed to care for a patient with a particular condition or disease. Paths through a clinical pathway can be adjusted for the particular needs of an individual patient and updated as they change.

Through clinical pathways and cases, there is the potential to coordinate caregivers better within one outpatient visit, within one inpatient stay, or over any combination of inpatient stays and outpatient visits. Coordination of patient care can occur within one facility, a number of facilities, and potentially among care provided in multiple healthcare organizations. Care can be multidisciplinary, across multiple medical departments. This coordination promotes the team approach to providing patient care.

Continuity of Care within an Encounter

Continuity of care within a stay in the hospital is clearly important as many different caregivers are involved. But continuity of care also applies to a single outpatient encounter.

If a patient talks to an advice nurse over the phone to seek advice and this sets up a subsequent outpatient visit with a physician or nurse practitioner, then the physician or nurse practitioner should know everything pertinent that occurred during the advice nurse phone call. This allows the physician or nurse to prepare for the visit and to spend her time more productively with the patient.

A diagnosis for an outpatient visit is often not completed until the results of a physician order come back, for example, the results of a clinical laboratory test, an interpretation of an x-ray, or the results of a procedure. Thus care extends beyond the time of the face-to-face meeting with the patient.

An automated patient medical record that associates all these care activities with the outpatient visit provides a more complete picture of the care given than one that does not.

5.4.1.5 Automated Assistance to the Caregiver in Providing Care

With the automation of the patient medical record, information that is input to the patient medical record can be validated as it is input. Consistent terminology could be checked for and enforced as it is input by the caregiver. Legibility of information is guaranteed.

With automated system ordering, tests can be ordered much more quickly than with a physician order sheet that is on paper. Orders and results would be automatically and immediately recorded in the patient medical record. The caregiver could be immediately informed of abnormal, STAT or panic results.

“Clinical checking” of medication orders can be done by the automated system as the order is input, including checking for wrong doses, wrong choices, wrong techniques, delays, known allergies, missed doses, wrong drugs, drug-drug interactions, wrong frequencies, and wrong routes. Prescriptions can be printed so mistakes due to poor handwriting and similarly named medications can be avoided. And ordered medications can be checked against the diagnosis—A report from the National Academy of Sciences’ Institute of Medicine estimated that 44,000 to 98,000 people die annually due to mistakes by medical personnel, mainly in improper ordering and administration of medication [7].

The system could inform a caregiver if an “at risk” patient is not complying with a drug regimen (e.g., by not picking up a prescribed medication or by not ordering refills within a specified time period) [8]. The system could inform the caregiver if the patient fails to keep important appointments or does not show up for an important diagnostic test.

The system could inform a caregiver of trends in the patient’s health based upon measurements taken over a period of time (e.g., increase in blood pressure over time).

The automated patient medical record system could record actual outcomes of treatments. Measuring outcomes based upon treatments is a way of evaluating treatments and from the results of these evaluations, determining future clinical practice guidelines for care of HMO patients. Guidelines that are based upon the best current scientific research, that produce the best outcomes, are called best practice guidelines. Use of the best treatments and practices for diseases that produce the best outcomes for the least cost as determined by the best scientific evidence is called evidence-based medicine.

The Agency for Health Care Policy and Research (AHCPR), a government agency, has established a National Guideline Database of clinical practice guidelines for treatment of a number of medical conditions in association with private and public healthcare organizations based upon the best available scientific evidence [9]. AHCPR guidelines exist for the medical conditions listed in figure 5.4.

Figure 5.4—Existing AHCPR Clinical Practice Guidelines

Number	Description
1	acute pain management
2	urinary incontinence in adults