8. Anticipated Future Use of the
Automated Patient Medical Record System
8.1 Project
Context: Describing the Future Environment and Systems
Projecting the future environment and systems after completion of the project is important for the following reasons: (1) The future environment and systems description is important in clarifying how the project results will eventually be used--This is particularly important for upper management to provide input into the future environment. (2) The future environment and systems description could be used to generate additional business requirements. (3) The future environment and systems could be used to identify new automated systems and changes to current ones. (4) The future environment and systems could provide input for reengineering the organization and definition of user interfaces. See figure 8.1.
This chapter gives an example of the results of determining the future environment and systems for the automated patient medical record system. Additional business requirements derived from the projection of the future environment and systems are listed in section 8.4.
Although the automated patient medical record helps phyisicians, nurses and other caregiver do their jobs, the real context should be on how the automated patient medical record helps patients.
8.2 Projected Future Use of the Automated
Patient Medical Record System
The following identifies one approach to use of an automated patient medical record, where the approach might be defined after discussions between HMO management, HMO staff and industry experts with the facilitation of business analysts, based upon business requirements determined so far. From this analysis additional business requirements for the project could be determined.
8.2.1 Overview of Changes
The automated patient medical record system presents a complete record of clinical information for patients in the HMO available at any time to all caregivers in the HMO, and has the potential of providing a universal patient health record.
The automated patient medical record system enables
· selection of the patient
· presentation of a quick overview of the patient’s health problems, current medication and previous encounters
· display and information retrieval of all the documents in the patient’s chart
· quick caregiver ordering, electronically sending of the order to an ancillary department and quick return of results
· appointment making
· input of documentation to be included in the chart, including e-mail.
The following additional features are provided if HMO caregivers make an effort to input information that is not collected in the current system:
· allow all those caring for the patient to quickly track the patient’s current treatments that span over multiple visits through defined outcome cases and chronic care management cases
· allow a case manager to record, evaluate, and manage care given to a high-risk patient (e.g., the frail elderly, patients with severe kidney disease, etc.)
· allow those caring for a patient to quickly access all the clinical information related to a particular health problem of a patient (e.g., all clinical information in the care for diabetes)
· allow all those caring for a patient to get a quick summary of each patient encounter
· allow the automated patient medical record system to automatically schedule preventive care for a member when required by age, health and sex and other guidelines by sending out letters in coordination with the appointment system requesting the patient to call in to make a specific type of preventive health care appointment through “life care paths”. A complete social, family, environmental and genetic history developed for the member could be used to identify members who have a propensity for a disease for which preventative care would be appropriate.
The following sections propose a list of duties of all caregivers which would organize the automated patient medical record and enable these additional features. See figure 8.2.
8.2.1.1 Extra Information Required for HMO Members
Soon after a new member joins the HMO and upon an outreach campaign for current HMO members, the HMO could invite each member in for an interview or could somehow have each member fill out a health questionnaire.
From this information, information for a summarization of the patient’s health, the “Overall Clinical Summary” could be created. When a member is new to the HMO or is a low utilizer, this information in the patient’s Overall Clinical Summary might be the only clinical information available. This information would be particularly significant for an unconscious or uncommunicative patient in the emergency department.
The questionnaire could also be used to start a ongoing social, family, environment and genetic history that could be added to and updated over time.
Based upon sex, age and health factors determined from the questionnaire, all new members could be assigned a life care path identifying preventive health care to be automatically scheduled for the patient by the automated system for the patient. This would send out letters requesting that the patient come in for a specific type of preventive health care (e.g., blood pressure check, sigmoid, etc.) The letter could be sent out in coordination with the appointment system to insure availability of appointment time. Determination of timing could also be based upon health information recorded in the automated patient medical record.
For patients who have reached a certain age or patients who have health concerns that indicate the possibility of future health problems, a “trend document” could be set up. For example, a member with borderline high blood pressure may be assigned a trend document for tracking blood pressure.
From the new member interview or questionnaire, very high-risk patients (e.g., needs custodial care, has life threatening diabetes, etc.) could be identified. Such a patient could be assigned a case manager to oversee his/her condition with the medical condition being recorded in the automated patient medical record through patient case documentation. If the patient has lower risk but significant and reoccurring health problems—the significant health problem could be recorded (and thus be available within the clinical summary) and identified as stable, not requiring a case manager.
8.2.1.2 Extra Information Required During Patient Visits
Whenever a member comes in for a visit due to a health complaint, the visit may involve a problem that could be handled in a single visit, it may involve a treatment over a number of visits, perhaps including inpatient stays, or it may involve a chronic disease which requires continuing long term care.
Defined Outcome Cases
As part of the outpatient appointment or inpatient stay, it would be determined if a defined outcome case going beyond the single appointment or inpatient stay needs to be established; if so, a clinical pathway/defined outcome case based upon the health problem would be established along with a recording of it as an “active” defined outcome case. If the treatment was completed, the case would be removed as a active defined outcome case. Over time, the defined outcome case could involve multiple encounters, either outpatient or inpatient encounters, or both, and involve care both inside and outside the healthcare organization. Treatment notes could be recorded as part of the defined outcome case. Trend documents could also be started.
Caregivers should make a significant effort to identify when a defined outcome case is no longer needed, so the defined outcome case can be made inactive. The automated system could also employ automated approaches to doing this inactivation of defined outcome cases also.
High-Risk Patients
Upon calling in or coming in, a patient could be assigned a case manager if it is now deemed that the patient is a high-risk patient. The encounter could be identified as being related to a particular significant health problem, with the possible identification of a new significant health problem. The patient could be identified as high risk due to a specific chronic condition, in which case the patient may be assigned a “chronic care management case”, tracking care for the chronic condition.
8.2.1.3 Improvements in Care from this Extra Information
Whenever a member comes in for a visit due to a health complaint, the visit may involve a problem that is handled in a single visit, it may involve a treatment over a number of visits, perhaps including inpatient stays, or it may involve a chronic condition.
What this process does is the following:
· It provides a summary of the health of each HMO member, including those who will seldom come in, thus always insuring that health information is always available (e.g., later in an emergency department)
· It establishes a defined outcome case to track a treatment, making the current treatment clear to all caregivers seeing the patient
· It may establish a chronic care management case for a high risk patient with a chronic condition
· It organizes encounters by significant health problems, allowing encounters to be associated with a particular health problem, thus allowing the encounters to later be easily found upon caregiver selection of the health problem
· It allows a caregiver, through encounter synopses, to quickly review the patient’s previous encounters
· It enables all caregivers, including advice nurses, to be aware of current defined outcome cases and chronic care management cases and to be aware of caregivers who are seeing the patient for these cases
· It enables an automated system to automatically schedule patients for preventive care
· It assigns case managers to high risk patients so case managers could assist such patients
· It allows caregivers to identify persistent and reoccurring patient health problems, including those where the patient could benefit from health education.
· Through a complete social, family, environmental and genetic history, it may identify diseases for which the patient has a propensity of developing.
8.2.1.4 Controlled Access to the Automated Patient Medical Record
Because giving the paper medical record to one practitioner would make it unavailable to others and because the paper medical record could easily get lost, it is best to limit access only to a physician or other practitioner who is seeing the patient or who is refilling the patient’s prescription. An automated patient medical record does not face these same restrictions of the paper medical record.
An automated patient medical record cannot get lost. It can be available to multiple caregivers at the same time. Because of this, the automated patient medical record could now potentially be available to a much wider variety of caregivers without the fear that it would get lost or not be available when really needed.
This availability of the patient medical record has the potential of improving medical care for a patient, but makes greater the risk of unauthorized access to sensitive patient information.
Access to the automated patient medical record still is governed by the same laws and restrictions of the paper medical record. These include federal and state laws, rules of regulatory bodies, and HMO rules and protocols.
Currently, the paper patient medical record is singularly available to practitioners: physicians, or nurse practitioners, physician assistants and nurses with the supervision of a physician. With the automated patient medical record, availability could be extended to new types of caregivers and to multiple caregivers at the same time. These new types of caregivers who might now have the patient medical record could include advice nurses talking to the patient on the telephone, pharmacists reviewing dispensed medications, case managers, those caregivers interpreting results of tests or procedures (for example, x-rays or pulmonary function tests), and others.
Even physicians may not have total access to a patient’s medical record. For example, depending upon HMO rules and protocols, psychiatric and genetic medical information may not be available to physicians outside these respective departments. Emergency department physicians would make a case that the total of patient medical information should be available to them.
Rules and restrictions on access to the patient medical record must be established for each of these types of caregivers. Rules and restrictions must also be established on concurrent access and concurrent updating of the automated patient medical record by multiple caregivers.
8.2.1.5 Patient-Centered Care
Care should be personalized for the patient. Provider instructions should be in the patient’s language and patients should be encouraged to have family members participate in the patient’s care, as both these things foster greater compliance of the patient with a physician’s instructions. A post visit report in the language of the patient after an outpatient visit is proposed. This is described further in section 8.3.2.
Family participation in the care of a patient applies both for inpatients and outpatients. As an outpatient, if the patient desires, family members could be involved in receipt of the outpatient physician’s instructions to the patient, thereafter supporting the patient in following the instructions. For inpatients, a close family member may be able to stay at the hospital to assist and provide emotional support for the patient and provide medical staff with information that the patient may find it difficult to convey because of his or her medical condition. For all inpatients, including a patient without a family, a Patient Representative or Clinical Social Worker could be assigned to assist the patient, in particular advising the patient on available patient services within the hospital or upon discharge.
The patient should be recognized as an individual, different from other patients. A personal profile is proposed, which identifies the patient’s description of herself or himself (e.g., a mother, having diabetes, with 3 children, Karol, John and Susan) together with a description of special care being given (e.g., assigned to case manager of Ellie Nelsen, CSW). A personal profile could provide caregivers with quick useful information about the patient.
For a patient with one or more major medical conditions, this might include the patient’s major ailments also within the patient’s medical record, but it would also need to include other patient information.
For example, the patient’s personal profile might also include the following:
· patient’s name
· whether the patient is male or female
· age (derived from date of birth)
· the major relatives (e.g., children, wife’s name, husband’s name)--pointing to another patient (member) profile.
But to be useful, the profile should be constantly changing to fit changes in the life and health of the patient.
One possibility is to have the patient create his personal profile and have the patient periodically update it.
Examples of personal profiles are the following:
Jay Leeds
53 year old male
Wife Sally Leeds, a paraplegic
No children
Prostate problems, BPH
Seeing a urologist
Old left leg fracture
Sulfa allergy
and
Lynne Spencer
Prefers to be called “Mrs. Spencer”
42 year old female
Husband John has diabetes
2 Children
Jane
Kelly
No significant medical problems.
A personal profile could enable transfer over to another personal profile or a telephone transfer to a clinical department. For example, the personal profile for a husband (John), wife (Sally) or child of a patient (Kelly) could be accessible from the personal profile of the patient by selecting the husband, wife or child name line respectively. Selecting a specialist (e.g., urologist) could do a telephone transfer over to the department of urology.
When a patient calls in to an appointment clerk and wanted to get an appointment for her daughter, this personal profile transfer capability would allow the booking operation to be quickly switched over to the patient’s daughter. When a patient calls in to an appointment clerk and is being seen in a specialty department (e.g., urology), this personal profile transfer capability would allow the patient phone call to be transferred quickly over to the specialty department.
8.2.2 New Members
When there is a new HMO member, he will be asked to come into the HMO facility that he expects to visit most often. When arriving at the HMO he will be directed to a new member’s area. There, the following will happen:
· The member will be assigned a healthcare service representative, who the patient can call to serve as an ombudsman and inform the member above his benefits.
· The member will be assigned a life care path, identifying preventive care appointments, based upon his age, sex and current health.
· The member will be given the choice of physicians and nurse practitioners in primary care who would be assigned as the patient’s principal primary care provider(s), either in family practice, internal medicine, or pediatrics, based upon his age.
· A woman will be given the choice of a physician or nurse practitioner who would be assigned to provide the bulk of any future care for the patient in family practice or Gynecology.
· The member will be asked “What do you want known about you, which should include your name, age, children, husband/wife, and may include major problems, etc.--anything brief and substantive?” This would be used to create an initial personal profile. This information will be used locally only and will not be given to anyone outside the HMO.
· A picture will be taken to be included in the patient clinical summary to insure against fraudulent use of an HMO identification card and resultant inaccuracy of information in the patient’s medical record.
The new member will be interviewed by a medical professional to evaluate existing health problems. Significant health problems will be recorded for input into the automated patient medical record system for the Clinical Summary. If it is determined that the member would be a “high risk” patient, then the member would be assigned a case manager.
Note that the automated patient medical record system upon identifying that there is a new member will request that all patient medical record information from outside the HMO be transferred to the HMO from outside CPR repositories and source document repositories.
Based upon the patient’s existing medical conditions and interest in medical information, a new member can pick his or her level of interest in medication information:
1. doctor’s opinions only: The member is only interested in receiving medical information from the doctor during the time of the visit.
2. preceding conditions and risk factors that increase the probabilities of a future condition occurring, and preventives for the future condition: The member is interested in the probabilities of certain diseases, conditions or situations occurring based upon preceding conditions and risk factors. For example, preceding conditions for knee replacements may be a severe knee injury, crepitus and cartilage tears. A risk factor increasing the chance of lung cancer is smoking; a preventative is to stop smoking.
3. health education classes: The member may be interested in health education courses in the future.
4. mentor program: The member may be interested in talking to other members with particular medical conditions who have had a particular treatment or procedure who will discuss the positives and negatives of the treatment or procedure (e.g., knee or hip replacement) with the member. See section 8.3.4.
5. medical research: The member may be interested in talking to employees of the HMO doing medical research on particular conditions or procedures (e.g., psoriasis).
After any visit, the member can update this information.
8.2.3 Internet Access to Members, Employers and Caregivers
The Internet will provide access to members, employers who have employees as HMO members, and HMO caregivers. In order to access information, the member, employer or caregiver must enter his PIN number.
HMO members will be able to get the following information, and perform the following activities through the Internet:
· get information on benefits
· get information on the patient’s healthcare service representative, assigned providers or case manager
· make appointments
· get a list of health care facilities and providers based upon entered zip code
· get information on providers who could potentially be assigned with the patient (e.g., biographies)
· select primary care and other providers to be assigned to the patient based upon characteristics (e.g., locations, sex, subspecialties, works on Saturday or Sunday, minimum and maximum years of experience, languages, affiliations, etc.) with identification of the most important characteristics
· send comments to the HMO
· enter periodic patient clinical values for trend documents (e.g., the patient’s blood pressure, blood glucose levels, height or weight)
· get information on preventive care recommendations by sex and age
· get information on the latest treatments, including alternative medical care provided by the HMO
· get multi-media explanations of health problems (e.g., asthma--showing animated diagrams of breathing, showing the constriction of breathing and build of mucous associated with asthma and showing how the lungs function normally and with asthma. [1])
· start chat rooms with psychiatrists and other medical providers and send e-mail for medical advice to nurse practitioners
· get information on the medical center layouts.
8.2.4 Healthcare Service Representatives
At any time, the member will be able to contact via telephone a healthcare service representative. During the day, the patient should normally be able to directly contact the healthcare service representative assigned to him. The healthcare service representative will provide the member with guidance through the health care system, especially as related to the member’s normal facility. She will be able to contact physicians, nurses and other HMO personal directly. She will be able to give advice on benefits, treatment options, providers to be assigned to the patient, and any other information that is also available to the patient through the Internet as mentioned in section 8.2.3. The healthcare service representative will also have all the capabilities of an appointment clerk as identified below, although she should normally have the patient call an appointment clerk to perform this function.
In areas of the nation where an HMO has a significant number of members from a non-English speaking community, the assigned Health Service Representative should be able to speak the preferred language of such a member.
The healthcare service representative will have available to her through the automated patient medical record system, the ability to identify providers who could be assigned to the patient, to identify referrals and active cases for the patient. She will be able to create and add to “Patient Lists”, call-back lists with comments about the member.
Healthcare service representatives from one facility should work closely with healthcare service representatives in other facilities. The member should be introduced to and transferred to a specific healthcare service representative in another facility when the patient also uses the other facility regularly (e.g., a facility near work, whereas the member’s normal facility is near home) or when the member wants to get information on caregivers in the other facility who could see the member to give a second opinion on a health concern.
8.2.5 Appointment Clerks, Advice Nurses and Call Centers
At any time, the member will be able to call a phone number that advises the member to call 911 for emergencies, asks the patient for his/her patient identifier, and allows touch-tone access, or, in the future, automated speech recognition (ASR) access [2], to the following choices:
· an appointment clerk to make an appointment
· an advice nurse to get medical advice
· an automated prescription number to refill prescriptions
· an automated cancellation number to cancel appointments
· an automated system to book some categories of appointments, and cancel and reschedule previously scheduled appointments.
For a patient with a high priority defined outcome case or chronic care management case, the automated system will automatically transfer over the call to an advice nurse, with potential of transferring over calls for some patient’s to the member’s case manager if the case manager is available.
Any member who feels intimidated by the touch-tone phone system could be given the option to call his or her healthcare service representative rather than go through the touch-tone or voice system. This is particularly important for frail and elderly members who may not be sick enough to be assigned a full time case manager but who might sometimes need immediate service or need more explanation than a touch-tone system could provide.
A further analysis will be done to determine whether appointment clerks, advice nurses or both should be located in call centers or in HMO facilities. Putting advice nurses in local facilities would simplify messaging between the advice nurses and local physicians, and make use of facility knowledge, such as the current unavailability of a physician. On the other hand, putting advice and appointment clerks in a call center would potentially decrease telephone call wait times and queue sizes.
Computer telephony integration (CTI), hardware and software that enables a computer to support a call center, provides capabilities for touch-tone and other control of incoming phone calls, for directing of calls (say to the longest waiting appointment clerk or advice nurse, or to a case manager), and for possible member input of a member’s patient identifier or desired facility or department (e.g., Pediatrics, Medicine, Gynecology). Additionally, the transfer of the call to the appointment clerk, advice nurse or case manager could include the popping up of a computer screen containing member entered information.
The HMO appointment clerk and advice nurse will function following HMO established protocols for each.
The call center appointment clerk will
· through the automated patient medical record system, identify case managers, providers assigned to the patient, referrals and active defined outcome cases and chronic care management cases for the patient; receive any alerts or alarms for the patient that are relevant to the appointment clerk
· help the patient choose or change assigned primary care and other providers, if the patient wants one and does not have one
· identify the reason or chief complaint related to the appointment
· transfer the patient’s call to the refill phone if a patient prefers to refill appointments this way; otherwise, transfers refills to an advice nurse or pharmacist
· transfer a patient over to his/her case manager
· transfer the patient’s call on a priority basis to an advice nurse if there is detected a medical urgency to the call, in particular if there is a “red flag” word such as “chest pain”
· transfer the patient’s call to an advice nurse if the member expressed any question at all about the medical need for an appointment and wants to talk to the advice nurse
· transfer the patient’s call to a healthcare service representative if there is a question about the benefits coverage for the patient and the patient is concerned about possibly paying an extra amount or if the patient needs guidance through the healthcare system, especially as related to the facility where the patient normally comes for medical care
· book an appointment for health education or initiate a tape on a specific medical area that the patient wants to learn more about (e.g., menopause, hypertension, mammography, sore throat, smoking cessation, etc.)
· book a same day or next day urgent care appointment as long as there is time within a schedule, ideally with a patient’s assigned provider; if none is available, follow protocol for booking or transfer the patient over to an advice nurse
· transfer the patient over to the correct facility department upon a referral; using a list of displayed patient referrals, the automated system should allow selection of the referral to transfer the call to the correct department’s appointment phone
· for a follow-on appointment associated with an active defined outcome case or chronic care management case, the automated system would provide a list of such cases for the patient from which the appointment clerk could select (see figure 12.20); from the case document selected, the appointment clerk could transfer the patient to the appointment phone for that case by a click of a “transfer” button (see figure 12.21); if the appointment clerk is unable to determine the case, the call should be transferred to an advice nurse
· cancel, and reschedule, appointments when requested; if an appointment is marked as part of a defined outcome case or chronic care management case and is thus a type of appointment that requires special consideration when canceling, transfer the patient to an advice nurse
· book a future routine appointment, especially one related to preventive health care generated by a life care path or an appointment in alternative medicine
· transfer the patient’s telephone call to an advice nurse, sending her a message, for advice, allowed member-initiated lab tests, etc., perhaps generated from a pre-formatted message
· view a call history for the member
· schedule allowed member initiated lab tests (for example, as allowed by California law, such as pregnancy, glucose, cholesterol and occult blood colorectal cancer tests) or just inform the member to drop in to the appropriate clinic
· accept patient input of a blood pressure reading or a blood sugar reading, with the automated system verifying the validity of the inputs and recommending transfer to an advice nurse if the values are out of range (note that such inputs could automatically be transferred to a previously set up “trend document” by the automated patient medical record system)
· through a personal profile for the patient available from patient demographics, the appointment clerk can transfer to information for the patient’s husband, wife, or children and transfer the patient to any identified specialty department where the patient is receiving care (see section 8.2.2).
The appointment clerk, based upon her conversations with the patient, should advise the patient of services that are available (e.g., assignment of a principal primary care or other provider with the patient, healthcare service representative conveyance of member benefits, health education classes and health tapes, member initiated lab tests). The appointment clerk will not deal with medical decisions other than to evaluate the member’s certainty of needing an appointment or, on the other hand, of determining if the patient has any medical concerns. Regarding medical concerns, the appointment clerk should take special note of whether the patient questions to come in immediately or not. She should listen for any “red flag” words, such as “chest pain”. Any such uncertainty or questions should result in the appointment clerk advising the member to talk to an advice nurse. Otherwise, in general, if the patient wants an appointment, the appointment clerk should attempt to find an appointment for the patient.
The call center advice nurse will be able to do the following:
· do anything the appointment clerk can do
· have controlled access to the automated patient medical record which may include the overall clinical summary (including assigned providers, active defined outcome cases and chronic care management cases, referrals, current medications, and lab test results) and the documents in the patient medical record; and through the automated patient medical record system, document all conversations with the member for inclusion in the automated patient medical record
· create personal Patient Lists, in particular to list patients to later call back
· give the patient medical advice based upon HMO protocols for the patient’s complaint
· view on-line medical references through the automated patient medical record system
· handle refill of medications (medications where the number of refills identified on the previous prescription has run out and where the prescription must be re-approved by a physician or nurse practitioner to continue)
· contact an on-call physician to get further medical advice
· contact an on-call pharmacist to get further advice on medications
· call physicians, nurses of physicians, or others in the call center directly or send messages to them (via a messaging system such is described in section 7.7.3)
· make all appointments, including when there is no available time in the physician’s schedule, based upon physician or HMO protocols, or contact appointment clerks associated with specialty areas to make the appointments
· for a follow-on appointment that the patient wants canceled and that the automated system marks as requiring special consideration when canceling, take efforts to reschedule or contact a specialist physician or primary care provider to determine if the appointment can be canceled without rescheduling
· make referrals to specialists based upon protocol
· give the member lab test results if allowed by protocol; otherwise, transfer patient to physician or send message to physician to return lab test results
· be aware of experimental programs and alternative medicine, and understand when they are appropriate.
With the optional recording of calls on the patient medical record together with the actions taken or to be taken as a result of the call, the advice nurse will be able to immediately upon the follow-on call identify situations where patient care has been delayed. Further, through a messaging system, the automated patient medical record system could require a follow-up action within an identified period of time, with the messaging system informing the advice nurse if that action has not been taken.
A team of advice nurses could be associated with a facility, whether they are located at the facility or at a centralized call center, and assist caregivers at the facility and their nurses with care of their patients. An advice nurse could, for example, convey important care information personally to a physician or the physician’s nurse within the facility, later returning a call to the patient. When located in a call center, the advice nurses could also serve as a resource providing information on the facility caregivers to other advice nurses in the call center.
Through the automated patient medical record system, an advice nurse should be able to document her conversations with a patient and include this in the patient medical record. Calls should be tracked and also recorded in the patient medical record.
With the availability of a complete automated patient medical record for each member calling in, a physician could also serve in the call center, providing consultative support to the advice nurses, providing expert medical advice to a member who does not require an in-person outpatient visit, or providing advice to a member on whether or not the member should come in to the clinic or to the ED.
Other participants in the call center could include pharmacists, who could provide medication advice, refill an existing prescription, issue “grace” refills on most drugs, or discuss drug reactions with the patient. The availability of the patient chart would be useful here also.
For certain sections of the U. S., touch-tone access should be provided for non-English speakers (e.g., in Spanish and Chinese). For such communities of foreign speakers, there should also be both healthcare service representatives and advice nurses, and possibly appointment clerks, who speak these languages. Additionally, translators during the time of the visit should be even more widely available; when there are few members of a language group, use of a family member to translate may be appropriate. Additionally, AT&T provides telephone translation services that could be used. In all cases, HMO personnel should be trained to be culturally sensitive.
To enable caregiver communication such as between the appointment clerk and advice nurse, the advice nurse and physicians and nurses in the unit, a caregiver messaging system such as described in section 6.7.3 should be available. This messaging system would enable messages to be sent from the “initiating caregiver” (e.g., the advice nurse) to the receiver caregiver (e.g., the patient’s physician) and for the “receiver caregiver” to respond with the response optionally sent to a “responding caregiver” (e.g., a nurse working with the physician), who calls back the patient. The message could be marked as “closed out”. The message could be assigned an “importance level” or priority identifying the maximum length of time before the message should be closed out. The various caregivers could be informed when a new message is received and when a message has not be closed out in the prerequisite time.
CTI enables telephone calls from patients to an HMO to be directed to a category of caregivers (e.g., an advice nurse or appointment clerk); this capability should also be supported for e-mails. For example, a patient might send an e-mail with a health question to an advice nurse, which could be answered by any available advice nurse. A re-fill request could be sent to the patient’s personal physician who could approve it and send it to a pharmacy. Such e-mails are most easily handled through the Internet, which would tack on the correct category or recipients, rather than having a patient do this himself or herself.
8.2.6 Primary Care Physicians and Nurse Practitioners, and Associated Care Teams
In an ideal situation, a primary care physician or nurse practitioner is assigned to each patient with the physician or nurse practitioner providing the bulk of primary care to the patient. Primary care physicians and nurse practitioners may be in internal medicine, pediatrics, family practice, and gynecology. Primary care physicians and nurse practitioners work together with nurses, medical assistants, and others in the department in formal or informal care teams.
With the automated patient medical record, a physician will be able to immediately view any part of a patient’s medical record that the physician has the authority to view (e.g., this may exclude psychiatric and genetics parts of a patient’s medical record). In addition to enabling a physician to always have the patient medical record at the time of an appointment, this will enable a physician to look at the patient medical record prior to drop-in visits, quickly respond to communications from advice nurses and case managers, and quickly evaluate prescription refill requests. This makes unscheduled and ad hoc telephone visits or consultations with the patient now feasible, whereas this was previously only possible with appointed visits or telephone contacts appearing on the provider’s schedule, where the patient’s medical record could be preordered. It makes consultations with specialists easier as both the primary care physician and specialist will concurrently have the patient’s medical record. And it makes telemedicine more feasible, with the caregiver seeing the patient having the patient medical record while a remote physician or nurse practitioner would also have the patient medical record. Patient medical records will no longer be fragmented and in many different places; the complete patient medical record will be available to each caregiver.
An assigned primary care physician or nurse practitioner should track the health of his/her assigned patients, communicating with the patient directly to emphasize health advice, convey important diagnoses and communicate significant diagnostic test results. The primary care physician or nurse practitioner or other caregivers in the department could set alerts or reminders to inform future caregivers at the appropriate time of special needs of the patient (e.g., sight, hearing, speech or mobility impaired), of safety or caution considerations (e.g., possible violent patient), or other matters (e.g., patient should be transferred over to a case manager upon calling in).
The primary care provider serves as the initial evaluator of what health problem ails the patient and as a gate-keeper for specialists. Further, the primary care provider provides long-term treatment for some chronic conditions, and is in charge of most types of preventive care (e.g., blood pressure checks, that might be scheduled for the patient via a letter, through a life care path).
The primary care provider could set up a trend document (e.g., to graph the patient’s blood pressure) that automatically records a reading whenever taken, with the system automatically informing caregivers to take the reading whenever the patient comes in. Additionally, the patient can be trained to call in readings to an appointment clerk or advice nurse, or to input it via the Internet. Whenever, a reading is recorded that is of concern, the primary care provider can be immediately messaged by the system.
Prior to a visit, a caregiver could get a quick overview of the patient’s medical history both by looking at the patient’s clinical summary and by scrolling through synopses of past encounters, optionally after filtering to pick out the encounters matching the medical concern of interest.
During a visit, a primary care provider uses the automated patient medical record, displaying clinical information and creating documentation for the automated patient medical record either directly through input to the computer or through forms later entered into the computer. The nurse also inputs to the patient’s medical record through the automated system, creating documentation for the automated patient medical record (e.g., a vital signs document).
If this is not an “episodic” (i.e., one-time) visit for the patient for a problem, the primary care provider may initiate a defined outcome case for continuing care.
Alternatively, the primary care provider could initiate a referral request to a specialist. If the specialist starts a defined outcome case, the automated patient medical record system could combine the referral request and encounter with the referring provider in the defined outcome case.
When the primary care provider recognizes that the patient has a chronic condition that dictates tracking of patient compliance with medications and other treatments, a chronic care management case could be established with the assignment of a case manager with immediate or future assignment of primary care or specialty care physicians, nurses, pharmacists and/or other caregivers in providing care. A significant health problem could be recorded for the patient.
Methods for use of computers during the patient interview need to be studied. An approach that allows caregiver access to the patient medical record during the patient interview is to use a pen computer during the interview. The pen computer could either be used to input informal notes and orders during the interview, which could be later read by the caregiver and input to patient chart via a desktop computer, or the pen computer could be used to directly input to the patient chart during the interview.
Through the automated patient medical record system, before and after the encounter, and depending upon the input method, possibly during the encounter, the primary care physician and nurses will have access to medical references, including those on best practice guidelines, on foreign travel disease risk and prevention from the Centers for Disease Control and Prevention (CDC), etc. If the HMO member has a recorded social, family, environmental and genetic history recorded, then this could be used to anticipate future diseases for which the patient may have a propensity to develop. “Expert systems” could be available to assist in diagnosis and preventive measures (see section 17.4.7). Other clinical decision support systems could automatically make recommendations of better practices, such as equally as effective but lower cost drugs (see section 17.4.9).
Most often best practice treatments and procedures should be followed, but the HMO should make a concerted and controlled effort to have primary care physicians also try other treatments and procedures with the consent of the patient, with the physician documenting these treatments and procedures in defined outcome cases or chronic care management cases. This insures that the HMO actively participates in the evaluation and the improvement of best practice guidelines.
Immediately after the visit, the physician instructions and orders could be printed at a nursing station for a medical assistant or nurse, who would in turn give the printout to the patient. The medical assistant would re-explain instructions and orders given to the patient during the physician interview. This would re-emphasize the physician’s care decisions. Where appropriate, family members who assist the patient in taking medications or following physician orders could be included in this review of physician orders and instructions.
Nurse practitioners and physician assistants are under the constant supervision of a physician. Having an automated patient medical record allows for “concurrent review” by a supervising physician of the care being given by the nurse practitioner or physician assistant, where “concurrent review” means “the investigation of patient care while it is in progress, with the intention of modifying that care if appropriate”. In fact, both the physician and nurse practitioner or physician assistant could be viewing a patient’s chart at the same time, despite being in different locations.
The nurse taking vital signs and the physician examining the patient currently use vital sign, history and physical, and progress note document forms on a clipboard. When this process is computerized, the ideal computer would be a lightweight wireless handheld computer that would not get in the way of patient care and that could substitute for the documents and clipboard. Since a keyboard is impractical for a handheld computer, what fits this description is a tablet computer, a pen computer with a document size screen. For such a tablet computer, entrance of information might best be accomplished through selection of templates and selection from drop down lists (see section 6.7.1, Documenting Patient Care) as input of textual information is slower on a pen computer. A nurse could be entering vital signs for a patient at the same time a physician is reviewing the chart and entering information in the chart; therefore, concurrent entrance of information in the automated patient medical record at the same time should be allowed. Alternatively, the nurse and physician could successively share the same computer, with the two accessing the same patient’s automated medical record; thus quick turnaround without a lengthy log-off and log-on process is required. Response time should be quick, perhaps within ½ second. When the computer is turned off, data entered must still be there.
Use of computers when examining or interviewing the patient is referred to as “point-of-care” computing. Other computing involving display or updates to the automated patient medical record when there is no direct patient contact happening at the same time is best done on a desk top computer with a typewriter style keyboard and large screen, rather than pen computer. Also, portable computers of any kind, including pen computers, may not be appropriate in any situation when the caregiver has to carry a lot of other equipment around (e.g., a respiratory therapist and many nurses).
Orders for the patient could be sent immediately to the pharmacy and ancillary departments through the automated system, recording them in the medical record. When the caregiver enters an order it would be immediately checked for correctness. More appropriate medications, test or procedures could be suggested. clinical checking of a medication order with other prescribed medications could be done to verify that would be no drug/drug interactions.
Medication orders could be sent directly to an HMO pharmacy, say with a pick-up number being returned at the time of the order. When the patient came to the pharmacy, there would be less, or no, waiting time for the medication (note: this may however result in more medications being returned to stock however).
When results of clinical laboratory tests came back, the caregiver could be informed of results by the automated patient medical record system. An alarm would come back to the caregiver or his care team when the results were abnormal or corresponded to STAT orders. The automated patient medical record system could also assist the caregiver in informing the patient of results. For example, it could
· automatically send letters to patients to inform them of normal results, perhaps giving the patient a number for an advice nurse to discuss the results
· specifically inform the caregiver, so the caregiver or his nurse can call the patient to report abnormal results and record in the medical record that he or she did so.
Many activities of a primary care physician, nurse practitioner, physician assistant or other primary care caregiver do not involve direct contact with patients, but handling communications from other caregivers, from the call center, from automated re-fill lines, and directly from the patient via telephone calls or e-mail; and communications to patients and other caregivers, such as results reporting, opening up schedule time, consulting with or supervising other caregivers, approving re-fills, and giving advice. A messaging system that combines, but also segregates, clinical messages, e-mails, orders, orders with results, and orders pending results, would assist this process. A caregiver could send out a clinical message or e-mail; an order made by the caregiver would be automatically recorded as a message that both the caregiver and his or her care team could view. A caregiver could receive and look at messages for the caregiver, for the caregiver’s care team(s), or messages for the entire nursing unit. The requirements for such a messaging system were discussed previously in section 7.7.3.
For example, the primary care physician or nurse practitioner could receive clinical messages from the call center regarding a patient (for example, a message indicating that the physician’s schedule is full but that a patient may need to be seen soon, that a patient wants a medication refill, etc.) The caregiver could respond to the message and close it out, or respond and send it to another caregiver to call back the patient, who would then close out the message. Messages that are not closed out in a the required period of time, say based upon priority, could be redirected to other caregivers; when the primary care physician or nurse practitioner is unavailable, their messages could be redirected to other caregivers.
The primary care provider could identify to the automated system that he or she be informed about the care activities of specific patients or of specific types of critical care activities. Also, the provider can request to be informed of curtailment of care by the patient, so that the caregiver could insure that the treatment is not curtailed. For example, the automated patient medical record system might be designed to automatically inform a primary care physician or nurse practitioner when a patient on his/her panel enters the Emergency Department or is admitted to the hospital.
The primary care provider could get a list of a specific type of patient on his/her panel. For example, he should be able to identify all patients with diabetes or all patients over 70, so he could, for example, send out tailored outreach letters.
As mentioned in section 8.2.1, the automated patient medical record system, say through critical pathways documents, could automatically send out preventive health letters for sigmoids, blood pressure checks, pap smears, etc. The primary care provider might have the capability to schedule additional preventative health letters. (Such letters, where appropriate, could be sent out in coordination with the appointment scheduling system when the preventative health measure requires an appointment.)
A paradigm is an original pattern or model of which all things of the same type are representations or copies. This section and the next assume the current paradigm for outpatient care described in section 8.4 and figure 8.3-1. Other proposed future paradigms for outpatient care are also presented in section 8.4.
8.2.7 Specialty Care Physicians and Nurse Practitioners, and Associated Care Teams
Referrals are made to specialty departments by primary care physicians, nurse practitioners, and advice nurses, who determine that the patient needs specialty care. Upon determining that there is indeed a problem, the specialty provider seeing the patient could initiate a defined outcome case including the referral. The initial defined outcome case would identify the initial treatment plan, expected outcomes of the provider and patient, case managers, the care team, and an appointment clerk for the specialty department. Optionally, a clinical pathway could be associated with the defined outcome case and/or a trend document could be created (e.g., a trend document collecting photographs of both eyes for a patient with macular degeneration in order to track the progress of the problem, or collecting x-rays of a patient’s knee with degenerative osteoarthritis over time to evaluate the progress of the disease).
Also primary care physicians regularly consult with specialty care physicians, often via direct physician to physician contacts via telephone. With an automated patient medical record, the primary care physician and the specialty care physician can simultaneously access the patient medical record during the conversation, as opposed to the paper medical record where only one can have access.
A formal or informal care team for specialty care physicians could consist of other specialty area physicians, nurse practitioners, nurses, medical assistants, receptionists, appointment clerks, and others in the specialty department. Physicians could have sub-specialties (e.g., a retinal expert in the ophthalmology department).
An agent could be set up by the specialty department that could be initiated automatically when any patient appointment is made with a specialist in the department, with the agent collecting patient chart information for all previous encounters associated specifically with the specialty area and organizing the information in a form useful for the specialist; this could supplement other information in the patient’s medical record. Prior to the visit, the caregiver could get a summary of the patient’s medical history by looking at the patient’s clinical summary and scanning through synopses of encounters pertinent to the appointment.
Upon seeing a patient, the specialist documents care either through a computer using the automated patient medical record system or on a form whose information is later transferred to the automated patient medical record system. Upon seeing a patient as part of a defined outcome case, the treatment plan could be optionally changed, treatment notes could be added, the clinical pathway could be followed or changed, or information could be added to the trend document.
A specialist seeing the patient must identify the completion of a defined outcome case. Later, a quality manager could evaluate actual outcomes of the treatment by contacting and interviewing the patient.
Specialists could also be involved in the long term treatment of a chronic condition using a chronic care management case. A chronic care management case is particularly suited for the periodic scheduling of telephone “visits” between the patient and caregiver. Telephone visits becomes more feasible with the automated patient medical record always being immediately available to the caregiver. This may be better for patient and more convenient for the patient, as well as almost always being more cost effective for the HMO than return visits in the clinic.
For conditions of a significant magnitude, a specialty care team could be assigned to the patient through the defined outcome or chronic care management case with a designated case manager who has responsibility for insuring that a patient comes in for care. By there being a defined outcome or chronic care management case identified with a specific medication condition, advice nurses in the call center would know to transfer patient phone calls for the identified medical condition to the specialty department, using a telephone number in the defined outcome or chronic care management case.
A life care path could send out letters advising members to make appointments for preventive care in specialty departments, for example, for a sigmoidoscopy by a gastroenterologist. (Generation of such letters based upon abnormal test results is also a possibility.)
Specialists could use the same chart input methods as for primary care physicians and nurse practitioners discussed in the previous section, for example, inputting informal interview notes to a pen computer or to forms during the interview and using the informal pen notes or forms for later input to the patient chart via a desktop computer or, alternatively, inputting directly to the patient chart via the pen computer during the interview. Like for a primary care visit, the patient could be given a printout of the visit record and orders immediately after the visit, reemphasizing care decisions made during the visit.
Orders would be sent immediately to the performing area, with the results returning back through the automated system to the caregiver. Orders could be checked, with checking for drug/drug and other interactions for medical orders. The caregiver would be alerted of results for STAT orders coming back or of abnormal results.
Specialty caregivers would also have a messaging system that could combine together or separate out e-mails, clinical messages, and orders and results. Through this system the caregiver could receive, send and display these messages.
The automated patient medical record also enables specialists to follow best practice guidelines and to do concurrent review of nurse practitioners being supervised.
All other capabilities for primary care departments would be available to a specialist department.
8.2.8 Urgent Care and Emergency Department Care Teams
Since ordering of a paper chart ahead of times is usually not feasible in the Emergency Department (ED), one the major benefits of an automated patient medical record is that it would be immediately available to the ED. The automated patient medical record also is likely to be much more complete, including information from multiple facilities and healthcare organizations. (One of the reasons for going through the clinical data collection effort of an extensive H&P in the ED is to make up for the possible lack of chart information; with existence of the automated patient medical record, this may be a less necessary step in ED care.)
Urgent care and ED physicians and nurse practitioners stabilize the patient, and possibly refer the patient to the patient’s assigned primary care provider or to a specialist. Also, like with the primary care physician or nurse practitioner, the urgent care or ED practitioner may consult directly with a specialist by telephone. Again, with an automated patient medical record, the urgent care or ED physician and the specialty care physician can simultaneously access the patient medical record during the conversation, as opposed to the paper medical record where only the urgent care or ED physician is likely to have access.
After the patient is stabilized, the ED physician may discharge the patient to the hospital and initiate a treatment plan and through the automated patient medical record system, initiating the admission process through the ADT clinical system.
Care within the ED could also potentially be vastly improved by the speed up of ordering and the receipt of results and the speed up of housekeeping notification of newly empty ED rooms to be cleaned. Clinical laboratory results could be returned to the ED physician at the instant they became available, instead of results being returned on paper, hand carried back from the laboratory. Medications can be more quickly prepared and transported to the ED. This is important, because unlike for the outpatient visit, the patient in the ED usually remains until the results of a test are received back.
The care process is speeded up but the ED triage process is also greatly speeded up, as described in section 4.3.2. As part of identification of the problem during the triage process, the system, at the approval of the triage nurse, could automatically schedule caregivers and equipment when time is critical, for example, immediately schedule an MRI.
8.2.9 Inpatient Care
Upon a patient’s admission to the hospital, the automated patient medical record system will automatically create two documents for the duration of the patient’s stay, which summarize information collected from other patient medical record documents, and which will disappear after discharge:
· Inpatient Clinical Summary: A document equivalent to the Kardex, which is a summarization document to quickly identify the current status of the inpatient and may include the following among other information:
à the patient’s name, age, sex, marital status and religion
à medical diagnoses, usually by priority
à nursing diagnoses, usually by priority
à current physician orders for medications, treatments, diet, IV’s, diagnostic tests, procedures, etc.
à consultations
à results of diagnostic tests and procedures
à permitted activities, functional limitations, assistance needed, and safety precautions
à care plan.
· Medication Administration Record (MAR): Medications the physician orders for the patient, including times and routes of administration. A nurse may record that a medication at a particular time was administered.
Information for the Inpatient Clinical Summary comes from various documents input by inpatient physicians and nurses, and unit assistants, during the stay. The MAR information comes from the medication order which was input into the automated patient medical record system by a physician, nurse or unit assistant. The medication order transmitted to the pharmacy system for fulfillment and is sent back to the automated patient medical record system to be displayed on the MAR.
(Note that the Inpatient Clinical Summary only exists during the patient’s stay and disappears at discharge--although it could be recreated. The Overall Clinical Summary, which collects information from outpatient, inpatient, ED and other documents, exists at all times for a patient and provides a more complete view of the patient’s health.)
Always available in an inpatient nursing unit (e.g., a “critical care unit”, ‘Medicine/Surgery unit”) will be a Unit Census listing all patients in the unit and their room locations. When a patient is admitted through the A