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 ADT (admission, discharge and transfer) clinical system--which would input information such as financial data, admitting and attending physician, nursing unit, room number, etc.--then ADT would pass this information to the automated patient medical record system which would update the corresponding Unit Census, putting the patient, room, physicians on the Unit Census. Transfer of a patient to another unit would update the Unit Censuses in both units.

The normal process of admission which would occur through ADT would be (1) a pre-admission through ADT during a prior outpatient visit to enter some admission information with the actual admission through ADT occurring when the patient shows up at a future date for admission to the hospital; or (2) an admission through ADT immediately following a visit to the Emergency Department.

In addition to this “normal” admission process will be a “quick admission” for situations where the patient ends up in the unit and is not yet admitted. Rather than through ADT, the quick admission will occur when the patient is put directly on the Unit Census by a nurse or unit assistant. The quick admission would be sent to the ADT system and other clinical systems. Users of the ADT system could then collect additional information to complete the admission.

Notification of admission to the unit, discharge from the hospital, and transfer to another unit is important to the automated patient medical record system and to other clinical systems (the pharmacy system, clinical laboratory system) because it locates the patient, which is necessary for ordering through those systems (e.g., the clinical laboratory system would know a patient’s unit, room and bed).

Through use of the Unit Census, nurse assignment could be automated, allowing assignment of nurses using the Unit Census. During this assignment process, the nurse supervisor doing the assignment could be presented with information from other clinical systems to assist in the assignment, such as nurse scheduling and patient acuity system information.

Upon a pre-admission, upon admission through the ED or upon a quick admission, the automated patient medical record system (via agents incorporating current HMO business policies) could automatically order patient chart information, including CPR information and source documents from multiple locations, including within the HMO and outside healthcare organizations. Source documents could include those on paper.

Physicians and nurses caring for patients and their unit assistants--including the admitting physician, attending physician, and on-call physicians and nurses, would have immediate controlled access to the patient’s medical record and could play an active role in the patient’s care no matter where he or she was physically located. With an automated patient medical record, a physician caring for patients could consult directly with a specialty care physicians, with them both having simultaneous access to the complete automated patient medical record, and again, with both being located virtually anywhere.

Access to the automated patient medical record would include the ability, if allowed for the caregiver, to order medications, clinical laboratory tests, procedures, etc. Again, the ordering of a medication would automatically add the medication to the Medication Administration Record (MAR).

With the automated patient medical record and case information, treatment of a patient could formally be viewed in a multi-disciplinary context, with care being provided across outpatient visits and inpatient stays and tracked via a defined outcome case or chronic care management case that allows collection of information across different types of encounters, both outpatient visits (in the ED, follow-up visits) and inpatient stays.

Care of an inpatient includes (1) care directly seeing the patient and (2) care not directly seeing the patient. Using computers, and an automated patient medical record system, during the former is referred to “point-of-care” computing. These situations where the patient is being seen include the following: (1) admission of the patient, especially when admitting occurs within the patient’s room or the ED, (2) during the physician’s examination and the nurse’s assessment of the patient, and (3) during the time that the nurse is recording interventions, especially when flow sheets are being used. Pen or portable computers might be appropriate for “point of care” computing.

For other situations, during the inpatient stay, the patient is not being seen. These situations include the following: physician review of the patient chart without the patient, nurse creation of care plans, nurse or unit assistant completion of chart information, ancillary department review of patient charts within the inpatient unit, and automated system notification of the patient’s discharge. In such situations, a desk top computer with a large screen and typewriter type keyboard might be a better choice.

Any nurse, physician, unit assistant or ancillary personnel input to the system, will be automatically summarized by the automated patient medical record system on the Inpatient Clinical Summary for the inpatient stay.

Upon nurse or physician notification to the automated patient medical record system of the patient’s discharge from the hospital, the automated patient medical record system could automatically inform caregivers of discharge activities to perform and/or automatically schedule discharge activities bases upon diagnoses and protocols. Examples of these activities could include system ordering of medications for use at home and scheduling of follow-up appointments.

8.2.10 Quality Managers and Medical Research Departments

Often, patient care and treatments are carried out by care teams, with care teams consisting of physicians, nurses and others, either in specialty or primary care departments. Some treatments could involve outpatient care and inpatient care and thus the care team may be a multi-disciplinary team of caregivers.

In order to evaluate care, and care given by both formal and informal care teams, an HMO quality manager or medical research department could use statistical methods to select and evaluate treatment plans as carried out by the various care teams, comparing treatment plans for similar treatments and taking into account the patient condition and other relevant factors in the evaluation of the treatment plan. Looking at defined outcome cases (and associated treatment notes, clinical pathway documents, trend documents and references to clinical practice guidelines followed) the quality manager or medical research department would compare different treatments for the same disease. Each patient’s medical record would also provide the quality manager or researcher with information to evaluate the physical condition of the patient at the start of the treatment and other factors, so these could be taken account in the evaluation of the treatment plan.

A treatment plan for a patient is evaluated by the actual outcomes of the treatment. Some groups consider outcomes to be related to the patient’s perception of his or her health after the care is finished. A good outcome occurs for a disease (e.g., knee replacement, BPH) if the patient’s perception of his quality of life is good. One method of evaluating these outcomes is a questionnaire given to a patient. SF-36 and HSQ-12 (Health Status Questionnaire 2.0) are examples of questionnaires measuring outcomes of treatments [3].

Sometimes outcomes can be directly measured. For example, the outcome of a treatment to lower a patient’s blood pressure is directly measurable. Indeed, in such a case and others, the patient may not perceive that his health has changed or improved. The outcomes of some treatments can be evaluated by statistically measurable quantities such as mortality rates (death rates), morbidity rates (those who are sick versus those who are well), returns to the hospital after treatment, and infection rates after surgery.

One HMO, Oxford Health Plans, intends to compare care teams as to success of treatments and treatment plans and to report results to patients so that future patients requiring the same type of treatment could make selections of the best care team. Evaluations of treatments by different care teams could also give the HMO information on how to improve care for various treatments, assuming the care team having the best outcomes would also have the best treatment plans, with resultant determination of “best practice guidelines”.

Together with physicians in the HMO who want to evaluate new treatments, medical researchers can develop new treatment plans, possibly embedding the treatment plan information in a clinical pathway. After completion of the new treatment, medical researchers can, through the associated defined outcome cases, compare the new treatment with existing treatments for the same health problem with consideration of the cost of the treatment.

Automation of the patient medical record also facilitates calculation of actual costs associated with various treatments.

Outcomes of long-term treatments for chronic conditions can be done with quality managers using the chronic care maintenance case in place of the defined outcome case. Outcomes of chronic care maintenance cases could involve comparing costs, quality and patient satisfaction for patients being tracked by chronic care management cases with patients with similar chronic conditions who are not being tracked; for example, patient satisfaction, patient quality of life, number and costs of hospital stays and outpatient visits, primary versus specialty care given, readmission rates, duplicated service, mortality and costs of medications could be compared.

Other duties of quality managers and personnel in associated departments could be hiring of outside organizations to evaluate individual clinicians especially after they are first hired, (1) to do credentialing and re-credentialing of physicians, nurse practitioners, and other clinicians, verifying that clinicians have the valid licenses to practice and (2) to do quality checks of healthcare organization clinicians and the care they give, “auditing” of medical records to evaluate the quality of a clinician’s care, also called “peer review” because it involves the review of medical professionals by other medical professionals. Auditing can either be done afterward the patient care is given, or while the patient care is being given--the latter is called “concurrent review”. An automated patient medical record would support auditing, supporting quick access by auditors to a patient’s medical record and supporting concurrent review, viewing a medical record at the same time care is being given to a patient.

Quality managers and related personnel also do evaluations of the overall care and cost-effective of care given in a healthcare organization to identify differences with other healthcare organizations so improvements in care can be made if necessary. This is called a “utilization review”, reviewing the necessity, quality, effectiveness, or efficiency of medical services, procedures, and facilities provided within the healthcare organization. A utilization review could be done through the automated patient medical record system by evaluating “defined outcome cases” and “chronic care management cases” with regard to the recorded outcomes and variances, and by taking statistics from available clinical data in the automated patient medical record system.

The automated patient medical record would also be of benefit to JCAHO and other healthcare regulatory agencies who do periodic quality checks of all affiliated hospitals. Besides visiting the healthcare organization, JCAHO auditors could view medical records via the automated patient medical record system, with the possibility of concurrent review of care.

An automated patient medical record would also assist in the review of rare occurrences referred to as “sentinel events” [4]. The healthcare industry equivalent of the airline industry airplane crash is a “sentinel event”. JCAHO defines a sentinel event as “an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof” occurring within a hospital or clinical setting. Examples of sentinel events are medication errors causing death, suicide of a patient, or deaths related to delay of treatment. JCAHO wants to review each sentinel event to determine what went wrong, so new regulations could be established and so healthcare organizations could learn how to prevent these sentinel events.

8.2.11 Case Managers

A case manager may be assigned to a “high risk” and “high cost” patient, such as an elderly and frail patient or a worker’s compensation patient, for overall care through a patient case. Along with physicians or nurses, a case manager may be assigned to a patient with a chronic conditions through a chronic care management case or assigned to a patient with a high cost, high risk, treatment through a defined outcome case to insure that the care is being given and to insure that the care is being followed by the patient.

The case manager may be involved in care activities in a clinical pathway document, which may or may not be part of a case document. The clinical pathway might identify care maintenance activities by the case manager or by other caregivers, and also identify what should be done by the case manager, or others, when problems occur.

The case manager might closely follow a patient’s health progress. The case manager might serve as a “go between” between the patient and caregivers and thus communicate with caregivers. When necessary, the case manager could initiate care activities, such as making appointments for the patient.

After a “high risk” or “high cost” patient is discharged from the hospital, the HMO could assign a case manager to oversee the patient’s follow-up care. The case manager could be in charge of insuring that post-hospital care activities, such as discharge to a SNF or a treatment plan that extends beyond the inpatient stay, are properly implemented or followed. Such follow-up activities could be part of a clinical pathway, possibly one extending across the hospital stay to the outpatient follow-up activities.

The identity of the case manager for a patient will appear in the automated patient medical record, specifically the overall clinical summary. This identification of the patient’s case manager to a caregiver looking at the automated patient medical record, would allow the caregiver to inform the case manager of care decisions and, if necessary, to participate in these care decisions, so the case manager could provide guidance to the patient and the caregiver on the most cost-effective care choices.

When a patient has an overall case manager, an appointment phone could automatically transfer incoming appointment calls to the patient’s case manager if the patient had one—if not answered, the call could then be transferred to an appointment clerk. This approach would insure that the case manager participated in the patient’s outpatient care decisions.

8.2.12 Home Health and Hospice

Case managers are often assigned to home health and hospice patients. Such patients often switch between home, hospice, the hospital, outpatient clinics, nursing homes, and SNFs (skilled nursing facilities). Often the person providing home nursing care for the patient is also the patient’s case manager.

Having one complete chart of all visits, home stays and inpatient stays would be beneficial medically and would be beneficial also for case management, especially to track the patient for purposes of reimbursement, especially through Medicare and Medicaid. Documentation of home visits would be greatly facilitated by the use of a mobile computer—perhaps a pen computer—to access the automated patient medical record system through a wireless network, which would allow the caregiver to quickly input and verify information.

A possible future use of computers mentioned previously is to provide the patient with a means for self-care through an Guardian Angel system. See section 5.4.3.6.

Telemedicine, with the home health nurse at the patient’s home and a consulting physician or nurse located remotely, is another future possibility given an automated patient medical record system that allows nurses and physicians to concurrently access the patient’s medical record.

8.3 Patients

8.3.1 Patient Care in Perspective

We are all patients, some of us all of the time.

Arthritis, pain, diabetes; menstrual, menopause or prostate problems; paraplegia, heart disease, the aftereffects of a stroke—these are all everyday conditions of some people, not just when they seek care.

Newborns, infants, children, and everyone, are injured some days, or are sick or just feel bad on others. Women are pregnant. People forget to take their medications or don’t remember whether they did or not. Patients—people who live life—must learn what to do when these problems and situations occur. Should they seek care or not? Can they afford to seek care?—Can they afford not to?

What can a person do today to avoid health complications later in life? What can a caregiver do? What can society do?

Patient care is as much an educational process of people in how to live their lives, than it is in alleviating or fixing acute or chronic problems. Patient care occurs all the time—Sometimes patients come in to be seen by caregivers.

For a caregiver, patient care is giving the patient exactly what the patient needs to stay healthy and to participate in life. And patient care is best if the patient is not dependent upon the caregiver, as each person needs to be in control of his or her own life.

It should always be up to the patient to determine when care is not to be given. This should include the patient’s right to get only the right pain medication without any other treatment. When the patient is unconscious or not lucid, advance directives or a durable power of attorney for healthcare should apply.

Caregiving is both common and uncommon—Everybody depends upon everyone else to survive in the world, but “We are all angels to the people who need us the most!”

Patient care is for everybody. Caregiving is for everybody to do, but angelic caregiving is for the privileged few in each of our lives.

And we are all patients, and all caregivers.

8.3.2 Post Visit Report

Physicians, nurse practitioners and other caregivers seeing patients often are very busy, pre-occupied or forgetful. As a result, they often do not put forth all necessary information to the patient pertaining to the patient’s problems.

On the other side, patients may not be knowledgeable about their medical conditions or may be emotionally distraught or sickly. As a result, patients often do not hear or understand the information given to them by their caregivers.

It is therefore my proposal that all medical problems (and associated diagnoses) be given a code number (such as the ICD-9 code) and all procedures be given a code number (such as the CPT-4 code). After a visit, a physician could identify the medical problems and procedures to the automated patient medical record system via these code numbers.

Through the automated patient medical record system, the diagnosis and procedure codes could be expanded to produce a usually one page “post visit report” that the patient can take home and carry with him or her. For patients who do not comprehend English, where appropriate and feasible, this report should be in the written language of the patient (e.g., Spanish, Chinese).

First there would be the overall doctor’s comments.

For each medical problem, the following could be displayed on the report:

· diagnosis

· possible causations

· external and internal symptoms

· preventions

· treatments

¨ medications, purpose and dosage

· doctor’s comments

· follow-up care (e.g., a referral, a phone number to talk to an advice nurse to schedule follow-up care, etc.)

For each procedure, the following could be displayed on the report:

· description of procedure

· why it was done

· results

· doctor’s comments

· follow-up care.

Special precautions should be listed (e.g., “Since you are allergic to Septra, an antibiotic, inform any doctor of this who might prescribe any antibiotics or other medications for you.”).

Probabilities of future conditions based upon preceding conditions and risk factors, and preventives should be listed (e.g., Since you smoke, you have an XX% chance of developing cancer compared to an X% chance for someone who does not smoke; if you stopped smoking now you could decrease the risk to X%. For every 100 people with hepatitis C, 20 recover on their own, while 80 develop chronic infection; of the 80 people who develop chronic infection, 60 remain clinically well despite chronic infection, while 20 develop cirrhosis [5]. This information could come from medical research based upon information from other patient medical records.

Also, immunizations and allergies for the patient should be listed, with the patient verifying that they are complete and correct. If any are incorrect, then these would be corrected through the nurse, with this information updated within the patient medical record.

The above report involves translation of medical problems into a patient medical language, a language for medical problems and procedures that all patients can understand.

The system could verify that each prescribed medication is appropriate for one of the identified medical conditions. Prescriptions could be printed out avoiding wrong medications accidentally being given to the patient due to a pharmacist not being able to read the physician’s handwriting; the physician could immediately sign the prescriptions and send them over to a nursing station.

The resulting post visit report could be printed at the nursing station. The report and prescriptions could be given to the patient by a nurse immediately after the visit. The nurse could explain the report , including medications and precautions, to the patient and, if appropriate, to accompanying family members who care for the patient.

8.3.3 Patient Medication Schedule

Now, one of the hardest things for any patient to do after a visit, especially where a new medication is prescribed, is to schedule or reschedule times to take his or her medications. Proposed here is the creation of a personalized patient medication schedule.

A patient medication schedule is a schedule for patients on when to take medications. A medication scheduler is a person who assists in creating such medication schedules.

Lack of good medication schedules is one reason that many people are not independent and are in nursing homes. Lack of medication schedules is one reason that many people suffer detrimental side effects from medications (e.g., they forget to take a medication or take a medication more often than prescribed)!

Proposed is that this personalized medication schedule would be created by a computer used by the medication scheduler and created as follows:

1. The patient would look at a list of his medications from the automated patient medical record system. The patient would identify medications he currently takes and add those he currently takes that are not on the list.

2. Medications could be checked against the patient’s medical problems. If there were any discrepancies, then a physician would be informed.

3. Expired and incompatible medications and interactions between medications could be identified by the computer program. A physician or pharmacist could be informed if this is the case.

4. The patient would verify medication dosages. Any discrepancies would be corrected. The patient may be informed of proper dosages.

5. The patient would be tested to insure that he could identify each medication and the he could otherwise deal with the medication schedule. Otherwise, he might be trained, or less ideally, a caregiver would have to be involved in administration of the medications.

6. The patient would inform the medication scheduler of the ideal times to take medications in order of preference of times.

7. A medication scheduler computer program would produce a patient medication schedule that tries to match the patient’s ideal times with the medications and dosage frequencies, minimizing the number of times medications would need to be taken. In order to do this, the program may have to make compromises on the dosages (e.g., taking some medications earlier or later than identified, adjusting for medication interactions, etc.)

8. The printout could identify what to do if medications were accidentally skipped.

The final result might be a complete medication schedule, say for a week, which could be put onto a usually one page paper, which might be put into the patient’s wallet!

8.3.4 Patient Education Classes, Patient Mentors and Medical Research

An HMO member will be able to take patient education classes to learn about a disease or medical condition and parent education classes to learn about how to take care of children when they are injured or sick. For example, through a class, a new parent could learn when self care for a baby, infant or child is appropriate, and when the child should be brought in to be seen. Through a class, a member with diabetes or severe asthma could learn how to take care of himself or herself, and when it is critical for the patient to come in to be seen.

An HMO member, who (1) may in the future require a future surgery (e.g., a knee replacement, a hip replacement), (2) may or has developed a medical condition (e.g., cancer), or (3) may undergo a significant treatment for a disease (e.g., chemotherapy), will have the opportunity to talk to other members (“patient mentors”) who have had the surgery, disease, medical condition or treatment. The HMO member should be able to talk to both patients who were happy with their surgeries or treatments and those who weren’t. Patients can volunteer to be patient mentors. To put things in perspective, the patient will also given probabilities of future conditions based upon the surgery or treatment (e.g., if the patient has the knee replacement at age XX, then there is a YY% probability that the knee replacement will need to be re-done in Z years).

HMO members will also have the opportunity to learn of organizations who do research on medical conditions (e.g., a psoriasis society) and to talk to the HMO research department to learn about potential new treatments and surgeries, or about current and future clinical trials they might be able to participate in.

8.3.5 Simple, Cheap Transportation

Transportation by ambulance for an emergency situation is sometimes important, but transportation for pre-emergent situations may be an even bigger saver of lives.

These various forms of non-ambulance transportation can be given simple and very “understandable” names. For example, an HMO, such as one which uses the automated patient medical record system, could provide a service which it calls “preambulance transportation” for patients who are unsure whether they need ER care or not.

For anyone who suspects they have a problem, they get an advice nurse. The advice nurse assumes that the patient needs to be seen in some way, and only changes her assumption if in any way the patient does not want to be seen or if it is very clear that the patient should not come in. Simple, cheap or free, and appropriate transportation would be sent to pick up the patient and take the patient to a clinic to be immediately seen!

Why is this useful and important? The reasons are many.

The patient may have been seen in the ER a number of times, and may not now know whether to come in or not. The patient may have suffered a severe life-threatening event--that the patient just happened to survive--and he or she knows he or she needs help.

But, more importantly, the patient may be alone and not be able to get transportation of any kind and may never have contemplated using an ambulance due to its great expense. Or the patient may be a driver but the only person in the family who drives, and is not in a condition to drive safely.

The patient may be too embarrassed or too proud to come in for medical care, such as often is the case for elderly people. The patient may be too macho to come in for care, such as is often the case for men.

Or the patient may not yet be schooled in the ways of life, such as often is the case for young children!--For children, a special phone number (similar to ‘911’) just for them might be more appropriate. The advice nurse would first contact the parent or guardian before continuing.

8.4 New Outpatient Care Paradigms

A paradigm is an original pattern or model of which all things of the same type are representations or copies. This section presents paradigms for outpatient care.

Figure 8.3-1 presents a paradigm for outpatient care as it traditionally occurs. Figure 8.3-2 presents a paradigm that produces a post visit report to be given to a patient after the appointment. 8.3-3 presents a paradigm that includes a pre-visit gathering of information from the patient.

8.4.1 Traditional Outpatient Care Paradigm

Figure 8.3-1 shows outpatient care as it traditionally occurs. The patient comes into the medical center and waits in the waiting room. The patient is called into the clinic where the patient’s temperature and blood pressure is taken by a nurse. The patient is then escorted to a room where he meets with the physician or nurse practitioner. The physician or nurse practitioner interviews and examines the patient and then gives advice and determines treatments, procedures or medications, giving advice to the patient. The patient thereafter leaves the medical center.

8.4.2 Outpatient Care Paradigm Modified to Include Post Visit Report

Figure 8.3-2 shows the traditional outpatient care paradigm modified to include a post visit report. A post visit report would be generated from physician or nurse practitioner identification of diagnoses, procedures, treatments and medications, and from practitioner comment. The nurse would review the post visit report with the patient and/or his or her family members to insure compliance with caregiver’s instructions.

A possible post visit report is presented in section 8.3.1. This should be a clear report understandable by a non-medical person, preferably of one page in length, which the patient would use every day.

The advantage of the post visit report is that it would improve patient compliance with following treatments and taking medications, and encourage patients to play an active role in taking care of his or her medical problems.

8.4.3 Outpatient Care Paradigm Modified to Include Pre-visit Gathering of Information

Figure 8.3-3 shows the outpatient care paradigm of the last section modified to include a pre-visit gathering of information from the patient. Gathering of information from the patient before an appointment insures that all of the medical problems of the patient are identified before the appointment and that the physician’s or nurse practitioner’s time is better utilized during the visit.

A “medical interviewer” gathers information from e-mails, patient pre-visit questionnaires, and the chart. The “medical interviewer” also gets information either by talking to the patient on the telephone or in person before the appointment.

The medical interviewer could get a complete list of medications that the patient is taking, or could encourage that the patient write down this list before the appointment. The National Academy of Sciences’ Institute of Medicine estimated that between 44,000 to 98,000 patients die each year due to mistakes by medical professionals, especially as a result of medication errors [6]; one reason stated for these medication errors is that caregivers do not have complete information on medications the patient is taking.

The “medical interviewer” identifies why the patient is coming in, and potential significant long-lasting problems that the patient has not properly taken care of. She gathers any additional information such as patient questions of the physician and what the patient expects from the physician. She could verify and update any social, family, environmental and genetic history for the patient, updating it as necessary. This information is all summarized in a communication sent to the physician prior to the patient visit.

Instead of the patient being fitted for the appointment time, the appointment time should be fitted to the patient. Often the patient comes in for an acute condition where a long-lasting condition is more serious. Especially in an urgent care setting, the acute problem is treated and the non-acute problem is not--This is really a disservice to the patient--although it could be viewed that it is the patient’s problem because he is not taking care of himself.

But many patients just do not have the time to take are of their chronic problems. Sometimes lack of time, fear or caring too much for someone else (who is much sicker) gets in the way. And a patient surely should not be penalized for that.

The medical interview, in particular, should identify if the patient has come in many times for the same problem and should record these dates. Although such problems may be minor, they may not be and may require care in a specialty department.

Once the medical interviewer determines the total of the patient’s problems, either the appointment should discuss all these problems, or the patient should be informed of follow-up options for the significant problems not discussed in the appointment (e.g., a patient could be given a contact number where an advice nurse could be contacted to potentially set up a specialty-care appointment for a chronic problem that was not discussed during the appointment).

8.4.4 Outpatient Care Beyond a Single Encounter

The previous sections describe paradigms for outpatient care with care all occurring during a single encounter. But, as noted earlier, outpatient care often extends beyond the single encounter; for example,

1. There may be a single encounter resulting in a first, preliminary, diagnosis that is revised after the results of a clinical test. Thus care also occurs after the encounter. Additionally, tests could occur before the encounter and care could start before the encounter.

2. Care could occur across two or more encounters (where encounters could even include inpatient care).

3. Care could be for an acute condition or for a chronic condition (in which case there may not be a final outcome).

This book advocates the use of defined outcome cases and chronic care management cases to combine these encounters and events (tests and test results) so that a comprehensive view of the treatment for a condition can be easily identified and so that continuing care can be provided.

Within some HMOs, continuing care is facilitated by setting up care teams, a set of physicians, nurse practitioners, and others who work closely together and have an understanding of how the team members treat patients for a particular medical condition. This facilitates consistent care, continuing the same treatment plan when a physician might be away, having the patient see another physician on the same team or having the patient see a nurse practitioner who works closely with the missing physician.

Use of defined outcome cases and chronic care management cases potentially allows for more flexibility than restricting the patient to being seen by a care team at a particular facility. As long as caregivers are willing to understand and abide by the treatment plan of the key caregiver and the key caregiver continues to take an active role in the case, then a treatment plan in a defined outcome case or chronic care management case allows care to continue any where, inside or outside the HMO if necessary, using the same treatment plan. This requires a change in the way physicians currently function in their work--physicians must be willing to follow the treatment plans of other physicians.

How the outpatient paradigms in figure 8.3-1, 8.3-2 and 8.3-3 relate to care beyond a single encounter is unclear. Is there a Post Visit Report after the treatment is finished or only after an encounter? Since chronic diseases are seldom cured, when do Post Visit Reports occur for chronic diseases?

8.4.5 Intermediate Care

In most HMOs, outpatient services provided to patients fall into three categories: standard medical care, patient education classes, and recently, alternative medicine (also referred to as “complementary medicine”). With this book’s view of patient care as being a means to (1) help a patient live his or her normal life, and (2) to not set up a dependency situation where the patient loses his or her independence, I think that this view of outpatient care is way too narrow.

People often encounter life situations that effect their health. This is a normal part of living. Some of these life situations lead to stress, insomnia, depression, raced thoughts and moderate to severe anxiety.

Further, during such situations, little things are magnified, and the body’s resistance or tolerance breaks down. Diseases that one used to be able to cop with, now, one cannot cope with.

One of medicine’s cures for these life situations are medications, whether this is standard or alternative medicine. An equivalent patient’s remedy for some of these situations may be drugs or alcohol. In either case, what may result is the patient’s dependence on the drug, medication or alcohol, rather than coping with the problem.

Another of medicine’s cures for these life situations is psychiatric care. This treats these life situations as abnormal, instead of a normal part of living and may stigmatize the patient, at least in the patient’s mind.

A better model for handling such life situations, instead of drugs, is the inpatient nursing care model for handling such life situations when they occur in the hospital setting: Treat the life situation as a “nursing diagnosis” and set up “interventions” to mitigate or alter the life situation. Where drugs are needed, the patient could be encouraged to take the least amount of the drugs that can handle the problem, so a dependency on the drugs is not set up. Because a little problem may be magnified (for example, the patient may be effected by a minor allergy), the full cure may not be needed (perhaps a lesser amount of an inhalant than the prescribed dose would be better).

Instead of looking at medical care as either standard medicine or complementary medicine, an HMO should instead put an emphasize on what I call intermediate care: off-chart, and strictly confidential, counseling by a psychologist or a clinical social worker (CSW) to either (1) provider the patient with a means to cope with the life situation, (2) refer the patient to appropriate medical care if this is necessary, or (3) suggest patient education classes to take. This solution better serves the patient than traditional or alternative medical care in that (1) it is a better way than medical care and medication to allow a patient to live his or her normal life, and (2) it probably will not set up a dependency situation such as the medication solution might.

“Intermediate care” is thus a preventive for more complex problems such as drug or alcohol dependence or more severe anxiety, and, thus a preventive for more costly standard medical care. In some cases, “intermediate care” is a preventive for suicide or for a patient lashing out against others.

Situations where “intermediate care” is most appropriate include the following:

· Work or personal stress

· Marital or relationship problems

· Parenting problems

· Loneliness or depression

· Alcohol or drug use

· Getting along with co-workers

· Health-related issues

· Caregiving for someone

· Loss and grief

· Domestic violence or abuse

· Family matters

· Stress from financial or legal pressures

· Anxiety

· Aging or aging relatives

· Eating problems.

8.5 Automated Help in Diagnosing and Treating Disease

According to a physician I talked to, disease diagnosis is first based upon risk and time. If the condition has a risk of getting worse or is time sensitive, then such a situation must be recognized and the patient must be given priority for immediate treatment.

Advice nurses often access risk and time criticality through a protocol based upon the patient’s chief complaint, asking a series of questions of the patient to determine cases where the patient should get immediate care or where a doctor should be contacted. Automating such a system could insure that care is consistent and that is based upon best practice guidelines. Similar protocols are used in the emergency department to triage patients and determine which patients should be seen first.

The physician told me that 90% of medical conditions are routine and are not difficult for any physician to diagnosis or are conditions that get better by themselves whether care is given or not. For the other 10%, exact diagnosis is often not important as many diseases that fall into the same general category all respond to the same treatments. Where exact diagnosis is important, a specialist in the area should be consulted who would know the difference between the diseases.

Diagnosis is both a science and an art. Some people exaggerate symptoms while others minimize them—the physician must be astute enough to determine the difference. A person’s facial expression could identify the true severity of a problem. And if a patient comes in for one condition, say a cold, the physician should also look for other more significant conditions, for example, a melanoma.

One inpatient registered nurse told me that nurses are often in a better position to recognize medical conditions than inpatient physicians, as nurses provide the primary care for patients while they are hospitalized, while inpatient physicians often spent very little time with the patient. One physician suggested that an automated system could allow the inpatient nurse to flag significant events recorded during the inpatient stay, which could help the physician in making diagnoses. (Note that the inpatient physician is responsible for reviewing the total of the data entered by the nurse, so the recording of these events by nurses are best if they are only transitory and not preserved in the permanent record.)

An automated system could provide diagnosis and treatment assistance in the following ways: expert systems to identify diseases based upon answers to a series of questions; protocols to identify the next step in care (advice, the patient coming in to be seen, a physician being contacted); alert systems to warn a caregiver of care situations that require special notice; or medical references.

An automated system could alert caregivers of inconsistencies in the care being given (for example, when a patient with already low blood pressure is prescribed a medication that lowers blood pressure), could alert the physician of test results that are out of range, or could alert the physician of a patient who is at high risk of developing a particular disease or medical condition, thus identifying a patient who should receive preventive care. A possible disadvantage of alert systems is that they could get in the way of care because they could provide obvious, already known, or irrelevant information to the caregiver.

An automated system could provide expert systems assisting the physician in making diagnoses. In the past, expert systems to identify diseases have not gained large acceptance. One of the reasons is the large amount information they require and the time to enter the information. Another reason is that expert systems may cause the physician to overlook the artistic, experiential, intuitive, face-to-face, and touching sides of diagnosis.

Another basic problem with expert systems is the issue of responsibility. The physician cannot just say that this diagnosis was chosen because this computer program told me it was the correct one. The physician must fully understand the reasons the diagnosis was chosen and take responsibility for one choice over another.

A proposal to limit the amount of information and physician time required to use expert systems is to have the expert system accept a tentative diagnosis from the physician and return conditions that must be satisfied for the diagnosis to be correct [7]. Such a system would help a physician in picking between potential diagnoses.

Capabilities mentioned in this section—expert systems, protocol systems, and alert systems—fall under the category of "decision-support systems". Professor Shortliffe, the principal developer of the MYCIN expert system, has a discussion of such systems in the book in reference [8]. (MYCIN was one of the earliest expert systems—It was used to diagnose and recommend treatment for certain blood infections [9].)

The diagnosis of disease may be more of a problem in developing nations than developed nations for many reasons: including the unavailability of clinical laboratories and medical devices to do diagnostic testing and the unavailability of specialists to diagnosis hard-to-diagnose diseases. However, even more of a problem than the proper diagnosis of disease in developing countries could be the unavailability of medical supplies to treat properly diagnosed medical conditions and the unavailability of specialists to treat conditions that require specialty care. Perhaps, the automated patient medical record system could be used to help dispense medical supplies and specialty care in a developing nation based upon criticality of need, thus providing assistance in allocating these scarce resources. (However, there may be other problems with medical supplies and specialists it cannot solve: costs and transportation logistics; storage and delays in receipt of medical materials; and the unavailability of infrastructure.)

Another problem in proper medical care, whether in developing or developed countries, is having the patient remember and follow the prescribed treatment. As mentioned in section 8.3.2, to insure that the patient has properly understood what the physician has told him, a written set of instructions produced by the automated system could be printed after a visit, with the physician’s instructions gone over by a nurse. (According to reference [10] non-adherence to treatments can run from 22% to 72%, with the largest percentage occurring for adherence to life-style changes.)

Of course, there are many other factors influencing the quality of treatment and diagnosis, and more generally the quality of medical care: the educational background, culture and experience of the caregiver. Some caregivers have mentors and reviewers to tell them when they are or were wrong; others do not have that luxury.

And in any case there is no certain way of identifying whether a diagnosis or treatment was correct. The most conclusive way of determining if a diagnosis was correct is doing an autopsy, but that obviously can only be done after the patient dies. And autopsies are seldom done.

For those in remote areas where there are few colleagues to be mentors or provide review, in particular review by specialists, the automated patient medical system could be used to discuss disease diagnoses and treatments with other caregivers located remotely.

8.6 Disease Prediction

This book views disease prediction as any approach to predicting that a patient will get a disease, or to predicting when a patient will get a disease, when a disease will worsen, or when a treatment decision for a disease will need to be made, most often expressed in terms of the probability of that event happening compared to the probability of that event happening for the general population or for an applicable population group. Various methods of disease prediction were identified in section 5.4.1.7.

Analytic disease prediction is predicting disease based upon the patient having known risk factors for a disease (e.g., the person has an increased probability of getting lung cancer later in life because he or she smokes) and having known protective factors against the disease. A caregiver recognizing and recording such risk factors is a normal part of current medical care. The automated patient medical record could assist in this process by insuring these factors are recorded and are communicated to later caregivers. If a patient has risk factors, the automated patient medical record system could inform the caregiver of this information and report to the patient on the Post Visit report something like the following: "Because you have risk factors or ______, _____, and _____, you have a probability of X% of developing the disease ______ instead of the Y% for the normal population of _______.  Risk factors that can be controlled are the following: _____, _____, and ______. We recommend that _________."

Disease progression analysis is determining the probable progression of a disease or progression to a disease by measuring medical values over time that are predictive of that disease and identifying risk factors and protective factors. Examples of such medical values are blood pressure as a measure of potential future heart disease, bone density as a measure of future osteoporosis, and x-rays of a knee as a measure of the degeneration of cartilage in a knee.

This book views disease progression analysis as consisting of the following steps:

1. recording a medical value or medical values over time for a patient as a measure of a potential disease, say using a trend documents

2. recording risk factors and protective factors

3. identifying controllable risk factors

4. prediction of the future changes in the medical values

5. countermeasures against the disease including removal of controllable risk factors

6. prediction of the probable time of when a treatment decision would need to be made, or of the probable time of unset of a disease or of a debilitating condition

7. prediction after countermeasures

8. identification of treatments or potential future treatments that could be applied at a treatment decision point.

Through the automated patient medical record and trend documents, disease progression analysis can track a medical values and risk factors measuring the potential for a disease for a patient over a long period of time (e.g., a patient’s blood pressure, bone density through bone density tests, x-rays of a degenerative knee). By using trend documents of many different patients, changes in these medical values state can be predicted for a patient, and predictions can be made of when treatment decisions would need to be made, when a disease might occur, or when a condition might become debilitating.

For the disease, a physician can propose countermeasures (e.g., blood pressure lowering medications for high blood pressure or exercise for low bone density). By using trend documents for many different patients who used the same countermeasures, a new prediction can be made of the unset of the disease or debilitating condition (e.g., the onset of heart disease). Through this approach, the physician could determine the long-term effects of the countermeasures and whether or not they would be effective.

Although there may or may not be any countermeasures for a disease, predictions of the onset of the disease, of the onset of a debilitating effect, or of an appropriate time to make a treatment decision could still be useful for a patient: The patient could plan for the future. The patient could be informed of current and potential future treatments (those currently in clinical trials) that applied at a treatment decision point.

Treatment decision points will vary according to the patient and to the disease. Reference [11] views critical points in the natural history of disease as (1) biological onset, (2) early diagnosis possible, (3) usual clinical diagnosis and (4) outcome (recovery, disability, death). It also views another critical point: a point in the disease before which therapy is either more effective or easier to apply than afterward [12]. And I think there is another critical point: a point after which either early detection is possible and an effective but expensive or invasive treatment is possible and advisable. Treatment decision points could potentially occur anywhere in the life cycle of a disease, for example, before its biological onset as a preventative measure, or much later after its onset (e.g., a hip replacement). Predicting potential treatment decision points may be as critical as predicting a disease.

The incorporation of disease progression analysis into medical care may require that physicians change their view of medical care from being almost exclusively re-active, to also being very proactive. In the past, preventive care has not been tailored for individuals but for groups of people (e.g., all women over 50 should have yearly mammograms); disease progression analysis enables preventive care to be combined with individualized care tailored to a specific medical condition of a patient.

In doing trend analysis, care must be given to not over-test. Performing clinical lab tests, taking x-rays, etc. more often than is needed to do the disease progression analysis may increase the cost of medical care. Identifying disease early and taking the correct countermeasures early should instead decrease the cost of medical care.

Descriptive disease prediction is identifying common patterns in the automated patient medical record for patients who all develop a particular disease, and then looking for these same patterns for other patients. In this way, these patterns might be used to predict these diseases for these other patients.

All these disease prediction approaches become more feasible with an automated patient medical record.

Whether disease prediction measures are appropriate for a patient is partially dependent upon the patient’s values. Would the patient want to know about a future disease if it could be predicted? Would it depend upon the specific type of disease? These questions could be asked of the HMO member as part of the healthcare questionnaire described earlier in this chapter.

8.7 Implementation of Business Policies

It takes many people in a healthcare organization to implement organizational business policies, in particular business policies dealing with patient care. And as stated in sections 2.4.4 and 7.6, some business policies could be implemented via agents: a combination of code and tables, interfaces between systems, databases, user interfaces (possibly all spread across a number of different software systems), and administrative and operational procedures followed by employees implementing the business policy. Agents are a way to make this set of items implementing a business policy distinct from other parts of the automated patient medical record system so that the business policy can be changed by people who are responsible for the business policy rather than only by technical people.

Before automation, business policies were probably all assigned to business employees to administer. With automation, some of these business policies are embedded in code and must be administered by technical people, who may not really understand the business policy. This book proposes returning this administration back to business employees.

This book proposes that agents, in a number of ways, be treated like employees. An agent should be assigned a business manager who is responsible for the agent and knows everything about the business policy the agent implements. Periodically, the agent should be evaluated by the manager and the manager’s managers to determine if the business policy should be changed. An agent can be fired, removing the business policy, or replaced, changing the business policy.

8.8 Additional Business Requirements from Projection

Additional business requirements were identified as part of this analysis of future systems and the future environment. Figure 8.4 lists these additional business requirements.

Figure 8.4—Additional Business Requirements Determined
From Projected Future Environment and Systems

Organiza-tional Objective	Num-ber	Project Objective	Addressed in this chapter?	Business Requirement
Quality Medical Care	1	Re-evaluate the entire clinical workflow of the HMO to completely eliminate unnecessary steps and restructure non-productive steps while incorporating the automated patient medical record system.	No	This would be done during the "Changes to Workflow / User Interface" step.
	2	Create a complete and always available patient medical record.	See Previous Chapter
	3	Allow simultaneous viewing and update to a patient medical record.	No	This requires further research to find system software to support it.
	4	Enable a caregiver to quickly find relevant information in the patient medical record by methods such as providing summarization information, organization, information retrieval and tailoring of information related to the type of caregiver.	See Previous Chapter
	5	Provide methods to track a treatment for a particular condition across multiple encounters, possibly with multiple different caregivers, potentially in different departments and in different geographic locations.	See Previous Chapter
	6	Automate and integrate caregiver ordering and results reporting to make it easier, quicker and more accurate.	See Previous Chapter
	7	Where possible, validate as correct all information input by the caregiver.	See This and Previous Chapter
	8	Automate the process of identifying situations where patients are not complying with orders that seriously affect the patient's health.	No
	9	Do automated clinical checking of medications, such as drug/drug interactions and patient allergy checking.	See Previous Chapter
	10	Where possible, automate the identification of trends in the patient's health, especially in cases where there is an emerging health problem (e.g., an increase in the patient's blood pressure)	See Previous Chapter
	11	Provide information to caregivers on best practice guidelines and medical reference information.	See This and Previous Chapter
	12	Collect clinical information to further evidence-based medicine (identifying best treatments and practices for diseases which produce the best outcomes as determined by the best scientific evidence).	See This and Previous Chapter
	13	Eliminate redundant entrance of information in multiple clinical systems, eliminating possible contradictory information.	See This and Previous Chapter
	14	Generate letters to patients to come in for preventative health exams (e.g., colonoscopies) based upon age, sex, family history and other factors.	Yes	This would be set up through "life care paths" generated for new members. This process should be coordinated with the scheduling / appointment system to insure that appointments are available.
	15	Provide the ability to record a detailed social, family, environmental and genetic history of HMO members who agree to provide this information. Identify family members of these HMO members and their relationships to the HMO member, especially family members who are themselves HMO members.	Yes	Periodically provide a detailed questionnaire to consenting HMO members that would be reviewed and verified within an interview of the HMO member by medical personnel.
	16	Explore the possibility of predicting diseases from information in the automated patient medical record.	See This and Previous Chapter	As part of the member questionnaire, record a member's values on disease prediction. Explore disease prediction methods that could be supported by an automated patient record: (1) recording patient risk factors for disease, and protective factors, for communication to later caregivers and for use in predicting disease, (2) use of trend documents to record medical measurements over time to predict diseases, and (3) identification of patterns that might be predictive of future disease.
	17	For medical research purposes, enable useful access to clinical information without providing the identities of patients.	See Previous Chapter
	18	For medical research purposes, enable controlled access to clinical information to identify patients who are appropriate for specific clinical trials.	See Previous Chapter
	19	Automate quality control checks which insure that clinical information complies with accreditation agency (e.g., JCAHO) and government standards.	See Previous Chapter
	20	Provide automated recognition of infection outbreaks.	See Previous Chapter
	21	Automatically collect registry information based upon patient diagnoses and alert a caregiver when registry information should be collected.	See Previous Chapter
	22	Evaluate the feasibility of including digitized diagnostic images to enable quick transmission of images to medical professionals who can display them on monitors and interpret them, to have automated assistance in interpretation of results, and to return the results.	No	Requires further research and analysis.
Reasonable Cost	23	Re-evaluate the entire clinical workflow of the HMO to eliminate or revise costly processes while incorporating the automated patient medical record system	No	This would be done during the "Changes to Workflow / User Interface" step.
	24	Support demand management in all its forms.	Yes	Demand management policies would be supported.
	25	Standardize clinical system interfaces using industry standards (such as HL7).	See Previous Chapter
	26	Have real-time interfaces between other clinical systems and the automated patient medical record system to insure accuracy and non-redundancy of information.	Partially Addressed in Previous Chapter
	27	Provide automated advice on least cost best practices, including lower cost medications which provide equal or better benefits, including advice to use generic medications rather than brand name ones.	See This and Previous Chapter
	28	Automate currently manual processes such as ordering, the MAR (inpatient medical administration record), etc.	See Previous Chapter
	29	Reduce errors, including reordered tests, adverse drug reactions, etc.	See This and Previous Chapter
	30	Support automated care documentation, including computerized generation of nursing plans. Provide this information for other clinical systems where applicable.	See Previous Chapter
	31	Decrease personnel requirements by electronic storage of the patient medical record and automated ordering with automatic inclusion in the medical record.	See Previous Chapter
	32	Evaluate the possibility, feasibility and cost-effectiveness of off-site storage of automated patient medical record information.	No
	33	For reporting based upon medical related information (e.g., HEDIS), set up automatic generation of these resports and transmission to outside agencies (e.g., the NCQA).	See Previous Chapter
	34	Identify and report on potential patient abuse such as "drug jumping", going from facility to facility for narcotics orders.	No
	35	Identify suspicious charges for medications and services when payments are to be made to outside healthcare organizations.	No
	36	Support automated collection of payments for medical services from the government and insurance companies via EDI. Support automated payment for medical services.	See Previous Chapter
	37	Support electronic commerce, in particular DME ordering such as over the Internet.	See Previous Chapter
	38	Where possible, standardize hardware, system software and clinical systems within the organization.	No
	39	Design the automated patient medical record system to eliminate documentation errors identified in figure 4.6 to protect against costly lawsuits.	See Previous Chapter
Satisfying Patient Needs	40	After an outpatient visit, provide patients and family information on clinician orders and other information to promote compliance with physician instructions and orders and encourage greater participation of the patient in his own care.	Yes	After outpatient visits, provide patients and their families with printouts of orders and physician instructions.
	41	Get patients and their families more involved in the patient care process.	Yes	After outpatient visits, provide patients and their families with printouts of orders and physician instructions.
	42	To reengineer the care process to eliminate roadblocks to the patient and his family receiving prompt care.	Yes--Also Addressed in Previous Chapter	New members will be interviewed and given health questionnaires to provide information for the "overall clinical summary", providing clinical information on the patient. If information may speed up care in emergency situations.
	43	Personalize care for the patient.	Yes	Provide a personal profile for each patient. See sections 5.4.3.4 and 8.2.2.
	44	Evaluate the feasibility of the automated patient medical record system receiving input from monitoring systems, including "Guardian Angel" systems.	See Previous Chapter
Employee Satisfaction	45	Reengineer the care process based upon input from employees so that employees’ work activities match the most productive and least stressful methods of providing care.	Yes	The "future environment and systems" should be determined with input from employees for the most productive and least stressful methods of providing care.
Ability to predict	46	Record services, tests and procedures given to patients, supplies and medications, provider time caring for patients, hospitalizations and visits, and trends in membership growth and patient utilization for prediction of HMO costs in the future.	See Previous Chapter
None	47	Provide support in reviewing Sentinel Events.	Introduced	This requires further analysis.

References

[1] Multi-media Presentation on Asthma for Children, on the web at http://hsc.virginia.edu/cmc/tutorials/asthma/asthma1.html.

[2] Kerstin Petersone, “Say Yes to Speech Rec”, Computer Telephony, October 1997, Vol. 5, Issue 10.

[3] Glamm Interactive, “Quality of Life Assessment in Medicine: Internet Resources” at Internet site http://www.glamm.com/ql/url.htm. Included at this site is information on health outcome questionnaires SF-36 and HSQ-12.

[4] J. Duncan Moore Jr., “JCAHO urges ‘Do tell’ in sentinel event fight”, Modern Healthcare, March 2, 1998, pp. 60-66.

[5] Harvard Medical School, “Hepatitis C: The Silent Epidemic”, Harvard Men’s Health Watch, Vol. No. 12, July 2000.

[6] Eileen O’Conner, The Associated Press, “Medical errors kill tens of thousands annually, panel says”, CNN.com, November 20, 1999.

[7] Douglas D. Dankel, II, PhD, Giuliano Russo, MD, “Verification of Medical

Diagnoses Using a Microcomputer”, Microcomputer-Based Expert Systems,

IEEE Press, 1988.

[8] Edward H. Shortliffe, “Clinical Decision-Support Systems”, Chapter 15 in the book, Medical Informatics: Computer Applications in Health Care, Edward H. Shortliffe, Leslie E. Perreault, Editors, Addison-Wesley Publishing Company, 1990.

[9] See website http://www.cee.hw.ac.uk/~alison/ai3notes/section2_5_5.html.

[10] Steven A. Cole, Julian Bird, The Medical Interview: The Three-Function Approach, Mosby, 2000.

[11] David L. Sackett, R. Brian Haynes, Gordon H. Guyatt, Peter Tugwell, Clinical Epidemiology: A Basic Science for Clinical Medicine, Little, Brown and Company, 1991.

[12] G. B. Hutchison, “Evaluation of preventive services”, J. Chron. Dis., 11:497, 1960.

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