Integrated Results Reporting Information System: The First Phase of Clinical Decision Support
Introduction
The automation of health care can be understood as processes of information gathering, analysis, communication, refinement, and completion. Although the current national debate on reduction of errors in medicine1 is focused on computerized physician order entry (CPOE), there is only one element of this information process appreciated as beneficial by physicians and patients.2 Indeed, the delivery of complete, organized, timely, and usable medical information by a well-crafted results reporting information system (RRIS) is both easier to implement and more rapidly adopted by health care workers than other systems. In this paper, we will describe the key elements of an RRIS and the most important success factors to achieving maximum benefits. Finally, we will illustrate the implementation an RRIS, the Care Web system, at the University of Michigan Medical Center.
This paper will focus on the key information strategies necessary to achieve success in creating and implementing an RRIS. Key technologies such as clinical data repositories (CDRs) and interface/integration strategies (interface engines, for example), have a rich literature and will be mentioned only to aid in illustrating this clinician and user-based discussion.
Key Characteristics of an RRIS
The key functional characteristics of an RRIS are: accuracy, timeliness, patient centricity, comprehensiveness, and presentation flexibility. Let's examine each of these.
Accuracy
In the complex world that is American health care today, information accuracy is imperative, but it is not a given feature of an information system; it is one that must continually be tested and pursued. There are a number of reasons for this, including the lack of information integration in American health care; the mobility of American society; and the complexity of testing technology, with rapid growth of new tests and new methods of performing old studies (for example, the remarkable changes from biochemistry through genetic assays in just the last 10 years).
One of the greatest frustrations Americans have with health care is the obvious poor integration of services. That is, everything from poor inter-physician communication, lack of coordination of primary through secondary and tertiary care, and finally the frustrating confusion between the clinical, administrative, and financial aspects of health care delivery. These elements have arisen in the current "mosaic" of managed care, fee-for-service, community, and integrated delivery systems that are the health care environment in American today. The reader is referred to anyone in their family who has required care at multiple clinical settings or worse, different health care institutions, to realize that health care testing and information standards are not yet a prominent feature. Because of this reality, RRIS systems are challenged to ensure that such mundane issues as normal lab test ranges, test result terminologies, and so on are properly normalized. This becomes particularly important as one considers the mobility of American society and the need to understand medical information trends across time, systems, and locales.
With the growth of air travel, not only are we faced with massively decentralized health care needs (for example, continuing chemotherapy protocols begun in Boston while the patient travels to a winter home in Arizona), but also with diseases that have actually been facilitated by travel technology (for example, tuberculosis or deep venous thrombosis). Information accuracy and delivery is becoming progressively more important, as historical information must travel with the patient. This is especially imperative for people requiring care of acute problems (for allergies, for instance), and for those requiring continuing care of chronic diseases (AIDS, malignancy). It is also essential to realize that the propagation of information technology in many other industries, and society's expectation of its availability, only seeks to heighten the issues with providing essential clinical information accurately and across locales.
Finally, the ever-changing technology of medical testing itself presents an important challenge to the provision of accurate information in an RRIS. For example, as of this writing, there are no less than four separate and distinct technologies employed at major medical centers for the measurement of blood sugars. Although results are similar using the modalities, normal ranges are not identical, making accurate reporting and trending a challenge. Understanding all sources of information in an RRIS, as a means of achieving true accuracy of information recording and reporting, is more challenging and important than ever.
Timeliness
Due to the continuous cost pressures of routine ambulatory care in America, previously leisurely doctor-patient meetings have now become intensively time-pressured, 10- to 15-minute interactions. With this amazing compression of communication time, if the patient and physician aren't working with the same up-to-date information, then at best delays in care will occur; at worst, errors will be made.
Frustrations with obtaining access to care remains one of the most important concerns of patients and physicians alike.1 Access is also a key element in the perception of improved quality and safety of care. An RRIS must deliver the latest information at the point of care in order to meet expectations of timely medical decision-making and quality care.
Patient Centric: Large Scale Data Integration - Information Across the Continuum of Care
In the Jan. 19, 2003, edition of the New York Times, Dr. Eugene Braunwald, Chief Academic Officer at Harvard Medical School's Partners Health Care System, was quoted as saying that the reduction in cardiac death rates was "one of the great triumphs of medicine in the past 50 years." The article goes on to state that so few Americans are dying of MI and stroke that rates can no longer be calculated. Patients are now surviving into their 60s, 70s, and beyond only to have chronic heart disease with congestive heart failure. This trend — converting previously life-ending diseases to chronic diseases — has occurred across a broad spectrum of conditions from heart disease to cancer. Therefore, the reality of ambulatory care practice in the new millennium is the care of patients over many years, some with complex diseases with exacerbations and remissions that require the monitoring of trends. The conversion of our information sources from episode-based to continuous, patient-centered has occurred slowly.
In addition to the challenges of information integration from disparate health care systems and geographic locations, patient care has been compounded by chronic diseases that are much more common, and that require clinicians to have the perspective of years, sometimes decades, of information from the RRIS in order to identify and treat them. Therefore, besides lab trends and archives of reports, the modern RRIS must have an accurate and continually updated diagnosis and patient problem list to allow clinicians to recognize everything from recurrence of old problems to drug disease interactions before they become real problems.
Facilitation of the Conversion of Data Into Information: Presentation Flexibility
The RRIS must present large amounts of information on individual patients over time that will allow the physician to have a better understanding of trends and patterns to discover the source of patient problems, as well as responses to treatments. To achieve the myriad of applications, tests, and evaluations, the RRIS must provide an unprecedented degree of flexibility. For example, recognized patterns of disease must be easily constructible by the user so that if a diagnostic profile exists, it will become apparent in the RRIS display. For example, a patient with chest pain usually requires blood work in the modern emergency department. The pattern of the so-called enzymes allows the physician to identify those individuals who are having dangerous, immediate heart muscle injury, as well as those that have chest pain due to other less catastrophic causes. The RRIS should allow the easy online display of the panel of tests allowing immediate recognition of problems by the clinician.
The modern RRIS must allow for display of test data in a manner that alerts to more than simple high or low results. For example, the system (or its source systems) must have the ability to identify and display delta values or greater-than-expected changes in test results even though the absolute values may still be within the normal range. For example, a patient may experience a fall in blood count immediately after a biopsy procedure that results in an absolute figure that's at the lower limit of normal, constituting an important warning that a possible continuing bleeding mishap has occurred.
Care Web: Transformation of an Integrated Health Care Delivery System by an RRIS
In 1997, the University of Michigan Hospitals and Health Systems (UMHHS) took stock of its clinical information environment both for any impending Y2K issues and to formulate a new strategy for the coming millennium. We found that the clinical information catalog consisted of more than 400 applications supported in over 60 departments in the medical center. It was clear that this situation resulted in increased support costs and maintenance for the organization. Even more concerning was the fact that these systems duplicated basic functions such as information retrieval and presentation. This analysis made it evident that a patient-centric results reporting information system, built upon a central data repository (CDR) was needed. At that time, fortuitously, programming expertise in Web-based architecture was growing the medical center information technology (MCIT) under the direction of Dr. Jocelyn DeWitt, CIO at UMHHS. The Web technology was attractive because it was evident that the architecture would provide rapid accessibility, require little training, and, it was hoped, decrease the cost of maintenance by standardizing systems, both from the standpoint of information access and integration, thereby avoiding the mass duplication of information access in the existing environment.
The system was dubbed Care Web. Development proceeded with the goals of increased patient throughput, standardization, and safety. The system was developed in incremental steps directed at specific information problems/issues within the organization. For example, the first problem was to combine information from a legacy homegrown patient scheduling system with the data from a new commercial scheduling system. The vendor had no product to integrate our legacy system, so Care Web was given the task, which it performed admirably. The key advantage of the Care Web system was the development of the CDR with what might be called opportunistic information integration. That is, acquisition of information from legacy systems in whatever manner was possible. For the more robust system, standards-based (HL-Seven, for example) communications were utilized. Where much smaller systems were encountered, FTP batch data transfers were used. Most importantly, the user interface was designed to be as Web-standard and familiar to any browser user as possible.
The system was first released in 1998, and within the following eight months became the clinical information resource for both the inpatient and outpatient enterprise (Figure 1). A survey of house staff, attending physicians, nurses, allied health, and the administrative users (over 10,000) was performed in 1998 to evaluate why this system was so rapidly and completely adopted by users. The top reasons for user satisfaction were:
Figure 1: Growth of Care Web use — 1998
- All clinical information in one place
- Ease of use
- Familiarity of the Web user interface
- Incremental growth of the system
Incremental growth was possible due to a remarkable synergy that developed with the medical, nursing, and administrative staff as Care Web grew in popularity. A Care Web steering committee (consisting of chairman-appointed representatives from each constituency) remains the main organizational body reviewing, prioritizing, and assisting in the management of Care Web development. The multidisciplinary committee increased the interest, excitement, and ownership of the system by the institution at large.
Since 1998, Care Web has continued to grow into areas beyond traditional results reporting (documentation, for example), and now exists as the primary means for clinical information editing and electronic signature. Physicians and others access it via the Web via secure socket and double-blind password technology from offices, homes, and the field. Attribution is always a difficult issue with information systems. However, over the past four years of Care Web's existence the following benefits have been observed:
- A reduction in ALOS (Figure 2)
- Compliance with rapid document signature by clinicians
- A marked increase in pediatric immunization rates (Figure 3)
Figure 2: A reduction in ALOS
Figure 3: A marked increase in pediatric immunization rates
For these reasons, the University of Michigan named Care Web Program of the Year in 2001.
Conclusion
RRIS is the key first step toward clinical decision support in any health care enterprise. Its advantages of improved patient care and IT resource consolidation are now facilitated by the existence and popularity of the Internet. With data integration and communication standards, the process of creation of a CDR is an essential first infrastructure step. It is also important to gain the trust, attention, and interest of your organization and medical staff in particular. An enterprise-wide RRIS strategy is, we believe, an excellent step on the way toward the electronic medical record.
Endnotes
1 Kohn, Linda T., Corrigan, Janet M., Donaldson, Molla S. Eds. 2000. "To Err Is Human: Building a Safer Health System." Washington: National Academy Press.
2 Blendon, R.J., DesRoches, C.M., Brodie, M., Benson, J.M., Rosen, A.B., Schneider, E., Altman, D.E., Zapert, K., Herrmann, M.J., Steffenson, A.E. 2002. "Views of Practicing Physicians and The Public on Medical Errors." New England Journal of Medicine. Dec., 12;347 (24):1933-40.
