Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions

Clinical decision-making is based on knowledge, expertise, and authority, with clinicians approving almost every intervention—the starting point for delivery of “All the right care, but only the right care,” an unachieved healthcare quality improvement goal. Unaided clinicians suffer from human cognitive limitations and biases when decisions are based only on their training, expertise, and experience. Electronic health records (EHRs) could improve healthcare with robust decision-support tools that reduce unwarranted variation of clinician decisions and actions. Current EHRs, focused on results review, documentation, and accounting, are awkward, time-consuming, and contribute to clinician stress and burnout. Decision-support tools could reduce clinician burden and enable replicable clinician decisions and actions that personalize patient care. Most current clinical decision-support tools or aids lack detail and neither reduce burden nor enable replicable actions. Clinicians must provide subjective interpretation and missing logic, thus introducing personal biases and mindless, unwarranted, variation from evidence-based practice. Replicability occurs when different clinicians, with the same patient information and context, come to the same decision and action. We propose a feasible subset of therapeutic decision-support tools based on credible clinical outcome evidence: computer protocols leading to replicable clinician actions (eActions). eActions enable different clinicians to make consistent decisions and actions when faced with the same patient input data. eActions embrace good everyday decision-making informed by evidence, experience, EHR data, and individual patient status. eActions can reduce unwarranted variation, increase quality of clinical care and research, reduce EHR noise, and could enable a learning healthcare system.     

Integration of Footprints Information Systems in Palliative Care: The Case of Medical Center of Central Georgia

Healthcare in America continues to be of paramount importance, and one of the most highly debated public policy issues of our time. With annual expenditures already exceeding $2.4 trillion, and yielding less than optimal results, it stands to reason that we must turn to promising tools and solutions, such as information technology (IT), to improve service efficiency and quality of care. Presidential addresses in 2004 and 2008 laid out an agenda, framework, and timeline for national health information technology investment and development. A national initiative was long overdue. This report we show that advancements in both medical technologies and information systems can be capitalized upon, hence extending information systems usage beyond data collection to include administrative and decision support, care plan development, quality improvement, etc. In this paper we focus on healthcare services for palliative patients. We present the development and preliminary accounts of a successful initiative in the Medical Center of Central Georgia where footprints information technology was modified and integrated into the hospital’s palliative care service and existing EMR systems. The project provides evidence that there are a plethora of areas in healthcare in which innovative application of information systems could significantly enhance the care delivered to loved ones, and improve operations at the same time..     

医疗卫生信息技术标准概述(一)

信息技术(IT)已经在医疗卫生领域中广泛应用于临床信息的收集、处理、管理和使用。IT技术的重要应用之一是建立病人不同来源的临床数据的长期记录,并在任何需要的时候和地点以安全的方式向医生提供这些信息。病人数据无缝集成将极大地改善医疗质量及减少医疗错误。为了在不同系统之间交换临床信息及实现互操作性,开放标准起着非常关键的作用。本文提供医疗卫生领域一些主要信息技术标准及其应用的一个概述。     

Clinical pathways--the new paradigm in healthcare?

A clinical pathway defines the optimal care process, sequencing and timing of interventions by doctors, nurses and other healthcare professionals for a particular diagnosis or procedure. It is a relatively new clinical process improvement tool that has been gaining popularity across hospitals in the USA, Australia and United Kingdom. Clinical pathways are developed through collaborative efforts of clinicians, nurses, pharmacists, physiotherapists and other allied healthcare professionals with the aim towards improving the quality of patient care. Clinical pathways have been shown to reduce unnecessary variation in patient care, reduce delays in discharge through more efficient discharge planning, and improve the cost-effectiveness of clinical services. The approach and objectives of clinical pathways are consistent with those of total quality management (TQM) and continuous quality improvement (CQI) and is essentially the application of these principles to the patient's bedside. This article examines the proliferation in the use of clinical pathways, its benefits to the healthcare organisation, its application as a tool for CQI activities in direct relation to patient care and the medico-legal implications involved.     

医院医疗事件报告系统解决方案

《医院管理评价指南（试行）》和医院管理年活动都将提高医疗质量、保证医疗服务的安全性和有效性作为重要目标和要求。鉴于以信息技术手段作为实现这一目标的重要方法,在医院内部局域网内建立了以意外和不良事件为主体的医院医疗事件报告系统。医护人员以无责、匿名和自愿的方式,登录该系统,并及时将各类不良事件、意外事故等情况在系统中报告、记录,管理部门依据报告,可及时反馈并予以解决;通过对各报告事件的统计、分析,对相关工作进行总结、教育、培训,促进日常医疗管理水平的提高。通过在将系统建立过程中积累的经验和实际功能效果予以展示。对国内医院医疗事件报告系统的建立、推广和完善将有所裨益。     

A systems approach to accepted standards of care: Shifting the blame

In healthcare, from a legal perspective, the standard of acceptable practice has been generally set by the courts and defined as healthcare professionals acting in a manner that is widely accepted by their peers as meeting an acceptable standard of care. This view, however, reflects the state of how practice “is” rather than what it “ought to be”. What is ought to be depends on whether you take a “person” or “system” oriented approach to practice.The increasing pressures of lack of money and resources, and an ever–increasing need for care are bringing pressure on the health services to move to a system approach and this is gaining acceptance both with clinicians and thus eventually the courts.A systems-type approach to healthcare will, by necessity, embrace clinical protocols and guidelines supported by clinical information systems. It will also see blame for errors shifting from clinicians to the organisations that employ them.This paper argues that a continued use of a person-based approach to healthcare, developed through an historical record of practice by individual clinicians, is no longer adequate defence in a case of supposed negligence.When the healthcare system has codified clinical guidelines and digital data gathered across thousands of clinicians and their patients, it is possible to compute adequate levels of care and expect clinicians and the healthcare system in general to meet these minimum standards.Future negligence decisions will rely on a systems-based best practice standard of care determined through evidence rather than opinion     

The future of health IT innovation and informatics: a report from AMIA's 2010 policy meeting

While much attention has been paid to the short-term impact that widespread adoption of health information technology (health IT) will have on the healthcare system, there is a corresponding need to look at the long-term effects that extant policies may have on health IT system resilience, innovation, and related ethical, social/legal issues. The American Medical Informatics Association's 2010 Health Policy Conference was convened to further the national discourse on the issues surrounding these longer-term considerations. Conference participants self-selected into three broad categories: resilience in healthcare and health IT; ethical, legal, and social challenges; and innovation, adoption, and sustainability. The discussions about problem areas lead to findings focusing on the lack of encouragement for long-term IT innovation that may result from current health IT policies; the potential impact of uneven adoption of health IT based on the exclusions of the current financial incentives; the weaknesses of contingency and risk mitigation planning that threaten system resilience; and evolving standards developed in response to challenges relating to the security, integrity, and availability of electronic health information. This paper discusses these findings and also offers recommendations that address the interwoven topics of innovation, resilience, and adoption. The goal of this paper is to encourage public and private sector organizations that have a role in shaping health information policy to increase attention to developing a national strategy that assures that health IT innovation and resilience are not impeded by shorter-term efforts to implement current approaches emphasizing adoption and meaningful use of electronic health records.     

A large-scale quantitative analysis of latent factors and sentiment in online doctor reviews

Online physician reviews are a massive and potentially rich source of information capturing patient sentiment regarding healthcare. We analyze a corpus comprising nearly 60 000 such reviews with a state-of-the-art probabilistic model of text. We describe a probabilistic generative model that captures latent sentiment across aspects of care (eg, interpersonal manner). We target specific aspects by leveraging a small set of manually annotated reviews. We perform regression analysis to assess whether model output improves correlation with state-level measures of healthcare. We report both qualitative and quantitative results. Model output correlates with state-level measures of quality healthcare, including patient likelihood of visiting their primary care physician within 14 days of discharge (p=0.03), and using the proposed model better predicts this outcome (p=0.10). We find similar results for healthcare expenditure. Generative models of text can recover important information from online physician reviews, facilitating large-scale analyses of such reviews.     

中美英基层医疗服务质量评价框架及“两病”质量指标对比研究

背景　为实现整合式医疗服务,中国所面临的一个突出挑战是如何改善卫生服务质量,什么是质量及如何衡量质量是我国和国际上正在辩论的主题。质量监测框架是帮助基层医疗服务评估质量状态、制定改进计划和激发对质量更广泛思考的系统工具。国内对基层医疗服务和质量的研究较少,尚未发现针对多个国家相关质量监测体系、疾病具体指标的横向对比案例研究报道。目的　通过整体分析中、英、美三国基层医疗卫生服务质量监测、考核或认证指标体系,以及其中涉及的具体病种指标,理解基层医疗服务的质量内涵,分析质量指标体系对服务质量改进的作用方式。方法　以Donabedian经典的基于系统的结构、过程和结果框架的质量框架为对比基线,检索案例国家关于基层医疗卫生服务相关文献。分析各案例国家在体现各自基层医疗卫生服务质量内涵上的相关投入、过程和结果关注,以及质量考核方式对质量绩效结果的影响。进一步通过对指标的横向对比,寻找政策关注差距。结果　三国人力资源结构和服务负荷不同,英、美平均每个全科医生团队服务1 200人（全人群）左右,而中国达到了4 632人。三国都将“两病”纳入基层医疗主流的考核范围。在质量监测结构上,中、英采用了类似的以病种或重点人群分类的临床循证指标监测方式,美国采用了以服务实践过程监测为主的方式;英、美都纳入了质量改进的监测领域。在质量指标上,英、美都采用了通过“例外报告”的方式考虑人群考核指标要求与患者个性化特征的平衡,中国主要采用了相对单一的抽样到个体来代表人群质量结果的方式。在评估结果反馈上,英、美都反馈到被评估对象和公众,中国主要在行政和考核体系内反馈。在信息化对考核和监测的支持上,英、美都配套了专业的数据抓取计划,最大限度规避了考核中用简单的个体抽样结果代替人群整体管理结果而导致的一系列问题,也是反馈、面向社会公布、分析研究、开发患者健康类应用的重要数据基础。结论　3个国家根据需求和资源不同,对基层医疗卫生服务的质量要求不同,但一直都随着供需和资源变化不断改进,并且呈现出在基层医疗卫生服务中鼓励“以人为中心”和“质量持续改进”的趋势。中国基层医疗卫生服务在资源有限的情况下,完成了较好的服务质量效果。在下一步质量指标完善过程中,必须与其他宏观意义上的体制机制改革配合才能有效实施,比如基层人力资源培养和结构调整、医疗和公共卫生真正结合的签约服务考核方式、基于基层“守门”的医联体运行管理模式和医保支付机制、以业务需求为导向的基层医疗数字化转型活动等。     

Healthcare information technology's relativity problems: a typology of how patients’ physical reality,clinicians’ mental models,and healthcare information technology differ

Objective

To model inconsistencies or distortions among three realities: patients'' physical reality; clinicians'' mental models of patients'' conditions, laboratories, etc; representation of that reality in electronic health records (EHR). To serve as a potential tool for quality improvement of EHRs.

Methods

Using observations, literature, information technology (IT) logs, vendor and US Food and Drug Administration reports, we constructed scenarios/models of how patients'' realities, clinicians'' mental models, and EHRs can misalign to produce distortions in comprehension and treatment. We then categorized them according to an emergent typology derived from the cases themselves and refined the categories based on insights gained from the literature of interactive sociotechnical systems analysis, decision support science, and human computer interaction. Typical of grounded theory methods, the categories underwent repeated modifications.

Results

We constructed 45 scenarios of misalignment between patients'' physical realities, clinicians'' mental models, and EHRs. We then identified five general types of misrepresentation in these cases: IT data too narrowly focused; IT data too broadly focused; EHRs miss critical reality; data multiplicities–perhaps contradictory or confusing; distortions from data reflected back and forth across users, sensors, and others. The 45 scenarios are presented, organized by the five types.

Conclusions

With humans, there is a physical reality and actors'' mental models of that reality. In healthcare, there is another player: the EHR/healthcare IT, which implicitly and explicitly reflects many mental models, facets of reality, and measures thereof that vary in reliability and consistency. EHRs are both microcosms and shapers of medical care. Our typology and scenarios are intended to be useful to healthcare IT designers and implementers in improving EHR systems and reducing the unintended negative consequences of their use.     

信息技术在肿瘤姑息治疗中的应用研究

阐述了信息技术与肿瘤姑息治疗的关系,分析肿瘤患者的行为干预、肿瘤治疗与疗效评价、肿瘤治疗数据流与信息系统的现状。提出以信息技术为基础,通过对可及信息的挖掘,以循证医学的方法,在对病人状况进行综合分析的基础上,构建以病人为中心的行为干预方法将有利于促进提升肿瘤姑息治疗的效果,延长寿命,提高生存质量;同时,借助现代信息技术,采用追踪研究的方法,通过获取肿瘤治疗的纵向资料,建立不同患者的数据库和肿瘤治疗疗效评价指标,分析同类肿瘤相关干预措施的效果,可为肿瘤治疗的循证决策提供依据。     

Enhancing Quality of Patients Care and Improving Patient Experience in China with Assistance of Artificial Intelligence

Improving health of Chinese people has become national strategy according to the Healthy China 2030. Patient experience evaluation examines health care service from perspective of patients; it is important for improving health care quality. Applying artificial intelligence (AI) in patient experience is an innovative approach to assist continuous improvement of care quality of patient service. A nursing quality platform based on patient experience data which is empowered by AI technologies has been established in China for the purpose of surveillance and analysis of the quality of patient care. It contains data from nearly 1300 healthcare facilities, based on which portraits of nursing service qualities can be drawn. The patient experience big data platform has shown potentials for healthcare facilities to improve patient care quality. More efforts are needed to achieve the goal of enhancing people's sense of health gain.     

A Balanced Scorecard Approach in Assessing IT Value in Healthcare Sector: An Empirical Examination

Healthcare sector indicates human-based and knowledge-intensive property. Massive IT investments are necessary to maintain competitiveness in this sector. The justification of IT investments is the major concern of senior management. Empirical studies examining IT value have found inconclusive results with little or no improvement in productivity. Little research has been conducted in healthcare sector. The balanced scorecard (BSC) strikes a balance between financial and non-financial measure and has been applied in evaluating organization-based performance. Moreover, healthcare organizations often consider their performance goal at customer satisfaction in addition to financial performance. This research thus proposed a new hierarchical structure for the BSC with placing both finance and customer at the top, internal process at the next, and learning and growth at the bottom. Empirical examination has found the importance of the new BSC structure in assessing IT investments. Learning and growth plays the initial driver for reaching both customer and financial performance through the mediator of internal process. This can provide deep insight into effectively managing IT resources in the hospitals.     

出院总结的标准化研究

准确、一致、完整、及时的临床信息对医生解决患者的健康问题大有裨益。临床事件总结在适当的详细程度和完整性上提供信息,使医生迅速捕获与服务对象健康相关的信息,可提高医疗质量和工作效率。本文以出院总结为例,对临床事件总结的规范化进行了探讨。     

Evaluating health information technology in community-based settings: lessons learned

Implementing health information technology (IT) at the community level is a national priority to help improve healthcare quality, safety, and efficiency. However, community-based organizations implementing health IT may not have expertise in evaluation. This study describes lessons learned from experience as a multi-institutional academic collaborative established to provide independent evaluation of community-based health IT initiatives. The authors'' experience derived from adapting the principles of community-based participatory research to the field of health IT. To assist other researchers, the lessons learned under four themes are presented: (A) the structure of the partnership between academic investigators and the community; (B) communication issues; (C) the relationship between implementation timing and evaluation studies; and (D) study methodology. These lessons represent practical recommendations for researchers interested in pursuing similar collaborations.     

令医生大失所望的临床信息系统：超越现有技术的机遇

目的：旨在论述当前的临床信息系统为何惨遭失败。方法：对过去几十年临床信息系统的发展进行主观分析。结果与讨论：富有挑战性的难题就是预先考虑到临床医生们到底需要什么样的信息，继而专门针对他们的独特视角。为其提供这些信息。临床医生需要的是那些能够提供由用户决定的。最大可能程度灵活性和用户化的工作站。我们设想并概括介绍了一种所谓的医疗服务点工作站。这种工作站能够在形形色色的医疗信息系统范围内，自动适应用户所需的显示方式、硬件能力、操作系统以及（本地或分布式的）应用程序。     

Factors Influencing Computer Literacy of Taiwan and South Korea Nurses

Healthcare is experiencing a major transformation in its information technology base. Hospitals are adopting information technology (IT) to reduce costs and increase competitiveness. IT applications in healthcare are trending towards electronic patient records and even health records. Therefore, practices in nursing are also affected by IT. Many researchers have studied what computer literacy a nurse should possess, but have focused less on factors that actually impact computer literacy. The purposes of this study are to examine current computer literacy levels of nurses, and to indicate what variables influence their computer literacy. Taiwan and South Korea both implemented a national health insurance system, and used state-of-the art IT to provide higher volume and better quality of services. The data were collected from two case hospitals which are located in Taiwan and South Korea, respectively. By using a structured questionnaire, a total of 203 nurses responded; 104 from Taiwan and 99 from South Korea. The results revealed that personal innovativeness in IT, computer education, and age are significant factors that affected computer literacy levels. These factors serve as reference for administrators and executives in hospitals, or nursing educators seeking the data necessary to make decisions on curriculum.     

An interview study with medical scribes on how their work may alleviate clinician burnout through delegated health IT tasks

ObjectivesTo understand how medical scribes’ work may contribute to alleviating clinician burnout attributable directly or indirectly to the use of health IT.Materials and MethodsQualitative analysis of semistructured interviews with 32 participants who had scribing experience in a variety of clinical settings.ResultsWe identified 7 categories of clinical tasks that clinicians commonly choose to offload to medical scribes, many of which involve delegated use of health IT. These range from notes-taking and computerized data entry to foraging, assembling, and tracking information scattered across multiple clinical information systems. Some common characteristics shared among these tasks include: (1) time-consuming to perform; (2) difficult to remember or keep track of; (3) disruptive to clinical workflow, clinicians’ cognitive processes, or patient–provider interactions; (4) perceived to be low-skill “clerical” work; and (5) deemed as adding no value to direct patient care.DiscussionThe fact that clinicians opt to “outsource” certain clinical tasks to medical scribes is a strong indication that performing these tasks is not perceived to be the best use of their time. Given that a vast majority of healthcare practices in the US do not have the luxury of affording medical scribes, the burden would inevitably fall onto clinicians’ shoulders, which could be a major source for clinician burnout.ConclusionsMedical scribes help to offload a substantial amount of burden from clinicians—particularly with tasks that involve onerous interactions with health IT. Developing a better understanding of medical scribes’ work provides useful insights into the sources of clinician burnout and potential solutions to it.     

Health IT Success and Failure: Recommendations from Literature and an AMIA Workshop

With the United States joining other countries in national efforts to reap the many benefits that use of health information technology can bring for health care quality and savings, sobering reports recall the complexity and difficulties of implementing even smaller-scale systems. Despite best practice research that identified success factors for health information technology projects, a majority, in some sense, still fail. Similar problems plague a variety of different kinds of applications, and have done so for many years. Ten AMIA working groups sponsored a workshop at the AMIA Fall 2006 Symposium. It was entitled “Avoiding The F-Word: IT Project Morbidity, Mortality, and Immortality” and focused on this under-addressed problem. Participants discussed communication, workflow, and quality; the complexity of information technology undertakings; the need to integrate all aspects of projects, work environments, and regulatory and policy requirements; and the difficulty of getting all the parts and participants in harmony. While recognizing that there still are technical issues related to functionality and interoperability, discussion affirmed the emerging consensus that problems are due to sociological, cultural, and financial issues, and hence are more managerial than technical. Participants drew on lessons from experience and research in identifying important issues, action items, and recommendations to address the following: what “success” and “failure” mean, what contributes to making successful or unsuccessful systems, how to use failure as an enhanced learning opportunity for continued improvement, how system successes or failures should be studied, and what AMIA should do to enhance opportunities for successes. The workshop laid out a research agenda and recommended action items, reflecting the conviction that AMIA members and AMIA as an organization can take a leadership role to make projects more practical and likely to succeed in health care settings.