Current Clinical Displays: Good, Bad, and Ugly

Seth Powsner, MD
Prof of Psychiatry & Emergency Med
Faculty, Center for Med Informatics
Yale University School of Med
http://ycmi.med.yale.edu/people/powsner.html

Interactive Visual Exploration of Electronic Health Records
HCIL 2008 Symposium Workshop
May 30th, 2008, Friday, 9:30am-5:30pm

Background
	New Haven, Connecticut (http://www.cityofnewhaven.com/)
		between Boston & New York City
		~125,000 live in New Haven City
		~300,000 including surrounding communities
		~825,000 in New Haven County
		originally a colony and port, later an industrial center
		now an academic center
	Yale-New Haven Hospital -- YNHH (http://www.ynhh.org)
		~500,000 outpatient visits/year
		~100,000 emergency visits/year
		~  50,000 hospital discharges/year
		         944 beds
		primary teaching hospital for Yale University (http://medicine.yale.edu/)
	Emergency Department
		Level 1 Trauma Center
		100,000 visits / year
		    5,000 Psych Evals (8 Bed locked unit within ED)
		(TLC -- The Learning Channel "Trauma: Life in the ER" 2001
		http://tlc.discovery.com/fansites/trauma/episode/season6/06_06.html)

Current Clinical Systems -- better remember your password
	Hospital Inpatients
		Eclipsys CCSS aka TDS
			outgrowth of the Lockheed - El Camino Hospital system (1971)
			order entry and results reporting 
				100% computerized physician order entry since early 1990's
			some nurse charting
			feeds hospital billing
		Sunrise Clinical Manager (http://www.eclipsys.com/solutions/clinical_solutions.asp)
			phasing in to replace CCSS (2008.06.08 cutover)
		Synapse
			Diagnostic Imaging reports and images
			(http://www.fujimed.com/products-services/network-systems/default.asp?location=1&area=5&id=0&subid=0)
		SoftMed Chartview (http://www.softmed.com/products/pim/index.aspx)
			discharge summaries from ~1995 forward
			(online repository of transcriptions)
		Library references: Harrison's Internal Medicine, Micromedex,
				Up-to-Date, PubMed, etc, are used by everyone
			http://info.med.yale.edu/library
			http://www.ncbi.nlm.nih.gov/pubmed/
	Outpatient Clinics
		Centricity aka Logician EHR
			(http://www.gehealthcare.com/usen/hit/products/centricity_practice/emr_index.html)
			visit notes: clinicians type into templates
			problem & medication lists
			allows viewing of transcribed reports: Lab, Pathology, Diagnostic Imaging...
			can be accessed from inpatient wards
		clinic staff have access to inpatient systems above
	Emergency Department
		all the systems listed above when looking for data about old patients
		Lynx E/Map (http://lynxmed.com/software/emap.html)
			scanned images of ED visit pages since March 2005
				bar coded forms / templates are printed as each patient enters
				visit records are scanned shortly after patient leaves or is admitted
				scanners located at all nursing stations and in satellite ED
			clinicians chart by hand on each patient's forms
			visit record images are available throughout the Medical Center
			billing charges are coded off-site by "coders" view the electronic images
				(http://lynxmed.com/software/ecode.html)

Practical Implications for Hospital Clinicians
			(Faculty, Housestaff, Physician Assistants, APRN, etc)
	Must be able to use Pen, Paper, Windows, Internet Explorer
	Must log in and out of various systems
		Must use CCSS / Sunrise Clinical Manager constantly (orders, results)
		Hard to avoid using SoftMed for discharge summary dictation / correction
		Probably need to access Centricity or Lynx E/Map a few times a day
		In Primary Care, Obstetrics, Neurology, & Geriatrics Clinics,
			and also in Psychiatric Day Hospital, Centricity is used constantly
	But, all inpatient histories, physicals, progress notes are written long hand
		except for a small number of physicians and students who use word processing
			and print their notes for their charts

GOOD (from a visualization standpoint)
	can see X-ray, CT-scan, MRI images directly
	can see chronological visit lists
	can see spreadsheet and trend plots of lab data
	can see discharge summaries, pathology & radiology reports, and some charts notes online
	can see where your patients are coming from (Yahoo & Google Maps)
	occasionally patients bring typed medication lists
	None of this might be considered "visualization" in a human computer interaction lab,
		but it's way better than when I finished medical school in 1978.
	Panning or sliding up and down through 3-d CT & MRI reconstructions might be considered
		"visualization," but it's most often used 'cause the radiologist doesn't provide a
		key snapshot with his/her report.
	
BAD
	most clinical notes are hand written
	typed reports with bureaucratic formatting, ie, top of report is internal accession numbers
		clinical findings are at the end of the report
	routine use of tabbed, spreadsheet data display
	outline lists that expand & contract
	single sided printouts
	old, VT100 style displays

UGLY
	handwriting
		is not quite as bad as claimed
			it's often formulaic / stylistic so clinicians know what to expect
			modern forms allow a lot of "check-offs" so there may not be much text anyway
		some of it is awful, looks bad at any magnification-- fractal ugliness
		It's not just the doctors! Patients & Police & EMS write notes that can go into charts
	typing / printing
		can be as bad or worse than handwriting, if poorly formatted
		may be copied & pasted into wrong patient's chart
			(see Hartzband & Groopman. N Engl J Med. 2008 Apr 17;358(16):1656-8.
				http://content.nejm.org/cgi/content/extract/358/16/1656 )
	medical records are WORN storage devices-- written once, read never
		main exception is review to support / deny Medicare / Insurance charges
		most medical encounters are for short, self limiting conditions
		neither doctor nor patient care about most encounters a year later
		bureaucratic & legal issues loom larger than medical efficacy
	iconic interface design (often combined with tabs)
		wastes display space
		may have meaning only in the eye of the designer
		reminiscent of hieroglyphics
	the numbers -- big, so small inefficiencies accumulate quickly
		USA 2005 National Surveys
		  964,000,000 Office visits
		  115,300,000 Emerg Dept*
		    90,000,000 Hosp Amb
	      		          www.cdc.gov/nchs
		          *39.6 vists/100 people
		National Hospital Discharge Survey: 2004
			  35 million discharges  (5.7k hosp’ls)
			168 million days           (947k    beds)
			    4.8 day average stay
			119 discharges/1000 population
			    4.4 million heart disease
			    4.1 million childbirth
					www.cdc.gov/nchs  (www.aha.org)
	long way to go
		less than 1/3 of medical practices in US use EMR see
		Advance Data from Vital & Health Statistics
			Number 393 + October 26, 2007 
			Electronic Medical Record Use by Office-Based
			Physicians and Their Practices: United States, 2006
			by Esther S. Hing, M.P.H.; Catharine W. Burt, Ed.D.; and David A. Woodwell, 			Division of Health Care Statistics 
			http://www.cdc.gov/nchs/data/ad/ad393.pdf

Major Issues--
	What's really helpful in a medical encounter?
	What information / facts do doctors really consider?
	What's more important?
		underlying diagnostic challenge for individual case
			see How Doctors Think by J Groopman, Houghton Mifflin 2008
			http://www.houghtonmifflinbooks.com/catalog/titledetail.cfm?titleNumber=1036291
		process efficiency (for population as a whole)
			see Grove A. Efficiency in the Health Care Industries: A View From the Outside.
				JAMA 2005;294:490-492.
				http://www.ncbi.nlm.nih.gov/pubmed/16046656
		repair vs manufacture ?
				Powsner S. "Manufacturing vs repair" in health care.
				JAMA 2005;294(20):2580
				http://www.ncbi.nlm.nih.gov/pubmed/16304071
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