3 rd Generation Hospital Information Systems (HIS) From Information Processing to Workflow Management

Transcription

1 1 3 rd Generation Hospital Information Systems (HIS) From Information Processing to Workflow Management 13-May-2014 Dr. Siegfried Bocionek Page 1

2 Content 2 Motivation Design goals for modern Hospital Information Systems Functionality Technology basis and System Architecture Where is this all going? Page 2

3 Solve the Management Equation of all Industries: Do more with less 3 Quality of Care Cost of Care By Innovation Process optimization Page 3

4 Re-engineering of Healthcare Processes 4 Physician Order MAR Transcription Nurse Review Chart copy sent to Pharmacy Medication Errors in the U.S.*: Ordering Transcription Administration Documented Dispensing Administration Order Entry (Rx System) Medication Administered Nurse confirms drug, dose, route, time, patient Medication Dispensed Pharmacist Verification * Data of 2001 Page 4

5 Optimized Medication Management 5 Physician Order Administration Documented Process simplification to reduce medication errors. With COE*, barcodes, and an automated dispenser robot system. And all data available for later evaluation. Pharmacist Verification Nurse confirms drug, dose, route, time, patient Medication Dispensed * COE = Computerized Order Entry Page 5

6 Positive Impact* of Clinician Order Entry on costs, quality and compliance (examples) 6 Medication turn around time (Order entry to Med. Admin.) 100% -66% Lenght of stay (e.g. renal transplant) 100% -21% 79% 34% Efficiency Conv. COE Conv. COE Costs Verbal orders/co-signature +44% 99% Total transcription errors 26% Costs -100% 55% Conv. / cosigned COE / cosigned Safety Conv. 0% COE *Efficiency study; OHIO State University Health System Page 6

7 Target: ALL Business Processes in Healthcare 7 Modalities Payor connectivity EDI Billing Physician connectivity Pract. Mgmt Patient connectivity Homecare schedule Admin Cycle bill Diagnostic Cycles Rad,Card RIS, CIS, Lab xis, Lab, Rx ADT ECG POE... Enterprise HIS ADT Clinical Cycle document ICU Ward... Care Cycles Monitors Therapeutic Cycles Surgery, Oncology, Modalities Page 7

8 Content 8 Motivation Design goals for modern Hospital Information Systems Functionality Technology basis and System Architecture Where is this all going? Page 8

9 Target: ALL Business Processes in Healthcare 9 Modalities Payor connectivity EDI Billing Physician connectivity Pract. Mgmt Patient connectivity Homecare schedule Admin Cycle bill Design Goals: Diagnostic Cycles Rad,Card RIS, CIS, Lab xis, Lab, Rx ADT ECG POE... - Workflow Automation - Performance Optimization - Workplace Ergonomics - Enterprise System Integration HIS - Quality á, Cost â ADT Clinical Cycle document ICU Ward... Care Cycles Monitors Therapeutic Cycles Surgery, Oncology, Modalities Page 9

10 10 Workflow Automation Page 10

11 Patient Management Example: Bed Turnaround Process 11 7 Pharm notified 8 Dietary notified 9 Resp notified 6 Pharm fills d/c Rx's 3 Nurse review orders 4 Nurse d/c process 11 Patient education 12 Transport notified 13 Pt out of room 2 Nurse notified 5 Family notified 10 Family arrives Patient Discharge 1 Hospital Discharge Order Room refresh Room assignment 17 Room queued 14 Housekeeping advised 18 Nursing supervisor notified 15 Housekeeping notified 19 Nurse assigned 16 Room cleaned 20 Notify admitting 21 Notify ER Handoffs Bed turnaround Page 11

12 12 Bed Turnaround Process: Modeled with workflow tool Page 12

13 13 Workflow Management System automatically triggers tasks: - Complete Final Diagnosis for Mr. Voss - Start Discharge Summary - Inform pharmacy to package discharge medication - Trigger nurse to prepare patient for going home, call relatives - Inform housekeeping to clean room and turnover bed Page 13

14 Clinical Example: Microbiology Responsiveness 14 Prolonged antibiotic / sensitivity mismatch Resistance emergence Higher morbidity Higher costs Failure to react to resistant strains Nosocomial infections Plasmid transference MRSA 10% mortality $31,000 avg. case cost Sequential multi-departmental process MRSA = Multi-Resistent Staphylococcus Aureus (Krankenhauskeim) Page 14

15 15 Page 15 Objective: automatically trigger isolation measures in case of MRSA 2014 Siegfried or Bocionek, VRE suspicion 13-May-2014

16 Case Study with US Clinic: Predicted Clinical Benefits 16 Page 16

17 17 Workplace Ergonomics Page 17

18 Multi-Workstation or Multi-Work Station? 18 Page 18

19 Workplace integration, easy access Desktop Integration 19 Biometric Identification Web Access Everywhere Patterson, Patterson, Maria L. Date of Birth: 02/06/1932 Mobility Page 19

20 Smart User Interface 20 Browser Based Universal Access Basis for Integration Easy Deployment Graphical Design Intuitive Easy to Use Consistent Process Efficiency Workflow based screens Actionable Contextual Provider Task Patient Page 20

21 21 System Integration Page 21

22 Knowledge based Clinical Process Automation 22 Optimized Processes Process Design & Automation Level Of Knowledge Aggregation Best Practices Repository Rules Engine Care Plans Smart Orders Order Sets Guidelines, Pathways Advanced Clinical Decision Support Normalized content Integrated Infrastructure Page 22

23 Content 23 Motivation Design goals for modern Hospital Information Systems Functionality Technology basis and System Architecture Where is this all going? Page 23

24 High-level Application Structure of a modern HIS 24 Common Workflow-Based Web UI Global Registration Care Management Revenue Management Image Access Enterprise Scheduling External Solutions Connectivity to Devices and networks Service & Object-Oriented Application Architecture Page 24

25 Workflow Automation: Example Alerts in Worklists 25 Alerts critical notifications Page 25

26 - Workflow = Coordinated Activities - Step = Worklist Item = Activity 26 Available step Actions STEP Page 26

27 WfMS items are presented on work lists 27 Notification/Alert (at discharge) Page 27

28 28 Page 28

29 Nurse is Alerted to decide on Action 29 Page 29

30 Doctor is Alerted to decide on Order 30 Action (consider discontinue Filgrastim) Page 30

31 Further examples of Automated Workflows (Hospitals are starting to exchange their WF models) 31 Page 31

32 Content 32 Motivation Design goals for modern Hospital Information Systems Functionality Technology basis and System Architecture Where is this all going? Page 32

33 Basis: Multi-tier Web architecture 33 Web Client Web Server Presentation Tier Event Manager Application Tier App Server EMPI Schedling Clinical Workflow Patient Mgmt Lifetime Record Image Mgmt Financial Workflow DB Server Database Tier Page 33

34 Typical Server Configuration (can be virtualized, e.g. on mainframe, for hosted services or Clouds) 34 Web Clients Integration Engine External Systems Multi-entity Database Servers (SAN, NAS) Web Servers Application Server Farm Output Management Server Page 34

35 Integration Engine helps Define Migration Paths à Interfacing via HL7, DICOM 35 EPR = Electronic Patient Record Page 35

36 Example: Cardiologist Exam Workstation 36 Cath Network Cath Reports Cath Data Cath Lab Echo Echo Reports Echo Data Rest EKG EKG Mgmnt System Cardiology workplace EKG Reports EKG Data EP Lab EP Reports EP Data Stress Lab Lab Results Registration Tracings Nuclear Reports Nuclear Data Nuclear and Post-processing Cardiovascular Surgery Page 36

37 Single Sign-on, Security, Context Sharing (via General Session Manager) 37 ECG Hemo Images Bla bla bla Bla bla bla Bla bla bla Bla bla bla Cardiac Exam Web-based Integrated Cardiac Exam Workplace ECG Server HIS Servers HL7 - DICOM GSM/Context Mgmt. Server Authentication / Authorization DICOM Imaging workstation HIS Database PACS Archive PACS/RIS workstation Page 37

38 Integration of a Workflow Engine 38 Workspace Manager (Common UI Framework) External Communication Engine MXS* MXS* Service Broker Messaging API Event Manager Business Layer Elect. Medical Record Patient ADT Financials Activity Handling Schedling Common Healthcare Objects Database Tier Event Management Worklist Clinical Documentation Clinicals Security Management Order & Results Invision LCR Persistence Framework Medication Rules Engine Predefined Clinical Documents Statistics & Research Common Tools Document Management Data Versioning * MXS = Message Exchange Services Page 38

39 Rules Engine and Workflow Engine 39 Page 39

40 Difference Rules Engine WF Engine 40 Rules Engine Has no process context Cannot readily synchronize parallel paths Cannot visualize process flows Would need many complex rules to implement workflows rule + rule + rule = mess Is simply the wrong tool for the job BETTER: Use rule as step in a workflow Page 40

41 Rules can be utilized for decisions & branching within the workflow definitions - Example: Stroke Management 41 order CT service in RIS Condition can be evaluated by the Rules Engine TPA = Tissue plasminogen activator CVA = Cerebrovascular Accident (Stroke) Page 41

42 Typical Trigger Events for the WfMS 42 Save Patient Registration Save New Patient Registration Receive a Patient Registration Save Visit Information Save New Visit Information Patient Transfer Patient Discharge Chart an Assessment Receive a Result Save a Result Select a Service Administer a Med Sign an Order Page 42

43 Typical Actions 43 Merge Patient Records Move Patient Visit Display Results View Visit Overview Route/Print Report Place an Order Sign an Order Display Result Detail Discontinue an Order Enter a Comment Link to a URL Trigger a Workflow Enter an alert or notification Initiate an A28 Transaction Display a Form Page 43

44 44 Technical Design Considerations Page 44

45 Design Considerations: Scalability and Portability 45 A typical HIS needs to be embedded in IT infrastructure Connectivity to ERP system Interoperability with legacy systems Utilize available campus licenses (OS, DB, others) Various operational models (in-house, outsourced, remote/cloud) Scalability depends on customer specifics From small country hospital to 100+ hospitals chain National healthcare systems Page 45

46 Performance Targets 46 Scalability Portability Costs Fast access for up to users (sub sec response time) Choice (HW, OS, DB) Easy migration from legacy systems Easy to extend / update High availability > 99.99% Compatibility Connectivity to other applications Page 46

47 Need: Support all Standard Technologies 47 Web Server OpenSource / Apache MS IIS Scalability App Server OpenSource / TomCat COM+/.NET Portability Middleware DB WebSphere Other JEE None.NET DB2 / UDB Oracle SEQEL Costs OS OS390 Linux AIX Solaris OS400 WIN Compatibility Hardware IBM390 RS6000 SUN AX400 INTEL Page 47

48 JEE middleware good candidate for application architecture 48 messaging Service Layer (SOA) Web Services CAE SVCS Façade Façade Façade EJB EJB EJB Business Logic Workflow Engine Transactions Mail Messaging Connectors Security Directory JEE Platform Database XML DB Server (Sequel, Oracle, DB2) e.g. IBM Websphere Security Auditing Messaging Logging Common Components Operating System (Unix, Windows, Mainframe) Page 48

49 Enterprise Architecture - Infrastructure (Example) 49 Page 49

50 50 Enterprise Architecture Enterprise Integration (Example) Page 50

51 Cloud Configurations (formerly data centers J) 51 Web Clients Firewall Web Servers Firewall Application Server DB Server Intranet Client Legacy Layer Page 51

52 Design for Scale Example (~ 2004): Hongkong Health Surveillance Concept (SARS) Workflow Process Efficiency / Effectiveness, Risk & Outcomes Report Generation Report Dissemination Web Publishing Notification Trending Analytical Real Time Data Filter Data Transform Internal to Organization Automated Analysis Health Surveillance Data Repository External Organizations Risk & Outcomes World Health Organization Cancer Registries Specialty Societies Chronic Disease Surveys Injury Reporting Behavioral Risk Factor Reporting 52 Real Scale - 44 hospitals - 27,000 beds Data Capture Data Filter Data Transform Health Surveillance Engine Health Surveillance Engine Data Requirements Collection Entry Editing - Storage Firewall: De-identification as needed; Re-identification on return Page 52 Clinical Information CMS System Medical Groups Elderly Homes External Data Sources Private Physicians

53 53 Elderly Homes Medical Groups Laboratory Results Templates SARS-specific reporting Other communicable disease reporting Private Physicians Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Page 53

54 Content 54 Motivation Design goals for modern Hospital Information Systems Functionality Technology basis and System Architecture Where is this all going? Page 54

55 All brought together in a Digital Hospital 55 Information Technology Medical Infrastructure Page 55

56 Patients Connected to the Hospital 56 Small portabel (holter) ECGs Multi parameter recordes "Telecare" by video "Measure & enter devices Page 56

57 57 With WebCam connection of the patient to the family at home... and vice versa... Page 57

58 A Place, Patients Will Love To Stay With Internet connection, VoIP* and EoIP** stuff in every room... * VoIP = Voice over IP ** EoIP = Entertainment over IP Page 58

59 59 Thank you very much for your attention Siegfried Bocionek, Martin Dugas: Hospital Information Systems Page 59