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A Bucket Full of Numbers? An Insight to Hemodialysis Data Management Systems Kevin Lyons Fresenius Medical Care, Bad Homburg / Germany Slide 2 Topics Evolution of Hemodialysis Data Management SystemsEvolution of Hemodialysis Data Management Systems Potential PitfallsPotential Pitfalls A case for automatic data acquisitionA case for automatic data acquisition The Current State of the ArtThe Current State of the Art What should a modern IT system provide? What about the future?What about the future? Slide 3 Evolution The early days.The early days. Paper record. -Only option available. -Manual. -Difficult to evaluate trends. -Prone to tpyographical error. -Very short term use. -Limited contribution to patient care. Slide 4 Life Cycle of the Paper Record Slide 5 Evolution over 25 years19731998 Number of Patients 27000325000 Treatment time 18-24 hours per week 9-12 hours per week Dialysers Hollow fibre just a prototype Hollow fibre dominates QB/QD200-300/500 Up to 500/800 DialysateAcetateBicarbonate Dialysate delivery CentralIndividual Volume control Kuf and TMP Volumetric Staffing Few actions required Multiple complex actions Machines Relatively simple Highly complex with physiological or bio-feedback ReimbursementStraightforward Increasingly complex Computers Mainframes and Character terminals PCs with Pentium processors Adapted from Ronco C 2000 Slide 6 A case for a Database? A dialysis unit may collect several GB of data per year Device & machine data Pressure, conductivities, flows, temperatures, physiological data Other treatment information Symptoms, access documentation, hospitalizations Laboratory results Diagnosis Demographic information Drug prescription & intake Reference data (medications, diagnosis catalogues, ) It is hard to store/maintain this information without databases Slide 7 COMPUTERISE! Driving Forces towards Data Management Downward pressure on healthcare costs Steady increase in patient numbers Compliance to Standards E.g. DOQI Keeping abreast of technology Desire to become paperless Optimisation of Resources Sheer Volume of data to manage Sharing & Exchange of information Slide 8 Industry Responds.. Sample for illustrative purposes only Slide 9 Evaluation of Clinical Computing Systems as Used by DOPPS Participants Nurse Medical Manager Director Nurse Medical Manager Director Pleased with current system41%34% Need to add additional functions75%73% Need a new system45%55% Current system is very good at Patient care.37%33% Current system is very good at Monitoring quality and outcomes44%38% Sargent J 1999 Slide 10 Factors Limiting the Effectiveness of Computer Systems Purchasing system before needs are defined System does not meet the requirements Data collection and entry Management of collected data is complex Lack of a friendly interface Reporting not targeted to improving patient care levels Not upgradeable Lack of an ongoing training program / poor training Adapted from Ronco C 2000 Slide 11 0.00.51.01.52.0 35 36 37 38 T [C] t[h] Tven Tbody -100 0 0.00.51.01.5 2.0 t[h] E[kJ] modern dialysis machines are able to provide much more treatment information...0.00.51.01.52.0 35 36 37 38 T [C] t[h] Tven Tbody -100 0 0.00.51.0 1.5 2.0 t[h] E[kJ] Online plus System Slide 12 Other Medical Devices Can Provide Information too in principle, any device with an RS 232 or similar interface can pass on its measured parameters Slide 13 The Missing Link File Servers Workstations Slide 14 Table 1: Time needed to produce dialysis prescription using automated data acquisition compared to manual data entry Manual -v- Automated Measurements (1) Source: Rourke E et al. Man or Machine Slide 15 Blood Pressure Pre-Finesse 150/90 140/92 150/110 150/80 140/90 150/90 202/100 150/90 150/85 Blood Pressure Post-Finesse 191/110 212/89 196/99 210/104 188/89 214/105 191/89 169/84 175/84 190/110 Table 2: Comparison of 10 Blood Pressure readings taken by a patient immediately before the installation of Finesse and 10 automated readings produced immediately after the installation of the system Source: Rourke E et al. Man or Machine Manual -v- Automated Measurements (2) Slide 16 Figure 4 : Comparison of reported symptoms 3 months prior to, and 3 months after installation of Finesse Source: Rourke E et al. Man or Machine Manual -v- Automated Measurements (3) Slide 17 Benefits of a Data Acquisition System Real time treatment informationReal time treatment information Accuracy of recorded dataAccuracy of recorded data Patient reported Typographical Therapy given based upon patient statusTherapy given based upon patient status Burden of data collection greatly reducedBurden of data collection greatly reduced Facilitates Audit and AnalysisFacilitates Audit and Analysis Slide 18 Dialysis monitoring Nephro 7 Database Computer Aided Dialysis & Clinic Management Patient master dataDiagnosis Laboratory dataMedication Accounting Dialysis documentation Information Dialysis regime LaboratoryQuarterly updates AdministrationAnamnesis Outdoor clininc Insurance Dialysis prescriptionStored data Hardware interfacesMonitoring software Slide 19 Acquisition alone is not enough It can only be successful when implemented with the right database. Slide 20 What Characterises an Outstanding Data Management System? FunctionalityFunctionality Data presentation & analysis Integration of dialysis machines & medical devices -Advanced features (decision support, bio-feedback) Integration with other systems Slide 21 What Characterises an Outstanding Data Management System? Acceptance: The user likes to work with it, Acceptance: The user likes to work with it, Simplicity, usability and workflow Dont have to drastically change their way of working Training Please Confirm F60 With workflow: The work looks for the worker Where do I have to enter what?? Without workflow: The worker looks for the work Slide 22 Acceptance: Training is an ESSENTIAL element NEVER underestimate the importance of trainingNEVER underestimate the importance of training Create local experts via the TTT conceptCreate local experts via the TTT concept Ensure ALL relevant disciplines are involvedEnsure ALL relevant disciplines are involved Bilateral responsibilitiesBilateral responsibilities Slide 23 What Characterises an Outstanding Data Management System? Cost effectivenessCost effectiveness Benefit from changing technologies and competition Scalability Slide 24 Cost Effectiveness Profit from competition, be independent ofProfit from competition, be independent of Platform (AS400, PC, SUN, ) Database (DB2, Oracle, MS-SQL, ) Operating System (OS400, NT, Win9x, Solaris, ) Profit from changing Telecoms market, chooseProfit from changing Telecoms market, choose LAN, Frame-Relay, Internet, Dial-up, Profit from global developer community and use open and (license) free standardsProfit from global developer community and use open and (license) free standards Java, HTML, XML, Servlet, Internet (www, ftp, ) Slide 25 XML: Extended Mark-up Language THE data exchange format Non proprietary, widely supported (Microsoft, SUN, IBM, oracle, ) Standard also in the medical field (HL7) XML 15.02.2000 19:47:21 1926 9548 7784 4153 1093 15.02.2000 19:47:26 3529 681 8225 1808... Standard-Interface 150220001947211926954877840000415300324331093de34ar153 150220001947260000000035290581822500deas01808de34ar154... Human readable Vendor specific Slide 26 Cost Effectiveness: Scalability Dialysis unit Dialysis clinic Hospital Chain Workflow Warehouse Entire medical documentation Disease state management 1 PC 10 PCs 100 PCs 1000+ PCs Functional Scope Technical Scope Single doctor Machine integration National Healthcare Slide 27 Internet.. Whats so Special? For the very first time in history we have: Option to share information and to communicate without any restrictions by borders and locations - -Send: text (letters), pictures (x-ray), movies (echo), sounds - -Discuss: chat-rooms, news-groups - -Retrieve information: on-line databases & journals Standardised technology Chance to share common data: consistent, non-redundant, without lavish interfaces, shared by larger community, e.g. Several clinics Affordable by nearly everybody For the very first time in history we have: Option to share information and to communicate without any restrictions by borders and locations - -Send: text (letters), pictures (x-ray), movies (echo), sounds - -Discuss: via chat-rooms, news-groups - -Retrieve information: on-line databases & journals Standardised technology Chance to share common data: consistent, non-redundant, without lavish interfaces, shared by larger community, e.g. Several clinics Affordable by nearly everybody State-of-the-art clinical IT systems have to utilize these opportunities! Slide 28 Kevin Lyons Service & Training Manager Fresenius Medical Care Regional Office Middle East PO Box 3264 Dubai UAE Kevin Lyons Service & Training Manager Fresenius Medical Care Regional Office Middle East PO Box 3264 Dubai UAE Tel +9714 332 9317 Fax +971 332 9316 Mob +971506250443 E-mail: kevin_lyons@hotmail.com Tel +9714 332 9317 Fax +971 332 9316 Mob +971506250443 E-mail: kevin_lyons@hotmail.com Thank you for your attention Thank you for your attention