medical information management

8/15/2019 Medical Information Management

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A Quest to ImproveA Quest to Improve

performance inperformance in

congenital heartcongenital heartsurgery:surgery:

One medical teams effortOne medical teams effortto Achieve Informationto Achieve Information

ResonanceResonance

Redmond P. Burke MD

Chief, Division of Cardiovascular Surgery

The Congenital Heart Institute

IBM, Boca Raton, USA

2007


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As physicians, we were painfully aware that we were not on the cutting edge.As physicians, we were painfully aware that we were not on the cutting edge.

We can instantly search 6 billion web pages, and find anything on earthWe can instantly search 6 billion web pages, and find anything on earth


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.except your medical record..except your medical record.


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DisclaimersDisclaimers

Im an uncompensated founder of a database company known as Cardioaccess

I am an investor in Teges Inc. an Internet software manufacturing company

I do get paid to perform congenital heart surgery.

My television career is on hold.


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A little background: One out of everyA little background: One out of every

800 babies is born with a heart defect.800 babies is born with a heart defect.

We repair most

of these babiesin the first week

of life, when

their hearts are

smaller than

your thumb.


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Over the past decade, we

merged two Florida cardiac

centers into a single

cardiovascular program

providing state of the art care,

and created an international

referral center for those

suffering from congenital heartdisease.

The Congenital Heart Institute at Miami

Childrens Hospital and Arnold Palmer

Hospital


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Ten years ago, we asked ourselves a crucialTen years ago, we asked ourselves a crucial

question. Could we use Information Technologyquestion. Could we use Information Technology

to achieve a state of information resonanceto achieve a state of information resonancewithin our medical teams, allowing eachwithin our medical teams, allowing each

caregiver to:caregiver to:

Capture and share data in real timeCapture and share data in real time

Access data on demandAccess data on demand

Measure and report our clinical performance inMeasure and report our clinical performance in

real timereal timePractice evidence based medicine (use data toPractice evidence based medicine (use data tomake decisions)make decisions)

and test a critical hypothesisand test a critical hypothesis


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The HypothesisThe Hypothesis

That by achieving thisThat by achieving this

state of informationstate of information

resonance, we couldresonance, we could

continuallycontinually improve ourimprove ourclinical performance.clinical performance.


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When we began this effort to achieveWhen we began this effort to achieve

information resonance a decade ago, weinformation resonance a decade ago, we

faced several challengesfaced several challenges

TechnologyTechnology

Team SizeTeam Size GeographyGeography

TimeTime

AccessibilityAccessibility


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Web Technology was immatureWeb Technology was immature

Bandwidth was narrowBandwidth was narrow

Data storage capacity was smallData storage capacity was small

Web development tools wereWeb development tools were

clunkyclunky

Wireless web access was in fetalWireless web access was in fetaldevelopmentdevelopment

You could not get smarter byYou could not get smarter by

logging in to the Internet at alogging in to the Internet at a

Holiday Inn ExpressHoliday Inn Express


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We had to integrate massive volumes of data in diverseWe had to integrate massive volumes of data in diverse

formats from isolated islands of information.formats from isolated islands of information.

Handwritten NotesHandwritten Notes

TeleconferencingTeleconferencing

E-mailE-mail

Digital ImagesDigital Images

Reference MaterialsReference Materials

DatabasesDatabases

Patient MonitorsPatient Monitors

Angiography andAngiography and

EchocardiographyEchocardiography

StudiesStudies

MRIMRI


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We had a very large, and growing, teamWe had a very large, and growing, team


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We needed to stay connected with geographically remote patients andWe needed to stay connected with geographically remote patients and

team membersteam members

Cardiac team members travel frequentlyCardiac team members travel frequently

Patients are referred to high volume centers from remote locations: Blue dotsPatients are referred to high volume centers from remote locations: Blue dotsrepresent patients.represent patients.


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We needed access to critical data minute by minute at the point of care,We needed access to critical data minute by minute at the point of care,

and year by year over our patients lifetimesand year by year over our patients lifetimes

Pediatric heart patients frequently requirePediatric heart patients frequently require

multiple staged procedures over timemultiple staged procedures over time

Newborn baby with

HLHS s/p Stage 1

Now 4 months

old s/p BDCPA

Next procedure

in 3 years


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We needed real time access to medical records to manage patients withWe needed real time access to medical records to manage patients with

complex problems,complex problems,

and the patients needed that access too.and the patients needed that access too.

What do you do when yourWhat do you do when your

child with complex congenitalchild with complex congenital

heart disease gets sick onheart disease gets sick on

vacation?vacation?

Do you bring a copy of his

medical record with you?


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Fortunately, when I arrived in Miami in 1995 to start thisFortunately, when I arrived in Miami in 1995 to start this

congenital heart program, we inherited a sophisticated networkcongenital heart program, we inherited a sophisticated network

based on the gold standard for medical information exchange:based on the gold standard for medical information exchange:


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How do you encourage technology innovationHow do you encourage technology innovation

and enhance adoption in a medical environment?and enhance adoption in a medical environment?

In 1996, we incorporated aIn 1996, we incorporated a

technology expert into thetechnology expert into the

cardiac team.cardiac team.

He got to know each teamHe got to know each team

member, and the types of datamember, and the types of data

they used.they used.

We encouraged him to shareWe encouraged him to share

the teams philosophy andthe teams philosophy and

goals, and to push technologygoals, and to push technology

to achieve them.to achieve them.


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We didnt let him operate, but he worked side by side with us from day one.


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And we began a journey together.And we began a journey together.

We knew we wanted to measure our performance from dayWe knew we wanted to measure our performance from day

one, so we initially built a PC based relational database,one, so we initially built a PC based relational database,

CardioAccess,CardioAccess,and grew to hate it.and grew to hate it.

You couldnt access it remotelyYou couldnt access it remotely

You had to enter all the data manuallyYou had to enter all the data manuallySupport was horribleSupport was horrible

You had to be an expert to use itYou had to be an expert to use it

It had no image storage capabilityIt had no image storage capability

Updates took forever to develop and installUpdates took forever to develop and install

You had to install it on every computer you might useYou had to install it on every computer you might use

Using strict medical terminologyUsing strict medical terminology

It sucked.It sucked.


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We thought a web based database wouldWe thought a web based database would

address these deficienciesaddress these deficiencies

The system could be accessedThe system could be accessed

anywhere, any time, with any webanywhere, any time, with any web

enabled device.enabled device.

The GUI could be designed toThe GUI could be designed to

enhanceenhance

decision makingdecision making

Edward Tuftes PrinciplesEdward Tuftes Principles

Key clinical data at a glance.Key clinical data at a glance.

Picture superiority effect:Picture superiority effect:

data is centered arounddata is centered arounda daily patient image.a daily patient image.


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And we lucked out, thanksAnd we lucked out, thanks

to Al Gore and Siliconto Al Gore and Silicon

Valley, the Internet andValley, the Internet and

web technology exploded.web technology exploded.

By 2001, 40 percent ofBy 2001, 40 percent of

physicians used thephysicians used the

Internet, and in 2002, thisInternet, and in 2002, this

increased to 78 percent.increased to 78 percent.

Cimino JAMIACimino JAMIA

These advances in web based technology allowed

us to invent Internet Rounds


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Internet Rounds is a web based version of traditional forms ofInternet Rounds is a web based version of traditional forms of

medical information exchangemedical information exchange

Teaching RoundsTeaching Rounds

Grand RoundsGrand Rounds

Work RoundsWork Rounds

Card RoundsCard Rounds

Walk RoundsWalk Rounds

Time of DayTime of Day

RoundsRounds

Attending RoundsAttending Rounds

TelemedicineTelemedicineRoundsRounds

Robotic RoundsRobotic Rounds
http://www.hippocritis.com/index_files/odor1.jpghttp://images.google.com/imgres?imgurl=http://www.humc.edu/calendar/images/xround70.gif&imgrefurl=http://www.humc.edu/calendar/caoct.html&h=151&w=181&sz=12&tbnid=Z1vmREG7GVza-M:&tbnh=80&tbnw=96&hl=en&start=5&prev=/images%3Fq%3Dphysician%2Brounds%26svnum%3D10%26hl%3Den%26lr%3Dhttp://images.google.com/imgres?imgurl=http://mednews.stanford.edu/stanmed/2002fall/story-images/bedside-teaching.jpg&imgrefurl=http://mednews.stanford.edu/stanmed/2002fall/demystifying_teaching.html&h=161&w=200&sz=7&tbnid=2Jvwds-nvbBZ-M:&tbnh=79&tbnw=99&hl=en&start=8&prev=/images%3Fq%3Dphysician%2Brounds%26svnum%3D10%26hl%3Den%26lr%3Dhttp://images.google.com/imgres?imgurl=http://www.nubar.com/realstock_images/h012-27.jpg&imgrefurl=http://www.nubar.com/realstock/h012-27.html&h=296&w=432&sz=31&tbnid=hcwGDzXR5sxT3M:&tbnh=84&tbnw=123&hl=en&start=14&prev=/images%3Fq%3Ddoctors%2Brounds%26svnum%3D10%26hl%3Den%26lr%3D%26sa%3DGhttp://images.google.com/imgres?imgurl=http://beckerexhibits.wustl.edu/gh21/images/bottompib.jpg&imgrefurl=http://beckerexhibits.wustl.edu/gh21/&h=165&w=200&sz=10&tbnid=jaDWEiGLKYRQvM:&tbnh=81&tbnw=99&hl=en&start=15&prev=/images%3Fq%3Ddoctors%2Brounds%26svnum%3D10%26hl%3Den%26lr%3D%26sa%3DGhttp://images.google.com/imgres?imgurl=http://www.simdot.org/simblog/images/jmn40165f1-1.jpg&imgrefurl=http://www.simdot.org/simblog/archives/2005/01/&h=560&w=400&sz=44&tbnid=UGpf8oJyQjvM0M:&tbnh=131&tbnw=93&hl=en&start=1&prev=/images%3Fq%3Dphysician%2Brounds%26svnum%3D10%26hl%3Den%26lr%3D%26sa%3DG


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Internet rounds, sharing patient information over the WWWInternet rounds, sharing patient information over the WWW

Video of I-rounds login from a moving vehicle in theVideo of I-rounds login from a moving vehicle in the

mountains outside Tokyo, Japan in July, 2002.mountains outside Tokyo, Japan in July, 2002.

d i ll d h i f


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Data was captured automatically or entered at the point ofData was captured automatically or entered at the point of

care.care.Using progressive disclosure (Amazon/Yahoo) gave us rapid access to comprehensiveUsing progressive disclosure (Amazon/Yahoo) gave us rapid access to comprehensive

clinical informationclinical information


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By 2004, we were able to virtually round on ourBy 2004, we were able to virtually round on our

patients in two cites at the same time. We could dopatients in two cites at the same time. We could do

rounds right now.rounds right now.

https://irounds.orhs.org https://irounds.mch.com
https://irounds.orhs.org/https://irounds.mch.com/https://irounds.mch.com/https://irounds.orhs.org/


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Despite this unprecedented access toDespite this unprecedented access to

information, we were still not exploiting the fullinformation, we were still not exploiting the full

potential of our system.potential of our system.

We were able to capture clinical informationWe were able to capture clinical information

automaticallyautomatically

We were able to remotely access data on demand inWe were able to remotely access data on demand in

the most complex situationsthe most complex situations

But we were still making up answers to importantBut we were still making up answers to important

questionsquestions


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When a family asked: What are your results for thisWhen a family asked: What are your results for this

operation? the response was something like:operation? the response was something like:

well, the published resultswell, the published results

for this operation arefor this operation are

the last time our fellowsthe last time our fellows

looked that uplooked that up

great, I cant remember thegreat, I cant remember the

last time we lost onelast time we lost one

as good as or better thanas good as or better than

Boston/Philadelphia/theBoston/Philadelphia/the

local competitionlocal competition

O f i i h h l k f i i l d


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Our frustration with that lack of precision led us toOur frustration with that lack of precision led us to

take a critical step.take a critical step.

We linked our electronic medical record (each patients legal medical record) to aWe linked our electronic medical record (each patients legal medical record) to a

web based outcomes reporting platform, and made it visible toweb based outcomes reporting platform, and made it visible to everyoneeveryone..

This changed our performance assessment from an episodic, historical exercise, to aThis changed our performance assessment from an episodic, historical exercise, to a

transparent, continuous real-time evaluation tool.transparent, continuous real-time evaluation tool.

http://www.pediatricheartsurgery.com
http://www.pediatricheartsurgery.com/http://www.pediatricheartsurgery.com/


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the technology enables us to base daily clinical decisions onthe technology enables us to base daily clinical decisions onactual data.actual data.

A recent conference scenario -A recent conference scenario -

A newborn baby presented with a complex defect, and one of the cardiologistsA newborn baby presented with a complex defect, and one of the cardiologists

asked if we should do the traditional open surgery, or try a new interventionalasked if we should do the traditional open surgery, or try a new interventional

procedureprocedure

We used our Web based research tool to retrieve the data on every one of ourWe used our Web based research tool to retrieve the data on every one of our

patients who had undergone these procedures in the previous 4 years, and reviewedpatients who had undergone these procedures in the previous 4 years, and reviewed

our actual experienceour actual experience

https://irounds.mch.com

When the decision was made, everyone

had confidence in the process.
https://irounds.mch.com/https://irounds.mch.com/https://irounds.mch.com/


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Our web base information system now allows us to preciselyOur web base information system now allows us to precisely

answer performance questions from families.answer performance questions from families.

And ironically, it turns out that theAnd ironically, it turns out that the

Federal government and otherFederal government and other

payors for health care, increasinglypayors for health care, increasingly

insist that medical teams doinsist that medical teams do

exactly that, measureexactly that, measure

performanceperformance

Or they wont pay you


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Every endeavor characterized by intense effort to achieve incremental improvementsEvery endeavor characterized by intense effort to achieve incremental improvements

over time depends on accurate, real time performance measurement.over time depends on accurate, real time performance measurement.

If you told this swimmer his practice times a year after each practice, could he improve?

Beyond helping us answer questions and make decisions, we reallyBeyond helping us answer questions and make decisions, we really

wanted performance measurement to improve our outcomes.wanted performance measurement to improve our outcomes.


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CurrentCurrent outcomes reporting for medical care is aoutcomes reporting for medical care is a

combination of archeology and cryptography.combination of archeology and cryptography.

The Society ofThe Society of

Thoracic SurgeonsThoracic Surgeons

Database: (2002-Database: (2002-

2005) Programs from2005) Programs from

the USA and Canadathe USA and Canada

are Ranked byare Ranked by

Mortality.Mortality.

The data is years old.The data is years old.

And its all a bigAnd its all a big

secret.secret.

MCH secret identity: BL


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0

20

40

60

80

100

120

0 500 1000 1500 2000 2500 3000 3500

Case Number

MortalityNumb

We are trying to envision the Next Generation of Real TimeWe are trying to envision the Next Generation of Real Time

Performance Measures:Performance Measures:

CUSUM Mortality: MCH 6/95-4/06CUSUM Mortality: MCH 6/95-4/06

GDT*

* :last case as of 4/20/06 4% mortality 2% mortality


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This concept rapidly moved fromThis concept rapidly moved from

design to live, and four years ago,design to live, and four years ago,we became the first medical teamwe became the first medical team

to measure and report ourto measure and report our

outcomes in real time on the Web.outcomes in real time on the Web.

www.pediatricheartsurgery.comwww.pediatricheartsurgery.com
http://www.pediatricheartsurgery.com/http://www.pediatricheartsurgery.com/http://www.pediatricheartsurgery.com/


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Advantages of Real-time PerformanceAdvantages of Real-time Performance

Measurement and ReportingMeasurement and Reporting

You can motivate a team to improveYou can motivate a team to improve

Performance feedback is a powerful motivating force.Performance feedback is a powerful motivating force.

You can create a foundation for evidence based decisions for your team, forYou can create a foundation for evidence based decisions for your team, forreferring physicians, and for patients.referring physicians, and for patients.

Referrals can be based on results, not program volume or personal bias.Referrals can be based on results, not program volume or personal bias.

You can improve data accuracyYou can improve data accuracy

Yearly reports by Congenital Heart Programs may under-report mortality by as much asYearly reports by Congenital Heart Programs may under-report mortality by as much as20% BMJ20% BMJ

Because these web based reports are always visible, they can be validated remotely byBecause these web based reports are always visible, they can be validated remotely bypatients, referring physicians and governing bodies.patients, referring physicians and governing bodies.


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We recently expanded our information networkWe recently expanded our information network

to include our patients and families.to include our patients and families.

I-Rounds Family Edition: to our knowledge, the first WebI-Rounds Family Edition: to our knowledge, the first Web

based electronic medical record for patients and familiesbased electronic medical record for patients and families

allowing them access to their hospital data and images.allowing them access to their hospital data and images.

www.pediatricheartsurgery.comwww.pediatricheartsurgery.com

B incl ding patients and families in o rBy including patients and families in our
http://www.pediatricheartsurgery.com/http://www.pediatricheartsurgery.com/http://www.pediatricheartsurgery.com/


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By including patients and families in ourBy including patients and families in our

medical information network, we canmedical information network, we can

leverage Metcalfs Lawleverage Metcalfs LawThe power of an information network is proportional to the square of the number of

users.


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i-Rounds Family Editioni-Rounds Family Edition

Patient Access EMRPatient Access EMR

Providing patients with web based access toProviding patients with web based access to


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Providing patients with web based access toProviding patients with web based access to

their medical record is a tremendoustheir medical record is a tremendous

opportunity.opportunity.Worldwide networks could develop between patientsWorldwide networks could develop between patientswith similar problemswith similar problems

Feedback from caregivers to patients could be used toFeedback from caregivers to patients could be used toimprove compliance with treatment plans (did youimprove compliance with treatment plans (did youtake your medicine today?)take your medicine today?)

Feedback from patients to caregivers could be used toFeedback from patients to caregivers could be used toimprove team performance and increase patientimprove team performance and increase patient

satisfactionsatisfactionWe could not have predicted the pattern of use weWe could not have predicted the pattern of use wehave seen with our first version of the patient accesshave seen with our first version of the patient accessrecordrecord


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Pattern of Utilization of Web Based MedicalPattern of Utilization of Web Based Medical

Record by Patients and Families: 2007Record by Patients and Families: 2007

Logins by Month (Patient and Families Only)

0

20

40

60

80

100

120

140

160

9/1/2006 10/1/2006 11/1/2006 12/1/2006 1/1/2007

Page Views

0 50 100 150 200 250 300 350 400 450 500

Patient Photos

Operative Images

History and Physical

Report

Patient Care Instructions

28 Families have now been signed up and have generated over

a thousand page views in 4 months.


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ConclusionsConclusions

A web based information management system hasA web based information management system has

been developed for a multi-disciplinary medicalbeen developed for a multi-disciplinary medical

team.team.

The system was rapidly and widely adopted byThe system was rapidly and widely adopted byour team, and is now available to our patients andour team, and is now available to our patients and

their families.their families.

Real time medical performance measurement canReal time medical performance measurement can

be achieved now, and has been our standardbe achieved now, and has been our standard

practice for the past four years.practice for the past four years.

medical information management

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