3rd Generation Hospital Information Systems (HIS) From Information

Transcription

1
3rd Generation Hospital Information
Systems (HIS)
From Information Processing to
Workflow Management
13-May-2014
Dr. Siegfried Bocionek
Page 1
©2014 Siegfried Bocionek, 13-May-2014
Content
2
n Motivation
n Design goals for modern Hospital Information Systems
n Functionality
n Technology basis and System Architecture
n Where is this all going ?
Page 2
Solve the “Management Equation” of all
Industries: Do more with less …
Quality
of Care
By
Page 3
3
Cost
of Care
Innovation
§ Process optimization
§
Re-engineering of Healthcare Processes
Physician
Order
Administration
Documented
Medication
Administered
4
Chart copy
sent to
Pharmacy
Nurse
Review
MAR
Transcription
Medication Errors in the U.S.*:
Ordering
Transcription
Dispensing
Administration
Nurse confirms drug,
dose, route, time, patient
Medication
Dispensed
Order Entry
(Rx System)
Pharmacist
Verification
* Data of 2001
Page 4
Optimized Medication Management
Physician
Order
Administration
Documented
5
Process simplification to reduce
medication errors. With COE*,
barcodes, and an automated
dispenser robot system.
And all data available for later
evaluation.
Nurse confirms drug,
dose, route, time, patient
Pharmacist
Verification
Medication
Dispensed
* COE = Computerized Order Entry
Page 5
Positive Impact* of Clinician Order Entry on costs,
quality and compliance (examples)
Medication turn around time
(Order entry to Med. Admin.)
Lenght of stay (e.g. renal transplant)
-21%
-66%
100%
6
100%
79%
34%
Conv.
Costs
Efficiency
COE
Conv.
Verbal orders/Co-signature
COE
Total transcription
errors
Costs
+44%
-100%
99%
26%
55%
Conv. / COE / cosigned
cosigned
Safety
Conv.
0%
COE
*Efficiency study; OHIO State University Health System
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Target: ALL Business Processes in Healthcare
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Modalities
Payor
connectivity schedule
EDI Billing
Physician
connectivity
Pract. Mgmt
Patient
connectivity
Homecare
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Diagnostic Cycles Rad,Card
Lab xIS, Lab, Rx
RIS, CIS,
ADT
ECG
POE
...
Therapeutic Cycles
Enterprise HIS
Surgery, Oncology, …
Clinical Cycle
Admin Cycle
ICU
document
Ward
ADT
bill
...
Care Cycles
Modalities
Monitors
Content
8
n Motivation
n Functionality
Page 8
Target: ALL Business Processes in Healthcare
9
Modalities
Diagnostic
Cycles Rad,Card
Design
Goals:
Payor
Lab xIS, Lab, Rx
connectivity schedule- Workflow Automation
RIS, CIS,
ADT
ECG
Performance
Optimization
POE
EDI Billing
...
Physician
connectivity
Pract. Mgmt
Patient
connectivity
Homecare
Page 9
- Workplace Ergonomics
-Enterprise
System Integration
HIS
- Quality á, Cost â
Clinical Cycle
Admin Cycle
ICU
document
Ward
ADT
bill
...
Care Cycles
Therapeutic Cycles
Surgery, Oncology, …
Modalities
Monitors
10
Workflow Automation
Page 10
Patient Management Example:
Bed Turnaround Process
7
Pharm
notified
6
Pharm
fills d/c
Rx's
2
Nurse
notified
8
Dietary
notified
11
9
Resp
notified
11
Patient
education
3
Nurse
review
orders
5
Family
notified
4
Nurse d/c
process
12
Transport
notified
13
Pt out of
room
10
Family
arrives
Patient
Discharge
1
Hospital
Discharge
Order
Room
refresh
Room
assignment
17
Room
queued
Page 11
14
Housekeeping
advised
18
Nursing
supervisor
notified
15
Housekeeping
notified
19
Nurse
assigned
16
Room
cleaned
20
Notify
admitting
Handoffs
Bed turnaround
21
Notify ER
12
Bed Turnaround Process: Modeled with workflow tool
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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
Clinical Example: Microbiology Responsiveness
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n Prolonged antibiotic / sensitivity mismatch
w Resistance emergence
w Higher morbidity
w Higher costs
n Failure to react to resistant strains
w Nosocomial infections
w Plasmid transference
w MRSA
§ 10% mortality
§ $31,000 avg. case cost
n Sequential multi-departmental process
MRSA = Multi-Resistent Staphylococcus Aureus (Krankenhauskeim)
Page 14
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Objective: automatically trigger isolation
©2014 Siegfried
13-May-2014
measures in case of MRSA
or Bocionek,
VRE suspicion
Case Study with US Clinic:
Predicted Clinical Benefits
Page 16
16
17
Workplace Ergonomics
Page 17
Multi-Workstation or Multi-Work Station?
Page 18
18
Workplace integration, easy access
19
Biometric
Identification
Desktop Integration
Web Access Everywhere
Patterson,
Patterson, Maria L. Date of Birth: 02/06/1932
Mobility
Page 19
Smart User Interface
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n Browser Based
w Universal Access
w Basis for Integration
w Easy Deployment
n Graphical Design
w Intuitive
w Easy to Use
w Consistent
n Process Efficiency
w Workflow based screens
w Actionable
n Contextual
w Provider
w Task
w Patient
Page 20
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System Integration
Page 21
Knowledge based Clinical Process Automation
Level Of Knowledge
Aggregation
Optimized Processes
Best Practices
Repository
Care Plans
Smart Orders
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Process Design
& Automation
Guidelines,
Pathways
Advanced
Clinical Decision
Support
Rules Engine
Order Sets
Normalized
content
Integrated
Infrastructure
Page 22
Content
23
n Motivation
n Functionality
Page 23
High-level Application Structure of a modern HIS
24
Connectivity to
Devices and networks
External Solutions
Enterprise
Scheduling
Image Access
Revenue
Management
Care Management
Global Registration
Common WorkflowWorkflow-Based Web UI
Service & Object-Oriented Application Architecture
Page 24
Workflow Automation: Example “Alerts in Worklists”
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Alerts
critical notifications
Page 25
- Workflow = Coordinated Activities
- Step = Worklist Item = Activity
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Available
step
Actions
STEP
Page 26
WfMS items are presented on work lists
27
Notification/Alert
(at discharge)
Page 27
28
Page 28
Nurse is Alerted to decide on Action
Page 29
29
Doctor is Alerted to decide on Order
30
Action
(consider
discontinue
Filgrastim)
Page 30
Further examples of Automated Workflows
(Hospitals are starting to exchange their WF models)
Page 31
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Content
32
n Motivation
n Functionality
Page 32
Basis: Multi-tier Web architecture
33
Web Client
Web Server
Presentation Tier
Event Manager
Financial
Workflow
Image
Mgmt
Lifetime
Record
Patient
Mgmt
Clinical
Workflow
Schedling
App Server
EMPI
Application Tier
DB Server
Database Tier
Page 33
Typical Server Configuration (can be virtualized, e.g. on
mainframe, for hosted services or Clouds)
Web Clients
34
Integration Engine
External
Systems
Web Servers
Application
Server Farm
Output
Management
Server
Multi-entity
Database Servers
(SAN, NAS)
Page 34
Integration Engine helps Define Migration Paths
à Interfacing via HL7, DICOM
35
EPR = Electronic Patient Record
Page 35
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Example: Cardiologist Exam Workstation
Cath Network
Cath Reports
Cath Data
Cath Lab
Echo Reports
Echo Data
Echo
Rest EKG
EKG Mgmnt
System
Cardiology
workplace
EKG Reports
EKG Data
EP Reports
EP Data
EP Lab
Stress Lab
Lab Results
Registration
Tracings
Nuclear Reports
Nuclear Data
Nuclear and Post-processing
Cardiovascular Surgery
Page 36
Single Sign-on, Security, Context Sharing
(via General Session Manager)
Bla bla bla
ECG
Bla
Bla bla
bla bla
bla
Hemo
Bla bla bla
Images
Bla bla bla
37
Web-based
Integrated Cardiac
Exam Workplace
Cardiac Exam
ECG
Server
HL7 - DICOM
HIS
Servers
Imaging
workstation
GSM/Context Mgmt. Server
Authentication / Authorization
HIS
Database
Page 37
DICOM
PACS
Archive
PACS/RIS
workstation
Integration of a Workflow Engine
Workspace Manager
38
External Communication
Engine
(Common UI Framework)
MXS*
Service Broker
MXS*
Messaging API
Event Manager
Common Healthcare Objects
Database
Tier
Event Management
Statistics & Research
Common
Tools
Medication
Rules
Engine
Order & Results
Invision LCR
Activity Handling
Schedling
ADT
Patient
Financials
Elect. Medical Record
Business Layer
Clinical Documentation
Clinicals
Worklist
Predefined Clinical Documents
Security Management
Persistence Framework
Document Management
Data Versioning
* MXS = Message Exchange Services
Page 38
Rules Engine and Workflow Engine
Page 39
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Difference Rules Engine – WF Engine
40
n Rules Engine
w Has no process context
w Cannot readily synchronize parallel paths
w Cannot visualize process flows
w Would need many complex rules to implement workflows
w “rule + rule + rule = mess”
w Is simply the wrong tool for the job
n BETTER: Use rule as step in a workflow
Page 40
Rules can be utilized for decisions & branching within the41
workflow definitions - Example: Stroke Management
order CT service in RIS
Condition can be evaluated by the Rules Engine
TPA = Tissue plasminogen activator
CVA = Cerebrovascular Accident (Stroke)
Page 41
Typical Trigger Events for the WfMS
42
n Save Patient Registration
n Chart an Assessment
n Save New Patient
n Receive a Result
Registration
n Receive a Patient
Registration
n Save Visit Information
n Save New Visit Information
n Save a Result
n Select a Service
n Administer a Med
n Sign an Order
n Patient Transfer
n Patient Discharge
Page 42
Typical Actions
43
n Merge Patient Records
n Discontinue an Order
n Move Patient Visit
n Enter a Comment
n Display Results
n Link to a URL
n View Visit Overview
n Trigger a Workflow
n Route/Print Report
n Enter an alert or
n Place an Order
n Sign an Order
n Display Result Detail
Page 43
notification
n Initiate an A28 Transaction
n Display a Form
44
Technical Design Considerations
Page 44
Design Considerations: Scalability and Portability
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· 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
Performance Targets
Scalability
46
· Fast access for up to
20.000 users (sub sec
response time)
Portability
· Choice (HW, OS, DB)
· Easy migration from
legacy systems
Costs
Compatibility
· Easy to extend / update
· High availability > 99.99%
· Connectivity to other
applications
Page 46
Need: Support all Standard Technologies
47
Web Server
OpenSource / Apache
MS IIS
Scalability App Server
OpenSource / TomCat
COM+/.NET
Middleware
WebSphere
Other JEE
None
.NET
Portability
DB
DB2 / UDB
Oracle
OS
OS390
Linux
Hardware
IBM390
RS6000
SEQEL
Costs
AIX Solaris OS400
WIN
Compatibility
Page 47
SUN
AX400
INTEL
JEE middleware good candidate for application
architecture
48
messaging Service Layer (SOA) Web Services
SVCS
CAE
Façade
Façade
Façade
EJB
EJB
EJB
Business Logic
Transactions
Mail
Security
Directory
Workflow
Engine
Messaging Connectors
Database
XML
JEE Platform
DB Server
(Sequel,
Oracle, DB2)
e.g. IBM Websphere
Security
Auditing
Messaging
Logging
Common Components
Operating System (Unix, Windows, Mainframe)
Page 48
Enterprise Architecture - Infrastructure (Example)
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49
50
Enterprise Architecture – Enterprise Integration (Example)
Page 50
Cloud Configurations (formerly data centers J)
51
Web
Clients
Firewall
Web
Servers
Firewall
Application
Server
DB
Server
Legacy Layer
Intranet
Client
Page 51
Design for Scale Example (~ 2004):
Hongkong Health Surveillance Concept (SARS)
External
Organizations
Workflow Process Efficiency / Effectiveness, Risk & Outcomes
Report Generation
Report Dissemination
Data
Filter
Data
Transform
Web Publishing
Email Notification
Trending – Analytical– Real Time
Risk & Outcomes
• World Health
Internal to
Organization
•
•
•
Automated Analysis
•
•
Health Surveillance Data Repository
Real Scale
- 44 hospitals
- 27,000 beds
Data
Capture
Data
Filter
Data
Transform
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Organization
Cancer Registries
Specialty Societies
Chronic Disease
Surveys
Injury Reporting
Behavioral Risk
Factor Reporting
Firewall:
De-identification as needed;
Re-identification on return
Health
Surveillance
Engine
Health
Surveillance Engine
Data Requirements
Collection– Entry – Editing - Storage
Clinical
CMS
Information
System
Page 52
Medical
Groups
Elderly
Homes
Private
Physicians
External Data Sources
53
Elderly
Homes
Private
Physicians
Medical
Groups
Templates
• SARS-specific reporting
• Other communicable
disease reporting
Laboratory Results
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Page 53
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Content
54
n Motivation
n Functionality
Page 54
All brought together in a Digital Hospital
55
Information Technology
Medical
Infrastructure
Page 55
Patients Connected to the Hospital
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n Small portabel (holter) ECGs
n Multi parameter recordes
n "Telecare" by video
n "Measure & enter“ devices
Page 56
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With WebCam
connection of
the patient to the
family at home ...
and vice versa ...
Page 57
A Place, Patients Will Love To Stay ...
58
With Internet
connection, VoIP*
and EoIP** stuff
in every room ...
* VoIP = Voice over IP
** EoIP = Entertainment over IP
Page 58
59
Thank you very much for your attention
Siegfried Bocionek, Martin Dugas: Hospital Information Systems
Page 59

3rd Generation Hospital Information Systems (HIS) From Information

Transcription

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