Clinical Information Systems Enabling Clinical Excellence

Date/Time:
Tuesday 12 March 2008

Speaker:
Dr Phillip Batin, Consultant Cardiologist

Description:

Dr Batin gave a most interesting talk, highlighting many key points in health informatics, having told us that he knows nothing of IT.

He went on to illustrate what he regards as “rocket science” and compared that to the paper based hospital medical records. He explained the legislative obligations to keep contemporaneous notes that are signed but also highlighted some of the problems associated with them.

Amongst these are:

  • The notes can only be in one place at any time - and need transporting to the patient’s location.
  • Only one person can access the notes at a time.
  • They are often long and therefore take time to read through to find the information that you need.
  • Extracting information from many sets of notes (e.g. for clinical audit or Government returns) is laborious and some information may be missed.

Audit is important in the clinical arena. It is used to assess, evaluate and improve upon the care of patients.

Dr Batin outlined where and how he thinks that clinical information systems can help at each stage of a patient’s journey from just after dialling 999 through admittance to hospital, investigations, procedures, discharge and follow-up in outpatients

Ambulance

Access to electronic records would help in getting the patient to the correct hospital within the area. Without this the patient is taken to the nearest hospital, where they are not known and where there are no notes. Also, if the paramedics had access to previous ECGs then they could compare the current one with these. This would help determine treatment - and the earlier treatment is started the greater the survival rate.

Admittance to hospital

Paper notes do not arrive at the same time as the patient. With a database of cardiac data, Accident and Emergency can look at the data already stored which helps with the initiation of prompt, effective treatment

Whilst in hospital

The system can help improve communications (within the ward, interdepartmental and with general medical practice), documentation of the case and ensuring completeness of data capture. This in turn helps with clinical audit. Efficiency is improved e.g. links between departments and a smooth discharge process can reduce the length of stay.

After discharge from hospital patient needs further investigations

The patient may need an angiogram. There is some special equipment that will show the strictures in the arteries and produce a film (of moving images). The film needs to be viewed by an interventionist at the regional centre. At the moment the details and the film are taken to the centre by physical means. The PACS system isn’t suitable as the images are moving but some form of electronic transfer of the images should be possible.

Discharge

Discharge There is a legible discharge summary (a lot are handwritten with a typed letter sent afterwards). The software helps ensure that the patient is discharged on the correct drugs – thanks to the mandatory fields (see below) and it has reduced the time taken to get the drugs from the pharmacy.

As the software is used it means that the discharge is coded. This means that the hospital will be paid for the episode of care and the amount of money should be appropriate.

The software

The software used records the information for an episode. The computer record helps provide continuity as staff change at shift changeover (e.g. morning staff and afternoon staff).

It has a series of “tabs”, one tab to collect clinical information, one to collect the history etc. This makes entering and retrieving the information quite quick. When entering data there are lots of drop down menus and lists which means that most of the data captured is auditable; there is very little free text.

It also means that entering data is quick and ensures consistency. Fields can be set as mandatory e.g. there must be justification if the patient is not discharged on aspirin - so the reason must be picked from a drop down list and the software will not allow the clinician to complete the discharge until a reason is selected. This rigorousness improves the quality of care.

However, the database is standalone - only his ward and certain other departments (e.g. A & E) have access to it so full hospital notes are needed as well and all the data in the database must be in the paper notes.

Pitfalls

There was a financial investment and then a further investment in time and money to incorporate the pathways into the software.

Staff training is a huge issue as is motivation because it does mean that all the information has to be duplicated (the paper notes and the database). The benefits outweigh this but people need to be shown the benefits. Dr Batin and a nurse have done all the training of other staff themselves. You need to bring enthusiasm and get the team behind the project.

Most IT issues are internal (e.g. network issues); there have been very few issues on the database side. For example, it crashed today in the middle of his ward round - so they reverted to paper.

Summary

The software supports the clinical process and facilitates appropriate and timely care. Audit results show improved outcomes for patient and for the hospital (ticks in boxes, payment by results). For example, the audits show a much higher level of appropriate drugs on discharge leading to an observed decrease in mortality of 7.5%.

The data can be used to support or repudiate statistics from other, less specialised applications. Having said that he knows nothing of IT, Dr Batin went on to show that this isn’t a barrier to seeing the benefits of IT and getting it working in a way which brings benefits to the patient, the clinical staff, the administrative staff and the hospital as a whole.

Dr Batin’s talk showed what can be done to improve service and outcomes given the right leadership and sufficient enthusiasm. There were questions throughout the talk and the evening ended with a lively debate. Those of us who adjourned to the bar were still discussing health informatics an hour later which shows the level of interest generated by the talk.