Free Medical Record Audit Templates for Psychiatry by ssp10761

VIEWS: 168 PAGES: 46

More Info
									Patient-Centered Information
Systems
                   Nazife Baykal
             Informatics Institute, METU



INTRODUCTION TO MEDICAL INFORMATICS   Nazife Baykal, Informatics Institute, METU
Patient-Centered
Information Systems
 1. Medical Informatics Applications and Systems
       in Primary Care

 2. Clinical Departmental Systems




  INTRODUCTION TO MEDICAL INFORMATICS   Nazife Baykal, Informatics Institute, METU
MI Applications and
Systems in Primary Care
 a) Introduction
 b) Shared Care
 c) The “Gatekeeper” Function
 d) Computers in General Practice: Example of Britain GP
 e) General Practice Systems
 f)   Features of Modern General Practice Systems
 g) Registration Details


  INTRODUCTION TO MEDICAL INFORMATICS   Nazife Baykal, Informatics Institute, METU
MI Applications and
Systems in Primary Care
 h)    Adding Data
 i)    Creating Computerized Prescriptions
 j)    Drug Budget
 k)    Creating Reports
 l)    Online Information
 m) Computerized Appointments
 n)    Referral Letters


  INTRODUCTION TO MEDICAL INFORMATICS   Nazife Baykal, Informatics Institute, METU
MI Applications and
Systems in Primary Care
                                “Primary care is the provision of
                                integrated, accessible health care
                                services by clinicians who are
                                accountable for addressing a large
                                majority of personal health care
                                needs, developing a sustained
                                partnership with patients, and
                                practicing in the context of family
                                and community.”
                                Institute of Medicine, US


  INTRODUCTION TO MEDICAL INFORMATICS            Nazife Baykal, Informatics Institute, METU
MI Applications and
Systems in Primary Care
 Primary care is the area where :
     – patients enter the health care system.
     – population-oriented care is given.
     – continuous care to patients with chronic
       diseases, elderly people, or patients who need
       home care and palliative care is given.


  INTRODUCTION TO MEDICAL INFORMATICS   Nazife Baykal, Informatics Institute, METU
Shared Care

                               Patients requiring shared care:
                                 –patients suffering from chronic
                                  disorders,
                                 –patients receiving palliative care at
                                  home
                               Properly structured coordination
                               of medical activities
                                 –clinicians should know what
                                  guidelines or protocols to follow
                                  and trust each other's actions and
                                  interventions

  INTRODUCTION TO MEDICAL INFORMATICS          Nazife Baykal, Informatics Institute, METU
Shared Care

  communication between clinicians about
   cotreated patients is prone to be delayed,
   incomplete, or erroneous
 Information systems may assist in
  improving this situation




  INTRODUCTION TO MEDICAL INFORMATICS   Nazife Baykal, Informatics Institute, METU
The “Gatekeeper” Function


  Guard an individual patient
                                           Authorize access
     from overtreatment




  Guard an individual patient            Authorize diagnostic
    from undertreatment                      procedures




  INTRODUCTION TO MEDICAL INFORMATICS   Nazife Baykal, Informatics Institute, METU
Computers in General
Practice: Example of Britain GP




  INTRODUCTION TO MEDICAL INFORMATICS   Nazife Baykal, Informatics Institute, METU
General Practice Systems

 • All general practice systems evolved into
   advanced practice management tools.
 • The systems contain extraordinary amounts of
   information on patients and disease.
 • It will eventually be possible to pool clinical data
   for audit and research.
    “General practice systems are likely to make an
    important contribution towards the development
    of evidence based medicine.”

  INTRODUCTION TO MEDICAL INFORMATICS   Nazife Baykal, Informatics Institute, METU
Features of Modern
General Practice Systems
 Basic Features:
 • Age-sex register                     • Clinical audit
 • Comprehensive                        • Word processing linked
   clinical records                       to database
 • Acute and repeat                     • E-mail between users
   prescribing                          • Electronic links to
 • Call and recall systems                family health services
 • Complex reporting                      authorities and hospital
   modules for                            pathology laboratories
 • Practice management

  INTRODUCTION TO MEDICAL INFORMATICS          Nazife Baykal, Informatics Institute, METU
Features of Modern
General Practice Systems
 Optional extras:
 • Appointment systems
 • Fund-holding software
 • Various "expert systems"
 • Portable computers for home visits



  INTRODUCTION TO MEDICAL INFORMATICS   Nazife Baykal, Informatics Institute, METU
Adding Data

 • New systems record comprehensive details of
   every consultation:date and time, the clinician’s
   ID, symptoms, signs, diagnoses, procedures
   carried out, prescribed drugs.
 • chronological recording or problem oriented
   approach in adding new data
 • Good systems display a list of all serious problems
   as soon as a patient's record is retrieved.

  INTRODUCTION TO MEDICAL INFORMATICS   Nazife Baykal, Informatics Institute, METU
Creating Computerized
Prescriptions
                                • greatly reducing the risk of
                                  dispensing errors
                                • reducing the risk of errors in
                                  prescribing out-of-date drugs
                                • warnings of potential contra-
                                  indications or reminders for
                                  allergy/intolerance seen in the
                                  past records
                                  “Hand written prescriptions are
                                  still required, however, for
                                  controlled drugs”


  INTRODUCTION TO MEDICAL INFORMATICS        Nazife Baykal, Informatics Institute, METU
Drug Budget

 ! Management of the drug budget is important.
 • Accurate statistics on individual and group
   prescribing patterns help:
     – to contain costs
     – to identify patients requiring expensive treatment
     – to identify the conditions for which expensive drugs are
       being prescribed and should the practice be asked to
       justify its costs
     – therapeutic audit


  INTRODUCTION TO MEDICAL INFORMATICS    Nazife Baykal, Informatics Institute, METU
Creating Reports

 • The system can be instructed to search the
   database and return the answer to a question in the
   form of a report.
     – Clinical reports allow searching for all patients taking a
       specific drug or with a particular diagnosis.
 • Lists of patients can be merged with standard
   letters to produce a personalized letter to each
   patient on the list.


  INTRODUCTION TO MEDICAL INFORMATICS     Nazife Baykal, Informatics Institute, METU
Creating Reports

Systems are usually supplied with most of the standard
reports that a practice is likely to need. E.g.:
     –   Cervical cytology recall
     –   Immunization recall
     –   Child health surveillance
     –   Item of service claims
     –   Referral data
     –   Rural mileage
     –   Clinical audits


  INTRODUCTION TO MEDICAL INFORMATICS   Nazife Baykal, Informatics Institute, METU
Online Information

 • impossible for a doctor to have expertise in
   all areas
 • many general practice systems now include
   a variety of online resources:
     – usually allows you to call up specific
       information about a particular disease or drug,
     – systems which analyze symptoms and signs and
       suggest appropriate investigations or a
       differential diagnosis are being developed

  INTRODUCTION TO MEDICAL INFORMATICS   Nazife Baykal, Informatics Institute, METU
Computerised
Appointments
traditional appointment  computerised appointment
          book                      system

• one strength of the book  it readily allows
  the receptionist an overview of activity in the
  practice.
• several advantages of computerised systems!


  INTRODUCTION TO MEDICAL INFORMATICS   Nazife Baykal, Informatics Institute, METU
Computerised
Appointments
– Good systems automatically offer patients a choice of dates
  and times.
– Access to the system is available at all terminals in a practice.
– Making an appointment can be as simple as typing 2W or
  3M. The system then searches for a vacant slot at about the
  right time.
– Most systems automatically generate lists of patients to be
  seen by each doctor, from which a patient’s record can be
  called up.
– Systems provide practices with statistics on consultation rates
  and workload and can be used to audit waiting times.

   INTRODUCTION TO MEDICAL INFORMATICS    Nazife Baykal, Informatics Institute, METU
Referral Letters

  • Referral letters:
     – details of a patient's medical history,
     – current problems, and
     – any drugs being taken.
  • Such details held in the DB. Can be retrieved for
    use in referral letters.
  • An electronic address book containing details of
    the hospitals, clinics, and consultants to whom your
    patients are commonly referred.
  • A basic word processor linked to the DB and a
    series of customizable letter templates.
  INTRODUCTION TO MEDICAL INFORMATICS      Nazife Baykal, Informatics Institute, METU
Clinical Departmental
Systems
 a)    Introduction
 b)    Internal Medicine
 c)    Cardiology
 d)    Neurology
 e)    Pediatrics
 f)    Obstetrics


  INTRODUCTION TO MEDICAL INFORMATICS   Nazife Baykal, Informatics Institute, METU
Clinical Departmental
Systems
 g)    Surgery
 h)    Psychiatry
 i)    Critical Care
 j)    Radiotherapy
 k)    Retrospective Review of Departmental
       Information Systems


  INTRODUCTION TO MEDICAL INFORMATICS   Nazife Baykal, Informatics Institute, METU
Clinical Departmental
Systems
                              Departmental approach
                              •Advantages:
                                –products better adapted to user
                                 requirements
                                –Progressive investment is made
                                 possible
                                –Data can be grouped together
                              •Disadvantages:
                                –Hard to integrate with other systems
                                 of choice for each department
                                –to the installation of incompatible
                                 hardware or software architectures
  INTRODUCTION TO MEDICAL INFORMATICS        Nazife Baykal, Informatics Institute, METU
Clinical Departmental
Systems
 •   Administrative support
 •   Patient data collection
 •   Decisions
 •   Monitoring
 •   Reporting
 •   Assessment
 •   Research

  INTRODUCTION TO MEDICAL INFORMATICS   Nazife Baykal, Informatics Institute, METU
Internal Medicine

                                registration of data on the
                                diagnosis and treatment of
                                cancer patients and giving
                                decision support for clinicians
                                for chemotherapy or
                                radiotherapy


  INTRODUCTION TO MEDICAL INFORMATICS       Nazife Baykal, Informatics Institute, METU
Internal Medicine

                             • Dialysis is a complex process.
                               Requires to be monitored for
                               minimizing probable complications.
                             • e.g., the nephrology department in
                               the Maria delle Croci Hospital in
                               Ravenna, Italy, uses computers and
                               telecommunication to monitor
                               dialysis treatments in its own clinic
                               as well as in clinics at other
                               geographical locations.

  INTRODUCTION TO MEDICAL INFORMATICS        Nazife Baykal, Informatics Institute, METU
Internal Medicine

                                • Institute for Diabetes
                                  Technology at the University of
                                  Ulm, Germany
                                • has a stimulating effect on
                                  patients
                                • immediate feedback motivates
                                  them to achieve an optimal
                                  result
                                their diabetes is relatively well
                                  regulated

  INTRODUCTION TO MEDICAL INFORMATICS       Nazife Baykal, Informatics Institute, METU
Internal Medicine

                              Regional Hemophilia Center at
                              Manchester Royal Infirmary in UK
                              • cumulative reports of patient
                                data replace previous ones in the
                                paper-based record
                              • patient database 
                                   – produces reports for the national
                                     hemophilia register
                                   – supports data retrieval for
                                     scientific purposes

  INTRODUCTION TO MEDICAL INFORMATICS         Nazife Baykal, Informatics Institute, METU
Internal Medicine

                              • Several computer applications
                                in endoscopy. Not yet in
                                widespread use.
                              • Usually used for reporting.
                                   – Free-text reports
                                   – Structured reports

                              • Digital endoscope enables
                                computer storage of images.

  INTRODUCTION TO MEDICAL INFORMATICS         Nazife Baykal, Informatics Institute, METU
Internal Medicine

                              Eurotransplant in Leiden, NL
                              • register and maintain data on
                                patients waiting for a donor
                                organ
                              • performs donor – recipient
                                matching
                              • organizes the transport of organs
                                to be transplanted

  INTRODUCTION TO MEDICAL INFORMATICS      Nazife Baykal, Informatics Institute, METU
Cardiology

  prominent role of computers in
  cardiology:
• it is possible to express processes in
  cardiac physiology in physical,
  biochemical, and mathematical
  terminologies  data in cardiology
  can be quantified and coded
• computers are also fully integrated in
  cardiac care in image acquisition


   INTRODUCTION TO MEDICAL INFORMATICS     Nazife Baykal, Informatics Institute, METU
Cardiology

                             • Signal processing for diagnostic
                               purposes
                             • enhancing and storing images:
                                  –     coronary angiograms
                                  –     myocardial scintigrams
                                  –     radionuclide scintigraphy
                                  –     echocardiograms
                             • In CPRs, patient data, cardiac
                               images, and cardiac signals are
                               collected, stored and transmitted to
                               care providers.
  INTRODUCTION TO MEDICAL INFORMATICS            Nazife Baykal, Informatics Institute, METU
Neurology

                             • MS-COSTAR: A special CPR. The
                               system calculates scores that
                               characterize the functional ability of
                               the patient.
                             • Chronic Daily Headache (CDH):
                               An Italian system supports
                               standardized recording of related
                               signs and symptoms. Combination
                               of large data set is essential for a
                               better insight into the causes,
                               influencing factors, and treatment
                               of CDH.
  INTRODUCTION TO MEDICAL INFORMATICS        Nazife Baykal, Informatics Institute, METU
Pediatrics

  • Deals with diseases that are specific for
    premature infants and young children

  • Large databases are collected to study
    history of children and people with
    congenitally acquired diseases which are
    the most seen in pediatric clinics.


  INTRODUCTION TO MEDICAL INFORMATICS   Nazife Baykal, Informatics Institute, METU
Obstetrics

                             University Hospital, Rotterdam, NL
                              –Obstetrics  Gynecology
                              –an electronic obstetric record.
                               Supports standardized reporting.
                              –System supports electronic requests
                               for ultrasound examinations and
                               patient scheduling, directly in the
                               clinician’s office. Saves considerable
                               waiting time for the patient.
                              –Possible to monitor cardiotocography
                               online. Enables a quicker response by
                               the attending clinician.
  INTRODUCTION TO MEDICAL INFORMATICS        Nazife Baykal, Informatics Institute, METU
Surgery

                             • Surgical planning systems. Mostly in
                               cosmetics and brain surgery.
                             • Desirable to have some insight into
                               the effect of the planned corrections
                               beforehand.
                             • Virtual reality for the education and
                               training of surgeons.
                             • Microsurgery deep in the brain.
                               Applications inform the surgeon
                               about the accurate position and
                               movements of his instruments.
  INTRODUCTION TO MEDICAL INFORMATICS       Nazife Baykal, Informatics Institute, METU
Psychiatry

 Psychiatry uses information technology only marginally.
    – no strict pathophysiological criteria, many data are collected
      in conversations with the patient
    – problem of ambiguity due to wide range of psychiatric
      problems; very large # of possible causes and varying
      nature of behavioral disorders

   “The data are extensive, they come from various
   disciplines and they contain a large variety of terms
   and the use of qualitative observation techniques is
   obligatory.”

  INTRODUCTION TO MEDICAL INFORMATICS     Nazife Baykal, Informatics Institute, METU
Critical Care

  Patient monitoring is very important in CCU! Many
  computerized monitoring systems are used for data
  acquisition, storage, data processing and the
  presentation of results.
      –Cardiovascular system
      –Respiratory system
      –Renal functions
      –Central nervous system
      –Fluid and electrolyte balances and blood gas levels

  INTRODUCTION TO MEDICAL INFORMATICS   Nazife Baykal, Informatics Institute, METU
Critical Care

 The most important reasons for computer-aided patient
 monitoring are:
  – Data acquisition                     – Integration
  – Data reduction                       – Efficiency
  – Error checking                       – Research
  – Information display                  – Decision support
  – Ethical and legal aspects


   INTRODUCTION TO MEDICAL INFORMATICS        Nazife Baykal, Informatics Institute, METU
Critical Care

 Patient Data Management System
 • To replace written ICU bedside flowcharts presenting
   the monitored data by a numeric or graphic
   presentation on a computer screen
 • To support care and to ease multidisciplinary
   communication
  “With all the data collected during patient care, the
  PDMS is a potentially valuable source for information
  for management and research questions.”

   INTRODUCTION TO MEDICAL INFORMATICS   Nazife Baykal, Informatics Institute, METU
Radiotherapy

 Radiotherapy is a treatment
 that is used to destroy
 tumors by using high energy
 X-ray beams, electrons, and
 other elementary particles,
 such as neutrons and
 protons.

  INTRODUCTION TO MEDICAL INFORMATICS   Nazife Baykal, Informatics Institute, METU
Radiotherapy

 • The dimensions of the beam are determined by the
   dimensions of the tumor. The cross section of the
   beam must be chosen such that the whole target
   volume is just covered by the beam.
 • To be able to calculate the dose distribution inside
   the body, at least one cross section through the
   body, including the tumor, is needed. Such a cross
   section can be obtained with the help of CT or
   MRI.


  INTRODUCTION TO MEDICAL INFORMATICS   Nazife Baykal, Informatics Institute, METU
Radiotherapy

                               • An accurate determination
                                 of the dose distribution is
                                 important!

                               • With modern radiotherapy
                                 planning systems, it is
                                 possible to determine the
                                 dose distribution in three
                                 dimensions.

  INTRODUCTION TO MEDICAL INFORMATICS      Nazife Baykal, Informatics Institute, METU
Retrospective Review of
Departmental Information Systems
                             • Many of the older applications are
                               highly dedicated and specific to the
                               environment in which they are used.
                             • designing widely applicable system
                                 – technical compatibility problems
                                   between systems
                                 – personal preferences, departmental
                                   habits, lack of standardized
                                   nomenclature, and cultural
                                   differences


  INTRODUCTION TO MEDICAL INFORMATICS         Nazife Baykal, Informatics Institute, METU

								
To top