Optimizing Ambulatory and Acute Care Health Information Technology

Course Overview and Professional Developments

• Health Information Technology (HIT) Scope:

  • The course covers the identification of problems, workflow mapping, and the management of a hospital's "operating system," which encompasses the suite of applications, architecture, and informatics-related components.
  • It integrates the Electronic Health Record (EHR) with the billing system for comprehensive care management.

• Professional Skills and Career Advice:

  • SQL (Structured Query Language):
    • SQL is a Microsoft product that is highly valuable for the analytics side of health informatics rather than purely engineering or configuration roles.
    • Platforms like NextGen Healthcare and specific systems, such as blood bank databases, are built on SQL.
    • SQL is noted for being "temperamental"; incorrect execution of a query in a live environment can lock the database. Using a test environment for practice is critical.
  • Advancing the Career:
    • Students are encouraged to list specific skills on their resumes, including Excel and knowledge of SQL, even if learned through micro-credentials like LinkedIn or Google courses.
    • Applying classroom case studies as "real-world" experience to demonstrate problem-solving in clinics and technology-based process improvements is recommended.

• Contract Negotiations and Vendor Management:

  • Vigorous oversight is required in contract negotiations to avoid vendor traps, such as the attempt to double-price licenses after introducing a new proposal plan.

Ambulatory EHR Optimization

• Adoption Trends:

  • By $2014$, $83\%$ of ambulatory settings had adopted some form of EHR.
  • By the end of $2015$, $78\%$ were using certified technology.
  • Meaningful Use benchmarks lagged depending on provider types, with clinicians in reform programs adopting certified technology at higher rates.

• System Functions:

  • Workflow Integration: The visit process includes pre-visit registration, insurance verification, chart review, exam, assessment, diagnosis, care planning, prescribing, billing (Charge Capture), and referrals.
  • Medication Reconciliation: Essential for safety; however, Pharmacy Benefit Management (PBM) services cannot entirely replace direct patient discussion because some medications may not appear in the digital record.
  • Patient Summary: Serves as a clinician's snapshot for rapid decision-making.

• Key Strategies for Optimization:

  • Strategic vs. Tactical Evaluation: Implementation should not be reduced to a "Meaningful Use checklist"; it must align with long-term operational goals.
  • PCMH and ACO Models: Patient-Centered Medical Homes (PCMHs) and Accountable Care Organizations (ACOs) use EHRs to focus on care coordination rather than isolated treatment.

Acute Care EHR Applications

• Definition: Acute care involves short-term treatment for severe illness or injury in settings like ICUs, ERs, surgery, and labor and delivery units.

• Five Major Components of Hospital EHRs:

  1. Result Management: $70\%$ of clinical decisions are influenced by laboratory results. Challenges include inconsistent test naming and alert fatigue.
  2. Point of Care Documentation: Includes nursing assessments, vitals, care plans, and physician progress notes. Issues include "copy and paste" concerns and duplication of effort.
  3. Medication Management: Focuses on closed-loop management to prevent adverse drug events (ADEs) and overdoses.
  4. Clinical Decision Support (CDS): Provides allergy alerts, dose alerts, and duplicate therapy notifications.
  5. Reporting and Quality Improvement: Measures performance to improve patient outcomes.

• Market Share (2021 Data):

  • Epic: $32.8\%$
  • Cerner
  • Meditech
  • CPSI

Foundational Health IT and AI Integration

• Core Processes of HIT:

  1. Data Collection (gathering from devices/systems).
  2. Data Processing (analyzing/organizing).
  3. Storage (securely maintaining records).
  4. Information Sharing (sharing among providers).

• Artificial Intelligence (AI) Statistics and Applications:

  • Radiology: Deep learning detects finding with $94.5\%$ accuracy, matching the performance of human radiologists.
  • Predictive Analytics: Models can predict patient readmission risk and the onset of sepsis up to $12\,hours$ in advance.
  • Drug Discovery: AI reduces timelines from $12\,years$ down to $4\,years$, representing a $70\%$ reduction in development costs.
  • Efficiency: Administrative AI is estimated to save the industry $\$150,000,000,000$ annually by automating scheduling and billing.

• Market Impact:

  • The global telehealth market in $2024$ was valued at $\$87,000,000,000$.
  • $60\%$ of patients prefer telehealth options.
  • MHealth (Mobile Health) app downloads reached $3,800,000,000$.

Clinical Decision Support and Quality Standards

• Standardization and Interoperability:

  • Alphabet Soup of Standards:
    • SNOMED: A product designed to map terminology (procedures and diagnoses) so doctors can search consistently across different platforms.
    • LOINC: Originally for laboratory tests, it has expanded to radiology. It uses aggregated codes to ensure different labs checking for the same values (e.g., neutrophils) are synced across systems.
    • DICOM: The standard for communicating and managing medical imaging information.     

• Leapfrog Group Accreditation:

  • An annual accreditation process where organizations perform tests and submit results to be graded on the effectiveness of their CDS systems.
  • Evaluates specific risks like geriatric medication interactions (e.g., using the Beers Criteria) and weight-based dosing for pediatrics.

• Data Governance: Ensuring every clinician documents data in the same manner. Without proper governance, quality metrics cannot be accurately aggregated because different doctors may record the same metric in different sections of the chart.

Emerging Healthcare Models and Technical Challenges

• Hospital at Home:

  • A government-approved model (approx. $4\,years$ old) where patients who meet specific acuity levels receive hospital-level care at home.
  • Includes home visits twice daily, remote monitoring of vitals/falls, and laboratory reviews.
  • Challenge: Mobile imaging equipment must be brought to the patient, and many mobile vendors are not yet motivated to integrate seamlessly with standard EHR packages.

• Technical and Security Hurdles:

  • Connectivity vs. Security: Devices like the "pupil meter" (used to track neurological activity in traumatic brain injury or stroke) often require constant outside vendor monitoring to maintain $99.6\%$ uptime. This conflicts with strict hospital Information Security (InfoSec) protocols that prohibit constant persistent external access.
  • Data Incompleteness: If ultrasound machines in surgery clinics fail to transfer images to the EHR sporadically, the legal electronic chart remains incomplete. Devices will eventually run out of storage space if they cannot offload data to the central record.

Questions & Discussion

• Question (Student): If you were a hospital administrator, which EHR feature would you invest in first to improve patient safety and why?

• Response (Twila/Class): Drug-to-drug interaction and Clinical Decision Support (CDS). This flags errors such as prescribing conflicting medications for patients with comorbidities (e.g., treating Lupus, congestive heart failure, and rheumatoid arthritis simultaneously, which can lead to kidney or thyroid complications).

• Discussion on Grady ER: A student mentioned a new role in the Grady Emergency Room. Advice was given to embrace the high pace/acuity environment and to use the position as a networking stepping stone, as healthcare is a "small world" for professional mobility.

• Course Logistics:

  • The final quiz (covering Chapters $9, 11, 17, 20$) is due on Tuesday, August 4, at $11:59\,PM$.
  • Final grades will be submitted/transferred by the following Wednesday at $5:00\,PM$.