[MUSIC] >> Welcome. Hello, I am Nicholas Genes. >> And I am Bruce Darrow. >> And this lecture, we'll focus on hospital health information technology. We've already covered ambulatory care, clinic base, health IT and I spoke about the emergency department in our unique needs. Now, it's time to talked about what happens in patient. So when a patient is admitted to the hospital and has a bed on the floor, as they say. >> One of the things to keep in mind when you're designing health information technology for an inpatient experience is that it's a whole new level of the information being generated for a patient and handled the amount of documentation, and the number of people involved in the care of somebody in the hospital. The way I think about it is if an ambulatory documentation process is like golf, then an inpatient documentation process is like baseball. With the golf analogy is that if a patient goes to an office provider say, three times over the course of a year, the first episode will be talking about whatever happened there. It's largely based on whatever that physician or small group of provider, caregivers associated with that physician being in charge of the office is what we doing, they sort of T up the documentation for that patient and then they hit it often to the future. And four months later, that patient and the doctor will meet again and then they have another similar episode and then they go into the future another four months. So, it's kind of like somebody hitting a golf ball on this endless fairway. Whereas in an inpatient setting while there may be on person who is predominantly in charge of the care of that patient, the number of people involved is astronomically higher. You have physicians. You have physician assistance. You have residence or interns. You have consultants. You have nurses. You have nursing students. You have physical therapist. You have social workers. You have respiratory therapist. You have care coordinators. You have the person who comes and says, your insurance thinks that you should be ready to leave tomorrow. All of these people will sort of contribute to the communal IT experience of that patient and they will dip into that pile of information to take what they need from it. >> Yeah, you really lay it out pretty clearly. I can't help, but draw a destination to the emergency department. First, because both sports that you mentioned don't feature a clock and we are always constantly looking at the clock in emergency department. So maybe be able to look at more like basketball advancing towards that goal or something like that, but the other difference in the emergency department and maybe you're connects to. I feel like we always have an opportunity to huddle, to touch base with each other and to kind of verbally interact with all the different teammates. I speak with my nurse. I speak with the patient. I speak with support staff, even the respiratory therapist and I can always get on the phone and talk to the radiologist. And so, the documentation is obviously important. It's useful. It's good for posterity. It's useful for billing. It's just a record of what happened, but I can often just do the documentation at the end of the visit or even at the end of my shift, I can write down everything that I need to write down. But in inpatient, I feel like documentation is kind of how everything gets coordinated. You have to see what the radiologist wrote, what the consultant wrote. There's these kinds of rounding first thing in the morning, there's not often an opportunity to get together with the whole team and with the patient and execute plans. >> One of the challenges and to that, that triggers this thought in my mind which is about the information stream. The information stream in an inpatient setting is ferocious in its velocit and asymmetric in its impact. So if somebody comes to the office and I order set of test, blood test, urology test. Those were run their course. If I ordered blood test, they'll comeback over the course next one day, two days have or many days. Depending on the type of test and then I'll have the chance to review them, and contact the patient make some decision Visions. So every once in a while, there will be an unexpectedly unusual results. But if your patient was healthy enough to come to the office and leave the office, the chances of that having to be dealt with on an emergent basis are going to be somewhat small. In the emergency department, everything is sort of condensed and you have everybody there. You know exactly what you ordered, you know how long it's going to take for that test to be done and you'll going to look at the results and then make decisions. >> Yeah. >> On the inpatient side, the stream of information includes new vital signs every four hours. The blood pressure all of a sudden drops, the heart rate all of a sudden spikes. You have blood tests that are being ordered sometimes multiple times a day and coming back in the middle of the afternoon, in the evening, in the middle of the night, very early in the morning. You have radiology test like an MRI that is ordered today, but depending on how things work and whether or not it's urgent or not that may be done in the middle of the night or it might be done tomorrow and then the results of that will come back at a different time. And all while this is happening, the different physicians involved and the different clinicians involved in the care of that patient may be wandering into the unit, out of the unit, out of the hospital, going out for the weekend. Somebody else is covering an oncall and managing this information stream, and putting it at the right time in front of the right people is a real challenge for any information technology systems. >> Yeah, yeah and imagine that the inpatient environment compasses both rehab specialist that are not ordering a whole lot of test, not generating a whole lot of data to all the way to ICU where the blood pressure is checked every five minutes and not every few hours and the blood tests are done almost. >> And operating rooms where the vital signs might be checked very 15 seconds and if a patient is on anesthesia or a heart lung machine. >> So yeah, it becomes really important to process that data. Again, in the emergency department, we have a few bullet points, a few action items and we're kind of conscious of what we're doing. And even if the system went down or went to paper, we kind of have in our heads a good plan of what we're looking for and what would come next for each patient. But yeah, in in patient, you really have a challenge sorting through all this information identifying outliers and abnormalities and coming up with a plan at the end of the day. In a way, it's harder to imagine inpatient functioning in that era before electronic health records. >> Right. >> I guess maybe just very diligent with clipboards and checklists and so forth, but- >> Yeah and the greater the complexity, the number of different work types and work streams that you would have to be able to handle in, even in a small to mid-size community hospital in terms of several hundred different types of surgery, dozens of different primary diagnosis for people who are being hospitalized for cellulitis. Skin infection is going to be different than some many hospitalize for stroke and the kind of care brought to bare is going to be different, but that's actually one of the areas were health information technology is potentially real acid in the inpatient basis is the ability to standardize the care given to different people who come in with the similar diagnosis. So for example, if you that you want the next hundred patient who come in to have a hip replacement to get a particular medication to decrease the chance the blood clot in the legs, you can very easily automate that process and make it. So that is the default way of doing work, unless there is a specific reason to deviate and then track what your records are for how many people are on the accepted clinically appropriate track versus those who are not. >> And so not only is the electronic health record serving to coordinate care and generate data and process data, but also can be used as a way of promoting change and putting multiple different providers into the same bucket or the same frame of minds, so that they're executing new policy. >> And this is where the change management side from information technology comes to the fore. Because you have the ability to say, if you have five different hip surgeons who have five different ideas about what's the best way to do blood thinners for reducing blood clots in the legs, chances are they can't all be right. It's possible that more than one are right, but of those five different approaches chances are that one of them is the worst of those five approaches. And so you start to get clinicians on the hook for making decisions about how are they going to have a shared sense of the best way to take care of their patients just more than one patient at a time, but every patient all the time. >> Bruce, you've been a great advocate for involving patients in their care and sometimes I feel like in the inpatient setting that can get lost. Of course, as I recall from days as a medical students and resident, we would round on the patients. We'd see them in the morning, they would meet us. And then in many cases, we would see them again for many hours or maybe not until the end of the day. How can electronic health records help change that? >> I think that one of the things that the electronic health records can do in the inpatient setting is to reduce the ambiguity for the patients of what exactly is going on. The complaints that I hear and when you look at what drives patient satisfaction in inpatient setting is that want to know that their clinicians patients are communicating with one another, and they want an explanations for what's going to happen, and how long it's going to take. If they can look at something electronically and say, okay, my doctor told me, I was going to go for CT scan and I can see that I am currently slated to get my CT scan three hours from now. Or there are five people ahead of me on the list and every 20 minutes, 1 of them bumps off and they bump up on the list, then this is the kind of information we give people at the daily counter and when the stakes are not nearly as high as they are in patient setting. So just being able to be straight with people that yeah, it's going to take a little time, but we can give you information all the way across. I think would be a huge step forward and we are starting to see systems that do that. >> Yeah, I'll throw another distinction to emergency department. The patients can often see us typing on the computer from across the room, they know that we're working, but they don't necessary know that we're working on their case and they don't know what we're doing in front of the computer. But somehow bringing to the bedside letting the patients know that we finished our note, we placed our calls, we're arranging for followup or we're arranging for that scan we're working to get things done. I think it would enormously reassuring to the patient and just helpful for them to understand. >> Yeah and in general, this is true in inpatients as well as you're describing. But in all settings, the more that you make the screen of your computer something that two people are looking at at the same time rather than like a tennis net that's in between two people and only is visible to one of them, then the more successful you're going to be at making it clear that the technology is helping with the care of your patient. >> Yeah and even just simple things like identifying the different caregivers, the different providers the nurses. I mean, we've all seen the little white boards that are inpatient rooms where people scrawl their names and contact info. But doing that digitally and keeping that updated through the day, it's involving all the different care members of the team. That's something that I would appreciate, as a patient. We can facilitate that today. >> So there's a lot that health information technology does on the inpatient side to facilitate care, but it does it in a different way. And the last point I want to bring up is one of the challenges, especially in inpatient care is that historically, HIT systems are difficult at handling things that are documented by more than one person. Pieces of paper are really good when one person can write on one piece and one person can write on another or I fill out my part of the form and then I hand it to someone else and they fill out their part of the form, but these interdisciplinary forms are a big challenge in the inpatient setting for health information systems. And I think of things like when someone goes through childbirth and their are portions of the documentation that need to be done by a physician, and portions that need to be done by a labor nurse or certain kinds of chemotherapy infusion where there is a doctor component to documentation, and then there is a nurse component to documentation. And potentially, a patient portion if they're signing off on something. Those are historically a challenge for IT systems and we see them more in the inpatient setting than we do elsewhere. >> I agree. Yeah, at the emergency department, you can only think about a few examples like that. But again, there are reasonable times to involve patients in the documentation and to important data from outside sources and make that kind of transparency or that kind of availability just signaling to the physician that data exist in one source or another when there's an update from a state database or a health information exchange. >> Well, we have enjoyed talking about how health information technology works in the inpatient setting and we hope you have enjoyed listening to us talk about it. Thank you. >> Thank you. [MUSIC]
