William W. Stead. M.D.and W. Edward Hammond. Ph.D. Department of Medicine ...... 0 .3 1.0 1.5 2.0 2.5 3.0 3.5 'e.0 11.5 5.0 5.5 C.0. coNz 1? 63 7'I 75 7? W 12 ...
HOW TO REALIZE LABOR SAVINGS WITH A COMPUTERIZED MEDICAL RECORD
William W. Stead. M.D. and W. Edward Hammond. Ph.D Department of Medicine Department of Community and Family Medicine Duke University Durham. NC
Abstract data is managed.
The implementation of a computerized record medical system is generally with an increase in labor associated an presents paper This expense. of a computerized medical application record that has achieved labor savings by the cost of data entry and reducing maximizing the use of each piece of data in the record. The portion of the system which manipulates laboratory data is used as an example.
TMR TMR is a computerized medical record system which has been developed at Duke University. TMR is written in GEMISCH and Digital Equipment on is operational PDP-11 of Corporation's family minicomputers under the RSX-11D or the UNIX operating systems. The modules,
of
which
captures
and
or medical data. The TMR modules allow of demographic data, collection the and data. financial data. provider generation of problem appointment data; lists and problem-oriented record review; of review time-oriented and entrU subjective and phyjsical examination data; management of laboratory data from-the to the of requisitions generation reporting and review of results; control of therapeutic interventions by writing prior drug prescriptions. identifying and interactions, drug allergies or creating therapy flow sheets; and entry of accounting data. generation of bills and filing of insurance claims. The modules mau be used stand-alone to fulfill a need such as an appointment specific system. or in concert to provide a complete medical information system.
Can the use of a computerized medical record system in a practice or hospital care health allow an improvement of delivery at a reduced labor cost? The medical care benefits could result from clinical of increased availability of techniques new and information Financial that information. analyzing benefits could accrue as the time required to provide health care decrease, and as manual information handling processes were eliminated.
Systems have been developed which benefits of medical the demonstrate record computerization of the medical (1.2), but the corresponding financial not materialized. benefits have Computerized medical record systems have generally increased instead of decreasing costs processing information total because they are added on top of the environment instead of being existing developed as an integral part of the health care process.
TMR utilizes a dictionary to provide for the idiosyncrasies of different applications. The dictionary contains the program modules that are activated, the amount of the record to be devoted to different types of data, specifics about and the data that can be collected; For example. the algorithms. medical the dictionary laboratory portion of defines the number of tests that may be retained in a record. the tests that may be performed. the format of requisitions, normals, of limits upper and lower emergency values for different categories of patients. messages to print on patient are values specified letters if encountered, and pricing information.
The computerized medical information system TMR (The Medical Record) (3,4.5) has been installed in the Nephrology Veteran's Durham the of Service has Administration Medical Center and resulted in labor savings. After briefly describing the TMR system and its use in the Nephrology Service, this paper focuses on the waus in which the implementation achieved labor savings using. as an example. the method in which laboratory
1200 0 1980 IEEE
each
displays a group of related administrative
Introduction
0195-4210/80/0000-1200$00.75
TMR program consists of a set of
The
Achi evina Labor
Neghroloou Service QOtimi z in
The Nephrology Service at the Durham Veteran's Administration Medical Center is responsible for three hundred active patients who have extensive medical records. The patient population includes inpatients and outpatients. One third of these patients require dialysis therapy and these patients are seen as often as three times per week. have an average of eleven problems. have at least twelve laboratory tests performed every one to four weeks, and take an average of eight different medicines. The remainder of the patients have primary renal disease or renal insufficiency, and although their records are complicated, their followup is less frequent. Seven phUsicians at different levels of training rotate responsibili ty for patient care.
Data Entru:
If labor savings are to be achieved. medical record system must not require special data terminal operators. Such operators represent added labor because they do not replace the medical and paramedical personnel that interact with the patient and the record. This is in contrast to business applications in which the computer operator. in conjunction with a computer program. is able to supplant
a
clerical, personnel.
accounting.
or
manangerial
TMR's data entry functions have
been allow direct entry of information byM the person capturing it. reducing the need for terminal operators. a control Log-on is simple; single character the activates appropriate program for the terminal in use. Security is maintained by entry of a non-echoed password. Data entry is interactive and self instructional. Each request for information is preceded by a prompting which describes phrase the type of If numeric codes are response expected. not text may be entered for known, translation to the correct code. Help displays are available at each question to provide detail about format. Responses are checked against edit constraints before they are accepted.
designed
Prior to implementation of the TMR record on the Nephrology Service, three decisions were made. All data entry and retrieval functions would be performed by existing employees. The system would be installed one module at a time. A module's data entry components would be optimized. and its data utilization capabilities would be expanded to the point that a labor savings was achieved before the next module would be implemented. The demographic and administrative package was implemented in October 1978, the laboratory module was installed in January 1979, the therapy section followed in September 1979. and the modules controlling the problem list and the subjective and physical parameters were implemented in July 1980.
All
Savinas
are
to
If paramedical and medical personnel going to interact directly with the
record
system#
the
number of
keystrokes
required to enter or display data must
be
minimized. Keyboard entry was selected over touch screen because responses do not have to be selected one at a time from menus. The user who is facile with the system and has learned both the sequence of questions and the types of required responses may type ahead of the questions or enter a string of information as a single response and avoid the slower step
data
is entered into the record it. The secretary enters the demographic data, the physicians and physician's associate enter diagnostic and therapeutic data. and the laoratory technician enters laboratory data. Data entry is an integral part of the health care process. For example. the physician uses the system to write his prescriptions and thereby maintains the therapy portion of the record. Despite the minimization of data entry cost. labor saving has only been achieved through extensive utilization of each piece of data entered into the record.
by the person who creates or captures
by step
process.
Each module of TMR has required mechanisms to enhance the entry of the type of data handled by the module. In the laboratory
system. the user is able to parameters such as the date of the tests being entered and the specify
default
system will insert that date until it is changed. A form of shorthand is provided for tests in that common ordering batteries of tests may be defined as a new test and ordered as a unit. For example. specifiying "Dialysis Weekl" actually orders Hematocrit, SMA 6. SMA 12. and Several tests Hepatitis Antigen. are usually performed on a patient at one
Use of the system requires one video terminal and one slow speed printer which are connected to a shared PDP-11/45 computer. A hard record copy is maintained to provide backup. This record is generated from the computer record. eliminating duplicative recording.
time. Therefore the system allows efficient entry of multiple orders or
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results for the same patient on the same However. certain tests come back day. from the laboratory in batches and the system has an alternate pathway that optimizes entry of results of one test for several patients.
"Maimizing
Each piece of laboratory data that is entered into the TMR record is utilized in seven types of reports that are necessary to run the Nephrology Service. The
Data Utilization:
Regardless of efforts to maximize the of data entry, it is impossible to enter data a into structured, retrievable record faster than the data can be scribbled on a piece of paper. Improvements in data entry reduce the overhead of a computerized medical record system, but they do not result in labor savings. Reduction in labor cost can only result from taking advantage of the power of the computer to use a datum in many
on
efficiency
wa
CUMMULATIVE
STUDIES
REPORT
(figure 1) is a time-oriented summary of all laboratory data from a patient. This report is available in part or in entirety demand.
As
data
is
entered into
pages which have been modified since the last printing. This printout is utilized to report the results to the responsible provider in context and are then filed to
provide hard copy backup.
s.
FIGURE 1 Cummulative Studies Report **CUMULATIVE STUDIES SUMMARY PAGE #: I - I 01/30/90 02/28/90 03/30/90 01/23/90 HCT 37-52 43 WBC 4. 8-10. 8 THOUS 9 SED WEST 0-20 65* GLUC 65-115 MG% 95 105 110 BUN 6-23 24* 22 MGX. 25* NA 136-148 MEQ/L 143 140 142 K 3. 5-5. 5 MEQ/L 4 3.9 3.5 CL 98-108 MEQ/L 99 100 ±02 C02 22-35 MEQ/L 28 27 29 TP 6. 4-8. 4 GM; 6*
ALB CA P04 U AC CREAT TBIL ALKP LDH SGOT PH-U SPGR-U PROT-U GLU-U BENZ-U WBC-U RBC-U
CAST-U TXT-S-U CRCL PROT-UT SEP UEP FANA CH5O UR C CHEST IVP EKG KID BX
TXT TXT TXT TXT
3. 9-5. 4
8. 9-10. 9
2. 2. 0. 0.
1-5. 3 5-8. 4
2. 8* 8. 9 2. 8 5
MG% MGB
6-1. 6
0-1. 4
21-113 100-221 7-40 1. 005-1. 03
0-3 0-3 90-120 0-. 5
1.1
MGB IU MU/ML MU/ML
ML/MIN GM/24 HR
a
patient's TMR record, an updated report is generated. The update contains only those
1.2
1.2
.4
90 ±90 20 6 1. 031* 4+* 0 1-2 WBC NORM TXT 3 N
6.5 1. 029 3+*
6 1. 029 4+*
0 1-3 0 TXT 2 N
0 2-3 0 TXT I N
89* 12*
NEG NEG NEG
15*
14*
NORM NEG NEG
NEG NEG
TXT 4
I = 1-2 COARSE GRRNULRR 2 = OCC CORRSE GRRNULAR 3 = CORRSE GRRNULRR 4 = DIF. THICKENING CRPILLARY WRLLS /S INC. CELLULARITY;
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IGG&C3 GRRNULAR PAT
The SUMMARY STUDIES (figure 2) contains the last available result for each test that has ever been performed on a patient. This document is used by providers to obtain an overview of a patient that they are seeing for the first time or whom they are seeing for a new problem.
FIGURE 3 Laboratory Letter
NEPHROLOGY SERVICE DURHAM VA HOSPITAL ERWIN RD. & FULTON ST.
DURHAM, NC 27705 09/11/99 CHARLIE F. BROWN 12 SHULTZ BLVD. PATTFORD, GH. 21456
FIGURE 2 Studies PRIMARY CARE SUMMARY NEPHROLOGY SERVICE
Summary * BROWN. CHARLES F.
* * *
RPV.
MARCUS WELSY 123 ASH RD. PATTFORD, OH. ------
*
21456
--------
HEMATOCRIT WHITE BLOOD CELL COUNT SED RATE (WESTERGREN) FERRITEN GLUCOSE-NONFASTING UREA NITROGEN SODIUM POTASSIUM CHLORIDE C02 CONTENT TOTAL PROTEIN ALBUMIN CALCIUM PHOSPHORUS CHOLESTEROL URIC ACID CREATININE BILIRUSIN TOTAL ALKALINE PHOSPHOTASE LACTIC DEHYDROGENASE SOOT PH SPECIFIC GRAVITY PROTEIN GLUCOSE SENZIDINk WSC RBC CASTS TEXT CREATININE CLEARANCE PROTEIN HEPATITIS AUSTRALIAN ANTI ANTI HEPATITIS C SERUM ELECIROPHOREIS URINE ELECTROPHOREIS LORESENT ANTINUCLEAR FACT TOTAL liEMOLYTIC COMPLEMEN URINE CULTURE CHEST XRAY METABOLIC DONE SERIES INTRAVENOUS PYELOGRAM EKG KIDNEY BIOPSY
12 SHULTZ BLVD. PATTFORD. OH. 21456 002-123-1234
Dear Charlie P. Brown: The following are the results of the blood work from 09/10/99.
9-99-9993
* 11/23/50 WHITE MALE
NA: CA: GLUC: TBIL: HCT:
------STU DIES SUMMARY-------------------09/10/99
02/15/99 01/30/90
06/25/99 09/10/99 09/10/99 09/10/99 09/10/99 09/10/99
09/10/99 09/10/99 09/10/99 09/10/99 09/10/99 05/02/99 09/10/99 09/10/99
09/10/99 09/10/99
21
5.5 65
139 8.9 145 .8 21
K:
P04: TP:
ALEP:
7.6 6.1 5.9 123
FERRITEN:
99 78 3.4 190 N
CL:
BUN: ALB: LDH: HAA:
C02:
23
CREAT-
15 7 12
U AC: SGOT: HAA AB:
Your potassium is dangerously high; avoid potassium containing foods. Increase basaljel by 1 tablet or tablespoon per dose.
900 145 78 139 7.6 99 23 5.9 3.4 8.9 6. 1 210 7
Sincerely yours, Steve Cox, PA for Willias Stead, N.D.
Copy to: MARCUS WELBY PATTPORD MEDICAL ASSOCIATES
1S .9
123 190 12 5. 5 1.015 3+ 0 0 2-3 02/15/99 1-2 02/15/99 COARSE GRANULAR WAXf 02/15/99 NEG 02/15/99 15 02/15/99 1. 5 09/10/99 NEG 02/15/99 NEG 01/30/90 NEG 01/30/90 NEG 01/30/90 NEG 01/30/90 NORMAL 01/30/90 NEC 02/15/"9 LVH. SILAT PUL EDEMA 02/15/99 NORMAL 01/30/90 NEG 02/15/99 LVH 01/30/90 DIF. THICKENING CAPILLARY WALLS /5 INC. CELLULARITYe IGG&C3 GRANULAR PAT 09/10/99 09/10/99
02/15/99 02/15/99 02/15/99 02/15/99 02/15/99 02/15/99
FIGURE 4 Service Summary K DATE HCT OWC Jt ? fF JOHIU 87/2824. 166 73 137 4.1 THnun, "F 64 138 4.6 07/21 33.5 37 134 6.1 87/2 28.5 87/28 441w 5.9 87/29 2i9 11 56 138 4.4 BOOTH, JOHI k 87/2 31.4 125 80 138 3.6 87/28 22. mWL JRES 1 5 145 6.6 56 146 5.6 67/87 2 5 ILu1 JOHI G CWEUE IN. NEVILLE 07/28 6.3 83 184 140 5.2 87/28 18.5 76 140 6.8 CHIIPPENDLL THOW15 87/29 3i6 100 46 36 3.8 uRfHILL WINSTON 07/B 228 82 98 137 6.1 Ca.w5.lS Cl*ISTOPE 87/29 26 7 95 71 1.38 5.3 56 137 3.9 COOLIDGE JOH C 87/2 485 COI LLIS. OiRES 7/28 2 4 78 76 137 3.8 49 136 4.8 DUIIN. CILES 7/2 33 5 DAYIS1 JEFFERSON 7/2 DICKENS, CHMES 87/29 21 8 89 98 138 I6.6 EINSTEIN, ALERT 07/28 FENES GWI 87/29 24.8 113 51 139 3.7 FRLIN, BE1 IN 87M 26 5 122 127 I8.5 ID SIGl FREL. 07/28 17.9 17 85 138 44.5 6WFIELD. JRUS 87/29 24.A 98 99 132 5.5 1ODVER OWES 07/28 1.5 93 81 136 44.7 WM, ULYSES 87/28 34.2 95 68 142 5.3 WLE NRMI 07/24 63 141 I5.0 WMILTON. FL DER 87/29 37.2 99 85 136 I5.8 W1 jaON 07/29 213 WfIEL ElORE 87/28 3.6 13 HFIRDING, 1 07/29 252
The LABORATORY LETTER (figure 3) reports resul.ts to patients who are at home. Results are printed and appropriate to messages are appended according algoritms specified in the dictionary. Similar for letters are generated referring physicians. Letters are also has patient missed a printed when appropriate followup. The SERVICE 4) SUMMARY (figure presents preselected laboratory data which has been entered into the TMR records of patients being followed by a clinical service. The report is alphabetized and can cover any specified time period. to Providers use the service summary quickly scan their patients' results at the end of the time period.
II
II
1203
CL C02 TP f 99 15 5.7 3. 96 18
6.8 1
7.2 7.2 5.8 6.2 6.0 18 17 7.0 6.7 15 97 28 6.1 94 23 7.1 188 17 6.3
14 19 99 255 187 183
182
3. 3. 3. 3. 3. 4. 4. 1 4.
4.8 1 18 20 7.1 * 98 6.5 168 22 6.8
181 27 6.2 85 7.3, 94 25 6.3 91 22 7.6 16 21 7.5 10 28 6.0 183 5.5 96 23 7.9
that patient's hepatitis antibody. This report allows the infectious disease nurse to follow the true incidence of hepatitis since that incidence is defined as the sum of antigen and antibody conversions. Correlation of red blood cell levels with iron stores is another application of this report.
The ACTION SERVICE SUMMARY (figure 5) reports the same data that is covered in the SERVICE SUMMARY. However, only those results that require immediate attention for the category of patient involved are results The acceptable are printed. The director of represented by dashes. the clinical service uses this report to providers that have not make sure overlooked emergent problems.
The HISTOGRAM (figure 7) displays the relative occurrence of different results for a test in specified a patient population. report can be all This inclusive, or it can be generated for a The HISTOGRAM specified date range. allows the physician to know the "normal value" for a test in an abnormal group of patients, all of whose results may be outside of traditional normal ranges. It also allows monitoring of the changes in a population over time.
The EPIDEMIOLOGICAL REPORT presents the results of two related tests over time. Figure 6 is an example in which the results of each patient's hepatitis antigen is reported next to the results of
FIGURE 5 Action Service Summary Sf15.
DRTE HCT MM 07/2 - -
3(61
K CLC2 TP R 15 5.7 1
MN
FSOR
FEA1 J"{S BOOTH 31NK
7/2 07/2 074m -
37 -44158_ _
--
FIGURE 7 Histogram of Peritoneal WBC
5.887/2. -- 6.6 187 -17 . - 8785 -CHRUCER EOFTF CHIPPBEFLL THO 07/9-- 46OURMILL WINSTON 8729---. - , 17 cO-.IESJS ORISTOIE87/9 4 8/21CO(LIDGE 301 CnOBMLLIS, OF1HES 49 - - 7/2 071nDRVIS, JEFFERSON 87/29- --- 6.6 -- DIOCNS& OMES 87/28 EINTEIN SIM 07/7 - FlIE GIN FHRLIN. ENBUIN RM4 --
87/28BOOTH, JOHI C 07/07 OEAIH NEVILLE07/28 3
JON FED
s JOHN C OIIIUEMAIN, NEVILLE OWHILL WINSTON CoLUW5. ORISTOPHER 0XNIDGE, 3m C 01INI OfUES DIOCS& OFES
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FIGURE 6 Hepatitis Report -, MW
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TABLE 1 Hours Required to Manage Laboratory Data
Results: The portion of the TMR application that manages laboratory data has been stable in the Nephrology Service since September 1979. Table 1 is a comparison of the labor expense related to laboratory In data before and after computerization. the manual mode. the laboratory technician It recorded data in a SERVICE SUMMARY. takes him twice as long to enter the data as to record into the computerized generate the report by hand. Therefore, computerized the initial creation of record results in an average cost of six hours per month.
Function M-anual TMR 1.3 S Cummulative Studies Report 12 S Demand ND Studies Summary
ef±er*ncL
s
(1) Fries, J. F., McShane. D., "ARAMIS: A National Chronic Disease Data Bank Syjstem. H Proceedings of the Third Computer on Annual Symposium pp. Applications in Medical Care, 798-801. 1979. "The et al., J. (2) McDonald, C. Regenstrief Medical Record System," Annual First the Proceedings of Symposium on Computer Applications in Medical Care. pp. 168-172. 1977. (3) Hammond, W. E. et al.. "Data Base for Management System Ambulatory Care. " Proceedings of the First Annual Symposium on Computer Applications in Medical Care. pp. 173-187, 1977. "A Clinical (4) Hammond, W. E. et al., System." Base Data Management Proceedings of the First International on Policy Symposium Analyis and 454-461. pp. Information Systems, 1979. "Functional (5) Hammond, W. E. et al., Clinical of a Characteristics of Information System." Methods Information in Medicine, vol. 19, no. 3. pp. 38-46. 1980.
are graphed below the standard
I Mi I ANL
ND
A computerized medical record system been installed in the Nephrology has Veteran's Durham the Service of with Center Medical Administration real-ization of a net labor savings. Labor savings were possibile because the system could be was designed so that data entry performed byj medical and paramedical personnel without the help of special data Despite both the operators. terminal avoidance of terminal operators and the optimization of data entry, entry of data more was record computer into the than entry into its manual expensive was saving only Labor predecessor. achieved after each piece of data was perform to utilized by the computer multiple functions.
display.
*E~ II *El
]E| |
Histograms
1.3 PA 12 LT .4 PA .3 N .3 MD Demand
Conclulion
FIGURE 8 Laboratory Video Display. In this example the results of creatinine time
12 PA 6 LT 4 PA 3 N I MD
NOTE: Labor is recorded in hours per month by the type of employee (S-secretary, N-nurse, technician, LT-laboratory PA-physician's associate. MD-physician. ND specifies not done, Demand indicates generation on demand.
This time has to be repaid by using the record to eliminate work performed by In the manual mode, the other employees. secretary, nurse, physician associate and physician reformatted and analysed the time SERVICE SUMMARY in a number of consuming ways. The computer was able to with perform those tasks as spinoffs little human help. The computer record is now created and utilized at a net labor savings of 23.4 hours per month. This labor savings is based on an in involved time assessment of the generation and maintenance of the record. terminal video Figure 8 depicts the display used by the physician to review a This display patient's l-boratory data. consists of the last available result of is review Time-oriented each test. available through a full display option or in The savings a graphics function. physician time that will result from using a structured and retrievable record are a bonus that has not been measured.
over
LaboratorV Letters Service Summary Action Service Summary Epidemiological Reports
.
1205
