Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_605_Библиотеки_им_академика_М_И_Перельмана.pdf
475Health Informatics/Health Information Technology
mentioned. The overall construction of an HIS is always a trade-off
between monolithic solutions usually designed by one single
(universal) provider and a combination of highly specialized “insula-solutions” which often have been developed locally or by special providers
(not infrequently companies providing the discipline-specific hardware)
(
Fig. 12.1).
Beyond supporting the clinical and medical care activities, the HIS
should also enhance administration (material services, financial tasks
including budgeting, payroll, etc.).
Thus, costs and performance can be continuously evaluated. This is of
outstanding importance, since the traditional practice for reimbursement
on a fee-for-service basis is internationally shifting to capitation or fixed
rates for the respective disease. Therefore, health care providers are forced
to provide high quality care at the lowest possible price. This can only be
achieved if information about the performance is valid, timely, and comprehensive. Accordingly, financial pressure is another driver for high quality HIS. Worldwide, a huge market came into existence with several
hundreds of local and international providers. This makes standardization
and communication difficult. Surgeons have to take particular care that
the pre-, intra-, and postoperative workflow is completely integrated into
the HIS
[2].
However, the more the function of a surgical unit depends on an
HIS, the more it is endangered if something happens to disrupt the HIS
operations. White et al.
[3] suggest a contingency plan in case an HIS
should stop functioning which encompasses the following elements:
• A data backup plan for creating and storing copies of electronic health
information
• A recovery plan to restore lost data
• An emergency mode operations plan so facilities can continue per-
forming required operations
• An assessment of all applications that would be affected (including the
impact of a widespread outage), and
• Protocol for testing and revising the contingency plan.
The most important aspect in a surgical unit, besides data backup and
a disaster recovery plan, is an emergency mode operations plan. Each single surgical unit must have, as a matter of course, a backup of its HIS
functions just as it is equipped with an emergency power generator in
case of electrical power failure.
476
Biomedical Engineering in Gastrointestinal Surgery
Figure 12.1 Centralized (“holistic”) (A) versus distributed (“heterogeneous”) (B) HIS
solutions. The holistic architecture is easier to mend, but the specifically designed
modules of the heterogeneous approach are more user-friendly, since they are better
focused on the clinical needs. All from MITI.
Health Informatics/Health Information Technology
477
The first HIS were introduced into surgery more than 20 years ago.
Some scientific analyses are available now concerning the real impact
upon quality of care which will be presented later.
First, some examples of typical surgical applications will be given.
12.1.2 Health Informatics On-Site
The practical importance of the HIS for surgery will be demonstrated in
four typical scenarios: Outpatient department, surgical floor, multidisciplinary conference, and the OR.
12.1.2.1 HIS in the Outpatients (Preadmission) Department
Prior to his/her surgery, the patient has to see the surgeon who checks
that the indication is given, and, if so, accomplishes the necessary procedures to prepare everything for the operation considered (see Section 3.3:
Structure and Organization of Surgical Care).
A new file has to be created for each individual case.
Information gained by previous (external) diagnostic procedures has to
be integrated.
Currently, this is still a major problem. Direct digital transfer (e.g.,
from the referring family physician) is still uncommon. In most cases, the
surgeon has to take over the relevant external information manually
which costs avoidable time and efforts (
Fig. 12.2).
Figure 12.2 Preadmission visit for elective surgery. From MITI.
478
Biomedical Engineering in Gastrointestinal Surgery
Modern imaging (CT, MR, etc.) are increasingly often presented by
the patient on a data storage device.
12.1.2.2 HIS in the Surgical Floor
The HIS is the key tool for the surgeon and the nursing team to organize
and to manage the specific tasks to be done on a typical surgical unit.
Admissions, discharges, but also scheduling of additional tests are based
on a digital basis.
Documentation of observations, prescription of drugs, etc. during the
doctor’s visit is increasingly often performed digitally by means of mobile
handheld devices, replacing gradually the handwritten notices on the
patient charts (
Fig. 12.3).
Laboratory findings and imaging results are directly accessible at the
point of care—the patient’s bed.
The extent of information directly available at the point of care could
be theoretically unlimited if the HIS could be used by means of a
suitable handheld device. Currently, suitable technical solutions are being
evaluated all over the world (
Fig. 12.4).
Figure 12.3 (A) The doctor’s daily visit at the patient's bed together with the nurse.
A manual card-filing system is used. (B) The documentation system (here: Kardex)
allows quick reference to the condition and needs of the patient. It contains the documentation of physical findings (blood pressure, pulse, body temperature, etc.), the
schedule of medications, level of activity allowed, diet, the care plan, and the treatment procedures. All from MITI.
Health Informatics/Health Information Technology
Figure 12.4 (A) The digital chart resembles the physical one, but is far more easily to
handle and is more neatly arranged; (B) Instead of turning over the different folders,
a simple finger touch leads to the selected patient. All: Courtesy: Dr. M. Härdtner,
Klinikum rechts der Isar.
479
12.1.2.3 HIS for Multidisciplinary Conferences
Historically, surgery was the exclusive answer to many, in particular,
oncological diseases. If surgery was impossible (or no longer feasible), the
disease took its natural course. Nothing was left for the physician to do
for his/her patient than provide the best supportive care.
Stepwise, alternative therapeutic options were invented. Radiation
therapy was developed, as soon as physicians became aware of the fact
that high-energetical X-rays were capable of reducing tumor growth.
Later on, chemical agents were identified to reach this aim (chemotherapy). The next step in this line was the detection of immunotherapeutic
approaches.
The availability of auxiliary therapeutic principles fostered combined
approaches (multimodal treatment strategies). Even if a tumor was not
resectable when it was diagnosed, a so-called “pretreatment” with
480
Biomedical Engineering in Gastrointestinal Surgery
Figure 12.5 A look into a typical “therapy board.” The individual case is presented
by the responsible physician. This is followed by the demonstration of the respective
findings by the experts (e.g., gastroenterologist: endoscopies; radiologist: X-ray, CT,
MRI; pathologist: histopathology). All aspects are discussed among the experts.
Finally, a consensus should be found of how to proceed. The recommendation on
the details of further treatment is documented. From MITI.
radiation and/or chemotherapy could bring it into tumor mass reduction
which, finally, made it possible to strive for a surgical resection.
The promising auspices of multimodal therapeutic options require the
elaboration of well-differentiated, individualized therapeutic strategies. It
is an interdisciplinary task requiring a good coordination and cooperation
of gastroenterologists, radiologists, oncologists, representatives of nuclear
medicine, pathologists, and some other experts. Well scheduled and structured conferences are required to discuss each individual case and to
define the adequate “multimodal” treatment (
Fig. 12.5). All necessary
information must be available immediately during the “therapy board,”
since each minute of this meeting of outstanding specialists is valuable
[4]
(Fig. 12.6).
Waiting breaks are intolerable. In addition, the decisions of the therapy
board have to be accessible to all who are involved in the further treatment at anytime and the decision has to be achieved according to the
legal requirements.
The use of the HIS, however, is not only a matter of organization
(improving velocity and comprehensive access to previous and elaborated
information). It is also a great opportunity to explore the data for scientific purposes (“data mining”).
12.1.2.4 HIS in the OR
The OR is the central point of care in surgical health care delivery.
Health Informatics/Health Information Technology
Figure 12.6 Overview of the most common data sources required in a therapy
board. The HIS must enable them to be accessed quickly and on the spot. Finally the
decision of the board has to be documented in a way that all medical shareholders
are able to recall it in the later course of the treatment. From MITI.
481
On the one hand, the surgical team needs access to all the information
on the patient which has been collected before. Relevant visual information (e.g., X-ray images, CT scans, endoscopic videos) should be displayed on a dedicated screen if needed (
Fig. 12.7).
Likewise, any other information should be available online (laboratory
findings, information about allergies, etc.).
No less important is the HIS for organizational purposes, since the
efficiency depends upon the OR scheduling. It should facilitate a frictionless patient flow to, through, and from the OR to maximize the
number of cases per day and to reduce as much as possible the required
resources and related costs.
The decision of how to use the ORs to care for a given number of
patients per day—and in which order—depends upon numerous parameters:
Availability (and qualification) of surgeons and anesthetists, availability
of qualified nursing staff, but also the capacity of the recovery room, just
to name a few. In addition, patient-related aspects strongly influence the
482
Biomedical Engineering in Gastrointestinal Surgery
Figure 12.7 During a laparoscopic surgery, a slice of the preoperative CT scan is displayed on the additional monitor (arrow). From MITI.
scheduling, like the estimated operating time, the germ load (e.g.
MRSA), etc. This makes the organizational part in the OR extremely
difficult. The use of an HIS with its specific extension for operating room
scheduling management, interlinked with an anesthesia management system, is indispensable.
Again, a wealth of dedicated information systems are on the market
which are certainly helpful but still lack the capability of active help. This
means they provide comprehensive and reliable data almost in real time
and help to prepare decisions, but they do not offer automatic support by
performing necessary actions on their own. Only in areas where potential
failures are less risky or dangerous, such as material flow, or some autonomous procedures, such as reordering of consumables, are the actions
already partially automated.
12.1.2.5 HIS and Quality of Care
Notwithstanding the importance of HIS concerning administrative and
financial aspects, the surgeon/clinician is primarily interested in the
impact on improving the quality of care. Most of us are convinced that
health information technology will improve quality and efficiency of
health care institutions, from small practices to large centers
However, as shown clearly by Yanamadala et al.
[6], the evidence up to
[5].
now is comparatively low. Most studies on the topic concentrated on the
process quality matrix, analyzing physician level variability and guideline
483Health Informatics/Health Information Technology
compliance rather than overall quality improvement of patient outcomes
[7]. One study suggested that electronic health care records have the
potential to decrease medical errors by providing improved access to necessary information, better communication, and integration of care
between different providers and visits, and more efficient documentation
and monitoring
[8]. However, overall improvements in patient outcome
associated with health care informatics are still not yet well documented.
In particular, the effect of the implementation of HIS on inpatient adverse
events, inpatient mortality, and the readmission rate for specific surgical
conditions has yet to be explored. Accordingly, Yanamadala et al.
[6] tried
to find out whether hospitals with fully implemented electronic health
care recording (EHR) systems had better patient outcomes compared to
hospitals with partial or no implemented EHR system. Insofar, the study
provided new information about the relationship between the implementation of HIS and a quality of health care delivery in inpatient setting.
The results were striking. In the cross-sectional analysis surgical
patients treated at hospitals with full EHR had higher mortality rates than
patients treated in hospitals with partial EHR or at hospitals with no
EHR. Patients treated at hospitals with full EHR had higher readmission
rates than patients treated at hospitals with partial EHR but lower readmission rates than patients treated at hospitals with no EHR. Surgical
patients treated at hospitals with full EHR had higher rates of complications than patients treated at hospitals with partial EHR. Surgical patients
treated at hospitals with full EHR had a shorter length of stay measured
in days than patients treated at hospitals with par tial or no EHR.
Obviously, the effect of EHR introduction was not associated with
improved patient outcomes (specifically inpatient mortality, readmissions,
and complications). Although EHR systems are thought to improve quality of care, this study suggests that in their current form EHRs have not
yet begun to reach meaningful use targets and may have a smaller impact
than expected on patient outcomes.
Another study reviewing evidence regarding the impact of health
information technologies on surgical practice came to rather disillusioning
results as well
[9].
In a careful meta-analysis, 32 observational studies and 2 randomized
controlled trials were evaluated. EHR improved appropriate antibiotic
administration for surgical procedures in 13 comparative observational
studies. Another five studies indicated that electronically generated reports
had increased accuracy, completeness, and availability in the medical
484
Biomedical Engineering in Gastrointestinal Surgery
record. Otherwise, no further advantages could be demonstrated. They
concluded that the quality of evidence about the effects of health information technologies in surgical practice is still low and further research
is needed to optimize the efficacy. The methodology is already well
established
[10].
12.1.2.6 Data Mining
Each single case produces a vast amount of data: individual state of the
patient and medical history, preoperative imaging, intraoperative findings,
surgical care including the specific type of intervention and the final outcome. These data will be easily accessible in the future since all of them
are stored in a digitalized manner. Self-evidently, these comprehensive
databases are too large-sized and complex for manual knowledge extraction, but computer science offers now sophisticated methods of automatic
analysis of large quantities of data that will also allow to extract previously
unknown information. The hidden treasure of information from a vast
number of cases is now accessible to identify the most adequate therapy
for each individual patient and to bring surgery to a new level of quality
(
Fig. 12.8).
Self-evidently, surgeons always tried to evaluate the mass of clinical
experience for predicting the prognosis and to individualize/optimize the
therapeutic strategy. Prof. K. Maruyama, a highly renowned specialist in
Figure 12.8 The nightmare of scientific surgery: The huge wealth of information collected over decades from tens of thousands of patients/treatments are buried in the
archives and destroyed after a certain period of time (mostly 30 years).