1. A Case Study of Computer Systems The Belfast City Hospital Nephrology unit

2. What is information? u Defined as “that which helps decision making”

3. Patient Information consists of two components u Clinical Data u Clinical Knowledge

4. Clinical Data u Presenting Symptoms and signs u Laboratory results

5. Clinical Knowledge u General Facts about diseases u How to interpret lab results u How to choose therapies

6. Question u How are Clinical Data and knowledge managed within the Nephrology unit at BCH?

7. Roles of information technology u Shifts away from conventional paper medical records towards computerised systems. u Many problems are associated with the use of paper records

8. Problems with Paper Records u Accessibility of Info ( necessary to search through numerous letters, reports and notes before finding answers). u Missing records u Bulk of paper storage u Incompleteness u Cost u Confidentiality (paper notes easily photo copied).

9. Use of computers in Nephrology u Unique coding and classification for presenting complaints u Computerised discharge system u E-mail for communication - I.e.. arranging meetings, forwarding test results and patient information. u Clinical programs u Office programs

10. The Clinical Programs u The Registrars Discharge program u Medline “Up to Date” u Online Lab Results u Online X-Ray Results

11. Patient Discharge program u This is a program used by the JHO’s and Registrars to discharge a patient from the Nephrology department. u Although it is configured slightly differently for Nephrology the same program is used by all of the departments of the hospital

12. Features u The program uses ICD-10 coding u All 27,000 codes are stored on the computer. u The 100 most common diseases in Nephrology appear in a scroll down list. u JHO’s use same system as registrars u Registrars can verify JHO’s diagnosis using the verify manager.

13. Details entered into the program include…. u Standard patient details u The Admission diagnosis u The procedure done to the patient u Any additional note to be forwarded to the GP. u Drugs given The Registrar checks what the JHO has entered and a Discharge note is generated for the GP and patient

14. Discharge JHO Performs discharge Registrar verifies discharge Info passed onto coding officeGP discharge letter produced Discharge letter produced for patient Patient Discharged (Currently a paper copy)

15. General Opinion u The program is good. Before this system paper discharge notes were used. u Registrars find it easy to check a JHO’s diagnosis. u Generally JHO’s do actually use the system though people still write discharge notes by hand when in a rush

16. Medline “Up to Date” u A CD-ROM which allows doctors to perform “Evidence Based medicine” u The CD is updated every few months by the supplier. u It contains the most up to date forms of treatment for patients.

17. What Does it contain? u Text book information u Articles u Treatment recommendations u Pictures ( e.g.. ECG’s) u Sound files ( e.g.. Heart sounds) u Movies / animation's u Microscopic slides u Slides for lectures

18. Features u Other information can be accessed by clicking on certain keywords in the article ( like the Internet). u The reference lists contain complete abstracts. u Pictures and other media are easily exported for lecture preparation.

19. Features u Medline is also available over the Internet and provides access to various medical journals. u Internet site contains a very powerful search engine. u Internet links are available u References are easily printed out or saved to disk.

20. Opinions u “ The program acts like an interactive text book” u “It’s Very handy for research or just if you want to leave one of your junior doctors to do a lecture for you” u Everyone spoken to found the multimedia features of use in diagnosis.

21. Online Lab and X-Ray Access u The Lab program is called Master Lab u It is a menu driven interface. u The X-ray program is known as BCH Rad

22. Features of Master Lab u Lab times for the program are quicker - results can be obtained the same day rather than the proceeding day. u It stores a history of previous test results for a patient - which is stored in easy to use, one-key menus.

23. Features of BCH Rad u Currently the X-ray results are limited to text format. That is you only get the radiologists report on the X-ray. u Plans are underway to use digital technology to store X-rays on the computer as well.

24. Other Non-Clinical Programs u E-mail u Microsoft PowerPoint u Microsoft Excel u Speech to Text

25. E-mail u Most consultants and registrars have E- mail on their own PC’s. u The PC’s are permanently connected to the Internet.

26. Uses of e-mail u General letters / Personal messages u Attachments of patient data files u Schedules of meetings u Patient appointments u Although it is currently not occurring there are plans for patient results to be sent to GP’s Directly over the E-mail.

27. PowerPoint u A tool used more frequently by medical lecturers in preparing lectures for medical students. u Images are easily imported from Medline. u Files can be transferred over the E-mail to junior doctors if they need to take the lectures.

28. Excel u During our visit the consultant received and Excel file attachment over the E- mail. u Excel is often the form that dialysis results and blood tests for patients on the ward are stored on. u It enables easy printing of specific patients details.

29. Speech to Text u Two versions on different computers u Older version (On Apple) - programmed to recognise medical terms. u Speech has to be slow and staccato. u Newer version - able to recognise fluid speech but not medical terms.

30. Opinion of Speech to Text u A method preferred by some of the older doctors who are less proficient at typing. u It will never replace high speed typing but is a useful tool for generating large quantities of text. u Takes a relatively long time to train to recognise your voice.

31. Security of Data u In response to growing use of computer technology, the BMA has developed nine principles of data security

32. BMA Confidentiality Principles u Access control u Record opening u Control u Consent and notification u Persistence u Attribution u Information flow

33. BMA Confidentiality Principles u Aggregation control u Trusted Computing base Strict adherence to those principles prevents breach of patient confidentiality

34. Security problems on Computers u Problems with access to all records by all users u Password sharing u Terminals left permanently on in wards u Information may be easily printed out ( though records may be made of this)

35. Security aspects u Patient information can only be accessed using passwords - these are needed to log on and access each individual program. u Each staff member has a different password and different access levels. u Only staff named on the access control list may view patient files.

36. Summary u Computer systems in Medicine are… u Time savers u Secure sites of information storage u Sites for research and stores of text book information u Ways of communicating u Convenient - though not always

37. Sometimes they can just be a Pain!