Biomedical Informatics 4th Edition by Edward Shortliffe, James Cimino

Exercise 1

Sect. 6.2.1 . James Johnson is a 42-year old man living in a medium-sized western U.S. city. He is married and has two children. He has TypeII diabetes, but it is currently well-controlled and he has no other health concerns. There is some history of cardiovascular disease in his family. James has a primary care physician, Linda Stark, who practices at a clinic that is part of a larger health delivery network, Generation Healthcare System (GHS). GHS includes a physician group, primary and specialty care clinics, a tertiary care hospital and an affiliated health insurance plan. James needs to make an appointment with Dr. Stark. He logs into the GHS patient portal and uses an online scheduling application to request an appointment. While in the patient portal, James also reviews results from his most recent visit and prints a copy of his current medication list in order to discuss the addition of an over -the - counter supplement he recently started taking. Before James arrives for his visit, the clinic's scheduling system has already alerted the staff of James's appointment and the need to collect information related to his diabetes. Upon his arrival, Dr. Stark's nurse gathers the requested diabetes information and other vital signs data and enters these into the electronic health record (EHR). In the exam room, Dr. Stark reviews James's history, the new information gathered today, and recommendations and reminders provided by the EHR on a report tailored to her patient's medical history. They both go over James's medication list and Dr. Stark notes that, according to the EHR's drug interaction tool, the supplement he is taking may have an interaction with one of his diabetes medications. One of the reminders suggests that James is due for an HbA1c test and Dr. Stark orders this in the EHR. Dr. Stark's nurse, who has been alerted to the lab test order, draws a blood sample from James. Before the appointment ends, Dr. Stark completes and signs his progress note and forwards a visit summary for James to review on the patient portal. A few days after his appointment, James receives an email from GHS that alerts him to an important piece of new information in his patient record. Logging into the patient portal application, James sees that his HbA1c test is back. The test indicates that the result is elevated. Dr. Stark has added a note to the result saying that she has reviewed the lab and would like to refer James to the GHS Diabetes Specialty Clinic for additional follow-up. James uses the messaging feature in the patient portal to respond to Dr. Stark and arrange for an appointment. James also clicks on an infobutton next to the lab result to obtain more information about the abnormal value. He is linked to patient-focused material about HbA1c testing, common causes for high results, and common ways this might be addressed. Lastly, James reviews the visit summary note from his appointment with Dr. Stark to remind him about suggestions she had for replacing his supplement. At his appointment with the Diabetes Specialty Clinic, James notes that they have access to all the information in his record. A diabetes care manager reviews the important aspects of James's medical history. She suggests more frequent monitoring of his laboratory test results to see if he is able to control his diabetes without changes to his medications. She highlights diet and exercise suggestions in his patient portal record that have been shown to help. The care manager sends a summary of the visit to Dr. Stark so that Dr. Stark knows that James did follow - up with the Clinic. A year later, James is experiencing greater difficulty controlling his diabetes. Dr. Stark and the Diabetes Care Manager have continued to actively monitor his HbA1c and other laboratory test results, and occasionally make changes to his treatment regimen. They are able to use the EHR to track and graph laboratory test results and correlate them with changes in medications. Due to family problems, James struggles with adherence to his medication regimen, and he is not maintaining a healthy diet. As a result, his blood sugar has become seriously unstable and he is taken to the GHS hospital emergency department. Doctors in the ED are able to access his electronic record through a Web-based interface to the clinic EHR. His medication and lab history, as well as notes from Dr. Stark and the care manager, help them quickly assess his condition and develop a plan. James is admitted as an inpatient for overnight observation and, again, doctors and nurses on the ward are able to access his full record and record new observations and treatments, which are automatically shared with the outpatient EHR. They are also able to reconcile his outpatient prescriptions with his inpatient medications to ensure continuity. James is stabilized by the next day. He receives new discharge medications, which simultaneously discontinue his existing orders. Because Dr. Stark is listed as James's primary care physician, she is notified both at admission and discharge of his current status. She is able to review his discharge summary in the EHR. She instructs her staff to send a message through the patient portal to James to let him know she had reviewed his inpatient record and to schedule a follow-up appointment. The GMS EHR is also part of a statewide health information exchange (HIE), which allows medical records to be easily shared with health care providers outside a patient's primary care provider. This means that if James should need to visit a hospital, emergency department or specialty care clinic outside the GMS network, his record would be available for review and any information entered by these outside providers would be available to Dr. Stark and the rest of the GMS network. In James's state, the local and state health departments are also linked to the HIE. This allows clinics, hospitals and labs to electronically submit information to the health departments for disease surveillance and case reporting purposes. Back at home, James's wife, Gina, is able to view his record on the GHS patient portal because he has granted her proxy access to his account. This allows her to see the note from Dr. Stark and schedule the follow-up appointment. Gina also views the discharge 6 Software Engineering for Health Care and Biomedicine188 This fictional case study highlights many of the current goals for improving health care delivery, including: improved access to care, increased patient engagement, shared patient-provider decision-making, better care management, medication reconciliation, improved transitions of care, and research recruitment. In the case study, each of these goals required software to make health information accessible to the correct individuals at the proper time. In today's health care system, few individuals enjoy the interaction with software depicted in the case study with James Johnson. Although the functions described in the scenario exist at varying levels of maturity, most health care delivery institutions have not connected all the functions together as described. The current role of software engineering in health care is therefore twofold: to design and implement software applications that provide required functions, and to connect these functions in a seamless experience for both the clinicians and the patients. The case study also highlights the usefulness of several functions provided by health care software applications for clinicians, patients, and administrators. Some of these functions include: 1. Acquiring and storing data 2. Summarizing and displaying data 3. Facilitating communication and information exchange 4. Generating alerts, reminders, and other forms of decision support 5. Supporting educational, research, and public health initiatives 6.2.2 Acquiring and Storing Data The amount of data needed to describe the state of even a single person is huge. Health professionals require assistance with data acquisition to deal with the data that must be collected and processed. One of the first uses of computers in a medical setting was the automatic analysis of specimens of blood and other body fluids by instruments that measure chemical concentrations or that count cells and organisms. These systems generated printed or electronic results to health care workers and identified values that were outside normal limits. Computer-based patient monitoring that collected physiological data directly from patients were another early application of computing technology (see Chap. 19). These systems provided frequent, consistent collection of vital signs, electrocardiograms (ECGs), and other indicators of patient status. More recently, researchers have developed medical imaging applications as described in Chaps. 9 and 20, including computed tomography (CT), magnetic resonance imaging (MRI), and digital subtraction angiography. The calculations for these computationally intensive applications cannot be performed manually; computers are required to collect and manipulate millions of individual observations. Early computer-based medical instruments and measurement devices provided results only to human beings. Today, most instruments can transmit data directly into the EHR, although the interfaces are still awkward and poorly standardized (see Chaps. 4 and 7). Computer-based instructions that were electronically sent to James's patient record. As she looks deeper into information about diabetes that GHS had automatically linked to James's record, Gina sees a note about a research study into genetic links with diabetes. Concerned about their two children, Gina discusses the study with James, and he reviews the on-line material about the study. Growing interested in the possible benefi ts of the research, James enrolls electronically in the study and is later contacted by a study coordinator. Because GHS researchers are conducting the study, relevant parts of James's EHR can be easily shared with the research data tracking system.
-Reread the hypothetical case study in Sect. 6.2.1 .
(a) What are three primary benefi ts of the software used in James's care?
(b) How many different ways is James's information used to help manage his care?
(c) Without the software and infor mation, how might his care be different?
(d) How has health care that you have experienced similar or different to this example?