The HEGP Case Study - SBIS

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The HEGP Case Study - SBIS

Implementing Shared EHRsThe healthcare context• The healthcare context– The evolution of practice– The expectations– The reality in France• The HEGP case study• Conclusion


Health care practiceBirthPractice evolutionDeathEpisodes of careSituation• Life long support (predictive, preventive, curative, palliative medicine)• Multiplicity of parameters (biological signals, images, etc.)• Multiplicity of highly specialized health actorsNeeds• Life long and shared patient records• Cooperative management by health professionals• Increased role of the patient


The healthcare contextSharing Health Records“the expectations”Practitioner2 recordsPatient personal1 recordsTrusted Hosting4 Services3 Hospitalrecords


The healthcare contextSharing Health Records“the reality in France”Practitioner2 recordsPatient personal1 recordsTrusted Hosting4 Services3 Hospitalrecords


The functional dimensionVertical applicationsPROs• The market exists• The pressure of professional lobbiesCONs• Duplication of functions• Heterogeneity of interfaces (end-user training)• Data redundancy• Integrity conflicts• Integration complexity (n*(n-1)/2 interfaces)


The information system contextFrench legislation• A strong security act– Loi “Informatique, Sécurité et Libertés” : January 6, 1978Mandatory declarationNational coordinating body (CNIL)– European council Directive : October 26, 1995• Direct access by the patient to their health record– March 4, 2002 law on patient access rightsHealth Professional Records, Hospital RecordsTrusted hosting centers– Various bills concerning the content of the Personal/PatientHealth Records and the Agreement process for hosting centers(2003-2005)


Implementing SharedElectronic Health RecordsThe HEGP case study• The health care context• The HEGP case study– The strategic objectives– The HEGP shared health record : a short visit– Report transmission to patients and their GPs– Transmission to hosting centers– Results and discussion• Conclusion


HEGP BackgroundA large restructuring effortHôpital Laennec Hôpital Boucicaut Hôpital Broussais


HEGP BackgroundA large restructuring effortBBL HEGP %1999 2003Beds 1,222 825 - 460 - 32%Personnel 3,619 2,792 - 827 - 22%


HEGP BackgroundArchitecture 9 floors 120 000 m² working area 40 000 m² glass walls« Main Street »


HEGPStrategic Goals• Improved Quality of Care Shared Electronic Health Record (EHR) High Quality Guest Services• Improved Openness80% single rooms and 15%rooms with family facilities Better Patient Participation Community Health Care Network Integration• Improved Accountability Decentralization of decision centers


HEGP BackgroundMain figures (2005)NoNumber of active beds 825Number of nurses 1,100Number of physicians (FTE) 400Total number of physicians 800Mean number of inpatient admissions/month 4,300One day hospital care (% of admissions) 31%Number outpatients visits/month 20,000Nb. Visits at the emergency department/day 130Nb. PC 2,300Nb. wireless portables computers 130Nb. simultaneous users (pic time) 1,200


The strategic objectivesFunctionalTo achieve a process-oriented,component-based, enterprise-wideHIS ?Target systemEnterprisewide coveringOrganizationalProcessorientedComponentbasedTechnical


The HEGP Case StudyThe health care context• The HEGP case study– The strategic objectivesThe functional dimensionThe technical dimensionThe organizational dimension– The HEGP shared patient record : a short visit– Report transmission to patients and their GPs– Transmission to hosting centers– Results and discussion• Conclusion


The technical dimensionThe issueTechnical ArchitectureMain-frame Client/server N-TierBDepartmental systems(1985-2000)AComponent-basedsystems (2000- …)Centralized systems(1970-1985)CVertical (structure-oriented)ApplicationsHorizontal (process-oriented)


The technical dimensionThe selection of componentsAZVUB, Brussels, 2000COMPOENT FRAMEWORKAdministrativeINFORMATION BUSWorkflowComponentADTAuthorizationComponentGENERIC COMPONENTSMedicalCarePatientComponentNursingHealthcareRecordMedicalSupportActivityComponentAncillaryServicesResourceComponentHEALTHCARE-RELATED COMMON COMPONENTSAPPLICATIONOBJECTSKnowledgeComponentCity J Jane Smith 561224-1234 # 15931212 Diagnosis : Fracture of femur 4pHFamily history : Both parents diedfrom myocardial infarctionPatient history : Fell on slipperypavement in Brussels yesterday ...PERSISTENT LAYERStatus : Examination of right leg shows ...32Medical RecordAlphanumeric data1ImagesBio signals (ECG)DocumentsR. Van de Velde. Framework for a clinical information system. Int J med Inf 2000; 57: 57-72.


The technical dimensionHEGP componentsClientIdentificationdeviceSessionManagerApplicationportalHealthcare componentsPatientcomponent (PC)Actcomponent (AC)Generic componentsContextManager (CM)Referencemanager (RM)DocumentProcessor (DP)CommunicationBus (Com)Health record(HR)Resourcecomponent (RC)SecurityManager (Sec)Workflow engine(WE)Decision SS (DSS)Supervisor (Com)Mediators (Com)Data/informationrepositoriesPatient-relatedidentityclinicalbiologicalimagesdocumentsInstitution-relatedterminologiesstructuresresourcesprotocols


The technical dimensionHEGP 4-tier architectureViews• By specialties (e.g., specialized records)• Profession-oriented (e.g., nursing record)Health BusinessComponents• Health “ERP”LegacyapplicationsIntegration middleware• Enterprise Application Integrationenvironment (EAI)Infrastructure layer(servers, network)• Resource layer


The HEGP Case StudyThe health care context• The HEGP case study– The strategic objectivesThe functional dimensionThe technical dimensionThe organizational dimension– The HEGP shared patient record : a short visit– Report transmission to patients and their GPs– Transmission to hosting centers– Results and discussion• Conclusion


The organizational dimensionDeployment strategyPilot unitsFunctional coverageLow HighPartialGlobalEnterprise coverage


The organizational dimensionDeployment strategyEnterprise wide coveragePROs• Voluntary approach (enterprise objective)– Personal investment of the board of directors• Nobody left behind• Patients and physician movements covered– EHR, POE coherence• Maximizes the expected benefitsCONs• High training workload– On site coaching, eLearning tools• Performance/availability risk– Infrastructure maintenance (24/24h, 7/7d), hotline


The organizational dimensionActors points of viewsHealthprofessionals• Functional coverage• Performance (e.g., response time)Hospitaladministrators• Costs, return on investment• Competing advantage• AccountabilityPatientsVendors• Quality and continuity of care• Privacy and security• Enterprise services• Revenue• Market share• Risk


The organizational dimensionActors points of viewsOrder entryOutcome studiesHealthprofessionals2a• Functional coverage• Performance (e.g., response time)Hospitaladministrators• Costs, return on investment• Competing advantage• AccountabilityDecision tools 2bPatientsVendors• Quality and continuity of careElectronic • Privacy and Health securityRecord• Enterprise servicesSecurity 1• Revenue• Market share• Risk


The organizational dimensionFunctionsDependency constraintsComponentsComplexity, costs7 Specialized records6 Orders (drugs)5 Orders (biology, imaging)4 Nurse transmissions3 Laboratory results2 In/outpatient reports1 Patient ID (ADT)AC SchDSS+PM HR Com, CCOW, Sec, RefPM HR Com, CCOW, Sec, Ref0 2 1 3 45Times (years)


The HEGP Case StudyThe health care context• The HEGP case study– The strategic objectives– The HEGP shared patient record : a short visit The application portal Electronic Health Record (EHR) Management Provider Order Entry (POE) Management– Report transmission to patients and their GPs– Transmission to hosting centers– Results and discussion• Conclusion


The HEGP clinicalinformation systemThe application portal(THALIS-portal)• Manages the login procedure (single sign on)• Remembers the user preferences• Gives access to authorized functions• Eases the workflow processes through direct access to objectsmanaged by the healthcare components and triggering of theadequate viewers


Application portal (THALIS-portal)Views of thehealth recordHIS FunctionsObjects withinthe healthrecordPatient event list


The HEGP Case StudyThe health care context• The HEGP case study– The strategic objectives– The HEGP shared patient record : a short visit The application portal Electronic Health Record (EHR) Management Provider Order Entry (POE) Management– Report transmission to patients and their GPs– Transmission to hosting centers– Results and discussion• Conclusion


Electronic Health Record (EHR) managementDRGsPatient ID and visitsCORBAMedical reportsRadiologyreports andimagesEHRClinical informationPhysician/nursingordersLaboratoryresultsNursing notesFlow sheetsCare plansAppointmentscheduling


EHR ManagementClinical questionnairesCORBA


EHR managementNursing questionnairesCORBA


EHR managementVital Signs Entry


EHR managementNursing care notes & plans


EHR managementMedical report production


Provider Order Entry (POE) : BiologyWorkflowAncillary DepartmentsPatient PortalTHALIS-PortalPortal®Passport to Lab ResultsLaboratoryISNetLabLabrequestLabresultsEPR - Care PlanningDxC@reŒICU EPRCareVue®ExamresultsExamrequestPathology ISAPIXCare Unit


Provider Order Entry (POE): BiologyPhysician ordersCORBA


Provider Order Entry (POE): biologyLaboratory orders :sampling supportCORBA


Provider Order Entry (POE): biologyAlertsCORBA


Provider Order Entry (POE): biologySample PlanningCORBA


Provider Order Entry (POE)Label printing


Provider Order Entry (POE)Sample transportationHidden in false ceilingsdifferent models ofsuitcases, simples orupholstered, transport…… mail or paper documents aswell as biological samples to thelaboratories


Provider Order Entry (POE)Sample arrival


Sample analysisLab specimens are handledby robots and automatons


Provider Order Entry (POE)Result flagsColored flags : newlab results, x-raycompleted


Provider Order Entry (POE)Result displayCORBAThick client interfaceWeb interface


Provider Order Entry : ImagingWorkflowPatient Portal THALIS-portal®Ancillary DepartmentsCare UnitPassport toradiologyreportWorklistRadiology ISRADOSModalitiesRadiologyrequestImagesPACSIMPAXEPR - Care PlanningOrderDxC@reRequest forappointment AppointmentAppointment &SchedulingŒOne-CallImage DistributionWeb1000RadiologyReportIHE


Provider Order Entry : ImagingImage OrderingCORBA


Provider Order Entry : ImagingWork lists


Provider Order Entry : ImagingAppointment schedulingCORBA


Provider Order Entry : ImagingPlanned appointmentsCORBA


Provider Order Entry : ImagingReport productionVoice dictation and recognition


Provider Order Entry : ImagingImage viewersCORBA


Provider Order Entry : Drug orders


Provider Order Entry : Drug ordersKnowledge coupling


Provider Order Entry : Drug ordersPharmaceutical validation


The HEGP Case StudyThe health care context• The HEGP case study– The strategic objectives– The HEGP shared health record : a short visit– Report transmission to patients and their GPs– Transmission to hosting centers– Results and discussion• Conclusion


Sharing Patient RecordsSecured transmissionto patients and GPsPractitioner2 recordsPatient personal1 recordsTrusted HostingServices (DMP)SecuredtransmissionSecuredtransmission3 HospitalrecordsShared healthrecord


Patient report transmissionAlert messageH E G PHÔPIT AL EURO PÉEN GEORGES POM PIDOU


Patient report transmissionConnection to “La Poste”serverH E G PHÔPIT AL EURO PÉEN GEORGES POM PIDOU


Patient report transmissionReport transferH E G PHÔPIT AL EURO PÉEN GEORGES POM PIDOU


The HEGP Case StudyThe health care context• The HEGP case study– The strategic objectives– The HEGP shared health record : a short visit– Report transmission to patients and their GPs– Transmission to hosting centers– Results and discussion• Conclusion


Sharing Patient RecordsHosting servicesPractitioner2 recordsPatient personal1 recordsTrusted HostingServices (PHR)3 Hospitalrecords


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Trusted hosting servicesProject ManagementPatient/Citizen supportToolsFrontdeskContract managementAccess PortalDocumentmanagementCall CenterVocal serverPHR storagePatient/Professional IDmanagementInternet accessData Warehouse


Trusted hosting servicesPHR Project (DMP)1) Testing phase (Q4 2005 – Q1 2006) Regional coverage• Patient-host contracts• Educational kits (citizen/health professionals)• PHR server configuration Patient private zone Professional zone Access right management• Technical and organizational assessment2) Deployment phase (Q2 2006 – Q4 2006) Regional coverage• Interoperability issues• Economic model consolidation3) Generalization phase (2007 - ) National coverage – 6 operators


The HEGP Case StudyThe health care context• The HEGP case study– The strategic objectives– The HEGP shared patient record : a short visit– Report transmission to patients and their GPs– Transmission to hosting centers– Results and discussion• Conclusion


ResultsImproved productivityInpatient admissions BBL HEGP1999 2001 2003Beds 1,222 650 825 - 32%Staff 3,619 2,792 2,828 - 22%Patient admissions 48,441 43,368 51,195 + 5%


ResultsUse of the clinical information system (Q3 2005)Nb. using/Nb. concernedhealth units %Admission, discharge, transfer 100%Electronic health recordIn/outpatient reports 100%Access to lab. data & images 100%Care plans 100%Nurse notes & transmissions (inpatients) 100%Physician notes (inpatients) 50%Provider order entryLaboratory, Rx order entry, Nursing, Education 100%Drug orders 25%SchedulingAppointments 100%


ResultsUse of the provider order entry functionsQ1 2002 Q1 2003 Q1 2004 Q1 2005Laboratory orders- Direct entry by physicians 65% 73% 79% 93%Imaging orders- Direct entry by physicians 55% 66% 68% 71%Drug orders*-Direct entry by physicians 100% 100% 100%* 30% of beds


Patient requests for record transmissionHEGPYear 2001 2003 2005* 2005/2001Number of requests 92 285 850* + 820%Number of admissions 47,502 51,195 52,000* + 9%Percentage 0,2% 0,6% 1,6%* x 8,5*Estimate from 2005 Q1-Q3 figuresSource : Jean Wils, House of Patients, HEGP


Implementing Shared EHRsConclusion• The healthcare context• The HEGP case study• Conclusion


Jules Verne (1828-1905)From the Earth to the Moon (1865)Twenty Thousand Leagues Under the Sea (1873)


ConclusionBenefitsImproved productivity• Reduction of the length of stay (from 6.6 to 5.6 days) at year 3Quality of care• Immediately and ubiquitously accessible EHR• Common provider entry through protocols (>1,500 in January 2005)Continuity of care• Direct communication with patients and their GPs through securedemails (2003)• Deployment of a trusted PHR server (Q4 2005 - )


ConclusionLimitsHuman resistance to change


The The future“The future will not just happen if one wishes hardenough.It requires decision —now.It imposes risk —now.It requires action —now.It requires allocation of resources and, above all, ofhuman resources —now...”and patient (citizen) willingness[Peter Drucker, 1993]

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