Introduction to the Global Patient Record and
Departmental Properties in function Medical Specializations

Draft version 3 on 11 May 2000
please sent remarks and suggestions to Etienne Saliez

Introduction

• The care of one patient requires usually the collaboration of a large team of specialized care providers. These care providers, i.e. the "Care Teams" of each individual patient, need common communication tools, i.e. they need access to a common global medical record.
• Since the main objective of the project is to improve the communication between all the members of these virtual care teams, the strategy of the Global Patient Record project is to focus initially on the generic properties which are common to most environments. The first priority is to make basic building blocs, in such a way that they can be reused in many situations.
• It is however also true that differences between the specialities exist. The approaches of the project are :
  • When properly identified, these differences will probably appear less important than expected at first sight.
  • Many differences consist of differences in relative priorities. At the end nearly everybody will require nearly all the functionalities, although at various degree and with a different planning. For example :
    • Some specialized doctors (as e.g. pneumologists or gastroenterologists) need frequent access to imaging facilities, while others nearly never use images (e.g. psychiatrists).
    • Some specialities want urgently help for the planning of their work (e.g. schedulling procedures), while others see here less immediate advantages, although they will realize the need soon or later.
  • Let begin with the definition of solutionsaddressing the most common requirements. Later on when and where necessary, the basic building blocs will be extended in function of specialized requirements.
• The purpose of this introduction is to propose guides lines about how to start from very generic concept and how to approach particular specialities.

Generic properties of user needs

This chapter tries to identify generic factors which have an influence on the requirements of patient records.

• Population :
  • Many specialized departments works for relatively large number of patients, e.g. more than 20.000. This is particularly true in preventive medicine where short check-up are performed. When there are many patients and many care providers the relation becomes more anonymous. Therefore the support of very reliable identification procedures is here particularly important.
  • GPs know very well relatively limited population of typically 1 to 3000 persons.
  • Other department are doing very intensive work for a very small number of patients, e.g. only 20 at a time in an intensive care unit or less than 100 in a dialysis unit. Identification is here not a problem, but the organization of very large amounts of information for the same patient.
• Time scale :
  • Specialized departments have usually a temporary mission, while GP have a life long and even familial scope.
  • The issues may be from minutes in anesthesia, to years for chronic diseases diseases as age related ailments.
• Nature of the work :
  • Some departments focus on analysis and diagnoses,
  • while other focus on the execution of already predefined activities.
• How far do activities follow schemes :
  • Some specialities follow very predictive schema, for example orthopedic operations, chemotherapy, dialysis, ...
  • while others face constantly new situations, e.g. internal medicine, emergencies, ...
• Diversity of problems :
  • Some departments focus usually on one central problem, e.g. to perform one type of operation as hip prothesis, or the safe delivery of mostly healthy young women.
  • Other departments need to cope with a large and complex list of problems, including possible complications of many antecedents, e.g. in geriatry and internal medicine.
• Degree of medical interaction with other departments :
  • Some doctors works mostly alone : GP in first line practice, as well very specialized doctors as e.g. opthalmologists.
  • while others works always in teams e.g. anesthesist and surgeons, or oncologists.
• Willingness to collaboration :
  • Public hospital or private clinics may have some difference. Private practices tend in general to be more individualistic. People having direct economic incentives could be less willing to share their work. The sharing of information is not necessarily better in large public hospitals where all doctors are employees of the same organization, but where some bureaucracy may exist..
  • Access to information is indirectly related to social status. The relations between the various professional groups may depend on the cultural context, which may be different across countries. For example the openness to share information with nurses may be different across countries.
  • From the ethic point of view, doctors must share their records when their have a common patient.
• Type of patient care :
  • Ambulatory care :
    • A great number of relatively short visits, of generally 5 to 20 minutes.
    • Information must often be shared by several care providers. Even when the patient comes back in the same unit, the same doctor is not always available.
    • Several specialists may be involved, each looking at only one problem. None of them has a clear overview of the situation as a whole. It is not obvious if anyone coordinates all the activities.
    • Formal reports and letters must be made from time to time when important information appear, but usually not for each contact.
  • Admissions :
    • Necessary when the ambulatory care is no more possible.
    • One doctor is normally responsible of the coordination of a period of admission. If necessary, he may ask advices to various specialized consultants.
      However during nights and week-ends, an assistant on duty may have difficult to find what is exactly going on.
    • Every admission must be concluded by a carefully reviewed discharge letter. This report should be available as soon as possible at hte end of the admission. This is particularly urgent when the patient is moved to an other department, who need to share all the information.
    • In most countries a statistical record is also mandatory at the end of every period of admission.
• Data acquisition :
  • The most important information is recorded during contacts with the patient. These notes are usually handwritten.
  • A lot of information is acquired by means of requests to technical departments, e.g. labs, radiology, etc.. Technical department provide generally typed reports, which are often available as electronic documents.
  • Reports and discharge letters are usually dictated and transcripted by secretaries a few days later.
  • Some departments use monitoring devices (intensive care, emergency, anesthesiology, ... )
• .......

Profiles of medical specialities

Specialities are of course necessary because they allow to perform better services in their domain. Since 50 years there is a trend to more and more specialization. The problem is the collaboration between all these narrow specialized worlds.

Clinical workstations are intended as a mean to help to share information. There is globally a far too great mass of information and the problem is to provide a selection of relevant information in function of the specialized context.

General Practice

• GP take care of the first line of medical care.
• GP have clearly a coordinating function between all other specialized colleagues. They have a global view on all problems, even if they are not able to cope with deep specialized issues.
• GP are members of the caring team of the patient. From that point of view, they should have access to the complete medical records of their patient. They should normally receive complete reports from specialists and discharge letters after admissions.
• Time scope of life long care, while specialists have more or less temporary missions.
• GP are often going to the home of patients. Portable computers are particularly useful.
• A particularly great number of patient record softwares were developed for general practice. Much can be learned from their very pragmatic experience. However the relatively weak aspect is often the integration with other medical systems.
• GPs are usually in contact with several hospitals at the regional level.
  Up to now, telecommunications are mainly limited to the transmission of lab reports. Many different and incompatible communication standards were developed in order to transfer lab results to GP.
• Most GP work as independent persons.
  • They must provide neutral advice about the choice of hospitals. In principle they may not depend of any particular hospital in any way.
  • They like to keep complete copies of the medical records of their own patients on their own machine. From this viewpoint every GP practice should be seen as a small health care center.
  • Working as independent, they need more administrative support to manage their own office. They are particularly sensitive to practical help which can save time, as for example the printing of certificates.
  • In most countries GP are paid on basis of their visits. but some countries have the principle of a global fee per patient per year.
  • In most countries the patient is free to go to any GP. In some countries there are geographical constraint. Other systems (as in the Netherlands) require a continuity in the scope of yearly contracts.
• A lot of paper work to be given immediately to the patient, including prescriptions and certificates.
• Gp are usually in charge of several members of the family. Their patient identification must provide facilities to retrieve easily all members of the same family.
• GP are often going to the home of the patient. Having a list of calls the same day, they need help to optimize their travels.
• Historically GP and hospital systems did appear as separated lines of development. The new approach for a Global Medical Record should include the best aspects of both worlds !

Group of departments focusing on an organ or a system

• This kind of specialization is the most obvious. For example oriented on respiratory, cardio-vascular, digestive, neurology, urology, dermatology, opthalmology, and many other systems. There are even specialist focusing on only one illness, e.g. diabetology.
• In some cases organ oriented specialists perform themselves a large range of technologies, e.g. surgery is often performed by gynecologists, urologists, opthalmologists, etc... In other cases they call specialized surgeons, neuro-surgery, cardio-vascular surgery, etc...
• These specialities use basically the medical record for their own domain, but they need also access to an overview of the general problem list and summaries from other domains.

Group of departments focusing on a technology

• The primary reason to organize these technical department arise from the need of heavy equipment and specially trained staff.
• The main typical departments in this group are surgery and radiotherapy.
• These clinicians need of course access to the general problem list as any other clinicians. However some chapters of the medical record are more detailed in function of their specialty.
• In most cases their mission is relatively temporary in the scope of a few weeks, although some patients need year long follow up.

Group of technical departments performing tests on request of others doctors

• The primary reason to organize these departments arise also from the need of heavy equipments and specially trained staff.
• The mission of these departments is focusing on the requests they receive from many other doctors. The main departments in this group are the laboratories and the imagery (formerly called radiology).
• Since the main issue is here to answer to a very specific question from their colleagues, they have a much more narrow vision of the patients, e.g. only to make a reliable measurement of blood sugar.
• As a consequence they are usually not much interested to read the global patient record. It is occasionally very important to have access to previous history and particularly to make comparisons with previous tests of the same type.
• At the other hand this group of departments produce very great amount of information, which must become available in the clinical data bases, as soon as possible.
  At the same time they have to send messages, in order to notify the requesters that new information is now available in these data base.
• These departments need large software which are out the scope of the clinical workstation project. They need support of their internal organization, data acquisition, image processing, quality control, etc...

Group of departments focusing on a particular kind of care

• The primary reason to create these specialized departments are related to the organization of the care. Patients having similar nursing needs are grouped here. This group includes intensive care, surgery, neonatology, paediatry, gerontology, psychiatry, coronary unit, revalidation, etc...
• All these departments need of course access to the general medical record.

The definitions here above are too simplified. In practice organ oriented specialities, technical oriented specialities and care oriented ones are often intermixed. Large hospitals can afford to create many more specialized units, e.g. neuro-surgery, coronary unit, etc...
The next paragraphs will highlight more details about particular departments.

Group of departments related to internal medicine

• Internal medicine can be seen as the second level of care at hospital level. Like the GP, general internal medicine has a coordinating function inside the hospital.
• From the internal medicine, patients are often referred to more narrowly specialized departments, because they need higher specializations, specialized technologies or particular kind of care.
• Since there is a trend to more and more specialization, the "general internal medicine" continue to exist, but seems to have less importance (?). The group of so called "internal medicine" consist in fact of many organ oriented specialities as cardiology, pneumology, gastro-enterology, nephrology, endocrinology, etc.... as well some care oriented groups as intensive care, but excluding all surgery related departments.
• The need of a global and well structured medical record arise mainly in the scope of internal medicine.
• An overview of all current orders is also very important, as well orders for any kinds of tests, as well orders for treatments.
  Think about the following usual problem : in large outpatients departments no one has a complete overview of all the medications currently prescribed to the patient.

Group of departments related to surgery

• This group include all the specialists who perform surgery as their main activity.
• Generic needs as above, but the world of surgery is a more systematically organized than internal medicine. Surgeons have often a more decisive attitude. If something must be done, there is here not much time for long discussions. When the decision of an operation has been taken, a sequence of activities can be planned during a period of 2 to 12 days.
• Nature of the work and timing :
  • Surgeon are requested by GP or by other specialistr to evaluate the need for operations as well the perspectives of success. Patients should normally not go directly to a surgeon.
  • The main activities are related to the operation theatre.
  • Surgeons take care of only the direct follow up in the days after the operation.
• While the surgeon focus on the problem to be solved by means of an operation, he delegate all the other problems related to the general condition of the patient to an anesthesist (see below).
• Surgeons participate in the global problem list of the medical record.

Emergency entrance

• Nature of the work
  • At any time any kind of medical problem may arise. The first question is to identify rapidly the few patients who present really sever and urgent problems. They are ready to perform urgent first aid, but when these patients will be stabilized they will be transferred as soon as possible to the intensive care unit or to surgery.
  • Population :
    • Patient are referred by their GP, as well by family or by the police in case of emergency. Some patients arrive even on their own initiative.
    • A relatively great turn over of typically several dozen patients a day, but for very short duration generally for less than 1 or 2 hours.
    • The emergency entrance has a very variable work load. For example in case of epidemics or of slippery roads many more entrances may be expected.
      They should be able to cope with very rare but large catastrophic situations as for example a train or airplane accident, large fire, earth quake, etc.. In that case the the most urgent patients need to be selected, and more staff must be called as soon as possible.
    • As a mean about 90 % of all arrivals are not real emergencies. The issue is essentially a dispatching problem, either to admissions in other departments or to send the patients back to their home, with advice to consult any other doctor in the usual way. When GPs become a little less available day and night, the first line care is in fact taken over by the so called emergency department of hospitals. For example a baby with fever is usually not an acute emergency, but the problem may indeed not wait unattended until the next Monday.
    • During nights and week-ends the emergency team provide also support inside the hospital, in case of any kinds of acute question.
• Easy access to previous information is critical in order to assess the new situation correctly. The primary requirement is a good summary of the medical record, but there is usually no time to look at all details.
• The mean duration of the stay of the patients in the department should be as short as possible, usually not more than one hour. Therefore there is a need for a good tracking of all activities. At any time it must be clear where the each patient is, what is the current step, and what could be the expected next steps. No patient may be forgotten somewhere (e.g. in the radiology) and remain there unnecessary waiting.
• New patients with potentially serious symptoms are provisionally connected to basic monitoring equipments. Typically heart rate and oxygenation. In case of alarm the staff can be immediately warned, even if the patient remain unattended for 10 minutes.
• Since many patients are transferred to other departments or refererred to their GP, the reporting of the observations is a critical issue. As far as possible the reporting need to be made immediately when the patient is transferred, because the receiving department need it to start.
• Large hospitals may have their own group of ambulances. When required they can send a team including a doctor and a nurse. These ambulances have radio communication, but it could be useful to install a mobile workstation providing the same facilities as inside the hospital.

Intensive care unit

• Population :
  • small population of patient in very critical situation, requiring intensive care. When possible the patient is transferred to an ordinary department after a few days
  • In principle after important surgery, all patients are monitored for a few hours before returning to their ordinary ward.
  • Large hospitals have usually several specialized intensive care units. Typically there may exist a specific units for neonatology and cardiology specialized on infarctions.
• Nature of the work :
  • Multiple monitoring of vital functions (cardiac activity, blood pressure, ventilation, frequent lab tests, etc...).
  • Support of vital function e.g. assisted ventilation.
• Timing : minutes to hours. The situation must be reevaluated at least every hour.
• Many parameters need to be continuously recorded. Many data can be acquired by means of interface to automatic monitoring devices, but other need to be entered manually. A workstation should be installed at the side of each bed.
• The result of all these observations need to be presented in a very easy understandable way. A large graphic screen should provide an overview of the evolution of the various parameters. Trends are critical. Observations must be correlated with treatments.
• Beside the intensive care aspects, all the general medical records facilities need to be available, as in internal medicine or surgery. Many intensive care department have specialized departmental systems, which may be difficult to interface with the general system of the hospital.

Nephrology and dialysis

• Nephrology is usually seen as a member of the internal medicine group.
• Nephrology include an intensive activity called dialysis, in order to maintain the normal fluid concentrations of patients who lack normal kidney function. This is a situation where a small group patients require very intensive care, but can be maintained during many years.
• This require frequent sessions where the patient must be connected to a machine performing chemical exchanges with the blood of the patient during a few hours. The patient must have this treatment at intervals no longer than 3 days.
• Many parameters need to be followed, blood pressure, weight, a set of lab tests, etc... and a large amount of data must remain available. The clinical workstation should be able to present synthesis as graphics of large groups of parameters on the same screen.
• These patients who are very dependent of the continuity of the treatment, should be allowed to move occasionally to an other city. Therefore the patient record should be available at any time on various types of installations. Since printouts are very unpractical, the interoperability is here a very critical issue.
• Transplantation :
  • These patients may be saved by means of kidney transplantation. Since there is a great specificity and few donors, they are very difficult to find. International networks allocate the most compatible kidney to the most appropriate receiver.
  • When a kidney becomes available somewhere, it must transported as soon as possible and the operation must be performed within a few hours. Police or military forces may be required to move the kidney and the patient to a specialized center.
  • The transplantation network must have access to the detailed record of the patient. This must be available at any time since decisions must be taken as soon as possible in remote locations, when a donor become available. For example it is important to know if a candidate receiver is temporarily out for any reason e.g. fever.
• Dialysis is a domain where clinical workstations are critical, as well for the daily treatment in the local center, as well for remote connections. Various specialized systems have been developed, but they have compatibility problems as well with their local hospital environments as well with other centers.

Anesthesiology

• Nature of the work :
  • Global check up, usually at the end of the afternoon the day before the operation. The question is an evaluation how far the patient can withstand the operation. If he sees a problem or if the routine check up are incomplete, the anesthesist may ask to postpone the operation.
  • Perform the anesthesia in order to allow the surgeon to work in good conditions. During the anesthesia the work is similar to the work of the intensive care unit, i.e. the monitoring and the support of vital functions. The planning of the work of the anesthesiology is almost completely dependent on the planning of the surgeons. The anesthesist must stay attentive for long hours with few things to do. However he must remain ready to take acute critical decisions.
  • Take care of the follow up during the first hours after the operation. Like intensive care for the first 2 - 3 hours, usually in a recovery room, in the surgery department. After that some follup up during the first 24 hours.
• Anesthesiology sees many different patients, but for a period of usually less than 2 days.
• Access to the medical record :
  • The general purpose clinical workstation is mainly useful during the preparatory stage. The anesthesist sees many new patients every day, and need an overview of the situation as well the result of the routine check ups. Particularly relevant types of information are :
    • Montivation of the request for an anaesthesia, surgical plan.
    • Current Problem list
    • History, including the history of previous anesthesia, with detailed reports.
    • Biometric parameters as weight, length, usual blood pressure, etc....
    • Risc factors as allergies, diabetes, etc ....
    • Complete overview of current medications, which may have been prescribed by various other specialist or the GP. Some drugs may interfere with anaesthesia.
    • etc....
  • Reports of previous anesthesias, if any, are important for the preparation of new ones.
  • During the operation he need to monitor various physiological functions. This is often achieved by means of a specialized system. During the operation :
    • Evolution of at a least a dozen of parameter, at interval of 1minute or less : presuures, frequencies, etc...
    • Cumulative report of the medications given during the anesthesia.
    • However the anaesthesist should always keep a possibility of access to the general system. For example in order to get access to lab test which are sometimes performed during the operation.

Oncology

• A multidisciplinary collaboration is here particularly important. A typical treatment (as a breast cancer) may require the participation of an organ oriented specialist (a gynecologist), of a technically oriented specialist (e.g. a surgeon), a department having heavy equipment (radiotherapy), as well experience about chemotherapy and hematology.
• Clinical workstations are particularly necessary here as a communication tool, because all these specialists are usually located in different departments.
• The treatments require precise planning of activities, which are outside the scope of the generic clinical workstation :
  • for schemes of chemotherapy,
  • for 3 dimensional computation of irradiations in the radiotherapy.

Diverses organ oriented specialities

This group include diverses specialities with a narrow focus on an organ :

• Ophtalmology
  • Software for measurement of the vision.
  • ...
• Oto-rhino-laryngology
  • Specific software related to audiometry.
  • ...
• Dermatology
  • Mostly ambulatory care, few admissions.
  • Like to take many images, with a magnification of usually 10 X.
  • While most other specialities use commercially packaged medications, the dermatologists continue to prescribe many magistral preparations to be made in the pharmacy
• .....

This group has relatively few interactions with the other groups. They need to be aware of a summary the general patient record, but most of their interest focus in their own domains. They use various software outside the scope of the generic clinical workstation.

Nursing Units

• Population : generally no more than 20 to 30 patients. With a typical mean duration of admission of 5 to 15 days, the turn over is a few new patients a day.
• Nature of the work :
  • Reception and assistance to the disabled patients at various levels. Nursing care, distribution of the meals etc...
  • To perform many tasks ordered by the doctors, including :
    • The critical responsibility of many treatments. Drugs must be delivered according to precise planning or by means of continuous perfusions, which need frequent supervision.
    • Planning and scheduling of many activities, e.g. organizing examination in technical departments
    • ...
  • First line monitoring of the situation of the patient :
    • Basic observations as temperature and pulsations several times a day.
    • To report any new intriguing complaints.
  • Management of the unit :
    • Nurses manage the supplies of the unit. Different types of organization may exist, but they have normally a cabinet containing the most usual pharmaceutical products for the few coming days.
    • Responsibility of data collection for the administration about activities which may be billed. The most important is the registration of the occupation of the beds.
    • In some circumstance nurses are required to collect statistical data about their activities.
  • Globally much paper work !
• Timing :
  • The planning is generally made one day at a time. Most activities have to be performed within a time range of about an hour.
  • Since nursing units works 24 hours a day, the continuity of the information is particularly critical. A lot of practical information need to be shared by 3 groups of persons, by means written notes and by means of short meetings when the next shift arrive.
• Each patient has normally a coordinating doctor. Several different doctors may have patients in the same ward. They give orders and may have specific requirement in function of their specialities.
• Priorities about the workstation :
  • Overviews of worklists
  • Management of activities, including the possibility to register various kinds of scheduling
  • Support for the management of the unit by means of well integrated applications, among others about the control of the supplies in function of the orders.

Social workers

• As far as allowed to get access to the medical record in function of cultural acceptance e.g. in UK and Nordic countries, the involved social worker may have access to the problem list.
• Information about the social situation should become available to the other care providers of the same patient. As for any specialized kind of information a summary should be available to the other care providers having other specializations, i.e. short messages should appear in the general problem list.

Clinical trials

• The problem is here to make reliable evaluations of treaments.
• There is a need for complete set of data at fixed intervals. Remin,ders are important.
• Support of clinical planning procedures.

.......