Clinical Information System (HealthDoc) - Sexually Transmitted Diseases Clinic

State: CO Type: Model Practice Year: 2006

This practice addresses the capacity to use web-based information systems to support routine care, public health preparedness and compliance with Public Health Information Network (PHIN) standards. The initial development and implementation costs for this system were approximately $300,000 over the span of about two and one-half years. These costs included the development of the HealthDoc system, implementation and integration of a rules engine, and interface development with agency and State computer systems. In-kind support to build interfaces, provide server and network configurations, and provide technical and clinical expertise and input was provided from numerous Denver Public Health staff, Denver Health Information Systems department staff, and Colorado Department of Public Health and Environment staff. A PHIN compliant clinical information system was developed that: 1) improves the patient flow process; 2) provides flexibility of capturing ever-changing clinical data requirements; 3) provides electronic interfaces to public health partners which eliminates significant labor costs in processing paper forms and reduced by several days the turnaround time to report morbidity to the State; 4) provides rules-based logic that improves data integrity, improves protocol compliance, and alerts clinicians of a patient’s eligibility to programs and studies; 5) consolidated disparate data systems into one unified data system; 6) provides flexibility to adapt to future services and needs; 7) eliminated over 20 different laboratory paper forms; 8) reduces patient registration time through integration with the Agency’s patient registration system; 9) improves reporting capabilities for standard and ad hoc reports; and 10) provides a complete Electronic Medical Record making it easier for clinicians to quickly review a patient’s past history of symptoms, diagnoses, treatments, lab results, and risk factors.
The HealthDoc system implementation addressed several Denver Public Health department concerns including: 1) the inability to electronically communicate with other Public Health partners through PHIN standards and messaging expectations; 2) inflexible aging computer systems; and 3) a variety of disparate data systems that did not interface well. Systems and processes that were over 20 years old were still in place and required significant data entry of paper-based logs into databases.The other issue addressed was the significant time being spent to complete paper forms to order tests from the State, report demographic and risk information to the State, and report morbidity data. Even though databases contained most of this information, there was neither a mechanism to extract the information onto the form nor a mechanism at the State to receive it in electronic format. It required replicating this information onto paper forms and sending these forms to the State. There are many innovative features of this new system. Flexibility is one of the most important features of this system. New forms can be easily added and existing forms can have questions added or deleted. The system is not only an STD Clinic system, but can be used for many other public health functions. The basic patient registration system, coupled with the ability to add services and forms, gives this system the capability of being used as a disease investigation tool, a quarantine/isolation tracking and services system, or in other clinical care settings. As a complete electronic medical record, it contains diagnosis, treatment, clinical assessment, and laboratory test order and result information. This PHIN compliant product permits electronic reporting of lab test result data from this system. Using LOINC codes, these data are semantically interoperable with other government agencies that track morbidity in our jurisdiction.
Agency Community RolesThe development of the HealthDoc system was a partnership between the Denver Public Health (DPH) STD Clinic, the DPH Infomatics department, the Information Systems department within the Denver Health organization, the Colorado Department of Public Health and Environment (CDPHE), the Interlink Group, Countermind, and Siemens Medical Solutions. Denver Public Health, a local health department, developed the vision about the scope and requirements of the new system through the leadership of the DPH Informatics and STD Clinic management. Denver Health, the parent organization of DPH, was also a key partner throughout the entire process by providing technical support and resources from the Information Services department. The Denver Health Information Services department was instrumental in configuring servers, network and security protocols, programming rules logic, testing, and troubleshooting. Another major partner in this project was the Interlink Group, Inc. They provided the expertise and resources to analyze our systems and processes, develop the computer system architecture, integrate with the other systems, and develop the HealthDoc product. Countermind provided the forms software and worked with Interlink to integrate their system into the HealthDoc product. Siemens was another invaluable partner in customizing their rules engine software to integrate it with the patient’s clinical and demographic information. Finally, an essential key partner was the CDPHE. As interfaces were developed to receive and send electronic messages, informatics staff at the State were very supportive in making technical and process improvement changes that correlated with the technology being developed by DPH. Through this partnership there has been a significant reduction of the paperwork that flows between the two organizations since electronic messaging has been implemented, which has resulted in less data entry and improved processes for both entities.   ImplementationThe implementation strategy followed a common rational unified information systems development process that included inception, elaboration, construction, and transition phases. The inception phase began in September 2002 and focused on system requirements and architecture modeling. It was critical that sufficient time be spent understanding the various clinical and laboratory requirements for the new system since it would integrate several existing database systems and paper-based logs, affect many patient flow processes, and be used by a number of specialty clinics within the STD Clinic including a Teen Clinic, a Continuity of Care Clinic, a Confidential HIV Testing Center, a Jail Clinic, and a Family Planning Clinic. The requirements analysis documented the current and proposed process flows, necessary data elements, rules that needed to be enforced by the system, data conversion mappings, and integration mappings between systems. This initial phase took approximately six months to complete. Occurring next was the elaboration phase, which went from January 2003 through September 2003. This phase identified additional requirements through more detailed process analyses. A small group of clinicians, laboratorians, physicians, and clerical staff were selected to provide input and feedback to the processes and designs during development. The construction phase lasted from September 2003 through December 2004. This phase involved building the new system from the designs developed during earlier phases. The committee would test the functionality of new screens and provide feedback to clarify system requirements. Analysis efforts continued during this phase to address how new data collection tools would impact clinical and laboratory processes. The final phase, transition, was very critical. It required setting up classes to train end-users on the new system, addressing and documenting process changes, and providing computer training to some clinicians that had minimal computer experience. The number of training sessions varied depending on the role of the end-user and their computer experience. Specific functionality was covered in a series of training classes and then open labs were set up for those that desired more training. Design committee members became designated super-users and assisted in training and answering questions from their peers.
Goal: To develop a PHIN compliant information system and electronic medical record (EMR) system that supports clinical care within an STD clinic setting and provides electronic messaging with other public health partners. Objective: Improve morbidity reporting processes and timeliness between DPH and CDPHE by transmitting electronic results to CDPHE within 24 hours: Performance measures: Morbidity reporting is received by CDPHE within 24 hours of an STD diagnosis.  Data collection: Two dates were collected: 1) the date when a lab result was posted; and 2) the date when a morbidity card was completed. These dates are automatically entered into the system.  Outcomes (long-term): Electronic morbidity reporting reduced the average number of days to notify CDPHE from 4.2 days to less than one day. Also, the reduction of clerical time completing the forms from nine hours per week to zero hours per week. Objective: Improve the timeliness of posting lab results into the clinical database so that they are posted on the same day as the result:  Performance measures: Posting of lab results in the database will occur on the same day as the result is determined.  Data collection: For the previous system, some lab tests results would be posted only on a monthly basis as part of a monthly process that identified missing results. No data were collected on the timelienss. In the HealthDoc system, a lab worklist screen immediately identifies non-posted results.  Outcomes (long-term): Lab results are now entered directly by the lab personnel, rather than having them write them in a log and have a data entry person eventually enter those data on a monthly basis. Results are now entered on the same day, resulting in more accurate and timely data. Objective: Improve patient registration times through integration of systems: Performance measures: Reduce by 30% the number of times that registration clerks have to enter demographic and address information on new patients.  Data collection: For the previous system, demographic and address information were entered into the STD Clinic database for 100% of new patients. Based upon the generation of a new medical record number, it can be determined how many patients were already registered previously in the Agency system.  Outcomes (long-term): The registration process is much faster since 35% of all new patients already have their information imported into HealthDoc through an interface with the Agency registration system. This reduces patient waiting and improves process flow.
After almost one year of use within the STD clinic, the HealthDoc system continues to represent a key infrastructure tool for the clinical care of STD Clinic patients. Clinicians and management recognize the value of having a flexible unified system for clinical data management. By eliminating dozens of paper forms and logs that used to be found throughout the clinic, the clinicians can focus on providing and documenting care electronically and worry less about pushing paper. Processes within the clinic are now more flexible, clinicians are guided to provide improved care and the HealthDoc system adapts to the process improvement changes that are made. Because of the flexibility of the system, new lab tests, diagnoses, and services have been entered and expanded within the system. Additional features that are requested by the STD Clinic, which may require design or programming, are prioritized and then change requests are submitted to the Interlink Group. Funding for future system design changes will be supported through various departmental infrastructure funds. The knowledge gained and capacity to use web-based, PHIN compliant technologies and better understand the challenges in such implementations is helping us guide appropriate informatics decisions and better direct our resources to achieve functional, valued and financially supported information systems.