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Electronic data utilization

Electronic data entry and presentation offers the following advantages over the traditional paper chart:

• Readability - While the difficulties involved in reading doctors' handwriting are virtually legendary, the problem is real. Not only does the interpretation of hieroglyphics slow down the process of health care, but misreadings can actually endanger patients via a variety of mechanisms, including pharmacy errors. The digital chart is always available while the paper chart may be difficult to find in a busy ICU (used by another health care provider, physically out of the unit with the patient), or simply missing chunks of time. If the writer slows down sufficiently to make his/her writing legible, the time difference between entering the note manually versus entering it digitally shrinks considerably and may even favor the speed of the secure digital record.
  
  
• Reduction of Errors - The effective use of information technology can reduce errors. The potential for pharmacy errors attributing to prescription readability was noted above, however electronic data system also improve drug prescribing by incorporating mechanisms to automatically screen for drug allergies and incompatibilities/interactions. AHRQ has advocated computer physician order entry as a way to reduce medication related error http://www.ahrq.gov/clinic/ptsafety/chap6.htm and the Leapfrog Group has made computer physician order entry one of its three initial methods and requirements for hospitalized patient safety - http://www.leapfroggroup.org/safety1.htm#CPOE
  
  
• Structure and Standardization - The structure of electronic data entry and presentation creates a framework to thinking that helps to avoid errors of omission (e.g. providing 'reminders') and standardize the approach to particular problems. Standardization of care has been shown to improve quality and reduce costs. For critically ill patients, important issues must be addressed on a daily basis (e.g. duration of invasive lines and antimicrobial therapy, etc); the eCareManager^™; eCare Manager facilitates tracking these therapies and insuring their appropriateness. For instance, the "line log" shows when a line was inserted - there is no need to flip through 25 unreadable pages of paper chart. "Medications" organize each drug by class, shows the start and stop date, and tabulates duration of therapy.
  
  
• Rapid access to essential data - Seeking out particular information in the fat paper chart of a long-term ICU patient is not a pleasant or easy task. eCareManager^™ allows the retrieval of all types of information (lab data, notes, microbiology, etc) in rapid fashion. It is analogous to quickly and precisely finding your desired location on a compact disc versus trying to locate a particular song on a cassette tape. In addition, the dashboard applications ("patient profile" and "care plan") aggregate data in a unique way that creates context and illustrates changes. This facilitates knowledge acquisition in a way that cannot be achieved with a paper chart or other electronic systems.
  
  
• Data Entry and Reports - Medicine has lagged well behind industries, such as banking and commerce, in its ability to retrieve and utilize essential information. The use of electronic data allows for most of the entered data to be stored, retrieved, and used for purposes such as quality management and clinical research. In more simple terms, it allows you to understand what has been done and the impact of change on clinical outcomes and costs. The eCareManager^™ maximizes the use of structured 'pick-lists' and has reduced free text down to the history of present illness and clinical assessment. The eCareManager^™ note writing system has been carefully designed to reflect the needs of the busy critical care practitioner while providing the capability to document the care of the most complicated medical and surgical patients. The benefit of this structure is that all of the information resides in a relational database and is therefore retrievable.

Standardization of Care/ Best Practices

Standardization of Care - Standardization of care has been proven to reduce errors, improve quality, and decrease costs in the ICU.
"The application of a systematic approach to ICU sedation can result in significantly better outcomes than less structured approaches that are based on the individual experiences of various practitioners. … the concept of individual patterns of practice is generally inferior to that of standardized approaches to clinical problems."
(Peruzzi WT. Practice in the new millennium: standardization to improve outcome. Critical Care Medicine. 27:2824; 1999)

Centralized eICU^® management and the constant availability of dedicated intensivists can insure consistent care practices across an integrated health system or large hospital.

The use of standardization to improve quality and productivity while concomitantly decreasing costs has been proven in a variety of non-health care industries, as well. These range from the manufacture of automobiles to high-tech radiology equipment to microchips. Standardization enables an organization to strive for the extremely low error rate (3.4 defects per million opportunities) reflected in a Six Sigma program. To paraphrase a giant of quality management, W. Edwards Deming- Do it right the first time. (He actually said - "Eliminate the need for inspection on a mass basis by building quality into the product in the first place") - Out of the Crisis, MIT Press, 1986. While doctors don't like to think of health care as an industry and believe that individual patient care should be immune, as an aggregate we are an industry and we must begin to look at patient care across-the-board.

Standardization based on the use of evidence based medicine (EBM) is recommended by the IOM for the redesign of the health care system. EBM allows for the translation of scientifically well-substantiated research findings into clinical care in a fashion that has been seriously underutilized in the culture of medicine.

Clinical Decision Support System (CDSS) - The use of CDSS's has been shown to improve the quality of health care (Durieux P et al, A clinical decision support system for prevention of venous thromboembolism: effect on physician behavior, JAMA, 283:2816, 2000) and enables clinicians to "keep up" with over 33,000 journal articles per month and the over 4 million citations in the National Library of Medicine.

There are a variety of excellent point-of-care sources of information such as MD Consult and ePocrates but the eVantage Source™ represents a unique resource for the working intensivist, house officer, critical care nurse or respiratory therapist in that it provides a concise, complete and immediately available source of reliable, referenced, and up to date information. It also provides interactive algorithms to assist in decision making by allowing the clinician to enter explicit patient information and to arrive at an evidence based or Delphi suggestion for subsequent care.

Communication and Teamwork

The eICU^® allows for personnel who are not on-site to assist in the care of the critically ill patient. With eCareManager's "care plan" and "task list" onsite/offsite collaboration and communication is facilitated and effective asynchronous work flow is allowed to continue without interruptions creating a critical care team practice as suggested by the IOM.

Real-time communication facilitated by a variety of modalities such as video-conferencing, standardized reports for nurse to nurse signouts, and 'hotline' telephones provide instant bi-directional access between eICU^® and ICU. These modalities improve the fidelity as well as the speed of information transfer in an intrinsically fast-paced environment. The eICU^® also encourages teamwork and improves morale for onsite staff by fostering a sense of pride in providing the best possible critical care.

Why does the eICU^® work?

While there may be some element of a Hawthorne or observational effect on behavior, (http://staff.psy.gla.ac.uk/~steve/hawth.html - orig) the supplemental oversight provided by the eICU^® has been shown by an independent group to cause long-term improvements in quality outcomes.

We must accept that technology will come to play an even greater role in the clinical process over time. The eICU^®, powered by eVantage is just the beginning of the technology-enabled care which we have all anticipated and dreamed of since the advent of the computer age. We must utilize technology to improve patient safety, much as the airline industry has done with the FAA and airline employees (pilots, maintenance workers, flight attendants, air traffic controllers) to engineer a culture of safety. VISICU's eSolutions provide technology tools to 'make health care safer' and they have been designed by critical care clinicians for use by other critical care clinicians. We hope to work as a team with our clinician and hospital customers to continuously improve our product and to provide the best possible care for high-acuity patients who can tolerate neither errors nor delays in their care. We must also employ technology to help control the spiraling costs of health care so that quality care for the critically ill will not become an unaffordable goal.

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