sábado, setembro 16, 2006

Clínica Informatizada

Nova Zelândia
Another country which is experiencing similar benefits is New Zealand. In 1994 only 10% of GPs in New Zealand were using computers for clinical care, and GP use of the Internet was non-existent. Today, over 95% of GP offices are computerised and using one of nine Physician Office EMR systems. Almost 75% use their systems to electronically send and receive clinical messages such as laboratory results, radiology results, discharge letters, referrals, and age-sex registers.
HealthLink - the national network - is used by 75% of all healthcare sector organisations in New Zealand. Message standards have now been implemented to connect over 40 different computer systems in New Zealand, including physician practice management systems, physiotherapy systems, hospital systems, laboratory systems, and radiology systems. All hospitals, radiology clinics, private laboratories and almost 1,800 general practices are involved and use it everyday. Over 600 specialists, physiotherapists, other allied health workers, including maternity providers, also utilise the network. Over three million messages a month are electronically exchanged, amounting to over 95% of the total electronic communication in the primary health care sector.
The HealthLink network is also increasingly being used to assist with the management of chronic diseases. Common software is used to enrol and track patients on chronic disease management (CDM) programmes. The software contains best-practice guidelines for care, and collects the latest clinical data about each patient from laboratory and GP physician office systems. Based on the latest available data, the software automatically issues alerts, reminders and recommendations to the relevant health care providers as appropriate for and specific to each patient.
As an example, one region recognized that particular 'at-risk' groups, such as children and patients with chronic conditions were requiring hospitalisation because early intervention had not taken place in the primary care setting. Two integrated care projects were set up to improve directly the health status of these at risk groups - the KidsLink Child Immunisation project and the Diabetes Integrated Care project. It is noteworthy that these projects were started in a particular region that had a lower socio-economic population with poorer health status than the average New Zealand population.
As a result of introducing these applications of computer technology into a networked and inter-connected health care system:
• Child immunisation rates have risen from 75% to 95%
• There has been an 80% reduction in wait time for statins for diabetes patients - the prescribing of statins by a New Zealand GP is typically a time consuming and complex process; in the past, many patients were not able to receive prescriptions or had to wait nine to 12 months for eligibility confirmation; with the new electronic system, eligibility for statins can be confirmed automatically and instantly via best practice guidelines
• There has been a reduction in the growth rate of acute admissions - this was running at 9% per annum and by 2002 had fallen to nearly 0%
To assure the quality of the patient care process, there is a formalised, secure message transfer process. Once a message is delivered to the doctor's office, an electronic acknowledgement is generated automatically to the sending system. This is delivered either in real time or in the next dial up. If an acknowledgement is not received within a certain period of time, the sending system (eg a lab) will be alerted and steps taken to ensure the GP or recipient receives the result or message depending on which error message is sent back. HealthLink software utilises data encryption to ensure safety and protect patient confidentiality.
British Columbia, Canadá
Another example of the power of computer technology to allow activities to take place that are virtually impossible to do in a manual, paper-based environment is the new CDM System in British Columbia, Canada. The System was designed to support more effective and efficient chronic disease management - an organised approach to improving care for patients with chronic diseases such as diabetes, depression and congestive heart failure. More than half a million British Columbians have chronic diseases and treating these conditions now accounts for 70% of all health care expenditures. (In the United States, by most estimates, people with chronic diseases account for more than two-thirds of the nation's $1.6 trillion medical bill, a figure that is expected to grow as baby boomers age.)
CDM, which relies on the use of evidence-based best practices, has the potential to reduce costs by improving health outcomes for chronic care patients. For example, analysis conducted in the Fraser Health Region, which serves about a quarter of the BC population, indicates that full implementation of CDM for diabetes alone (ie active involvement by all diabetes patients in the region and their care providers) could reduce avoidable diabetics' death rates by up to 32% and result in gross savings of $13 million over five years.
With these broad goals and benefits in mind, the CDM System was developed to:
• Deliver a computer technology solution that allows doctors to organise and use their chronic care patient information efficiently
• Provide fast, easy access to evidence-based clinical guidelines and protocols that reflect best practices for treating chronic diseases, along with tools like recall reports (reminders of when to schedule follow-up appointments) that help doctors implement clinical guidelines
• Support structured CDM collaboration among doctors and other care providers, by allowing them to share, compare and analyse patient data securely and confidentially
• Provide secure, multi-layered confidential access to chronic care patient information
• Ensure that the system is extendable and that it can be expanded to include additional clinical guidelines and other supports for a wider range of chronic illnesses in future
The CDM System is a web-based application which:
• Is easy to use; the System is accessible to any BC doctor with Internet access and a current web browser; anything more complex would face significant barriers in a province where over 90% of doctors still keep paper records and few have resources available to invest in new technology or training to support it
• Provides easy access to a range of helpful tools; doctors log on to the system using a secure username and password; from there, they simply choose from a range of functions that include maintaining patient records, using patient flow sheets, accessing clinical guidelines, and generating clinical and administrative reports such as:
- recall reports, listing patients due for office visits and which tests or procedures they need to undergo
- practice profiles, detailing age and gender breakdowns of the practice's population of patients with a particular chronic disease
- run charts, graphing changes in the practice's clinical processes and patient health outcomes over time
- patient-specific education reports that help patients self-manage their conditions
• Supports improvements in patient care - and in the healthcare system - by making best practices easier to follow; in addition to providing clinical guidelines and other CDM tools, the System provides easy access to patient flow sheets - one page reminders that support the implementation of clinical guidelines for individual patients; they include, for example, what measures should be checked on each patient visit (eg blood pressure, weight, activity level), what medications the patient should be taking, which lab tests should be repeated and when, and what self-care reminders the patient should receive
• Supports effective teamwork; two of the key principles of effective CDM are interdisciplinary care (different professionals working together to support a single patient) and collaboration (groups of care providers sharing, comparing and learning from results as part of a continuous quality improvement process); the CDM System supports interdisciplinary care by making it easy for doctors to share information securely and confidentially with other members of a patient's care team; it supports collaboration by allowing groups of doctor-led teams to compare results in treating specific conditions over time
• Integrates patient-specific information with evidence-based clinical guidelines to create tools that any member of a patient's care team can access easily; for example, a nurse, dietician or other care provider may use a patient education report or patient flow sheet from the System to help a patient set and meet self-management goals; similarly, a medical office assistant may use recall reports from the System to proactively schedule follow-up appointments
• Meets the needs of all doctors, regardless of their technological skills; the System's simplicity and ease of access make it ideal for doctors unaccustomed to using computer technology in their practices; at the same time, it offers extra features for the roughly 6% of doctors using electronic medical records (EMR); for example, it allows them to transfer patient data directly and securely from their EMR to the System, avoiding the need for duplicate data entry
As a result of this innovative application of computer technology to the problems associated with chronic disease management, the proportion of patients on appropriate beta blockers rose from 16% to 89%; clinical guidelines recommend that all congestive heart failure patients use these drugs. Additionally, the proportion of patients with documented self-management goals rose from 5% to 57%; patient self-management is critical to effective chronic disease management.
While it's too early to measure improvements in actual health outcomes, research and experience have clearly shown that, when clinical guidelines are followed, patient health improves. And the System makes it easier for all users to follow clinical guidelines for chronic disease management.
It also provides clinical data analysis otherwise not available to most family physicians, encouraging continuing improvements in care. Experience has shown that doctors and their care teams work even harder to improve patient health outcomes once they have data that demonstrates the value of changing how they practice.
Within seven months of its introduction, about 13% of BC's family doctors (more than 450) were voluntarily using the System, along with about 250 nurses, specialists and supporting staff. The number of users is growing weekly and is projected to exceed 2,000 by March 2005.
Chronic disease is a universal problem. In the United States, according to Bringewatt and Petrakos, it accounts for 80% of deaths, 90% of morbidity, and 70% of medical expenses. Effective disease management programs can have measurable results; they can manage information to support intervention better, preventing or minimising the impact of chronic conditions on the patient and the health system. One programme for congestive heart failure patients reduced the 30 day re-admission rate to zero and cut the 90 day re-admission rate by 83% through tele-monitoring and patient education. The positive impact of using computer technology in healthcare is perhaps no greater than in chronic disease management.