Think you’ve got a great technology idea to improve your clinical work experience and optimize patient care?
You’re probably not alone. But identifying an opportunity and taking it to the next level – a successful business solution adopted by many of your colleagues – are a long, arduous, and complex process, according to two hospitalists who are developing apps designed to improve productivity in daily practice, optimize patient care, and save money.
Courtesy Dr. William Morris
Dr. William Morris (Cleveland Clinic) holds a mobile device displaying his new EMR interface.
Dr. William Morris, vice chair of clinical informatics and director of the Clinical Solutions Group at the Cleveland Clinic, is in the final phases of testing a novel electronic medical record (EMR) interface, which he developed along with a cardiothoracic surgeon and an orthopedist at the Cleveland Clinic.
Dr. Elizabeth Farrell of Beth Israel Deaconess Medical Center in Boston has just released an iPhone app that uses Bayes nomograms to inform decision-making on testing and treatment. The app draws on a database of likelihood ratios and performs the calculations at the point of care.
Both physicians saw gaps in their daily practices – things that didn’t work well or were inefficient – and devised app-based solutions to solve those problems.
Dr. Morris saw the limitations in the existing EMRs being used in his hospital. The EMRs contained a lot of data, but provided little clinical information in a context that mattered according to the type of provider, the particular setting within the hospital, and the particular patient status, he explained.
"For example, if you open any electronic medical record, a normal value for creatinine is set across the enterprise," Dr. Morris said. The value appears in red if the patient has kidney dysfunction. "But a patient with end-stage renal disease should be red – you already know that."
Dr. Morris and his colleagues realized that the EMR needed to be taken to the next level. They began by devising an interface that synthesizes and presents the newest and most relevant information at the point of care. The experience is "like having a seasoned resident standing right next to you who is only going to give you those pertinent things" needed to have an impact on that patient’s care.
To get that depth of information, the physicians developed several "novel data presentation layers" that work with the EMR in real time to present data that is tailored to the specific clinical situation – it is context-, provider-, and patient-aware. Clinical items that a physician typically puts together now "cohabitate" the screen. As an example, a chest x-ray might come up along with a trend line showing a patient’s oxygen saturation.
The app designed by Dr. Farrell grew out of her experience teaching on medical rounds at Beth Israel several years ago. Multiple providers varied widely in how they were accessing and interpreting data for individual patients.
As an initial solution, Dr. Farrell printed out index cards with Bayes nomograms that internists, residents, and medical students could use on rounds to convert a pretest probability to a post-test probability for a particular patient.
But the low-tech approach was too limited in its scope. "I ran into a lot of problems because someone would lose their cards or leave them in their white coat back in the workroom," Dr. Farrell said. "Sometimes a test would come up that we wouldn’t have the likelihood ratio for. It got a little frustrating."
Images courtesy Alan Nawoj/Beacon Mobile
Graphical depiction of a Bayes nomogram, showing how the user's pre-test probability for a particular diagnosis combined with the appropriate likelihood ratio for the diagnostic test produces a corresponding post-test probability.
Dr. Farrell realized that iPhones were ubiquitous among the medical staff, many of whom were already using the devices to seek out information for patient management. "Once I thought about putting the nomograms on the iPhone and having the app perform the calculations, the idea came to me that building a database of likelihood ratios would be even more useful," said Dr. Farrell, staff internist in Beth Israel’s Hospitalist Medicine Program.
And both hospitalists credit their success to strong business cases built in collaboration with their hospitals.
It didn’t hurt that Dr. Farrell’s husband, Alan Nawoj, is a software developer who has started a business developing iPhone apps. "We felt like this would be a great way for us to work together and partner my content expertise with his software development skills to create a new product," Dr. Farrell said.