Question

how do I differentiate the clinical logic vs. the patient-centered logic basis of IT architecture and the financial programs that support them?

Answer 1

*Creation of a general-purpose medical record is one of the more difficult problems in database design. In the USA, most medical institutions have much more electronic information on a patient’s financial and insurance history than on the patient’s medical record. Financial information, like orthodox accounting information, is far easier to computerize and maintain, because the information is fairly standardized. Clinical information, by contrast, is extremely diverse. Signal and image data X-Rays, ECGs, requires much storage space and is more challenging to manage. Mainstream relational database engines developed the ability to handle image data less than a decade ago, and the mainframe-style engines that run many medical database systems have lagged technologically.

The scope of informatics is thus enormous. It finds application in the design of clinical decision support systems for practitioners, consumer decision aids and online health services, in the development of computer tools for research, and in the study of the very essence of healthcare – its corpus of knowledge. Yet the modern discipline of health informatics is still relatively young. Many other groups within healthcare are also addressing the issues raised here and not always in a coordinated fashion. Indeed, these groups are not always even aware that their efforts are connected, nor that their concerns are ones of informatics.

*Patient-centered care includes listening to, informing and involving patients in their care. The IOM (Institute of Medicine) defines patient-centered care as: “Providing care that is respectful of, and responsive to, individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions.”

CPRSs are designed to review clinical information that has been gathered through a variety of mechanisms and to capture new information. From the perspective of review, which implies retrieval of captured data, CPRSs can retrieve data in two ways. They can show data on a single patient (specified through a patient ID) or they can be used to identify a set of patients (not known in advance) who happen to match particular demographic, diagnostic or clinical parameters. That is, retrieval can either be patient-centric or parameter-centric. Patient-centric retrieval is important for real-time clinical decision support. “Real-time” means that the response should be obtained within seconds (or a few minutes at the most), because the availability of current information may mean the difference between life and death. Parameter-centric retrieval, by contrast, involves processing large volumes of data: response time is not particularly critical, however, because the results are used for purposes like long-term planning or for research, as in retrospective studies.

In general, on a single machine, it is possible to create a database design that performs either patient-centric retrieval or parameter-centric retrieval, but not both. The challenges are partly logistic and partly architectural. From the logistic viewpoint, in a system meant for the real-time patient query, a giant parameter-centric query that processed half the records in the database would not be desirable because it would steal machine cycles from critical patient-centric queries. Many database operations, both business and medical, therefore periodically copy data from a “transaction” (patient-centric) database, which captures primary data, into a parameter-centric “query” database on a separate machine in order to get the best of both worlds. Some commercial patient record systems, such as the 3M Clinical Data Repository (CDR) are composed of two subsystems, one that is transaction-oriented and one that is query-oriented. The patient-centric query is considered more critical for day-to-day operation, especially in smaller or non-research-oriented institutions. Many vendors, therefore, offer parameter-centric query facilities as an additional package separate from their base CPRS offering.