TheJournal of Bone and Joint Surgery
American Volume

PAGE 1502  
October 2000, VOLUME 82-A, NUMBER 10

The Emerging Impact of the InformationAge on Orthopaedic Surgery*. Implementation of a Computer-BasedPatient Record and an Outcomes Data-Collection System at theDepartment of Orthopaedic Surgery, University ofIowa

BY RICHARD C.JOHNSTON, M.D., M.S.

American Orthopaedic Association

    *Presented at the AnnualMeeting of the American Orthopaedic Association, Sun Valley, Idaho, June 7,1999.Address for R. C. Johnston: Department of Orthopaedic Surgery,University of Iowa Hospitals and Clinics, 200 Hawkins Drive, JPP 01016, IowaCity, Iowa 52242. E-mail address for R. C. Johnston:richard-johnston@uiowa.edu.
Quick Access Outline

Introduction
Background
Study of the Existing Process of PatientEncounters in the Orthopaedic Clinic
Design of the New Process for Patient Encountersin the Clinic
Clinical Content
Critical Concepts in Collecting OutcomesData
References

The goal of thispresentation is to report our experiences to date withimplementation of a computer-based patient record along with asystem for the collection of patient health-status outcomes data asan integral part of routine patient care in theorthopaedic department. We are "going live"in our first clinic as this is written. Therefore, this is areport of all activity leading up to this point in the project.

Background

An excellent argument for the collection of health-statusoutcomes data in orthopaedics was recently published(3).Health-status outcomes data are defined as data about thestate of health, the primary disease, and comorbidities before andafter an appropriate interval following the application of aselected treatment strategy. It is widely agreed that collection ofthese data is important; however, they are collected rarely,and for practical purposes they are never collected in asustained, generalized manner. Most policy analyses requiring suchdata use surrogate data, as they are more easily, quickly, orcheaply acquired than are actual outcomes data. For example, lengthof stay is used as a surrogate for total resourceexpenditure, and satisfaction with recent hospitalization is usedas a surrogate for actual improved health status. It ishelpful to use surrogate data if they have been found to correlatewith the actual outcome of interest, but that is rarelythe case because that conclusion must have been reached by thestudy of the actual outcomes data at some time in the past.
The process of collecting outcomes data involves severalcritical concepts. First, in order to provide the necessaryaccuracy and precision, a very large amount of data isrequired. Second, the volume of required data is so great that itmust be managed in an electronic system. Third, because oftime constraints in the practice setting, the need to gatherany information over and above standard clinic processes is viewedas an imposition. Consequently, it is extremely rare that such data,no matter how minimal, are collected consistently over along time-period. Fourth, data must be collected as anintegral part of standard clinic processes in the routine care ofpatients, in a manner that does not increase the burden ofcare. Fifth, much of these data must be in the form ofpatient-administered health-status measures. Sixth, it is extremelyimportant that these structured data can be stored in a relationaldatabase that can be used for business as well as clinicalpurposes and can be merged with a narrative word template toproduce clinical notes. With use of such a relational database, thesaving of resources can be great.
Collection and use of outcomes data as a routine part ofthe clinical care of patients has rarely been done and has not beendescribed in the literature. Collection of data both withinand outside of the health-care field has been studied. Paperand pencil and computer mouse and computer touch-screen technologieshave been compared(2). Bothtypes of computer technology are cheaper to use than paper andpencil if the volume of data is more than minimal, and usersprefer touch-screen technology to the mouse. Most computermonitors in business settings where users either are notfamiliar with computer technology or work in a rushed environment(such as in a bank or a restaurant) utilize touch-screentechnology.
The implementation of such a program requires a radicalchange in the patient-encounter process in clinics. Theimplementation requires three phases. In the first phase, onemust study and document the present process with an analysis ofpatient flow and a survey of all stakeholders regarding satisfactionand judgment of quality of care. This information is thenused in the second phase, the design of the new process, andalso as a baseline when the new process is evaluated, which isthe third phase.

Study of theExisting Process of Patient Encounters in the OrthopaedicClinic

The existing clinic process was studied by observing patientand information flow. The patient checks in at the mainreception desk, is sent to the adjacent registration desk ifnecessary, and is then sent to the waiting room until he orshe is called into one of the clinics. The next stop is thespecific clinic reception desk; the patient then proceeds to thesub-waiting room or directly to the examining room. Thepatient waits in the examining room until he or she is seen bythe nurse, medical student, resident, or faculty physician. Usuallythe resident is the first to see the patient; theresident then returns to see the patient again, with thefaculty physician. The patient typically goes to the adjacentradiology suite and returns with radiographs at some point duringthe encounter. Most commonly, the patient goes home after seeingthe faculty physician. Occasionally, the patient goes to theadjacent physical therapy department, the occupational therapydepartment, or the prosthetist. Alternatively, these providers maysee the patient in the examining room. The patient may goelsewhere in the facility for other diagnostic tests orconsultations. A large amount of paperwork must then occur.
Time data: In order to understand the patient flow inmore detail, we had three student workers collect time data inthe clinics (Table I). One wasstationed at the waiting-room door; one, at the receptiondesk/sub-waiting-room area; and one, in the hallway, to monitor theexamination rooms. We recorded the times when the patient enteredand left the waiting room, entered and left thesub-waiting room, and entered and left the examination room aswell as the times that the nurse, the medical student, the resident,and the faculty physician each entered and left the examinationroom. All parties may have entered and left the examinationroom multiple times. We also recorded where the patient was goingupon leaving the examination room. Data were collected with paperand pencil, were stored, and were analyzed with acomputer-software program (Access 97; Microsoft, Redmond,Washington).

Design of the NewProcess for Patient Encounters in the Clinic

We envision that the patient will use the time in thewaiting and examination rooms prior to seeing the doctor tocomplete, utilizing computer touch-screen technology, a series ofquestionnaires regarding health status. Thus, an interim report willbe available to the physician prior to seeing the patient. Thephysician can use these data as the core of the clinicalhistory. The physician will examine the patient and enter the datainto the computer, utilizing the same touch-screen technology. Thesedata then can be merged in a narrative fashion to producea clinic note. This note can be edited minimally in typical casesand extensively in unusual cases, and reports can be sentto appropriate parties and places, such as the referringdoctor and the medical record.

ClinicalContent

The clinical content was developed in a modular fashion.At present, we have ten clinical tracks matching the clinicalsubspecialties, based on anatomical area, problem type, and patientage. These tracks are spine, hip/knee reconstruction, sports,foot/ankle, shoulder, wrist/hand, pediatric scoliosis, pediatricother, tumor, and trauma. A series of initial questions wasdeveloped to algorithmically lead the patient to the correctquestionnaires. Each track comprises five types of visits: new,short-return, definitive-return, return by an established patientwith a new problem, and remote follow-up forms.
Each track contains a generic package of forms that arethe same for all adults. Children or their parents will use similarbut age-appropriate forms. This generic package consists of theShort Form-36 (SF-36) health-status questionnaire(4) as well asquestionnaires regarding expectations of treatment, comorbidities(both systemic and musculoskeletal), family history, and socialhistory. We also have a series of demographic fields, which arefilled out at each encounter from the institutional registration.All of these forms are either identical to or compatible withthe Musculoskeletal Outcomes Data Evaluation and Management System(MODEMS) forms of the American Academy of Orthopaedic Surgeons(AAOS)(1).
Each track contains a group of forms that arefunctionally similar from track to track but are tailored tothe specific track. These consist of a disease/anatomicalarea-specific health-status form that is also identical to orcompatible with the AAOS MODEMS forms. A treatment-history form anda series of questions about the patient's specific problem, suchas when and how it started, what makes it worse orbetter, and whether it is getting worse or better, make up theremainder of the patient-administered portion of the forms. Themean time required for 150 new patients to complete thesequestionnaires was thirty minutes (range, fifteen to sixtyminutes).
Using simulation methods, we analyzed these times and thewaiting times mentioned above and determined that, with ourcurrent scheduling patterns, only about 40 percent of our newpatients would have completed the forms before being seen by thedoctor. We determined that we must bring new patients inat least twenty-three minutes earlier so that 95 percent willbe able to complete the forms. Since it is vital that the formsbe completed and the results be made available before thepatient is seen by the doctor, we are bringing in our new patientsthirty minutes earlier than we have in the past.
It is necessary, for practical purposes, to select aminimal interval between the dates for collection ofhealth-status outcomes data. These intervals will vary greatlyaccording to the clinical problem and the rapidity of changein the health status. Currently, we think that six months afterbaseline is soon enough to collect such data for total jointand spine problems. Carpal tunnel syndrome may warrantcollection of such data at one month. Since patients do notreturn like clockwork, and because we do not want to excludepatients with follow-up data, these times become windows, withno gaps in between. Thus, for a total joint or spineproblem, six months can become four to nine months; one year, ten toeighteen months; and two years, nineteen to thirty-six months.(The interval until the next follow-up would begin with themost recent visit.) Therefore, at intervals of less than fourmonths, we are not interested in measuring health status but simplyin recording what has happened with the problem since thepatient's last visit. Simple outcomes measures, such as the datethat the patient returned to work, are recorded. This is what werefer to as the short-return visit. It takes the patientabout one to two minutes to complete this form.
We have called the visit at six months or later thedefinitive-return visit. At this visit, we seek to compare thehealth status of the patient with his or her baseline and withsome norm or norms. Therefore, we repeat the health-statusmeasures that we used for the new-patient visit, but we do not againcollect the additional material about general health that wasused for risk adjustment unless the patient indicates thatthere has been a change. If there has been no change, the datacollected at baseline can be used for adjustment at six months.It takes the patient about five to twenty minutes (mean,twelve minutes) to complete these forms.
If it is impossible or impractical for the patient toreturn to our clinic, these forms may be completed from thepatient's home, either electronically on our Web site or with paperand pencil. The data then can be keyed in by one of ouroffice personnel.
The time-consuming data acquisition is done, as it is fornew patients, in waiting-room kiosks or clinical examination rooms,with a touch-screen computer terminal. An interim report is thenproduced for the physician to use, as he or she deemsappropriate, in reviewing the clinical history with thepatient.
Considerable savings in overhead expense might be contemplatedfor the after-visit documentation. However, additional assistancewill be required to help the patient in the data-acquisitionstage. We plan to have an additional person in the kiosk areaand another in each clinic. Since the extra help is needed fromthe beginning of the project and the savings do not come untillater, there is an initial increase in expenses.
The resident and/or faculty physician then examines the patientand records the data in the computer with use of the touchscreen. The diagnosis and management plan also are recorded. Thisprocess requires between one and eight minutes, depending onthe complexity of the examination and the specific problem.
The software associates each answer from both the patientand the clinician with certain preselected words, and thesystem produces a narrative clinic note, which is very similar instyle to a classic dictated and transcribed note. The clinician canedit this note as needed and can sign it electronically;it then can be sent to referring physicians and otherselectronically or on paper, or both. This step can greatly reducethe time and expense needed for documentation of the encounter.
Each diagnosis in the system is associated with an ICD-9(International Classification of Diseases, Ninth Revision) code.Each question in the history and physical forms is associatedwith a body system and a component of the "Historyand Physical." The software can count the answers andtheir location, and, utilizing Health Care Financing Administrationrules, it can calculate the Evaluation and Management CPT-4(Physicians Current Procedural Terminology, Fourth Revision) codeafter the physician answers five additional questions aboutcomplexity. From this information, an automated bill can begenerated, greatly reducing the time and expense of producingbilling and insurance forms. To the extent that interpretation ofthe Health Care Financing Administration rules is correct, one canbe assured that the billing level and the documentation are inagreement.
Finally, and most importantly, a database with detailedinformation on each patient's health status, risk-adjustment data,diagnosis, detailed treatment strategy, and other outcome measuresover time is available for analysis. If we can collectthese data on a large enough scale, we can use real rather thansurrogate data for decision-making.

Critical Conceptsin Collecting Outcomes Data

1. A very large amount of data is required to provide thenecessary accuracy and precision.
2. The volume of data is so great that it must be managedin an electronic system.
3. In the practice setting, because of time constraints,the need to gather any information over and above standardclinic processes is viewed as an imposition. Consequently, it isextremely rare that such data, no matter how minimal, areconsistently collected over a long time-period.
4. If data are to be collected consistently from allpatients over an extended period of time, they must be collected asan integral part of standard clinic processes in the routinecare of patients in a manner that does not increase theburden of care.
5. Much of these data must be in the form ofpatient-administered health-status measures.
6. These structured data can be stored in a relationaldatabase, used for business as well as clinical purposes, and mergedwith a narrative word template to produce clinical notes. The savingof resources can be great.

REFERENCES: 1-4

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