Decision Support Systems in Critical Care PDF
Preview Decision Support Systems in Critical Care
Computers and Medicine Helmuth F. Orthner, Series Editor Computers and Medicine Information Systems for Patient Care Bruce l. Blum (Editor) Computer-Assisted Medical Decision Making, Volume 1 James A. Reggia and Stanley Tuhrim (Editors) Computer-Assisted Medical Decision Making, Volume 2 James A. Reggia and Stanley Tuhrim (Editors) Expert Critiquing Systems Perry L. Miller Use and Impact of Computers in Clinical Medicine James G. Anderson and Stephen J. Jay (Editors) Selected Topics in Medical Artificial Intelligence Perry L. Miller (Editor) Implementing Health Care Information Systems Helmuth F. Orthner and Bruce l. Blum (Editors) Nursing and Computers: An Anthology Virginia K. Saba, Karen A. Rieder, and Dorothy B. Pocklington (Editors) A Clinical Information System for Oncology John P. Enterline, Raymond E. Lendhard, Jr., and Bruce l. Blum (Editors) HELP: A Dynamic Hospital Information System Gilad J. Kuperman, Reed M. Gardner, and T. Allan Pryor Decision Support Systems in Critical Care M. Michael Shabot and Reed M. Gardner (Editors) M. Michael Shabot Reed M. Gardner Editors Decision Support Systems in Critical Care With 136 Illustrations Springer-Verlag New York Berlin Heidelberg London Paris Tokyo Hong Kong Barcelona Budapest M. Michael Shabot, M.D. Reed M. Gardner, Ph.D. Associate Director of Surgery Co-Director, Medical Computing Director of Surgical Intensive Care LDS Hospital Cedars-Sinai Medical Center Salt Lake City, UT 84143 and Los Angeles, CA 90048-1865 Professor of Medical Informatics and Clinical Associate Professor of University of Utah Surgery and Anesthesiology Salt Lake City, UT 84112, USA UCLA School of Medicine Series Editor: Los Angeles, CA 90048, USA Helmuth F. Orthner, Ph.D. Professor of Computer Medicine The George Washington University Medical Center Washington, D.C. 20037, USA Library of Congress Cataloging-in-Publication Data Decision support systems in critical care I M. Michael Shabot. Reed M. Gardner, editors. - 1st ed. p. cm. - (Computers and medicine) Includes bibliographical references and index. ISBN-13:978-1-4612-7632-6 1. Critical care medicine-Data processing. 2. Medical informatics. I. Shabot, M. Michael. II. Gardner, Reed M. III. Series: Computers and medicine (New York, N.Y.) [DNLM: 1. Critical Care. 2. Decision Making, Computer-Assisted. 3. Medical Informatics. 4. Decision Support Techniques. WX218 D2944 1993 RC86.7.D445 1993] 616'.028 '0285-dc20 DNLM/DLC for Library of Congress 93-11902 Printed on acid-free paper. © 1994 Springer-Verlag New York Inc. Softcover reprint of the hardcover 1st edition 1994 All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer-Verlag New York, Inc., 175 Fifth Avenue, New York, NY 10010, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use of general descriptive names, trade names, trademarks, etc., in this publication, even if the former are not especially identified, is not to be taken as a sign that such names, as understood by the Trade Marks and Merchandise Marks Act, may accordingly be used freely by anyone. While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Production managed by Christin R. Ciresi; manufacturing coordinated by Vincent Sceita. Typeset by Asco Trade Typesetting Ltd, Hong Kong. 987654321 ISBN-13:978-1-4612-7632-6 e-ISBN-13 :978-1-4612-2698-7 DOl: 10.1007/978-1-4612-2698-7 Series Preface This monograph series intends to provide medical information scientists, health care administrators, physicians, nurses, other health care provid ers, and computer science professionals with successful examples and ex periences of computer applications in health care settings. Through the exposition of these computer applications, we attempt to show what is effective and efficient, and hope to provide some guidance on the acquisi tion or design of medical information systems so that costly mistakes can be avoided. The health care industry is currently being pushed and pulled from all directions, from clinicians, to increase quality of care; from business, to lower cost and improve financial stability; from legal and regulatory agen cies, to provide detailed documentation; and from academe, to provide data for research and improved opportunities for education. Medical in formation systems sit in the middle of all these demands. The generally accepted (popular) notion is that these systems can satisfy all demands and solve all the problems. Obviously, this notion is naive and is an over statement of the capabilities of current information technology. Eventual ly, however, medical information systems will have sufficient functionality to satisfy most information needs of health care providers. We realize that computer-based information systems can provide more timely and legible information than traditional paper-based systems. Most of us also know that automated information systems provide, on average, more accurate information because data capture is more complete and automatic (e.g., directly from devices). Medical information systems can monitor the process of health care and improve quality of patient care by providing decision support for diagnosis or therapy, clinical reminders for follow-up care, warnings about adverse drug interactions, alerts to ques tionable treatment or deviations from clinical protocols, and more. Since medical information systems are functionally very rich, must respond quickly to user interactions and queries, and require a high level of secur- v vi Series Preface ity, these systems can be classified as very complex and, from a develop er's perspective, also as "risky." Information technology is advancing at an accelerated pace. Instead of waiting for three years for a new generation of computer hardware, we are now confronted with new computing hardware every 18 months. The forthcoming changes in the telecommunications industry will be revolu tionary. Within the next five years and certainly before the end of this century, new digital communications technologies, such as the Integrated Services Digital Network (ISDN) and very high speed local area networks using efficient cell switching protocols (e.g., ATM), will not only change the architecture of our information systems but also the way we work and manage health care institutions. The software industry constantly tries to provide tools and productive development environments for the design, implementation, and mainte nance of information systems. Still, the development of information sys tems in medicine is, to a large extent, an art, and the tools we use are often self-made and crude. One area that needs desperate attention is the interaction of health care providers with the computer. While the user in terface needs improvement and the emerging graphical user interfaces may form the basis for such improvements, the most important criterion is to provide relevant and accurate information without drowning the physician in too much (irrelevant) data. To develop an effective clinical system requires an understanding of what is to be done and how to do it, and an understanding on how to in tegrate information systems into an operational health care environment. Such knowledge is rarely found in anyone individual; all systems de scribed in this monograph series are the work of teams. The size of these teams is usually small, and the composition is heterogeneous, i.e., health professionals, computer and communications scientists and engineers, biostatisticians, epidemiologists, etc. The team members are usually dedi cated to working together over long periods of time, sometimes spanning decades. Clinical information systems are dynamic systems; their func tionality constantly changes because of external pressures and administra tive changes in health care institutions. Good clinical information systems will and should change the operational mode of patient care, which, in turn, should affect the functional requirements of the information sys tems. This interplay requires that medical information systems be based on architectures that allow them to be adapted rapidly and with minimal expense. It also requires a willingness by management of the health care institution to adjust its operational procedures, and, most of all, to provide end-user education in the use of information technology. While medical information systems should be functionally integrated, these sys tems should also be modular so that incremental upgrades, additions, and deletions of modules can be done in order to match the pattern of capital resources and investments available to an institution. Series Preface vii We are building medical information systems just as automobiles were built early in this century (1910s), i.e., in an ad hoc manner that disre garded even existing standards. Although technical standards addressing computer and communications technologies are necessary, they are insuf ficient. We still need to develop conventions and agreements, and perhaps a few regulations, that address the principal use of medical in formation in computer and communication systems. Standardization allows the mass production of low-cost parts which can be used to build more complex structures. What are these parts exactly in medical in formation systems? We need to identify them, classify them, describe them, publish their specifications, and, most importantly, use them in real health care settings. We must be sure that these parts are useful and cost effective even before we standardize them. Clinical research, health services research, and medical education will benefit greatly when controlled vocabularies are used more widely in the practice of medicine. For practical reasons, the medical profession has developed numerous classifications, nomenclatures, dictionary codes, and thesauri (e.g., lCD, CPT, DSM-III, SNOMED, COSTAR dictionary codes, BAlK thesaurus terms, and MESH terms). The collection of these terms represents a considerable amount of clinical activity, a large portion of the health care business, and access to our recorded knowledge. These terms and codes form the glue that links the practice of medicine with the business of medicine. They also link the practice of medicine with the literature of medicine, with further links to medical research and education. Since information systems are more efficient in retrieving in formation when controlled vocabularies are used in large databases, the attempt to unify and build bridges between these coding systems is a great example of unifying the field of medicine and health care by providing and using medical informatics tools. The Unified Medical Language System (UMLS) project of the National Library of Medicine, NIH, in Bethesda, Maryland, is an example of such an effort. The automation of intensive care units in hospitals has advanced re markably in the last 20 years. Two decades ago, we barely introduced pa tient monitoring and automatic alarms when vital signs reached a critical level. Our efforts to combine expertise from multiple disciplines such as physiology, biomedical engineering, computer science, biomathematics, and critical care medicine has resulted in state-of-the-art systems which utilize decision support technology based on experiences collected from numerous hospitals (e.g., the APACHE III System) and on rule-based expert system technology (e.g., intelligent respiratory monitoring for ventilated patients). Today, intensive care units (ICUs) are full of auto mated equipment. The problem, however, is not to collect data but to filter unnecessary redundancies that cause information overload. Today's decision support systems for ICUs are sophisticated clinical information systems drawing on many expert experiences. These systems are not only viii Series Preface used for patient care but also for the efficient management of ICUs. The latter is important since ICUs are very expensive suites within a hospital. The purpose of this series is to capture the experience of medical in formatics teams that have successfully implemented and operated medical information systems. We hope the individual books in this series will con tribute to the evolution of medical informatics as a recognized profession al discipline. We are at the threshold where there is not just the need but already the momentum and interest in the health care and computer sci ence communities to identify and recognize the new discipline called Medical Informatics. Washington, DC HELMUTH F. ORTHNER Preface Modern critical care is characterized by the collection of large volumes of data and the making of urgent patient care decisions. The two do not necessarily go together easily. For many years the hope has been that in tensive care unit (ICU) data management systems could playa meaning ful role in ICU decision support. These hopes now have a basis in fact, and this book will detail the history, methodology, current status, and fu ture prospects for critical care decision support systems. Computerized ICU data management is just 25 years old. As editors we are privileged to bring together a group of authors who are the pioneers, developers, system managers, and philosophers in this field, the individuals who transformed the dream into reality. Although this book is about intelligent systems, it is not about artificial intelligence per se. The state of the art in critical care and ICU data management does not yet permit the general application of artificial intelligence techniques, though it may in the future. A number of commercially available ICU data management systems are beginning to reach the level of functionality at which decision support will be routinely available. In the current era of health care reform, prospective payment, and cost controls, multiple levels of decision sup port are required to practice auditable, cost~effective and medically effec tive critical care. This book will describe those levels, the successes and failures of past and present systems, and the practical aspects of bringing such systems to fruition in your own hospital. Our hope is that this book will serve as an interesting and informative explanation of where we are in ICU decision support, how we got there, and where we are headed in the future. Please settle back and enjoy the trip. M. MICHAEL SHABOT REED M. GARDNER ix The book is dedicated to my parents, Sam and Mona Shabot, who gave me everything, asked for nothing and provided the framework for my life. M. Michael Shabot July 1993 November 1993 will be a special month for me. This book will be printed and my mother will be 95 years young!! I dedicate this book to her. She has been a continual inspiration to me all of my life. She has en couraged each of her five children to be life-long learn ers. Learning and teaching have been a family value that I hope I can pass along to my children and to those I associate with. This specialized book about decision-making using computers is in large measure a result of the principles she taught me. When the going got tough at times it was her lively encouragement and spirit that encouraged me. Thanks mother. Reed M. Gardner July 1993
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