The 2002 Annual HIMSS Conference and Exhibition was held in Atlanta from January 27 to 31, 2002.  This meeting continued the tradition of  a comprehensive exhibition coupled with a broad range of educational offerings.

Anecdotal information suggests about 600 exhibitors and 19,000 delegates.

The educational programme was again awe-inspiring, with 156 sessions across 11 timeslots. This equates to 14 sessions per time-slot. There was something for everyone involved in health informatics. My only concern was that I generally wanted to attend at least 2 sessions per time slot, making it difficult to actually go to all the sessions that I would have liked to!

Atlanta was particularly warm for the time of year, making the stay quite pleasant. There is less of a tourist atmosphere and milieu than New Orleans, but Atlanta is still a clean and pleasant city. New Orleans, the site of last years HIMSS conference, certainly appeals much more to a non-American, with its old-quarter architecture being much more like parts of Europe and Australian cities, compared to the vast expanses of concrete and steel of many in the US.

The birthplace, grave, and museum of Martin Luther King Jr are truly inspirational, reflecting as they do the life and achievements of one of the great men of the 20th century.

Differences from last year:

• The welcome disappearance of the “dot coms”
• The increased emphasis on Computer-based Physician Order Entry (CPOE), (and the Leapfrog Group and California Senate Bill 1875).

Noteworthy items:

? The purchase of the US point of care system “SMS” by the European giant Siemens. I had not been aware just how big Siemens is…an interesting development, bringing the important imaging modalities into the point of care information system paradigm. Siemens are re-writing parts of the SMS point of care system, and it will apparently be available by the end of the calendar year.

? The continued prominence of the Leapfrog Group with its emphasis on patient safety. In order to meet Leapfrog’s Computerised Physician Order Entry (CPOE) standard, hospitals must:

1. Require physicians to enter medication orders via computer linked to prescribing error prevention software;
2. Demonstrate that their CPOE system intercepted at least 50% of common serious prescribing errors, using a testing protocol specified by First Consulting Group and the Institute for Safe Medication Practices;
3. Require documented acknowledgment that the physician read the directives to any override.

The Leapfrog Group is sponsored by the Business Roundtable, the latter group being composed of the CEOs of the Fortune 500 companies. The group clearly has a significant quantum of market power in purchasing health services and health insurance for large number of Americans. The group has become concerned at the medical misadventure issues in the USA, and the resulting costs incurred by health insurance payers.

? California Senate Bill 1875 mandating CPOE by January 2005:

California Senate Bill 1875 requires health facilities and clinics (including general acute care hospitals, specialty hospitals, and surgical clinics, but excluding small and rural hospitals) to implement a formal plan to eliminate or substantially reduce medication-related errors by 2005. “This plan shall include technology implementation, such as, but not limited to, computerized physician order entry or other technology that, based upon independent, expert scientific advice and data, has been shown effective in eliminating or substantially reducing medication-related errors.”

“Each facility's plan shall be provided to the State Department of Health Services no later than January 1, 2002.  Within 90 days after submitting a plan, the department shall either approve the plan, or return it to the facility with comments and suggestions for improvement.  The facility shall revise and resubmit the plan within 90 days after receiving it from the department.  The department shall provide final written approval within 90 days after resubmission, but in no event later than January 1, 2003.  The plan shall be implemented on or before January 1, 2005.”

This has subsequently, apparently, been incorporated into the Californian Health & Safety Code SECTION 1339.63  (www.leginfo.ca.gov/

? The significant progress towards providing technical frameworks applicable for imaging modalities, PACS, RIS, and point of care systems. This has been achieved with the joint efforts of the Radiological Society of North America and HIMSS. The standard is known as Integrating the Healthcare Enterprise (IHE) and stands at version v4.6. The framework provides profiles for:

o Scheduled workflow – admit, order, schedule, acquire images
o Patient information reconciliation – unknown patients and unscheduled orders
o Consistent presentation of images – hard and softcopy grayscale and presentation
o Presentation of grouped procedures
o Key image notes – ie the “sign of the arrow”
o Simple image and numeric reports – exchange simple reports with image links
o Access to radiology information – consistent access to images and reports

? Continued gradual development of the major PoCCS systems

Notes from Specific, selected sessions:

Session 4 – Who’s Counting? CIOs & CFOs Tackle IT ROI – handout not available

Session 12 - Improving Outpatient Care Through IT

      John Glaser – Partners (grateful thanks for the slides)

      The literature demonstrates similar problems in Outpatient care to the inpatient setting:

• Honigan JAMIA 2001 – 5.5 ADEs per 100 patients, 23% of these life-threatening or serious; 3.4 ADE related-inpatient admissions
• Gandhi J Gen Intern Med 2001 – analyzed 1173 OPD scripts; 27% patients reported an ADE, of these 145 were serious & 36% preventable
• Rothschild J Gen Intern Med 2001 – 4.3% potential ADE rate
• Poon J Gen Intern Med 2001 – 36% women did not receive appropriate follow-up after marginally abnormal mammogra

    Overall:

• 14 serious or life threatening ADEs per 1000 OPD patients
• 40 medical errors per 1000 OPD scripts
• 250 referring Drs have not received follow-up information 4 weeks later of 1000 referrals
• 380 patients of 1000 qualifying for prevention of hyper-cholesterolaemia will not have an LDL-C test on the record

     Evaluating the Impact of a Computerized Ambulatory Record Bates AMIA Proc 2000

      For 1431 new prescriptions

•  747 drug substitution suggestions were generated
•  14 allergy alerts were generated
•  846 duplicated medication alerts were generate

      Mean time to enter a paper prescription of 35 seconds. Range of 23 to 161 seconds to enter a prescription electronically 
 

      Patient- Specific Computerized Outpatient Reminders to Improve Physician Compliance with Clinical Guidelines

      Karson AMIA Proc

      Reminders were generated prior to office visits and printed on face sheets

• Diabetes care, e. g., HbA1C
• Therapeutic recommendations ,e, g, beta- blocker use in CAD patients
• Expensive medication substitution suggestions e. g., ACEIs
• Health maintenanc

      Diabetic patients

• Received overdue HbA1C studies (60% vs. 46%)
• Cholesterol studies (39% vs. 20%)
• Eye exams (17% vs. 10%)
• Nursing visits (3.1% vs. 1.4%)

Obstacles…

Challenges

• Leadership
• Capital
• Diversity of outpatient care settings
• Incorporation into existing care operations
• Privacy
• Care boundaries

Ten tensions…

 Ratio of Inpatient Serious or Life-Threatening Medication Errors to Outpatient Serious or Life- Threatening Medication Errors is 1 to 1.7- 4.1

Session 16

Dave Garets – Gartner Group – HealthCare’s Uncertain Future: Four Scenarios for 2010

Drivers

Predetermined – social (entitlement mentality, aging), economic (uncontrolled medical costs), technology, environmental (globalisation of disease), political (more legislative oversight)

Critical uncertainties – social (privacy, medical quality), economic (world economy, health financing unsustainable), technology (security, structured data & standards, human genome), environmental (bio-terrorism), political (HIPAA)

Axes – accountability for payment vs. standards & structured data

 Session 21- Power & Value of Embedded Clinical Decision Support

Robin Raiford – Eclipsys

A very good presentation – again thanks for the slides

 Objectives

• Differentiate between levels of CDS – basic, advanced, expert (new stuff!!)
• Identify eight essential functionality issues - What, How, When, Escalation of alerts, Algorithms, Language platform, Multifactorial knowledge capability, Ability to track alerts and report alerts, outcomes and statistics 
• Describe strategies and issues in implementing CDS
• Outline achievable benefits from implementing CDS
• Visualize future uses of information technology in healthcare

Different levels of clinical decision support within a CIS

      Basic

• Simple duplicate orders
• Drug - drug, drug - allergy interactions
• Dose - range checking
• Simple and complex order sets

      Advanced

• Temporal & location specific duplicate checking for orders and tasks
• Dose calculations (e. g, BSA), used in rule evaluation
• CDS with full access to all CPR data elements

• Chaining of multiple rules
• Intelligent alert escalation paradigms
• Multiple rule triggers [allergies, ADT, problems, results, observations, tasks & orders] incl. time delayed processing
• Expert dosing guidelines, using multiple CPR data elements
• Algorithm- based guidelines for decision- making

Session 27 - Integration of an Integrated Delivery System

John Glaser – Partners

An interesting reflection on how information systems may not integrate so easily across an “integrated” delivery network

Session 28 – Strong IT Governance – Don’t Even Think about Not Doing It!

Repeating the message once more for the dummies…probably still necessary!!
 

Session 30 - Delivering Value from IT Investments

John Glaser – Partners

Adds to last years presentation by Glaser.

Essentially, there is no “real” ROI analysis for a computer system.

But there is a real cost and life saving with appropriate technologies properly managed.
 

Session 41 – The Digital Revolution in radiology – What IT needs to know.

 An overview in these terms of PACS

Session 49 – Next Generation Clinical Information Systems – Is it time to jump?

Basically, yes (in the US context).

Session 55 – Integrating the Health Care Enterprise (IHE)

Valuable – The IHE v 4.6 is set to make point of care, modalities, RISs and PACS really work together!!

Session 68 – Why does IT cost so much, and how can you make the most of the funding you have?

Kaiser Permanente

Bottom line – long term planning, with strong business-led IT governance, can make a difference to clinical information systems, with benefits for patients and the health system…

Session 69 – The IHE Initiative from RSNA & HIMSS – What is it, and why do I need it?

Dave Channin – RSNA

As per session 55 – but from a radiologist who knows first hand about the problems in a clinical environment of systems that don’t integrate – the concept of taking over the basement carpark of the RSNA for a weekend and asking vendors to demonstrate that their systems can really interact is great!!
 

Session 72 – The CEOs Panel – Cerner, Epic, Siemens…

Not quite sweetness and light between vendors…

Session 77 – Next generation Clinical documentation using XML & HL7

Interesting, but really for the techos…

Session 91 – Trends in health Care systems

RL Johnson – an experienced and reflective observer & participant of the health IT market in the USA.

2001 & beyond:

• Patient centred
• Replace old systems
• Hospital/VMO/GP integration
• Privacy & HIPAA
• Medical error concerns
• ?changing reimbursement method
• increased government control & intervention
• patient health record
• use of internet
• how to protect wireless systems
• major vendor acquisitions
• disease management
• data access by patients
• PACS
• Home health with hand helds
• ?ASP focus
• PACS/RIS integration
• Voice/image inclusion
• Reduced use of IT consultants, but increased specialization
• Outsourcing
• Moderate sales growth of ~ 8-10%

  

Keynote – Al Gore

Challenges:

• Lack of capital
• Privacy
• Security
• Info when required Integration

Efficiency, quality
IOM
Moore’s law
Genome + internet = the future
Metcalfe’s law – value of a network = O (n2)
Yogi Bear – what we have here is an insurmountable opportunity
Paperwork=20% of costs

?? a form of universal health insurance may be the way forward for the US health care system

Session 101 – Using Information Systems to Screen for Adverse Events

R S Evans – Intermountain Health Care

A perspective on the N Evans study

Session 115 – Clinical Informatics and medical record systems in the Bio-informatics and genomic enterprise

Zac Kohane - Partners

Fascinating stuff – detailed and conceptually hard to grasp – not for the faint –hearted – but worth attending to see how informatics underlies most of health care

Informatics-Review > Thoughts >  Reflections on the Health Information Management Systems Society 2002 Meeting