Update: Workflow Diagram

The updated workflow diagram is shown below. We are still getting some feedback on the diagram.
But early feedbacks are positive.

RPA Site Visit

On Friday afternoon, Hendy and I made our way to the RPA for a meeting with Angela Ryan. We verified all workflow diagrams surrounding the care of the patients. Only minimal changes need to be made. These include:

• Redefining "Doctor On Call"
  
• Nurse workflow additions to admission, discharge and bed management.
• Extra workflows regarding the requests for tests (e.g. x-rays and blood gas).
• Routine workflows regarding nurses and doctors

Hendy and I will post the updated workflows once we have updated them.

ICU General Workflow (Meeting with Angela on 25th and 27th July 2007)

On the 25th and 27th of July 2007, Hendy and I had meetings with Angela Ryan of RPA hospital. Briefly, the core purposes of the meeting were to discuss:

• The ICU structure at the Royal Prince Alfred Hospital
• The flow of patient in a general ICU.
• Brief overview of the “Whiteboard”
• Core users of RPA ICU’s information system; CareVue
• Extension of Functional and Non Functional Requirements

ICU Department at RPA

The ICU at the RPA hospital is divided into three/four sub division/department based on the three types of patient that is administered into the ICU. They are:

1.General ICU – The most generalised ICU unit that is designed to deliver the highest of medical and nursing care to the sickest of patients with non-unique conditions.
General ICU High Dependency Unit (HDU)– deals with patients which need constant care. Often up to two nurses can be assigned to each patient in the High Dependency ICU

2.Cardiothoracic Intensive Care Unit (CICU)/High Dependency Unit (CICU-HDU) - CICU cares for patients who need heart (cardiac) and chest (thoracic) surgery. Surgical procedures may include operations on the heart, the heart’s blood vessels, the chest or the lungs.

3. Coronary Care Unit (CCU) - The Coronary Care Unit or CCU cares for patients who have heart disease and occasionally other medical or surgical problems. In RPA, this unit is more or less combined with CICU.

4. Neurosurgical Intensive Care Unit (NICU)/High Dependency Unit (NICU-HDU) - The Neurosurgical Intensive Care Unit cares for patients with brain or spinal cord conditions and occasionally other medical or surgical problems. (Source)

The General ICU and Neurosurgical ICU/HDU patients are cared by specialist doctors relevant to their area whereas the General ICU HDU and Cariotherastic ICU/HDU care is driven by ICU specific doctors.

Flow of patient in a general ICU

Patients who come into ICU often need constant monitoring and medical care. These are usually patients from lengthy surgery, unconscious and/or require ventilation hookup. A new patient administered into the ICU would follow the procedure:

1. Upon arrival (or even before arrival) a new patient is created in CareVue. Given the MRN, a linkage to the hospital’s patient administration system automatically uploads all other administrative (not medically relevant) data.

2. The patient physically arrives to the ICU department, usually accompanied with several nurses and doctors. During the setup procedure, necessary equipment (such as ventilator, machines measuring vital signs) are attached and linked to the patient. Once linked some of these medical equipment automatically update data into CareVue.

3. Nurses and/or doctors then create a care plan for the patient. (Different depending on diagnosis or investigation).

4. Nurses and doctors perform their duty in caring for the patient (To be investigated next week).

ICU Whiteboard

In almost all hospital departments, exist a whiteboard used to record and keep track of patients, nurses and doctors on shift. The RPA’s ICU uses a whiteboard as a tool to map patients to nurses and to record which doctors are on shift.

Core Users of CareVue

• Doctors – heavy user
• Nurses – heavy user
• Physios – medium user
• Dieticcian – heavy user
• Social workers – light users
• Visiting Medical Teams – medium users
• Speech Pathologist – medium users

Note: Physios, Dieticians, Speech Pathologists and Pharmacists are usually referred to as Allied Healthcare professionals. These set of users have limited use in CareVue. They often view CareVue information and only enter notes compared to Doctors or Nurses whom extensively use CareVue.

Update: Meeting with Angela Ryan

Tomorrow, Hendy and I have scheduled our first meeting with Angela Ryan, one of our major contacts down at the Royal Prince Alfred Hospital. Our aims are to cover the following issues:

1. Work flow of ICU department - how patients are administered into ICU, what process they go through ICUs and when/how patients exit the ICU ward and where they go from there.

2. System Analysis of CareVue including:

• Range of Current functionality
• Critique of CareVue - advantages, disadvantages,
  
• How CareVue is implemented into their current work flow

3. What an ideal ICU should encompass.

4. Set up meetings with other RPA personnel as required.

A list of interview questions have been listed on thesis notebook but is continually updated on Trac (a wiki and sub version repository and project management tool used for this project).

In addition, a weekly meeting with Jon Patrick (Supervisor) has been scheduled on Thursday at 12 every week. I will update this blog in the following days after the meeting.

Project Definition and Demonstration of CDAL

As discussed in my previous post, I will give a more detailed summary of the meeting and site visit.

Meeting on 18/07/2007

The objective of the meeting was to meet with 2 other students (David Ding, Victor Chan and Peter Budd) who will be working on extending and developing the Clinical Data Analytical Language (CDAL), discuss how the projects were to be monitored and managed, and increase the understanding of the scope of how all different aspects of the project fit in as a whole.

Administration and Management of projects

In conjunction to this blog, Trac (a project management software) is to be used to record my progress, documentation, code and subversion tool. There may be some redundancies between the blog and information contained in Trac but I do not anticipate that this will poise a significant problem.

Overall Project Picture

The figure above shows the overall picture of how a generalised clinical management information system can be used to develop department specific IS, yet still retain its interoperability across systems.

CDAL is essentially a restricted natural language allowing analytical procedures to be expressed as a query such that it can be computationally executed. It is similar to SQL except it is less restricted and more closely resembles human language. In the above figure, it can be seen how Victor and David's work on CDAL will fit into the IS. An initial prototype of this (developed by YuZhong) was demonstrated at the RPA site visit.

Task

Following the meeting and site visit, our initial tasks has become a lot clearer. These include:

1. System Analysis of ICU - A comprehensive system analysis of ICU is to be undertaken in order to gain an understanding of what an ICU IS should be fundamentally be achieving, data capture requirements (design of forms) and overall functional and non functional requirements. Incorporated in this system analysis is a SRS for an ideal ICU IS (SUICUIS). ICU work flow analysis. If possible, system analysis would be conducted at the RPA ICU and two other hospital departments to gain a greater understanding of how hospital information systems differ from department to department.
2. Extending previous thesis work on G.H.I.M.S (now referred to as G.C.I.M.S) - particularly on the generation of forms and form version control.
   
3. Develop a functional ICU IS - using methodology in G.C.I.M.S and incorporating the use of medical terminology server to deliver (in this case) SNOMED-CT terms to instantiate and record data.
   

While we are undertaking these tasks, we will likely be using all open source software if possible.

Meeting with 2007 RPA Health Informatics Team and demonstration at RPA

Today, I had a meeting with Jon Patrick with regards to the theses projects that were concurrently in action in the Health Informatics field in conjunction with the RPA. Present were Jon Patrick, Peter, Hendy, David and Victor. During this meeting we had discussed general overview of all projects, administrative and management of projects as well as dwelling into a more detailed discussion of the thesis project itself.

In the afternoon, the project group headed to the RPA ICU where a prototype of clinical data analytics language was demonstrated to both the team and RPA employees by Yuzhong. The CDAL is effectively a less restricted natural language that allows users to ask complex analytical questions to the ICU database. For example a question could entail "Find the average heart rate for a class of patients exhibiting x,y,z characteristics over a x,y,z time interval".

Tomorrow, my aim is to continue to update this blog with a more detailed recount of the meeting, finish off a rough project plan, as well as update TRAC (a subversion and wiki that the team will also be using to track our progress, ideas and source code). I will also continue to work on my sections of the SRS which Hendy and I aim to at least get a draft level before next week.

Speaking of next week (week 1), we have organised a meeting with Angela (RPA contact) to discuss the how ICU works and the type of workflows that occur within an ICU at the RPA.

System Analysis of current ICU IS and ICU SRS

Our first concrete task for the thesis is to develop a comprehensive ICU SRS (Intensive Care Unit Software Requirement Specification). This is to be done in conjunction with Hendy.

Objective:
The ICU SRS is to be used as an input specification to generate an ideal ICU IS. Therefore the ICU SRS is to be the broadest description of what an ICU IS should be. The document would be used as a platform to:

1. Obtain a comprehensive understanding of an ICU, ICU workflows, information requirements and its place in RPA.
2. Achieve an ultimate and ideal ICU that satisfies all users: Administrators, Clinician, Auditors, Researcher.

The figure below (extracted from the Meeting with Jon Patrick) shows a rough idea of how Hendy and I will attack this problem. Note that data is to be obtained through user interviews (interview questions) and analysis of CareVue software itself.

The thesis notebook will continually be updated with interview questions, findings and any other comments related to the ICU SRS.

A visit to the Royal Prince Alfred Hospital for Induction

On Friday 1st of June, Hendy and I went to the Royal Prince Alfred Hospital (RPA) to begin the induction process. While there, we were introduced to our main contact within the RPA. After a brief introduction, she took us on an eye opening tour of the hospital. Most, if not, all of my work will be centered around the intensive care unit (ICU)'s information systems.

The main information system used at the RPA is somewhat old and basic. While it performs its basic duties well, there is the opportunity for vast improvements and by doing so, we envisage the new age H.I.S will enhance the information quality and delivery to patients at point of care as well as provide administrators with superior data analytics.

Near the end of the induction, we were given some reading material to ponder upon. It should be mentioned that the scope of this project is very large. While my thesis scope is still being refined, I'm finding this topic quite interesting and challenging. Hopefully, I will be posting a more detailed scope of my project as it becomes more clearer.