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ST. ELIZABETH MEDICAL CENTER & ARNETT CLINIC
LAFAYETTE , INDIANA
Medical Director’s Viewpoint
The following interview was conducted with Dr. Stephen Ash in March 2001. Dr. Ash is a renowned Nephrologist with a private practice and dialysis clinic. He is also the Medical Director for three dialysis units at St. Elizabeth’s hospital, with locals in rural parts of Indiana. Dr. Ash uses the Velos clinical system - seamlessly integrated in each of his nephrology practice, dialysis clinic, and in-hospital settings. In this interview, Dr. Ash speaks about his experience with Velos.
Velos: What are the major value additions you get from using Velos?
Dr. Ash: The driving force that
brought me to Velos is the organization of the clinical data,
especially around the problem title list. I’ve been a firm believer
that in order to organize medical information successfully, we have
to have an index according to the patient’s problem. Even though
this system structure was described by Dr. Larry Weed as far back as
1968, and implemented in my practice in the 1980’s, it has never,
until Velos, been implemented as a structure for medical data in a
commercially available clinical information system. There has not
been any other means proposed for organizing patient data other than
by the patient problem.
Now, a problem in Velos has a very
broad definition: it could be a patient complaint, it could be a
physical observation, a chemical abnormality, and it could even be a
therapy itself. Using the problem list, and then associating data
and comments with it, gives you the chance to essentially use the
problem list as the index for the rest of the whole medical record.
That’s a hugely important feature of Velos and very unique among the
systems that are out there.
The other important feature of
Velos is the fact that it was designed such that it could be
configured specifically for use in a dialysis setting, including
machine and lab interfaces, and the capability to do billing. As an
aside, I believe so much in this (concept) that I developed my own
product called Smart Chart, a problem-oriented database in Unix,
before migrating to Velos.
When I look at the other products
on the market, what I find is a re-creation of the flat file concept
of visit notes that appears currently in the paper chart. All
they’re doing is replacing the paper chart, and that doesn’t add a
lot of value. The other systems basically bring up a blank screen,
like a blank piece of paper, allow the physician to type in whatever
he or she wants, tack chief complaint on the top and a short problem
list on the bottom, and think that’s satisfactory. Whereas in
reality, everything in medicine is pushing us towards the use of
problem lists.
The E and M codes themselves are clearly based
on problems. The justification of lab tests in dialysis, for
example, is based now on proper definition of the diagnosis and
giving the patient the proper hematocrit values. So, everything is
pushing us towards associating therapies, numerics, and problem
titles.
The Velos system helps clinicians take a step forward
in thinking when caring for a patient. They have to think a little
more about, “Wait a minute, what is the patient’s problem that I’m
addressing?” If they don’t take that step, then they really don’t
get the value out of using a computer system any more than they
would using a paper chart.
And, by the way, because of the
fact that we’ve used such a system and seen the value, and proven
that nurses, dieticians, doctors, and patients can all use problem
titles and the whole thing works – not only do I feel that way, but
the rest of the people in the various areas where I practice feel
that way – from my office practice, to the hospital floors, to the
dialysis units.
Velos: Can you describe life before and after Velos?
Dr. Ash: If you look at what Velos
gives that the other systems don’t, the very first, simplest thing
to describe is that you get an accurate problem list, one that’s
really detailed, really works, and is up-to-date. Any other system
that you use will not give that to you. They say, “Oh, we have
problem lists,” or, “Yes, we have problem orientation.” But if you
say this is not just something to bill on, but I want to know the
status of each of the patient’s problems and some history around
that, you can only get that when you go to that line to put data
in.
If I were to grade other systems or the paper chart, I
would go to what every doctor says they think should be kept up –
which is the problem list – and look at the accuracy of that list.
With Velos, it will be accurate, and all available in one view. In
fact, it will probably be more accurate and detailed than most
people want to review, but that’s a function of how complex patients
are today.
One of the many things that you get with Velos,
that you won’t get with any other vendor, is the capability to
create a history and physical (H&P), a discharge summary, or a
suitable insurance company summary on the whole history of the
patient at the push of a button.
If you don’t have Velos’
problem organization, the system won’t give it to you. If you look
at the other systems on the market, and they say “Oh, yes. We do
H&Ps (history and physicals).” You say “Well, what do you mean?”
Well, you can look at a list of problems, and you can probably find
visits in the past that address those problems, and you can then
review all that and essentially re-dictate an H&P.
What I say is, “Wait a minute, that’s what the computer is supposed to do.”
I don’t want to put in information again that’s probably less
accurate and more general, and certainly less complete than what was
entered in real-time. Not to mention the amount of effort that
saves. Every vendor will tell you that they automate history and
physical, and every doctor will tell you they should absolutely have
a complete problem list and history and physical, but they never are
automated and rarely complete. The combination of quality and
efficiency in Velos is exceptional.
And, I did it three times
today. I can actually go to a computer in the hospital, call up the
Velos database at the clinic or my office, update a couple of the
patients’ medical problem titles, put in what happened in this
admission, push a button and get a complete history on that patient
for discharge or admission. The other systems just don’t have
it.
The other thing is that the accessibility of clinical
information in Velos is wonderful. You can get access to data in
other systems, but with most of them, you have to get access visit
by visit – and, that’s a real pain. For example, you can search for
CHF (Chronic Heart Failure) on some of our patients, in the hospital
system for example, and find 50 visits over time where people tacked
on CHF in the description. Well, where are the supporting
observations, how important were the noted factors, where are the
EKG results interpreted by the cardiologist? You have to guess, work
from memory, or call around.
Another big thing is access to
the system from different locations with different needs. Continuity
of care among hospital, clinic, and office is wonderfully
accomplished by a computerized medical record. But, it’s not an easy
task. Even in my own relatively small network, you have three, now
four, dialysis centers, a private clinic, that’s right next to those
centers but is on a different computer network, and then the
hospital, which isn’t attached to any one of the dialysis centers.
You’ve got hardware problems and, more importantly, political
problems to work through to actually get continuity.
Most doctors, and most nephrologists, assume they’ll never actually
accomplish this – that they’d actually be able to go into their
dialysis unit and see the record on a patient in their private
practice, or go to the hospital and see one from either place. We’ve
accomplished that.
But, if you didn’t have a software program
that was built to handle information within a medical practice, and
also work within a dialysis unit, or other specialties, like the
dialysis run record, the PD record, the dietician report, et cetera,
it just wouldn’t work. And, I know Velos has the same software
running in hospitals, too. So, Velos is the only one I’ve seen that
has accomplished that kind of breadth, which in turn unlocks a
wealth of opportunities for quality, cost, and efficiency
improvements. Designing a system that does that is very complex.
They’ve done it and made it easy to use.
Velos: Great. So, if you were to look at other improvements, in terms of saving
time, communications, better compliance, are there other advantages to Velos?
Dr. Ash: Oh, absolutely. If you work in a
world of paper charts, for example, and the patient comes in at,
say, one of two local hospitals like in our community, and you want
to find out what happened yesterday at my clinic, you’re sunk. There
is no way you’ll get that paper chart. In fact, even if they come
into my own clinic in the urgent care area, after hours, and I want
to find out what I did yesterday at my office, I’m sunk. It’s all by
memory, it’s all fill in.
Doctors have been covering this
deficiency in information and discontinuity of information by using
memory as best they can. This has always been the case. But it
really doesn’t work well. Doctors say, “Well, it’s all up here,” and
they point to their head. Well, that’s great, but what if he’s off
and I’m on call?
So, accessibility of information in the
paper chart world is a mess. And no one has solved it, whether
through faxes and even central databases. Hospitals are trying
through central databanks and that’s beginning to work, if you’re
within that institution; but try doing it across institutions – it’s
just hopeless.
Then, of course, you get to the question: “How
good is the chart?” My clinic had a paper cardboard sheet next to
the chart for 25 years, which had on it med list, important
allergies, and problem list on the patient, and they were virtually
never halfway complete. This is all cleaned up now – and
current.
Designing a system that allowed the kinds of
correlations among problem, numerics, and labs that Velos does is
hard enough, and involved a lot of foresight and dedication on
Velos’ part. But what is also in Velos, which I think isn’t very
apparent when people first look at the system, are parallel and
almost overlapping approaches to organizing information. I’ve talked
a lot about the problem list, but you also have whole diagnosis list
section, which is very parallel to what has always gone on in
hospitals.
For example, in hospitals, doctors have always
written or dictated what’s wrong with the patient, and the medical
records department transcribes it. Then you have a chief complaint
section for people who want to focus on that. And, for people who
don’t like problem orientation, you can still put visits in block by
block, one by one, and associate the whole visit with a problem
title. So, there are many different ways to use the system which
makes it simple for people with different work habits and different
perspectives, such as the nurse, physician, dietician,
administrator, and so forth. So there’s a tremendous amount of
flexibility built into Velos which, once configured, makes it easy
and powerful to use for each perspective.
Velos is powerful because of its combinations. Basically, you combine list-based and
free text entry, problem-orientation or a complete lack of it, and a
high degree of configurability, and allow the system to be easily
adapted to the way medicine works and doctors think – far better
than any system I’ve seen.
Now, so far, I’ve talked about the system from what I see as a quality perspective. Now, let’s talk about cost-effectiveness and efficiency . . .
The overall operation of the system, from the standpoint of data entry, takes
slightly more than what it takes using a paper chart. We in the
medical community spend decades evolving dictation systems, file
handling systems, and other processes to support the paper chart. If
your cost effectiveness is looking at how much quality of
information you get out, Velos beats the heck out of a paper chart.
I don’t like to suggest to people that you’ll save time in
implementing a system like Velos. Number one, you’ll spend time
implementing the system, and you also need someone on staff
committed to implementing the project and getting staff up-to-speed.
So, the time of data entry is, overall, perhaps equal to a paper
chart. But, speed of the subsequent preparation of documents and
data recall with Velos is light years ahead of our old paper-based
systems. If you look at our office on a day-to-day basis, I bet our
office is 50% more efficient with Velos than it used to be. Part of
it is just the accessibility: A nurse gets a phone call from a
patient; she brings up the patients med list, finds what the
patient’s on, can call a pharmacy immediately, call the doctor to
make suggestion. Perhaps, she looks at the visit before and sees
where they were and what the labs were last time.
People in
my clinic come by and marvel at how our nurses work. The fact is
that our nurses don’t have to say to the patient, “Wait a minute,
I’ll call for the paper chart, I’ll call the doctor and get back to
you later this afternoon,” which is how most every other clinic in
America works today.
And my staff loves it. Velos, as in velocity, was very aptly named.
Velos: Thank you, Dr. Ash.
About Velos
Velos is a leading designer and developer of next-generation healthcare
information systems. Velos offers an integrated suite of clinical,
administrative, and financial products and technology, bridging
legacy and net-centric architectures. Velos licenses its turn-key
solutions and technology, together with consulting and systems
integration services, to healthcare providers, systems vendors, and
other industry suppliers. Velos is privately held with headquarters
in Silicon Valley.
For information regarding Velos, please contact Madalynne Chapman (510-608-5744 / mchapman@velos.com
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