Survey of Medical Informatics

1. Survey of Medical Informatics CS 493 – Fall 2004 August 30, 2004

2. Components of a National Health Information Infrastructure Chapter 2: Patient Safety - Achieving a New Standard of Care. IOM Report

3. Improving Safety • Clinical Decision Support Systems (CDSSs) – ex. for medication order entry • Computer-based alerts and reminders – facilitate adherence to care protocols • Computer-assisted diagnosis can help with evidence-based practice of medicine • Access to clinical information at the point of care – for ex. Access to lab results, radiology results can eliminate need for redundant tests

4. Trends in technology adoption • “it takes an average of 17 years” before research results make into practice.

5. NHII Defined (NCVHS definition) The NHII is defined as a set of technologies, standards, applications, systems, values, and laws that support all facets of individual health, health care, and public health (National Committee on Vital and Health Statistics, 2001).

7. Some examples of LHII • New England Healthcare Electronic Data Interchange Network (NEHEN) • A network of providers, health plans and payers • Indiana Network for Patient Care (INPC) • Started by Regenstrief Institute 10 years ago • 13 acute care hospitals and 20% of the outpatient physician practices in the metropolitan (Indianapolis) area. • The Santa Barbara County Care Data Exchange • 75% of healthcare providers in the Santa Barbara County participating in this experiment

8. From IOM Report, pg 57

9. EHR in clinical practice • 17% in US; 58% in UK; 90% in Sweden • Lack of incentives in US for change

10. Data Capture Speech Free text Document imaging Video Structured data Signal data Abstracted data Coded data Guidelines on UI Usable Grouped Minimalist Standards-based Prioritized Use of graphics and icons Data Acquisition Methods & Interfaces

11. Health Care Data Standards • Standardized measures and data elements • Datasets for clinical practice • Terminologies standards • Clinical Concepts and guidelines knowledge representation standards • Identifiers • Reference information models • Document standards

12. Data Repositories • Collects and collates patient information from numerous sources • Patient centric • Supports health care delivery, surveillance, and clinical decision support • Need to migrate to such repositories from current departmental “silos” systems.

13. Clinical Event Monitors • Clinical event monitors can be used to support real-time error prevention • Used in conjunction with data repositories • Bates et. Al., 2003 • Prevent adverse drug events • Nosocomial infections (infections that originate or occur in a hospital – basically infections acquired at a hospital) • Injurious falls Bates, D. W., S. Murff, H. Evans, P. D. Stetson, L. Pizziferri, and G. Hripcsak. 2003. Policy and the future of adverse event detection using information technology. J Am Med Inform Assoc 10 (2):226–228.

14. Data Warehouse • Clinical data warehouse is similar to data repository but designed for long term archival of clinical data and aggregation across institution, regional, national or even international.

15. Data Mining Techniques • Methods to obtain useful information from data warehouses • Data mining is useful for surveillance, case-based reasoning and even rule induction for expert systems • Natural Language Processing can also be applied to extract information from narrative texts • Data Mining Presentation

16. NLP and Data Mining • MedLEE – rule-based NLP system • http://lucid.cpmc.columbia.edu/medlee/ • Dept of Medical Informatics of Columbia University • Medical Language Extraction and Encoding System

17. Clinical Document Architecture • XML markup of clinical documents • Standardizing structure of clinical documents • Ability to handle structured and semi-structured documents • CDA + Standardized terminology can help to apply clinical decision tools

18. Digital Sources of Evidence or Knowledge • Bibliographic • MEDLINE: http://medlineplus.gov/ • Comprehensive source for medical journal articles maintained by National Library of Medicine (and other information related • OVID: http://www.ovid.com/site/index.jsp • Commercial database supporting medical research: including 1,200 journals, over 160 books and more than 300 databases • Structured evidence: • Trial Bank Project: http://rctbank.ucsf.edu/ • Captures clinical trial results that are published in journals in a standardized way so that evidence-based medicine can become a reality

19. Digital Sources of Evidence or Knowledge • Practice parameters • American Association of Critical Care Nurses http://www.aacn.org/ • National Guideline Clearinghouse http://www.guideline.gov/ • American Diabetes Association http://www.diabetes.org/home.jsp • National Committee for Quality Assurance (NCQA) – a watchdog group for the managed care industry • The Health Plan Employer Data and Information Set (HEDIS) – tool used by health plans to measure performance of care and service provided. About 60 different measures are tracked across health plans.

20. Digital Sources of Evidence or Knowledge • DXplain • http://www.lcs.mgh.harvard.edu/ • From Massachusetts General Hospital and Harvard Medical School • Decision support tool that helps physicians with clinical diagnosis • Illiad: http://www.openclinical.org/aisp_iliad.html • National Drug File: http://www.medsphere.com/products/clinical.wpl?m=55#module • Genbank: http://www.ncbi.nlm.nih.gov/Genbank/ • Molecular Modeling Database

21. Computer based guidelines Greenes, R. A., M. Peleg, A. T. S. Boxwala, V. Patel, and E. H. Shortliffe. 2001. Sharable computer-based clinical practice guidelines: Rationale, obstacles, approaches, and prospects. Medinfo 10 (Pt 1):201–205. • Disease management • Encounter workflow management • Reminders/alerts • Clinical trial support • Care plan/critical path support • Appropriateness of treatment determination • Risk assessment • Demand management • Education and training • Reference

22. Digital Sources of Evidence or Knowledge • Diabetes Quality Improvement Project (DQIP) • Infobutton

23. Factors Bandwidth Transmission latency Availability Security and confidentiality Access Type of communication Physician-physician Physician-patient Patient-patient Mass media communication Medical Literature dissemination Communication Technologies

24. Clinical Information Systems NHII + EHR

25. What is NHII ? Population Health National Infrastructure Interoperability Standards Evidence-based Decision Longitudinal EHR Avoidance of Medical Errors

26. Trends Evolution of the EHR concept • EHR • Comprehensive • Distributed and • Federated. • Emphasis on: • Evidence-based Medicine • Public Health • Functional: • Direct Care • Clinical Support • Infrastructure EMR Structured data Transcribed Text Orders/Results Enterprise Systems IDN CPR Scanned Docs Unstructured Text Limited Discrete Data Limited to single facility 1980 1990 2000

27. Acute Care Facility EHR Notes EHR EHR Images Structured Distributed concept

28. Integrated Delivery Network (IDN) ACF ACF Long Term Care Clinics Federation concept

29. IDN Other Clinics Federation concept Local Health Information Infrastructure (LHII) Community Area Network IDN Long Term Facilities

30. National Health Information Infrastructure LHII LHII LHII LHII LHII Goal: Access to longitudinal electronic health record from cradle to grave for every individual by those authorized to access it from anywhere across the nation and the world. Federation concept

31. Implementing the systems IOM-HL7 Demonstration Project

32. HIMSS 2003 – Interoperability Demonstration Project • CDC • FDA • Markle Foundation/Connecting for Health Initiative • 19 participating organizations • Results • Gaps in interoperability standards • Lack of standards to represent ADE

33. Davies Award Winners • CPRI-HOST started • Now part of HIMSS • Recognizes organization for implementing CPR systems

34. Other factors • Organizational leadership • Financial incentives • Technical assistance • Privacy & Confidentiality