Survey of Medical Informatics

1. Survey of Medical Informatics CS 493 – Fall 2004 October 18, 2004 V. “Juggy” Jagannathan

2. Review Chapter 1-6: Patient Safety - Achieving a New Standard of Care. IOM Report

3. Crossing the Quality Chasm: A new health system for the 21st Century • IOM Report that identified six major quality goals: • Safety • Effectiveness • Patient Centeredness • Timeliness • Efficiency • Equitable

4. Recommendation 1 • Establishment of patient safety systems that rely on • Access to complete EHR and decision support tools at the point of care • Capture safety information – near misses and adverse events as a by-product of delivering care

5. Recommendation 2 • Develop a National Health Information Infrastructure (NHII) that will serve as the foundation for all care • Federal Government should provide incentives for the creation of NHII • Healthcare providers should invest in EHR systems that support key capabilities facilitating safe delivery of care and implement a process of continuous improvement

6. EHR System • Longitudinal collection of health information pertinent to care received by a person • Access to any authorized person • Knowledge and decision support tools • Tools and infrastructure to provide efficient support for care delivery process

7. Recommendation 3 • This recommendation focuses on roles and responsibilities of various government agencies • Department of Health and Human Services (DHHS) – to promote standards supporting patient safety • Consolidated Health Informatics (CHI) initiative with National Committee on Vital and Health Statistics (NCVHS) identify appropriate data standards and needs for standardizations • Agency for Healthcare Research and Quality (AHRQ) to oversee and support implementation efforts • The National Library of Medicine (NLM) to be the lead organization dealing with national clinical terminologies

8. Data Standards • Data Interchange Formats • X12 – Administrative/Financial • HL7 – Clinical Data • DICOM – Medical Images • NCPDP – Prescription Data • MIB – Medical device data • Coding/Terminologies • ICD, CPT, SNOMED, LOINC • Knowledge Representations

9. Recommendation 4 • Federal Government to encourage acceleration and adoption of standards in: • Clinical Data Interchange • Eg. HL7 CDA • Clinical Terminologies • Initially focusing on 20 priority areas • Knowledge Representation • Develop standards for supporting evidence-based medicine practice and clinical guidelines

10. Recommendation 5 • All healthcare systems should establish patient safety programs that: • Identify failures • Analyze failures • Redesign processes to prevent such failures from happening again

11. Recommendation 6 • The federal government should pursue an applied research agenda that focuses on: • Knowledge Generation • Identifying patients at high risk • Analyze near-misses to improve overall safety • Hazard analysis – retrospective and prospective techniques • Identifying approaches that work the best • Identifying the role of the patient • Develop tools • To support early detection, prevention, data mining techniques • Dissemination • Knowledge and tools

12. Recommendation 7 • Entrust AHRQ with developing: • Adverse and near miss events taxonomy • Standardized format for reporting such event • Identifying data elements that needs to be used in such reporting and use of Eindhoven Classification Model – Medical Version • Clinical context documentation

14. From IOM Report, pg 57

15. European Standards and overlapping efforts • Comite’ European de Normalisation (CEN) • ANSI counterpart in Europe • Significant overlap in standards body roles and responsibilities (Table 3-1 – page 102) • Standards in US are formulated by voluntary participation by vendors and providers • Europe, Japanese, Australian and others rely on government funds to establish standards for their country.

16. Terminologies • Over 150 terminology systems in use • Very little standardization – not interoperable • International Classification of Diseases [ICD] • Box 3-2 – pg 104

17. Server “Data” Integration VisualIntegration Server Server The Clinical Applications The Provider's Workstation The Provider * Acknowledgement: Slide provided by Wes Rishel, Gartner Group CCOW – Visual Integration

18. The Reference Information Model Act – something happened or may happen. Any action of interest. Entity – a person, animal or organization or thing Role – a part played by an entity Participation – the involvement of a role in a act Act_Relationship – a relationship between two acts Role_Link – a relationship between two Roles

19. Technology solutions Healthcare Standards Sample CDA Document

20. Direct Care DC1.0 Care Management Care Management DC2.0 Clinical Decision Support Ops Mgt & Comm DC3.0 OpsMgt& Comm S1.0 Clinical Support Supportive S2.0 Measurement, Analysis, Research, Reporting S3.0 Admin & Financial Information Infrastructure II1.0 Security Care Management Ops Mgt & Comm II2.0 Information and Records Management II3.0 Unique Identity, Registry, and Directory Care Management Ops Mgt & Comm II4.0 Support for Health Informatics & Terminology Standards II5.0 Interoperability Care Management Ops Mgt & Comm II6.0 Business Rules - Administrative Functions II7.0 Workflow Care Management HL7 EHR Functional Model* * Slide courtesy of Dr. Don Mon, Vice President of AHIMA

21. Criteria for terminologies • Technical Criteria used by NCVHS for evaluating and selecting terminologies • Page 145 – Table 4-2 • CHI focus areas • Page 146 – Table 4-3

22. Overview of Core and Supplemental Terminologies • Box 4-1 • Pages 150-151 • Figure 4-4 • Page 157

23. Online Mendelian Inheritance in Man National Center For Biotechnology Information Gene Ontology University of Washington Digital Anatomist Figure Source Material: Oliver Bodenreider: “The Unified Medical Language System (UMLS) integrating biomedical terminologies,” Nucleic Acids Research, 2004, Vol. 32, Database issue D267-D270

25. Clinical Guidelines • National Guideline Clearinghouse  contains 1,000 publicly accessible guidelines • http://www.guideline.gov/ • Box 4-2 pg. 159 • Comparison of these representative schemes • http://www.openclinical.org/gmmcomparison.html • http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=150359

26. Safety • A model for introducing safer care • Pg 179 – Figure 5-1 • Retrospective reviews based on ICD-9 CM discharge codes and External Causes of Injury Codes (E-Codes) • Pg 182 – Figure 5-2 • Pg 183 –Table 5-1

27. Automated review approach • Four different approaches: • ICD-9 codes • Reports of new allergy • Rule-based • Box 6-2 rules for detecting ADEs., page 207 • Data mining of textual reports • Diuretic drug  fatigue could be a potential adverse event • Box 6-3, page 208

28. Near miss • Phases • Initial failures • Dangerous situation • Inadequate defenses • Recovery • Figure 7-1 pg 228