1 / 65

A Population-Based Laboratory Information Strategy

A Population-Based Laboratory Information Strategy. Michael McNeely MD FRCPC Consultant in Medical Informatics, Victoria BC. Overview.

loki
Download Presentation

A Population-Based Laboratory Information Strategy

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. A Population-Based Laboratory Information Strategy Michael McNeelyMD FRCPC Consultant in Medical Informatics, Victoria BC M. McNeely APIII 2006

  2. Overview • There will be an ever-increasing need for laboratory results to be knowledge-based: to be interpreted, to guide treatment, and to smoothly integrate with the medical record. • Canada Health Infowayis a government of Canada project whose goal is to have electronic medical records (EMR) for 80% of Canada’s population by 2010.   • The Provincial Laboratory Information Solution is a BC project to provide a unified database of all laboratory results produced in the province. These two projects are at an early stage but eventually (phase III-IV) will incorporate knowledge support. • The presentation will, by way of a review, discuss the potential for these initiatives to carry forward existing programs involving laboratory utilization control, risk management, chronic disease management, telepathology, epidemiology, genominformatics, and sample management. M. McNeely APIII 2006

  3. Canada Health Infoway http://www.infoway-inforoute.ca/ • What is Infoway? • Canada Health Infoway Inc. invests with public sector partners across Canada to implement and reuse compatible health information systems that support a safer, more efficient healthcare system. Infoway is an independent, not-for-profit organization whose Members are Canada's 14 federal, provincial and territorial Deputy Ministers of Health. Launched in 2001, Infoway and its public sector partners have over 100 projects, either completed or underway, delivering electronic health record (EHR) solutions to Canadians – solutions that bring tangible value to patients, providers and the healthcare system. M. McNeely APIII 2006

  4. Canada Health Infoway http://www.infoway-inforoute.ca/ • Mission • To foster and accelerate the development and adoption of electronic health information systems with compatible standards and communications technologies on a pan-Canadian basis, with tangible benefits to Canadians. • To build on existing initiatives and pursue collaborative relationships in pursuit of our mission. M. McNeely APIII 2006

  5. Canada Health Infoway http://www.infoway-inforoute.ca/ • Vision • A high-quality, sustainable and effective Canadian healthcare system supported by an infostructure that provides residents of Canada and their healthcare providers with timely, appropriate and secure access to the right information when and where they enter into the healthcare system. Respect for privacy is fundamental to this vision. • Goal • To have an interoperable EHR in place across 50 per cent of Canada (by population) by the end of 2009. M. McNeely APIII 2006

  6. Canada Health Infoway http://www.infoway-inforoute.ca/ • Components of the HER • Patient and provider registries $110 m • Laboratory Results $ 150 m • Medical Imaging $ 220 m • Drugs $ 185 m • Interoperable EHR $ 175 m • Telehealth $ 150 m • Public Health $ 100 m • Innovation and adoption $ 60 m • Infostructure $ 25 m M. McNeely APIII 2006

  7. Order entry and results viewing for laboratory tests, medications and images. • Alert notification (eg. duplicate tests, drug interaction) • Provisioning of leading practices (i.e., CPG’s) • Scheduling Generation 3 plus complex Decision Support Generation 4 The Mentor • Patient demographics • Provider demographics • Location demographics • Encounters Generation 3 The Helper Generation 2 Functionality and Value Chain Optimization • Results Viewing • Laboratory test results • Dispensed medications • Diagnostic image results The Documenter Generation 1 The Foundation Includes investments to support project management, user-adoption, change management, knowledge transfer, standards and benefits evaluation, representing 30% of program investments overall Enablers End of 2009 Evolution of EHR M. McNeely APIII 2006

  8. Canada Health Infoway http://www.infoway-inforoute.ca/ • Progress to date • Standards adoption: • HL 7 • LOINC • SNOMED CT • Provincial Projects • Ontario • Others • British Columbia M. McNeely APIII 2006

  9. BC - The Provincial Strategyhttp://www.healthservices.gov.bc.ca/cpa/publications/ehealth_framework.pdf • An HER provides each British Columbian with a secure and private lifetime record of their key health history and care within the health system. • The record is available electronically to authorized health care providers and the individual anywhere, anytime, in support of high-quality care. • For more information on the Electronic Health Record, please see:http://healthnet.hnet.bc.ca/index.html M. McNeely APIII 2006

  10. Provincial Laboratory Information Solution (PLIS) • Planning and development activities to support Technology Transformation are being led by a dedicated PLIS Office within the PLCO, working with the Ministry of Health’s Knowledge Management Branch. A joint PLCO/Ministry strategy which will lead to the creation of a Provincial Laboratory Information Solution (PLIS) for British Columbia. • The overall guiding vision behind the creation of a Provincial Laboratory Information Solution (PLIS) for British Columbia is to provide access to clinical laboratory information (results, orders and decision support) to care providers at the point of care anywhere in British Columbia. PLIS is also a leading initiative within the Ministry of Health's broader E-Health strategy to develop the Electronic Health Record and support IT infrastructure for health care in BC. • The Provincial Laboratory Information Solution (PLIS) will: • provide a standardized province-wide approach to presenting a patient's lab test results M. McNeely APIII 2006

  11. Provincial Laboratory Information Solution (PLIS) • electronically distribute lab test results to ordering and/or copied physicians • make historical lab test results from both public and private laboratories within the province available to physicians • create an electronic lab test ordering system with decision support tools • improve the ability to aggregate laboratory information in order to support both administrative and clinical decision-making • provide a provincial capacity to measure and manage the provision and utilization of laboratory services • contribute to the realization of the provincial Electronic Health Record (EHR) • Through the use of technology and standards, the new system will ensure laboratory information is: of a high quality, available to authorized health care providers and administrators throughout the province, part of each patient's provincial Electronic Health Record M. McNeely APIII 2006

  12. Provincial Laboratory Information Solution (PLIS) • Features • Organizational structure • Unique bid process – Joint Services RFP • Development • Time frame FUTURE COMPONENTS OF INTEREST • Data Mining • Clinical Decision / Knowledge Support • Telepathology M. McNeely APIII 2006

  13. Data Mining • Utilization Control • Reduce unnecessary duplication of testing • Ensure adherence to utilization protocols • Facilitate data evaluation in order to design utilization strategies M. McNeely APIII 2006

  14. Chronic Disease Management • Clinical Practice Guidelines • Provide objective data for CPG development • Outcomes analysis • Follow-up of adherence • Follow-up for outcomes studies • Makes more elaborate CPGs possible • Disease epidemiology • Assist individual physician’s patient tracking (e.g. lists of diabetics in a physician’s practice). • Provide physician reminders re chronic disease patient reviews • Provide availability to a “package” of physician specific database searches on their own patients (e.g. a list of all “registered” diabetics in a given practice with statistics on their frequency of A1C testing compared to provincial norms). • Patient reminders M. McNeely APIII 2006

  15. Special Disease Registries/Services • Automated development of registries of diseases characterized by laboratory test results (e.g. hemoglobinopathies, hypercholesterolemia, diabetes, hemochromatosis, and many others as genetic testing expands) • Specialized knowledge support tools and information for both physicians and patients • “Mailing list” of physicians/patients to be informed when new information becomes available. • Epidemiology • Classic infectious disease epidemiology (but closer to “real-time”) • Real-time epidemiology for epidemics (e.g. SARS) and bioterrorism • Chronic disease epidemiology (non-infectious) • Health Care System Management • Outcomes data • Utilization management • Population trends • Test usage and deployment of resources • Physician ordering profiles M. McNeely APIII 2006

  16. In 1982 I gave a talk on this very same subject. I covered the following types of automated interpretations. • Level 1: Standard comment on every report of a specific test. • Level 2: Result specific comment: 1-test. • Level 3: Result specific comment: 2-or more tests, over time, or other clinical information • Level 4: More sophisticated approaches. Now, in 2006 we haven’t managed Levels 1-3 completely but we’re now looking at Level 4 and various projects may bring Level 4 to fruition within the next few years. M. McNeely APIII 2006

  17. “Canned” Comments GOOD THINGS • Demonstrated ability to change physician behaviour • Demonstrated ability to enhance use of laboratory testing (e.g. utilization, diagnosis) CAUTIONS • Limited clinical information • Comment added whether needed or not • Consume space on a paper report • Paper report has a rigid format • Some doctors feel threatened/insulted • Patient overreaction (patient access) M. McNeely APIII 2006

  18. Human Generated Comments • Questions: • Are the interpretations part of the legal report? • Should the interpretations be added to EMR? • Who should be permitted to prepare such interpretations? • Human generated reports have error rate of up to 50% (Lim Clin Chem 2004) • Marshall & Challand (Ann Clin Biochem 2000) • Variation amongst interpreters • Communication style variable • Clinical information available is not always appropriate to the test being interpreted • Little feedback regarding usefulness • Interpretations should be recipient specific M. McNeely APIII 2006

  19. Laposata(Clin Chem 2004; 50: 471) • Laposata has championed the need for human-generated, patient-specific narrative interpretations • He has criticized the “canned” comment • BUT he compares Apples and Oranges • Laposata makes the case for why Knowledge Support is needed. M. McNeely APIII 2006

  20. Knowledge Support • a.k.a. Clinical Decision Support • Two forms: • Static: PubMed, Lab Tests On-Line, ARUP • Dynamic or CARTKS (Context Appropriate Real Time Knowledge Support) • Specific Interpretations M. McNeely APIII 2006

  21. The “Case” for Knowledge Support / Clinical Decision Support • Hundreds of publications have demonstrated its potential usefulness • Several publications have pointed out potential problems but none has undercut the basic premise. • Clinical Practice Guidelines: • Ever increasing numbers • Poorly applied (~ 25% adherence) • Limited complexity M. McNeely APIII 2006

  22. “It is likely that when electronic knowledge support tools become a standard feature of medical practice, the protocol and CPG approach will be maximized.” McNeely Clinics of Laboratory Medicine 2002; 22: 1-10 • “It is so apparent that computerization will enhance the application of CPGs that it may be unethical to continue to perform trials to answer this question.” Ellson and Connolly JAMA 1998; 279: 989. • “To be widely accepted by practicing clinicians, computerized support systems for decision making must be integrated into the clinical work flow. They must present the right information, in the right format, at the right time, without requiring special effort.” James BC NEJM 1999; 340: 1202. M. McNeely APIII 2006

  23. Ripple-Down Rules • Developed by Paul Compton and Gordon Edwards of St. Vincent’s Hospital, Sydney AU • Original system PIERS • Now marketed by Pacific Knowledge Systems http://www.pks.com.au/asLabWizard™ • Rule-Based but no knowledge engineer M. McNeely APIII 2006

  24. Ripple-Down Rules Lab Completes Test Knowledge Base & Inference Engine Verified Result Combination? No Yes LIS Reports: Result And Interpretation Result Combo Interpreted Integrator M. McNeely APIII 2006

  25. LabWizard (example) M. McNeely APIII 2006

  26. BloodLink Clin Chem 2002; 48: 605. Marc van Wijk MD PhD Delft, The Netherlands M. McNeely APIII 2006

  27. M. McNeely APIII 2006

  28. M. McNeely APIII 2006

  29. M. McNeely APIII 2006

  30. M. McNeely APIII 2006

  31. Number of Requisitions Number of Tests Requested BloodLink Restricted CONTROL 12,786 87,634 BloodLink Guideline TEST 12,700 70,479 BloodLink – Evaluation Test reduction of 19.6% 50 GPs Two Groups 1-Year M. McNeely APIII 2006

  32. Laboratory Advisory System • Chang E, McNeely MDD, Gamble K. Strategies for choosing the next test in an expert system. Proceedings of the congress on medical informatics. AAMSI 1984; 2:198-202. • McNeely MDD, Smith B. An interactive expert system for the ordering and interpretation of laboratory tests to enhance diagnosis and control utilization. Canadian Medical Informatics. May/June 1995;16-19. • Smith BJ and McNeely MDD. The Influence of an Expert System for Test Ordering and Interpretation on Laboratory Investigations. Clinical Chemistry 1999; 45(8): 1168-1175. • Clinical-Laboratory.com Old Marlebone Rd, London, England M. McNeely APIII 2006

  33. M. McNeely APIII 2006

  34. M. McNeely APIII 2006

  35. M. McNeely APIII 2006

  36. M. McNeely APIII 2006

  37. M. McNeely APIII 2006

  38. M. McNeely APIII 2006

  39. M. McNeely APIII 2006

  40. M. McNeely APIII 2006

  41. M. McNeely APIII 2006

  42. M. McNeely APIII 2006

  43. M. McNeely APIII 2006

  44. Results of a trial M. McNeely APIII 2006

  45. The LAS – Study Conclusion • The developmentof test ordering strategies can be enhanced. • The interpretationof the test results can be enhanced. • A statistical databaseof diagnosis, clinical information,test orders, and resultscan be readily derived. Such informationis unique and is availablefor optimizing and developing testingstrategies and for laboratorymanagement. M. McNeely APIII 2006

  46. The LAS– study conclusion(con’t) • An appropriate search of the databasewould enable clinician-targetededucation and utilization feedbackto be derived. • Examination of the database at the timeof ordering wouldenable the development of a module to identifyunnecessary, duplicatetesting. M. McNeely APIII 2006

  47. Contextualized ReportDr. Jonathan Kay (Oxford)Drs. Bruce Friedman and Jules Berman Lab Medicine 2006; 37: 121. M. McNeely APIII 2006

  48. Smith, John H. Male 46 yoa 23957988-1 Dr. Louis Pasteur DOS June 7, 2006 Test Name Result Reference Interval Alkaline Phosphatase 128  20 – 105 U/L M. McNeely APIII 2006

  49. Smith, John H. Male 46 yoa 23957988-1 Dr. Louis Pasteur DOS June 7, 2006 Test Name Result Reference Interval ALERT !! Patient is taking Chlorpromazine which is known to cause Cholestasis with increased Alk Phos. Alkaline Phosphatase 128  20 – 105 U/L • Analytical Information – Alkaline Phosphatase • Laboratory validation studies • Method reference • Instrument validation studies • Proficiency testing record • Complete Bibliography –Click here  M. McNeely APIII 2006

  50. Smith, John H. Male 46 yoa 23957988-1 Dr. Louis Pasteur DOS June 7, 2006 Test Name Result Reference Interval Alkaline Phosphatase 128  20 – 105 U/L • Analytical Information – Alkaline Phosphatase • Laboratory validation studies • Method reference • Instrument validation studies • Proficiency testing record M. McNeely APIII 2006

More Related