What the dormouse said;

1. HIRI Information in the Service of Health What the dormouse said; Bio-medical Informatics; Systems Engineering; Ontologies and other things you didn’t know about EMRs by John Hughes and Michel Lortie January 2011 Medbase Research – Confidential and Proprietary Information

2. HIRI Information in the Service of Health Medbase Research – Confidential and Proprietary Information

3. Standards for Accreditation of Residency Training Programs Page 1 9 HIRI Information in the Service of Health • Each residency program must demonstrate a commitment to integrating the tools of information management into patient care, teaching and research. • This will require that the program have an organized approach to promoting the use of, and fostering the teaching of informatics. • Essential elements of this commitment will include: • 1. Providing residents and faculty with ready access to the tools of information management in the areas where they usually conduct patient care. • 2. Developing, implementing and evaluating a resident curriculum and faculty development program in family medicine informatics. Medbase Research – Confidential and Proprietary Information

4. National Academy of Sciences “BUILDING A BETTER DELIVERY SYSTEM A New Engineering/Health Care Partnership” Proctor P. Reid, W. Dale Compton, Jerome H. Grossman, and Gary Fanjiang, Editors 2005 “provides a framework and action plan for a systems/informatics approach to health care delivery based on a partnership between engineers and health care professionals” HIRI Information in the Service of Health Medbase Research – Confidential and Proprietary Information

5. HIRI Information in the Service of Health • HiRES Project - Mission Statement The advancement of research, education and service in healthcare through the application of systems engineering and biomedical informatics principles “information in the service of health” Medbase Research – Confidential and Proprietary Information

6. HIRI Information in the Service of Health What is Informatics? S: (n) information science, informatics, information processing, IP (the sciences concerned with gathering, manipulating, storing, retrieving, and classifying recorded information) http://wordnetweb.princeton.edu/ Medbase Research – Confidential and Proprietary Information

7. What are systems? HIRI Information in the Service of Health • S: (n) system, scheme (a group of independent but interrelated elements comprising a unified whole) • e.g. a “healthcare system” http://wordnetweb.princeton.edu/ Medbase Research – Confidential and Proprietary Information

8. What is Engineering? S: (n) engineering, engineering science, applied science, technology (the discipline dealing with the art or science of applying scientific knowledge to practical problems) http://wordnetweb.princeton.edu/ HIRI Information in the Service of Health Medbase Research – Confidential and Proprietary Information

9. What is Ontology? HIRI Information in the Service of Health • S: (n) ontology ((computer science) a rigorous and exhaustive organization of some knowledge domain that is usually hierarchical and contains all the relevant entities and their relations) • S: (n) ontology (the metaphysical study of the nature of being and existence) http://wordnetweb.princeton.edu/ Medbase Research – Confidential and Proprietary Information

10. What is an EMR? HIRI Information in the Service of Health • an evolving concept defined as a systematic collection of electronic health information about individual patients or populations. • It is a record in digital format that is capable of being shared across different health care settings, by being embedded in network-connected enterprise-wide information systems. Medbase Research – Confidential and Proprietary Information

11. Why is this man upset? There is growing pressure from the public The public is using computers - why are their medical records on paper? HIRI Information in the Service of Health Medbase Research – Confidential and Proprietary Information

12. Mortality “More than 98,000 Americans die and more than one million patients suffer injuries each year as a result of broken health care processes and system failures.” (IOM, 2000; Starfield, 2000); A Failure of Systems HIRI Information in the Service of Health Medbase Research – Confidential and Proprietary Information

13. A Failure of Systems HIRI Information in the Service of Health Morbidity • “…little more than half of patients receive known ‘best practice’ treatments for their illnesses and less than half of physician practices use recommended processes for care” (Casalino et al., 2003; McGlynn et al., 2003) Medbase Research – Confidential and Proprietary Information

14. A Failure of Systems HIRI Information in the Service of Health Waste • “…thirty to forty cents of every dollar spent on health care, or more than a half-trillion dollars per year, is spent on costs associated with “overuse, underuse, misuse, duplication, system failures, unnecessary repetition, poor communication, and inefficiency” (Lawrence et al, “Building a Better Delivery System: A New Engineering/Health Care Partnership”; The National Academies Press 2005) Medbase Research – Confidential and Proprietary Information

15. A Failure of Systems HIRI Information in the Service of Health An opportunity? • “…the cost of the failure to take advantage of the tools, knowledge, and infrastructure that have yielded quality and productivity revolutions in many other sectors of the economy has been enormous.” (“Building a Better Delivery System: A New Engineering/Health Care Partnership”; The National Academies Press 2005) Medbase Research – Confidential and Proprietary Information

16. Paper vs Computers HIRI Information in the Service of Health It is hard to believe that this ‘performs better than computer records’ Medbase Research – Confidential and Proprietary Information

17. Or is it? HIRI Information in the Service of Health • “merely automating the form, content and procedures of the current patient records will perpetuate their deficiencies and will be insufficient to meet emerging user needs” • R.S. Dick; E.B. Stein: “The Computer Based Patient Record; An Essential Technology for Health Care”; Institute of Medicine, National Academy of Science 1991 Medbase Research – Confidential and Proprietary Information

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31. Isn’t this what we want? HIRI Information in the Service of Health Medbase Research – Confidential and Proprietary Information

32. EMR Generations HIRI Information in the Service of Health The Mentor The Partner The Helper Medbase Research – Confidential and Proprietary Information

33. HIRI Information in the Service of Health EMR Generations 1st: The Collector- simple systems that provide a site-specific solution for the need to access clinical data which is imported through scanning or other forms of aggregation 2nd: The Documenter - basic systems that clinicians use at the point of care to adequately document rather than merely access clinical data 3rd: The Helper- Systems that include episodic and encounter data and use decision support tools to assist clinicians, functional in at the minimum both ambulatory and inpatient settings 4th: The Partner - Advanced systems that provide more decision support capabilities and that are operational and accessible across the continuum of care, and providing sufficient credibility as to become the patient's legal medical record 5th: The Mentor- Complex and fully integrated systems that include all previous capabilities and that are a main source of decision support in guiding patient care for both clinicians and consumers Medbase Research – Confidential and Proprietary Information

34. The Computable Medical Record HIRI Information in the Service of Health • To get past the document manger EMR and achieve the “quality and productivity revolutions” seen elsewhere in society we need “computation” • S: (n) calculation, computation, computing (the procedure of calculating; determining something by mathematical or logical methods) Medbase Research – Confidential and Proprietary Information

35. The Computable Medical Record HIRI Information in the Service of Health But • Cancer is more complicated than a bank overdraft • We are not born with an instruction manual and set of blue prints • In fact the human being is the most complex entity in the known universe Medbase Research – Confidential and Proprietary Information

36. The Computable Medical Record HIRI Information in the Service of Health “I don't know who discovered water but it certainly wasn't a fish.” Marshall McLuhan Medbase Research – Confidential and Proprietary Information

37. Information; the water we swim in HIRI Information in the Service of Health • In attempting to arrive at the truth, I have applied everywhere for information, but in scarcely an instance have I been able to obtain hospital records fit for any purposes of comparison. • If they could be obtained, they would enable us to decide many other questions besides the one alluded to. • Nightingale, Florence; “Notes on a Hospital” 1873 Medbase Research – Confidential and Proprietary Information

38. Merck Manual HIRI Information in the Service of Health Medbase Research – Confidential and Proprietary Information

39. The Tsunami of Information HIRI Information in the Service of Health • The scientific method is under threat due to its own success • 4 exabytes (4.0 x 10^19) of unique information was generated in the last 12 months • Health practitioners are being swamped by a tsunami of clinical research Medbase Research – Confidential and Proprietary Information

40. “Four rules for the reinvention of health care” Enrico Coiera, BMJ  2004;328:1197-1199 (15 May), HIRI Information in the Service of Health “Two hundred years ago enlightened physicians understood that empiricism needed to be replaced by a more formal and testable way to characterize disease and its treatment. The tool they used then was the scientific method. Today we are in an analogous situation. Now the demand is that we replace the organizational processes and structures that force the arbitrary selection amongst treatments with ones that can be formalized, tested, and applied rationally.” Medbase Research – Confidential and Proprietary Information

41. Foundations in the Weeds HIRI Information in the Service of Health “If communities were the size of cells and if hospitals, pharmacies, laboratories, patients and physicians were the size of sub cellular particles, no doubt they would be the subjects of a great deal of research, and much more would be known about their relationships and pathophysiology.” Weed, Lawrence; “Medical Records, Medical Education, and Patient Care”; The Press of Case Western Reserve University; 1969 Medbase Research – Confidential and Proprietary Information

42. Solutions HIRI Information in the Service of Health • real improvement in outcomes will occur only when clinical systems reconfigure themselves specifically to address the needs and concerns of chronically ill patients (Wagner EH. “Chronic disease management: what will it take to improve care for chronic illness?” Eff Clin Pract. 1998;1:2-4) Medbase Research – Confidential and Proprietary Information

43. “Make it so Number One” HIRI Information in the Service of Health • This journey to reinvent health care begins by recognizing that to design health services, we need to understand systems. • The behavior of a system emerges out of the interaction of its components, and the more components there are, the harder it is to predict the outcome of a seemingly simple change. • The nature of complex systems such as health care means that simple fixes will always have unexpected consequences. Medbase Research – Confidential and Proprietary Information

44. The Therac 25 Disaster HIRI Information in the Service of Health • Between June 1985 and January 1986 six patients were killed or massively overdosed by radiation therapy because • The software designers did not understand that many of the assumptions that were left implicit in the specifications would quickly become invalid in slightly changed circumstances and would lead to catastrophic failure. Medbase Research – Confidential and Proprietary Information

45. How do unexpected consequences occur? HIRI Information in the Service of Health ‘‘When Iuse a word,’’ Humpty Dumpty said in a rather scornful tone, ‘‘it means just what I choose it to mean—neither more nor less.’’ ‘‘The question is,’’ said Alice, ‘‘whether you can make words mean so many different things.’’ ‘‘The question is,’’ said Humpty Dumpty, ‘‘which is to be master—that is all.’’ “Alice's Adventures in Wonderland”;1865 Charles Lutwidge Dodgson (aka Lewis Carroll). Medbase Research – Confidential and Proprietary Information

46. So how do we avoid implicit assumptions? HIRI Information in the Service of Health • Unambiguous terminologies, • Systems models of our processes • Knowledge ontologies Medbase Research – Confidential and Proprietary Information

47. What is a Terminology? HIRI Information in the Service of Health • S: (n) terminology, nomenclature, language (a system of words used to name things in a particular discipline) • e.g. the “Systematized Nomenclature of Medicine; Clinical Terms” (SNOMED CT) Medbase Research – Confidential and Proprietary Information

48. What is a Model? HIRI Information in the Service of Health • “Man tries to make for himself in the way that suits him best a simplified and intelligible picture of the world and thus to over come (sig. understand) the world of experience, for which he tries to some extent to substitute this cosmos (sig. picture) of his. • This is what the painter, the poet, the speculative philosopher and the natural scientist do, each in his own fashion... one might suppose that there are any number of possible systems... all with an equal amount to be said for them; and this opinion is no doubt correct, theoretically. • But evolution has shown that at any given moment out of all conceivable constructions one has always proved itself absolutely superior to all the rest.” • Einstein, A. “The World as I See It” (1931) Medbase Research – Confidential and Proprietary Information

49. What is an Ontology? HIRI Information in the Service of Health • A multi-axial relational hierarchy that veridically represents a portion of reality (POR) Medbase Research – Confidential and Proprietary Information

50. How do we model clinical reality HIRI Information in the Service of Health The Ogden and Richards (1923) semiotic triangle Medbase Research – Confidential and Proprietary Information