Transcript Chapter 2: Components of NHII

Survey of Medical
Informatics
CS 493 – Fall 2004
August 30, 2004
Components of a National
Health Information
Infrastructure
Chapter 2: Patient Safety - Achieving a
New Standard of Care.
IOM Report
Improving Safety
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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
Trends in technology adoption
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“it takes an average of 17 years” before
research results make into practice.
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).
Some examples of LHII
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New England Healthcare Electronic Data
Interchange Network (NEHEN)
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Indiana Network for Patient Care (INPC)
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A network of providers, health plans and payers
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
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75% of healthcare providers in the Santa Barbara County
participating in this experiment
From IOM Report, pg 57
EHR in clinical practice
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17% in US; 58% in UK; 90% in Sweden
Lack of incentives in US for change
Data Acquisition Methods & Interfaces
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Data Capture
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Speech
Free text
Document imaging
Video
Structured data
Signal data
Abstracted data
Coded data
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Guidelines on UI
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Usable
Grouped
Minimalist
Standards-based
Prioritized
Use of graphics and
icons
Health Care Data Standards
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Standardized measures and data elements
Datasets for clinical practice
Terminologies standards
Clinical Concepts and guidelines knowledge
representation standards
Identifiers
Reference information models
Document standards
Data Repositories
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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.
Clinical Event Monitors
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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.
Data Warehouse
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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.
Data Mining Techniques
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Methods to obtain useful information from
data warehouses
Data mining is useful for surveillance, casebased reasoning and even rule induction for
expert systems
Natural Language Processing can also be
applied to extract information from narrative
texts
Data Mining Presentation
NLP and Data Mining
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MedLEE – rule-based NLP system
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http://lucid.cpmc.columbia.edu/medlee/
Dept of Medical Informatics of Columbia
University
Medical Language Extraction and Encoding
System
Clinical Document Architecture
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XML markup of clinical documents
Standardizing structure of clinical documents
Ability to handle structured and semistructured documents
CDA + Standardized terminology can help to
apply clinical decision tools
Digital Sources of Evidence or
Knowledge
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Bibliographic
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MEDLINE: http://medlineplus.gov/
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OVID: http://www.ovid.com/site/index.jsp
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Comprehensive source for medical journal articles maintained
by National Library of Medicine (and other information related
Commercial database supporting medical research: including
1,200 journals, over 160 books and more than 300 databases
Structured evidence:
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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
Digital Sources of Evidence or
Knowledge
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Practice parameters
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American Association of Critical Care Nurses
http://www.aacn.org/
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National Guideline Clearinghouse
http://www.guideline.gov/
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American Diabetes Association
http://www.diabetes.org/home.jsp
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National Committee for Quality Assurance (NCQA) –
a watchdog group for the managed care industry
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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.
Digital Sources of Evidence or
Knowledge
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DXplain
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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
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.
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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
Digital Sources of Evidence or
Knowledge
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Diabetes Quality Improvement Project (DQIP)
Infobutton
Communication Technologies
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Factors
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Bandwidth
Transmission latency
Availability
Security and
confidentiality
Access
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Type of communication
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Physician-physician
Physician-patient
Patient-patient
Mass media
communication
Medical Literature
dissemination
Clinical Information Systems
NHII + EHR
What is NHII ?
Populatio
n Health
National
Infrastructure
Evidencebased
Decision
Avoidance
of Medical
Errors
Interoperability
Standards
Longitudinal
EHR
Trends
Evolution of the EHR concept
EHR
CPR
Scanned Docs
Unstructured Text
Limited Discrete Data
Limited to single facility
1980
EMR
Structured data
Transcribed Text
Orders/Results
Enterprise Systems
IDN
1990
Comprehensive
Distributed and
Federated.
Emphasis on:
Evidence-based Medicine
Public Health
Functional:
Direct Care
Clinical Support
Infrastructure
2000
Distributed concept
Acute Care Facility
EHR
Notes
EHR
Images
EHR
Structured
Federation concept
Integrated Delivery Network (IDN)
ACF
ACF
Long Term
Care
Clinics
Federation concept
Local Health Information Infrastructure (LHII)
Community Area Network
IDN
Other
Clinics
IDN
Long
Term
Facilities
Federation concept
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.
Implementing the systems
IOM-HL7 Demonstration Project
HIMSS 2003 – Interoperability
Demonstration Project
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CDC
FDA
Markle Foundation/Connecting for Health
Initiative
19 participating organizations
Results
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Gaps in interoperability standards
Lack of standards to represent ADE
Davies Award Winners
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CPRI-HOST started
Now part of HIMSS
Recognizes organization for implementing
CPR systems
Other factors
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Organizational leadership
Financial incentives
Technical assistance
Privacy & Confidentiality