Transcript Review

Survey of Medical
Informatics
CS 493 – Fall 2004
October 18, 2004
V. “Juggy” Jagannathan
Review
Chapter 1-6: Patient Safety - Achieving
a New Standard of Care.
IOM Report
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
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
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
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
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
Data Standards

Data Interchange Formats






Coding/Terminologies


X12 – Administrative/Financial
HL7 – Clinical Data
DICOM – Medical Images
NCPDP – Prescription Data
MIB – Medical device data
ICD, CPT, SNOMED, LOINC
Knowledge Representations
Recommendation 4

Federal Government to encourage
acceleration and adoption of standards in:

Clinical Data Interchange


Clinical Terminologies


Eg. HL7 CDA
Initially focusing on 20 priority areas
Knowledge Representation

Develop standards for supporting evidence-based
medicine practice and clinical guidelines
Recommendation 5

All healthcare systems should establish
patient safety programs that:



Identify failures
Analyze failures
Redesign processes to prevent such failures from
happening again
Recommendation 6

The federal government should pursue an applied
research agenda that focuses on:

Knowledge Generation






Develop tools


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
To support early detection, prevention, data mining techniques
Dissemination

Knowledge and tools
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
From IOM Report, pg 57
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.
Terminologies




Over 150 terminology systems in use
Very little standardization – not interoperable
International Classification of Diseases [ICD]
Box 3-2 – pg 104
CCOW – Visual Integration
“Data”
Integration
Server
Server
Visual
Integration
Server
The Clinical
Applications
The
Provider's
Workstation
The Provider
* Acknowledgement: Slide provided by Wes Rishel, Gartner Group
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
Technology solutions
Healthcare Standards
Sample CDA
Document
HL7 EHR Functional Model*
Direct
Care
Care Management
Management
DC1.0 Care
Ops Mgt & Comm
DC3.0 Ops Mgt & Comm
Supportive
Information
Infrastructure
S1.0
Clinical Support
S2.0
Measurement, Analysis,
Research, Reporting
S3.0
Admin & Financial
II1.0
Care Management
Security
Ops Mgt & Comm
Information and Records Management
Care Management
Unique
Identity, Registry, and Directory
Ops Mgt & Comm
Support for Health Informatics & Terminology Standards
II2.0
II3.0
II4.0
II5.0
II6.0
II7.0
DC2.0
Clinical Decision
Support
Care Management
Interoperability
Ops Mgt & Comm
Business Rules - Administrative Functions
Care Management
Workflow
* Slide courtesy of Dr. Don Mon, Vice President of AHIMA
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
Overview of Core and Supplemental
Terminologies

Box 4-1


Pages 150-151
Figure 4-4

Page 157
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
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.fc
gi?artid=150359
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
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
Near miss

Phases





Initial failures
Dangerous situation
Inadequate defenses
Recovery
Figure 7-1 pg 228