Transcript Health information systems: the integrity of measurements

Health Information Systems: The
Integrity of Measurements and Measures
W. Ed Hammond, Ph.D.
President, AMIA
Chair, Data Standards WG, Connecting for Health
Vice-chair, HL7 Technical Steering Committee
Convenor, ISO TC 215 Working Group 2
Professor-Emeritus, Duke University
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The Vision and the Need
Providers, those responsible for
population health, those responsible for
paying for health, those setting the policies
that determine the nature of health care
provided, and most importantly, consumers
will have ready access to timely, relevant,
reliable, and secure health care data,
information and knowledge through an
interconnected, electronic health
information infrastructure, to drive better
health and health care.
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Major Concerns in Health Care
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Reducing cost of care
Increasing the quality of care
Reducing medical errors
Accommodating an aging population
Biosurveillance and health surveillance
Better management of chronic disease
We need the aggregation, integration and
sharing of data among all stakeholders
including patient care, research, policy making,
management and reimbursement.
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Barriers
• Lack of political will and the need for more Federal leadership
• Independence of stakeholders in sharing, collaboration and
use of data
• Lack of incentives to make the changes that are necessary
and to support maintenance of such systems
• Lack of processes that would create unambiguous reuse of
clinical measurements. Need consensus standards.
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Terminology
Definitions
Data or information model
Data types and formats
Data interchange standards
• Need for implementation guidance and migration strategies
• The need for a clear value proposition for all stakeholders
• The importance of privacy and security
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The value of measurement
• Theories about heat and entropy evolved after
the development of measuring tools –
thermometers and accurate readings
• The ability to measure the speed of light led to
theories of relativity.
• We cannot model or evaluate what we cannot
measure. When we can measure, we can act.
• Measurement of cholesterol led to
understanding its role in cardiovascular
disease, and resulted in emphasis on diets and
exercise and medications.
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Measurement and Measures
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Key to the creation of knowledge
Key to judgment and evaluation
Key to understanding outcomes
Key to the creation of processes
Key to decision making and action in health care
The evidence of evidence-based ________
• Measurements are the key to health care and
thus to the Electronic Health Record.
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Measurement and measures (data)
• Quantitative data
– Height and weight
– Laboratory data
• Soft data (judgmental)
– Quality of pain
– Rating scale
• Specialized data
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Outcomes
Quality indices
Polls and surveys
Comparative functional imaging
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Characteristics of data
• Data must be timely.
• Persistence and value of data will vary as a
function of site, time and purpose.
• Data must be of high quality. Algorithms
should be used to insure quality in real time.
– Block impossible entries by using gender specific and
age specific filters
– Use previous data, trends, and deltas to question
implausible data
– Use high/low limits to constrain data
• Data must be comprehensive
• Data must be aggregated
• Data must be finely grained for understanding
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Cost of data
• Obtaining data is an arduous and timeconsuming task.
• Manual creation and entry of data into the EHR
is expensive. People like to use data but no one
wants to enter it.
• Entry of data is most preferably done by the
person creating the data. <clinicians, nurses,
technicians, clerks, citizens,…>
• Automated capturing of data is best.
• Data should never be entered more than once.
• Data should be shared for all appropriate
purposes.
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The process of health care
• The fundamental process of health care is to
collect data and use that data for decision
making; then collect more data to evaluate the
results of those decisions.
– The process starts with a query of the patient “What’s
wrong?” or the chief complaint.
– Next is the process of taking a history and doing a
physical exam.
– Next comes tests: laboratory, radiology, pathology,
microbiology, etc.
– Then decisions are made and a treatment is
prescribed.
– Finally the follow-up to determine the results and
effectiveness of the treatment.
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Data Representation
Reference terminology model + term
Knowledge representation
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Creation of Information
Data
Mining
Clinical
Data EHR
Decision
Support
System
Information
Knowledge
Database
Real time use by
all interested
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Defining the Problem
• Health care is not taking full advantage of the
information and communications technologies
that have revolutionized other industries.
• Until clinical data can be reliably, efficiently and
consistently shared and integrated in a manner
that protects patient privacy and security, the
health care system will continue to struggle
with large gaps in the information that is
needed at the bedside, in the office, at home, in
the emergency room and at local and state
public health departments.
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Defining the Need
• Taking full advantage of IT in healthcare means
going beyond “siloed” information systems and
toward creating an information infrastructure that
enables rapid, secure, private, and complete
communication among varying information
systems to meet the needs of patient care.
• The highest goal of an information
infrastructure is to enable the timely and
efficient access to vital health data when and
where its needed to improve the quality, safety
and cost-effectiveness of care and to
strengthen the efforts of consumers, patients,
and caregivers.
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Vision for an Information Infrastructure
• Our view for realizing this high level objective of an
information infrastructure requires the creation of a
dynamic network within health care that allows the
movement of health information that is characterized
by moving only necessary information, when its
needed and to where its needed in a private and
secure manner.
• A cooperative, collaborative relationship between
government, business, academia, providers and
patients is a necessary culture for a system of
“dynamic connectedness”[
• This infrastructure necessitates appropriate
permissioning and authentication standards
throughout its deployment.
[1]
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[
Markle National Security Task Force Report
[2]
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The Culture of Dynamic Connectedness
• All participants in the delivery system have
responsibilities to the data that ultimately center on
the need to provide the best possible care for
patients.
• All stakeholders have responsibilities to protect the
privacy and security of health information.
• All have additional responsibilities to make
appropriate information available when and where
it’s needed for patients and the physicians who treat
them.
• This will require a change in culture, policy and
practice.
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Interoperability
• Interoperability based on common data
standards is a pre-requisite of this kind of a
dynamic network.
• In health care, widespread interoperability
opens the door to extraordinary change in
areas ranging from individual patient safety
during treatment, to population safety from
epidemics, to the everyday chronic and acute
care of millions of citizens.
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Requirements for sharing of data
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Uniquely semantically understandable
Based on common reference information model
Based on common data type
Based on common terminology
• Interchange of data requires data messaging
standard
• May be contained using standard clinical
document architecture
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Standards for Interoperable Health Care
• Movement towards standards will require
effective processes for:
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Standards development
Standards support and maintenance
Integration of standards
Creating the demand for standards at all levels of the
delivery system
– Strategies for compliance and conformance
– Clear and actionable consensus by both the public
and private sectors on the standards to be adopted
– Implementation support (e.g. implementation guides
and other practical tools to assist with migration)
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Benefits
• All stakeholders have much to gain from data
standards adoption and an interoperable health care
system:
– Hospitals will benefit from improvements in quality and
safety driven by a more comprehensive patient record,
reductions in integration costs, and an easing of reporting
burden
– Practicing Clinicians will benefit from access to patient
information across multiple, fragmented components of the
health care system to improve clinical decision-making
– Public Health and National Security will benefit from more
rapid, accurate, cost-effective access to data to support
surveillance, detection, management and response to public
health threats
– Payers will benefit from a more efficient, more effective
method of assessing and facilitating the improvement in
quality of care across populations
– Researchers will benefit from improvements in the quality
and cost-effectiveness of data collection to support analysis
and evaluation
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Benefits (continued)
• Patients and consumers will derive the most value from the
quality, safety, and cost-effectiveness gains that will be achieved
through the use of interoperable health care systems. They will
also benefit from the ability to make portable health care records
more likely and easily achievable.
• Information Technology companies will benefit both from being
able to provide products that easily integrate into existing
infrastructure (and therefore reduce unnecessary costs), and
from providing the marketplace with innovative products that
maximize the potential of health information at the point of care.
• Pharmaceutical companies will benefit from the ability to do
better drug research, reduce costs for data collection and
conduct more real-time monitoring of drug safety and efficacy.
• Government Agencies who deliver health care will benefit by
being able to improve health outcomes, increase patient safety,
improve quality and help achieve optimal use of scarce
resources.
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The Role of the Clinical Community
• The clinical community plays an active role in
efforts to migrate toward an interoperable
health care system if we are to be successful.
• This will require:
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Leadership and commitment
Commitment to organizational change
Investment of resources
Keeping the focus on delivering higher quality, safer
health care
– Engaging in activities related to clinical content and
terminology
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EHR Interoperability Diagram
Enterprise
Data
Warehouse
Patient
Encounter
Research
Database
Billing/Claims
Profile
Profile
Institution
Provider
EHR
Database
Profile
Profile
Profile
Profiles contain business rules
Personal
EHR
Disease
Registry
Longitudinal
EHR
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Download Process
Double
Encryption
Silicon
Encoder
ID
HL7
Message
Identifying Data,
name, address, etc.
Identifying Data,
Translated (e.g. Zip).
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D
Sensitive
Demographic
Data
Encrypted ID
Aggregated
Summary
Longitudinal
EHR
Summary Data
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Policy Requirements at National Level
• Share in the grand vision of informed health
care
• Support <mandate> creation and use of data
standards at the national level including one
integrated terminology.
• Create infrastructure for sharing of data among
all stakeholders.
• Become the enabler sharing decisions,
evaluations, and process with all constituencies
including citizens
• Policy set at national levels; execution at local
levels; coordinate at appropriate points.
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