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Survey of Medical Informatics
CS 493 – Fall 2004
August 30, 2004
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Components of a National Health Information InfrastructureChapter 2: Patient Safety - Achieving a
New Standard of Care.
IOM Report
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Improving Safety
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
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Trends in technology adoption “it takes an average of 17 years” before
research results make into practice.
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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).
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Some examples of LHII
New England Healthcare Electronic Data Interchange Network (NEHEN) A network of providers, health plans and payers
Indiana Network for Patient Care (INPC) 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
75% of healthcare providers in the Santa Barbara County participating in this experiment
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From IOM Report, pg 57
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EHR in clinical practice
17% in US; 58% in UK; 90% in Sweden Lack of incentives in US for change
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Data Acquisition Methods & Interfaces Data Capture
Speech Free text Document imaging Video Structured data Signal data Abstracted data Coded data
Guidelines on UI Usable Grouped Minimalist Standards-based Prioritized Use of graphics and
icons
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Health Care Data Standards
Standardized measures and data elements Datasets for clinical practice Terminologies standards Clinical Concepts and guidelines knowledge
representation standards Identifiers Reference information models Document standards
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Data Repositories
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.
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Clinical Event Monitors 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 AmMed Inform Assoc 10 (2):226–228.
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Data Warehouse
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.
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Data Mining Techniques
Methods to obtain useful information from data warehouses
Data mining is useful for surveillance, case-based reasoning and even rule induction for expert systems
Natural Language Processing can also be applied to extract information from narrative texts
Data Mining Presentation
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NLP and Data Mining
MedLEE – rule-based NLP system http://lucid.cpmc.columbia.edu/medlee/ Dept of Medical Informatics of Columbia
University Medical Language Extraction and Encoding
System
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Clinical Document Architecture XML markup of clinical documents Standardizing structure of clinical documents Ability to handle structured and semi-
structured documents CDA + Standardized terminology can help to
apply clinical decision tools
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Digital Sources of Evidence or Knowledge Bibliographic
MEDLINE: http://medlineplus.gov/ Comprehensive source for medical journal articles maintained
by National Library of Medicine (and other information related OVID: http://www.ovid.com/site/index.jsp
Commercial database supporting medical research: including 1,200 journals, over 160 books and more than 300 databases
Structured evidence: 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
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Digital Sources of Evidence or Knowledge Practice parameters
American Association of Critical Care Nurseshttp://www.aacn.org/
National Guideline Clearinghousehttp://www.guideline.gov/
American Diabetes Associationhttp://www.diabetes.org/home.jsp
National Committee for Quality Assurance (NCQA) – a watchdog group for the managed care industry 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.
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Digital Sources of Evidence or Knowledge DXplain
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
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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.
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
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Digital Sources of Evidence or Knowledge Diabetes Quality Improvement Project (DQIP) Infobutton
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Communication Technologies
Factors Bandwidth Transmission latency Availability Security and
confidentiality Access
Type of communication Physician-physician Physician-patient Patient-patient Mass media
communication Medical Literature
dissemination
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Clinical Information Systems
NHII + EHR
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What is NHII ?
Interoperability Standards
NationalInfrastructure
Evidence-based
Decision
LongitudinalEHR
Population Health
Avoidance of Medical
Errors
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1980 1990 2000
CPRScanned DocsUnstructured TextLimited Discrete DataLimited to single facility
EMRStructured dataTranscribed TextOrders/ResultsEnterprise SystemsIDN
EHRComprehensiveDistributed andFederated.Emphasis on: Evidence-based Medicine Public HealthFunctional: Direct Care Clinical Support Infrastructure
Evolution of the EHR conceptTrends
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Distributed concept
Acute Care Facility
EHR
EHR
EHR
Notes
Images
Structured
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Federation concept
Integrated Delivery Network (IDN)
ACF ACF
Clinics
Long Term Care
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Federation concept
Local Health Information Infrastructure (LHII)Community Area Network
IDN IDN
OtherClinics
LongTermFacilities
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Federation concept
National Health Information Infrastructure
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.
LHII
LHIILHIILHII
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Implementing the systems
IOM-HL7 Demonstration Project
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HIMSS 2003 – Interoperability Demonstration Project CDC FDA Markle Foundation/Connecting for Health
Initiative 19 participating organizations Results
Gaps in interoperability standards Lack of standards to represent ADE
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Davies Award Winners
CPRI-HOST started Now part of HIMSS Recognizes organization for implementing
CPR systems
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Other factors
Organizational leadership Financial incentives Technical assistance Privacy & Confidentiality