emr overview: opportunities, realities and the practice/research divide rockville, md 2009 07 13...

EMR overview:EMR overview:Opportunities, Realities and the Opportunities, Realities and the Practice/Research Divide Practice/Research Divide

Rockville, MDRockville, MD2009 07 132009 07 13

Clement J. McDonald MDClement J. McDonald MDLister Hill National Center for Biomedical CommunicationsLister Hill National Center for Biomedical Communications

National Library of MedicineNational Library of Medicine

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DisclaimerDisclaimer

These remarks are based on my opinion and These remarks are based on my opinion and experience and do not necessarily represent experience and do not necessarily represent an official opinion or position of the National an official opinion or position of the National Library of Medicine or NIHLibrary of Medicine or NIH

20009 06 03 Clem McDonald - Lister Hill Center

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BACKGROUNDBACKGROUND

OPPORTUNITIESOPPORTUNITIES

Where are the opportunitiesWhere are the opportunities

Repositories , EMRs Repositories , EMRs Personal health recordsPersonal health records Networked devices and instrumentsNetworked devices and instruments

Clem McDonald - Lister Hill Center

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REPOSITORIES, EMRSREPOSITORIES, EMRSLOTS OF DATA – MORE LOTS OF DATA – MORE

TO COME TO COME

Current state of world Current state of world

Clinical repositoryClinical repository Everyone has or is close to having themEveryone has or is close to having them If they are only halfway decent - everyone loves If they are only halfway decent - everyone loves

them -doctors and administratorsthem -doctors and administrators EMR (with CPOE +- note entry)EMR (with CPOE +- note entry) Slower uptakeSlower uptake

Takes doctors time – Takes doctors time – Primary care doctors have NO timePrimary care doctors have NO time


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Typical clinical repository content Typical clinical repository content

Any information generated via computer Any information generated via computer systemssystems

ORDERS /PrescriptionsORDERS /Prescriptions Dictation (op notes, visit notes discharge summaries) Dictation (op notes, visit notes discharge summaries) Laboratory resultsLaboratory results Radiology reportsRadiology reports Radiology images Radiology images Endoscopy reportsEndoscopy reports Admission and discharge DX’s =and moreAdmission and discharge DX’s =and more


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EKG flow sheet- click to get the tracingEKG flow sheet- click to get the tracing


Radiology studies- click to get the studyRadiology studies- click to get the study


Radiology images - thumbnail


BIGGER

Clem McDonald

Lister Hill Center NLM

Research usesResearch uses Find numbers and statistics needed to plan Find numbers and statistics needed to plan

studies and write grants. studies and write grants. Help to recruit study patients with providers Help to recruit study patients with providers

consent and involvement- consent and involvement- E.g. Regenstrief Institute, Columbia, HarvardE.g. Regenstrief Institute, Columbia, Harvard

De-identified studies and statistical analysis De-identified studies and statistical analysis (many examples)(many examples)

Provide follow up data for longitudinal studies. Provide follow up data for longitudinal studies. At IU , 80% of human studies used the At IU , 80% of human studies used the

Regenstrief Data during some point of their Regenstrief Data during some point of their evolution. evolution.

Clem McDonald


Huge repositories with much Huge repositories with much research use at many institutions research use at many institutions

Broad spectrum of structured data - billions of Broad spectrum of structured data - billions of data points data points Partners HealthCare (Sean Murphy)Partners HealthCare (Sean Murphy) Regenstrief Institute (Marc Overhage) Regenstrief Institute (Marc Overhage) Kaiser PermanenteKaiser Permanente Veterans Administration Veterans Administration Columbia UniversityColumbia University Mayo ClinicMayo Clinic

Tools available for querying EHRs at Tools available for querying EHRs at many institutions many institutions

They have invested in the hard work of They have invested in the hard work of regularizing / standardizing the data - at many regularizing / standardizing the data - at many levels.levels.


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Clem McDonald


Query itemsPerson who is using tool

Query construction

Results - broken down by number distinct of patients

Harvard-Partner’s Query toolHarvard-Partner’s Query tool

Clem McDonald


Vanderblit’s clinical and Vanderblit’s clinical and specimen search specimen search

Select

•Researcher selects samples

•Researcher executes search using defined parameters

Search requirements specify to return only records with biological samples available over a certain volume amount

Researcher selects most appropriate

records

Keywords in context provide information for evaluating records

Clem McDonald


Regenstrief SPIN tool Regenstrief SPIN tool

What use for drug and alcohol abuse What use for drug and alcohol abuse researchresearch

Care institutions can and do capture info about Care institutions can and do capture info about smoking, do CAGE screening- etcsmoking, do CAGE screening- etc

Should be a part of routine data gathering at intakeShould be a part of routine data gathering at intake Can be the basis of interventions Can be the basis of interventions Treatment center data is never available, by law.Treatment center data is never available, by law. But repositories do carry related data obtained in But repositories do carry related data obtained in

course of routine care- e.g. Ethanol levels. course of routine care- e.g. Ethanol levels. Medications – prescribed during acute careMedications – prescribed during acute care

2009-07-13 Clem McDonald - Lister Hill Center, National Library of Medicine 20

Clem McDonald


RHIOS –the next step –even RHIOS –the next step –even more data, population basedmore data, population based

Examples Examples INPC central Indiana (2 Billion results- (Marc INPC central Indiana (2 Billion results- (Marc

Overhage) Overhage) (McDonald 2006 Health Affairs) (McDonald 2006 Health Affairs)

Memphis – (Marc Frisse -Vanderbilt) Memphis – (Marc Frisse -Vanderbilt) The Ontario Children's network (all test results from The Ontario Children's network (all test results from

all pediatric hospitals made available to all all pediatric hospitals made available to all pediatricians ) Gill Hill pediatricians ) Gill Hill

Massachusetts e-Health project - five practices, Massachusetts e-Health project - five practices, many sites (David Bates) many sites (David Bates)

2007 12 14 Clem McDonald


More RHIOs on the wayMore RHIOs on the way

A national infrastructure, RHIOs and A national infrastructure, RHIOs and standards standards

Big federal push for clinical data and Big federal push for clinical data and message standards message standards

This will facilitate and foster RHIOs (EHIs). This will facilitate and foster RHIOs (EHIs). And they will ink blot across the countryAnd they will ink blot across the country

And permit links between these regional And permit links between these regional networks.networks.

Huge research opportunitiesHuge research opportunities Will return to the subject Will return to the subject


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PERSONAL HEALTH PERSONAL HEALTH RECORDS (PHRS) RECORDS (PHRS)


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PHRs - who is providing them PHRs - who is providing them

Everyone Everyone Google Health Google Health

https://www.google.com/health/html/faq.htmlhttps://www.google.com/health/html/faq.html

My Medicare (and 2 other pilots) My Medicare (and 2 other pilots) http://www.mymedicare.gov/http://www.mymedicare.gov/

Microsoft- HealthVault Microsoft- HealthVault http://www.healthvault.com/http://www.healthvault.com/

Intuit – Quicken Health Intuit – Quicken Health http://quickenhealth.intuit.com/

Many other institutionsMany other institutions

25Clem McDonald , Lister Hill Center, NLM

Special features of PHRs Special features of PHRs

Some connect to home instruments Some connect to home instruments E.g. weight, glucometers, exercise (esp Microsoft)E.g. weight, glucometers, exercise (esp Microsoft) Continua – a consortium of device vendors working on Continua – a consortium of device vendors working on

standards for capturing home instrument datastandards for capturing home instrument data

Many research and treatment opportunitiesMany research and treatment opportunities Collect day-to-day status of patients in research studiesCollect day-to-day status of patients in research studies With patient consent- options for patient recruitmentWith patient consent- options for patient recruitment Rule rules can provide he behavioral interventionRule rules can provide he behavioral intervention Could be the core of a drug treatment record – with patient in Could be the core of a drug treatment record – with patient in

chargecharge

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Some examples of active and Some examples of active and research use – (of PHR Portals) research use – (of PHR Portals)

Active research projects and patient usage Active research projects and patient usage Partners HealthCarePartners HealthCare Children's Hospital of BostonChildren's Hospital of Boston Vanderbilt UniversityVanderbilt University Department of Veterans Affairs Department of Veterans Affairs Kaiser PermanentKaiser Permanent


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NLM’s PHRNLM’s PHR

Overview Overview

Uses NLM’s standard vocabulariesUses NLM’s standard vocabularies LOINC for observationsLOINC for observations Rx.Terms (subset of Rx.Norm) for drugsRx.Terms (subset of Rx.Norm) for drugs SNOMED CT for conditions and findings SNOMED CT for conditions and findings HL7 data types HL7 data types

Links to information sources from NLM Links to information sources from NLM (MedlinePlus, ClinicalTrials.gov), CDC, etc(MedlinePlus, ClinicalTrials.gov), CDC, etc

Open Source Open Source

NLM-PHR Highlights NLM-PHR Highlights

One page data entry form – no jumping around to One page data entry form – no jumping around to complete an entrycomplete an entry

Codes key information - e.g. drugs, problems, etc Codes key information - e.g. drugs, problems, etc One click links to educational info One click links to educational info Rule-based reminders about prevention and healthy Rule-based reminders about prevention and healthy

behavior ( Behavioral interventions)behavior ( Behavioral interventions) Automatic computation of derived values and defaults Automatic computation of derived values and defaults Rule-based form morphing Rule-based form morphing

What shows on the form changes based on what What shows on the form changes based on what is enteredis entered

Gender, female, Pap and mammogramGender, female, Pap and mammogram

Change to male and immediately Change to male and immediately

Discontinue, Revise, Delete to Generate Discontinue, Revise, Delete to Generate Dynamic Accurate Medication Tracking Dynamic Accurate Medication Tracking

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Delete the beclomethazone Delete the beclomethazone (permanently) (permanently)

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Form can morph to ask any set of Form can morph to ask any set of questions- e.g. Phq-9questions- e.g. Phq-9

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Could (will) use exact same method Could (will) use exact same method for NIDA’s abuse screenerfor NIDA’s abuse screener


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NLM PHR Demo NLM PHR Demo

https://phr.nlm.nih.gov/ not yet publicly availablenot yet publicly available


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HOME MONITORING HOME MONITORING DEVICESDEVICES


Opportunities for NIDA treatment Opportunities for NIDA treatment programsprograms

Devices getting cheap – and options for direct Devices getting cheap – and options for direct delivery to PHRs or treatment centers are comingdelivery to PHRs or treatment centers are coming

Conceivable that a package of physiologic measures Conceivable that a package of physiologic measures –pulse, skin conductance, activity level, could –pulse, skin conductance, activity level, could provide info for titering drugs during initial treatmentprovide info for titering drugs during initial treatment

We have an epidemic of methadone related deaths We have an epidemic of methadone related deaths Would continuous O2 monitoring and email alarms to Would continuous O2 monitoring and email alarms to

treatment centers prevent ?treatment centers prevent ?


THE DIVIDETHE DIVIDE


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Different directions in standardsDifferent directions in standards

Clinical world has been using the HL7 message Clinical world has been using the HL7 message standard for 15 yearsstandard for 15 years

Federal government has defined very specific Federal government has defined very specific standards that leverage these existing standards standards that leverage these existing standards HL7 V2.5 and HL7 CDA for messagesHL7 V2.5 and HL7 CDA for messages LOINC and Rx.Norm and SNOMED for codesLOINC and Rx.Norm and SNOMED for codes http://www.himss.org/ASP/topics_FocusDynamic.asp?f

aid=211


HITSPI HITSPI

ONC has $2 billion to push and complete this ONC has $2 billion to push and complete this trend.trend.

Research interest in standards is newish – and Research interest in standards is newish – and mostly going in its own directionmostly going in its own direction


The two worlds have different ways of The two worlds have different ways of thinking about data structuresthinking about data structures

Makes it harder to even talk about the differencesMakes it harder to even talk about the differences Researchers uses a flat data structure (often a spread Researchers uses a flat data structure (often a spread

sheet) where the variables are defined as column sheet) where the variables are defined as column headers. So you see Cholesterol as the a column name headers. So you see Cholesterol as the a column name and a value 210 (below it ) The units are assumed.and a value 210 (below it ) The units are assumed.

Clinical systems use a stacked data structure. So Clinical systems use a stacked data structure. So reading across a row you see Cholesterol within one reading across a row you see Cholesterol within one cell, 170 in another cell and mg/dl in yet another cell. cell, 170 in another cell and mg/dl in yet another cell.


Flat structure Flat structure

Patient ID

Name Surgery date

Hgb DBP # of BPU

Bypass Minute

Cholest

1234-5 Doe Jane 12May95 13 95 3i 80 180

9999-3 Jones T 1Aug95 12.5 88 2 90 230

8888-3 Doe Sam 4June95 16 78 0 80 205


Stacked structure Stacked structure

Pt ID Relevant Date

Observation ID

Value Units Normal Rang

Place Observer

Doe J 12-May-95

Hemoglobin 13 mg/dl 12.5-15 St Francis Dr Smith

Doe J 12-May-95

Hemoglobin 11.5 mg/dl 12.5-15 St Francis Dr Smith

Doe J 12-May-95

Dias BP 95 mm/Hg 80-140 St Francis Dr Smith

Doe J 12-May-95

Dias BP 110 mm/Hg 80-140 St Francis Dr Smith

Doe J 13-May-95

Bypass minutes

80 min St Francis Dr Sleepwell

Doe J 12-May-95

Cholesterol 180 St Francis Dr Bloodbank


Operational Data Base: One Record Per Observation

Research World Uses Flat Structure Research World Uses Flat Structure

When number of variables (questions) is When number of variables (questions) is small , they are easier to manage and small , they are easier to manage and analyze as a flat structureanalyze as a flat structure

But – for longitudinal studies, the changes But – for longitudinal studies, the changes that creep into study protocols generate many that creep into study protocols generate many different flat files that are difficult to integratedifferent flat files that are difficult to integrate Woman’s Health studyWoman’s Health study

Easier to combine data from across studies if Easier to combine data from across studies if stacked structures were used --stacked structures were used --


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Clinical World Uses Stacked Structure Clinical World Uses Stacked Structure

More general structure More general structure Can accommodate the thousands (or tens of Can accommodate the thousands (or tens of

thousands ) of variables thousands ) of variables Allows repeat measures at varying time intervals Allows repeat measures at varying time intervals Allows storage of additional attributes per result Allows storage of additional attributes per result

– like who recorded per variable, normal ranges, – like who recorded per variable, normal ranges, etcetc

Allows rich definitions of variables in a master file Allows rich definitions of variables in a master file tied directly to the variable in the databasetied directly to the variable in the database


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Crux of HL7 V2.xCrux of HL7 V2.x

The messages have a stacked data The messages have a stacked data structure ( structure (

Contain only printable characters (ASCII Contain only printable characters (ASCII text) ––V2.5 and uses delimiters to define text) ––V2.5 and uses delimiters to define the fields and sub fields within its “records” the fields and sub fields within its “records”

Vertical bars (|) separate fields Vertical bars (|) separate fields Hat ( ^ ) separate subfields Hat ( ^ ) separate subfields (There is also an XML version of HL7 V2. (There is also an XML version of HL7 V2.


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Fields have data types.Fields have data types. An espescially important oneAn espescially important one

CWE = CodedCWE = Coded»Code1 ^ print text ^ Code systemCode1 ^ print text ^ Code system


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Here it is Here it is – yellow is variable. Orange is value – yellow is variable. Orange is value


Patient level PID|||0999999^6^M10||TEST^PATIENT^||1992022 5|F||B|4050 SW WAYWARD BLVD |

Order/report level OBR|||H9759-0^REG_LAB|24358-4^Hemogram^LOINC Discrete Results

OBX|2|NM||789- 8^RBC^LOINC||4.9|M/mm3| 4.0-5.4

OBX|3|NM|718-7^HGB^LOINC||12.4|g/dL|12.0 5.0||||F|

OBX|4|NM||20570-8^HCT^LOINC||50|%|35-49|H|||F|

OBX|5|NM||30428-7^MCV^LOINC||81|fL|80-94||||F|b

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Some things to noticeSome things to notice

Most clinical measurements . Test results, survey Most clinical measurements . Test results, survey instruments data can be delivered by this structure or a instruments data can be delivered by this structure or a nested version (supported in HL7)nested version (supported in HL7)

For cross institutional communication need a universal For cross institutional communication need a universal code for the variablescode for the variables

The columns of HL7 are “fixed” so little need to worry The columns of HL7 are “fixed” so little need to worry about individual data base elements.about individual data base elements.

The free LOINC data base is a source for such codesThe free LOINC data base is a source for such codes

As well as form defining packages As well as form defining packages


LOINC Web site – http://loinc.org/LOINC Web site – http://loinc.org/-can download everything-can download everything


Our plea to the research world Our plea to the research world


Look carefully at the coming HTSP standardsLook carefully at the coming HTSP standards If nothing else it will provide some access to most If nothing else it will provide some access to most

of the data in clinical systemsof the data in clinical systems

Use universal codes (LOINC ) for defining Use universal codes (LOINC ) for defining variables variables

Use SNOMED CT for coding variables with Use SNOMED CT for coding variables with categorical values, e.g., anatomic sites, categorical values, e.g., anatomic sites, findings, diagnoses, etcfindings, diagnoses, etc

Use Rx.terms (RX.norm) to identify drugsUse Rx.terms (RX.norm) to identify drugs

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THE END THE END


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emr overview: opportunities, realities and the practice/research divide rockville, md 2009 07 13...

Documents

regenstrief data

emrslots of data

human studies

longitudinal studies

discharge dxs

official opinion

querying ehrs

providers consent