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 X12 – Administrative/Financial HL7 – Clinical Data DICOM – Medical Images NCPDP – Prescription Data MIB – Medical device data

Coding/Terminologies ICD, CPT, SNOMED, LOINC

Knowledge Representations

Recommendation 4

Federal Government to encourage acceleration and adoption of standards in: Clinical Data Interchange

Eg. HL7 CDA Clinical Terminologies

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

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

Develop tools 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

The Provider's Workstation

“Data” Integration

The Clinical Applications

Server

Server

ServerVisual

Integration

* Acknowledgement: Slide provided by Wes Rishel, Gartner Group

The Provider

The Reference Information Model

Act – something happened or may happen. Any action of interest.Entity – a person, animal or organization or thingRole – a part played by an entityParticipation – the involvement of a role in a actAct_Relationship – a relationship between two actsRole_Link – a relationship between two Roles

Healthcare StandardsTechnology solutions

Sample CDA Document

HL7 EHR Functional Model*

Care ManagementII7.0 Workflow

Ops Mgt & CommCare Management

II6.0 Business Rules - Administrative Functions

II5.0 Interoperability

Ops Mgt & CommCare Management

II4.0 Support for Health Informatics & Terminology Standards

II3.0 Unique Identity, Registry, and Directory

Ops Mgt & CommCare Management

DC3.0 Ops Mgt & Comm

DC1.0 Care Management

S3.0 Admin & Financial

S2.0 Measurement, Analysis,Research, Reporting

S1.0 Clinical Support

Direct

Care

Direct

Care

Su

pp

ortive

Su

pp

ortive

Info

rmatio

nIn

frastructu

reIn

form

ation

Infrastru

cture

DC2.0 Clinical DecisionSupport

Ops Mgt & CommCare Management

II2.0 Information and Records Management

II1.0 Security

* 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

Figure Source Material: Oliver Bodenreider: “The Unified MedicalLanguage System (UMLS) integrating biomedical terminologies,” Nucleic AcidsResearch, 2004, Vol. 32, Database issue D267-D270

National CenterFor BiotechnologyInformation

Online MendelianInheritance in Man

University of WashingtonDigitalAnatomist

Gene Ontology

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.fcgi?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