Transcript Medic Alert

HL7-UK 2003
Conference
Healthcare Interoperability
Past Efforts-Present
Benefits-Future Prospects
Clement J. McDonald, M.D.
December 11, 2003
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Work of many Regenstrief faculty
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Mike Barnes, M.D.
Paul Dexter, M.D.
Burke Mamlin, M.D.
Mick Murray, PharmD.
Marc Overhage, M.D., Ph.D.
Susan Perkins, Ph.D.
Gunther Schadow, M.D.
Bill Tierney, M.D.
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Where we were in early 80’s
• Building our own systems to collect data
– Lab
– Pharmacy
– Scheduling system
• Horrible batch and cobbled interfaces to
collect data from other institutions systems
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What to do?
• Impossible except for nutty people
• We needed an easier way
• Standards…
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Plea for standards help
• 1981
• 1983 (Jan.)
• 1983 (Nov.)
• 1984 (Nov.)
1st rejection of grocer’s paper
Grocer paper published 1
Plea for standards at fall
SCAMC meeting 2
A discussion of the draft proposal
for data exchange standards for
clinical laboratory results. 3
(1)
McDonald CJ, Park BH, Blevins L. Grocers, physicians, and electronic data processing. AMA Cont Med Ed Newsletter
1983; 12:5-8.
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McDonald CJ. Standards for the transmission of diagnostic results from laboratory computers to office practice
computers -- an initiative. Proc Annu Symp Comput Appl Med Care 1983; 123-24.
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McDonald CJ, Wiederhold G, Simborg DW. A discussion of the draft proposal for data exchange standards for clinical
laboratory results. Proc Annu Symp Comput Appl Med Care 1984; 406-13.
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1984 SCAMC Fall Symposium
• Panel Members:
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Clement McDonald, M.D.
Gio Wiederhold, Ph.D.
Donald W. Simborg, M.D.
Ed Hammond, Ph.D.
Fredrick R. Jelovsek, M.D.
Ken Schneider, M.D.
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1984 Proposal- Familiar?
FIGURE 1
Patient 1 (general information about patient)
Battery 1 (information about first battery reported/requested)
Result 1 (information about the first result of battery 1)
Result 2 (information about the second result of battery 1)
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Result n (information about the last result of battery 1)
Battery 2 (information about battery 2)
Result 1 (information about the first result of battery 2)
Result 2 (information about the second result of battery 2)
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Result n (information about the last result of battery 2)
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Battery n (information about the last battery for the first patient)
Result 1 (information about the first result of the last battery)
Patient 2 (all of the structure repeats)
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Patient N
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Pleas answered
• 1988
• 1989
• 1990
ASTM 1238-88 4
HL7 published version 2.0 5
SCAMC – Progress, Promises
and the Conductors Wand 6
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Standard Specification for Transferring Clinical Laboratory Data Messages Between Independent Computer Systems. Annual
Book of ASTM Standards; Philadelphia, PA, 1988.
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Health Level Seven, Version 2.0. An application protocol for electronic data exchange in healthcare environments. Ann Arbor,
Michigan: Health Level Seven, 1989.
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McDonald CJ. Standards for the electronic transfer of clinical data: progress, promises, and the conductor's wand. Proc Ann
Symp Comput Appl Med Care. 1990;14:9-14.
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Music & words 1990
• MIDI to orchestra what HL7 is to EMR
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1995-2003
• Messages fairly good
• Could get HL7 result messages working in
1-3 weeks
• Vendors knew the standard
• Most “BAD” messages due to conscious
placement of right info in “wrong” field
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Example bad messages
• Value, units, normal ranges, flags, and
performance site put ALL in OBX-5
• Value and units both jammed into OBX-5
• OBX-5 says “see comment” - everything
jammed into following NTE
• Whole report (many test results) jammed
into single OBX-5
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Life good but not perfect
• Codes for the same question (observation)
different every where
• Need most-Standard question (observation)
codes
– If answer is text- all’s well
– If answer is numeric - all’s well
– If answer is a code (but come with text
representation) – not perfect, OK
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LOINC standard for codes
• First meeting – 1994
– Select group of interested parties
• Mayo medical laboratories
• CORNING MetPath (since merged with SHF to
become Quest)
• University of Washington
• Indiana University/Regenstrief Institute
• University of Utah (Intermountain Healthcare)
• Veterans Administration
• University of Ghent Belgium
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LOINC Actual
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Identifies the observation (OBX3 and OBR4)
The question not the answer
First file distributed April 1995 (6000 terms)
Now 34,000 terms
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Battery structures
Hierarchy
Synonym
Free Mapping and browsing program
• Free for all uses – url: http://www.loinc.org/
McDonald CJ, Huff SM, Suico JG, Hill G, Leavelle D, Aller R, et al.
LOINC, A Universal Standard For Identifying Laboratory Observations:17A
5-Year Update. Clin Chem 49:4; 624-633
Medical Records
Without Standards
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[G]
The present
medical records
with standards
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Wishard the oldest and the
broadest coverage
• Data beginning in 1972
• Since early 80’s
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All laboratory data
All pharmacy (in patient and out)
All dictation
All diagnostic studies ( radiology, cardiac, etc)
Al encounters ( with DX's and procedures etc)
Coded clinical information from largest clinics ( OB and Medicine
and med subspecialty
• Since late 80’s
– All- physician entered orders
• Recently – Inpatient vitals, MD note entry, etc.
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Standards that
support EMRs
Display: courtesy
of HTML and IP
standards
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VISIT INFORMATION From
registration system Courtesy
of HL7
VITAL SIGNS DATA FROM
AUTOMATIC BP- PULSE –
TEMPERATURE
courtesy of HL7
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Chest x-ray 12 bit,
400 x 400 resolution
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Chest x-ray 12 bit,
1024 x 1247 resolution
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Chest x-ray 12 bit,
2048 x 2494 (full) resolution
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Radiology &
images courtesy
DICOM, JPEG,
and JPEG2000
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Trade offs between JPEG and
JPEG2000
• JPEG decodes much faster (5X)
• JPEG Compresses “small” images (e.g. CT
and MRI as well as JPEG200
• JPEG2000 compresses large films (chest
x-rays) (2000 x 2700) 12 bit depth by 5 x
better
• Use JPEG for “small” CT and MRI images
and JPEG 2000 for large plain films.
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Echo reports
courtesy of HL7
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• Echo images Courtesy
of Motion JPEG
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Scanned images
•Courtesy of TIFF
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Telemedicine Courtesy of:
•H232
•IPSEC
•MPEG 1
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IT is ALL in the Standards
HL7
(most)
•DICOM (to capture uncompressed images from PACS
•NCDP (Prescriptions from outpatient pharmacy
•JPEG , JPEG 2000 for storing clinical images in Clinical
Repository
•IP (Everywhere)
•JPEG, MPEG 1
•Code Standards Currently Used:
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CPT
ICD
LOINC
CDO-3
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Guard Rails
• Improve preventive care from 30% to 400%
over control state (1)
• Improve drug dosing and reduce errors in
drug prescribing
• Increase required corollary orders 5%-64%
(e.g. test Vancomycin levels when giving
Vancomycin)
1. McDonald CJ, Hui SL, Smith DM, Tierney WM, Cohen SJ, Weinberger M. Reminders to physicians from
an introspective computer medical record. Annals of Internal Medicine 1984; 100:130-138.
2. Overhage JM, Tierney WM, Zhou XH, McDonald CJ. A Randomized Trial of “Corollary Orders” to Prevent
Errors of Omission. JAMIA 1997;4:364-375.
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Percent Response
Preventive Reminders
Control
Study
McDonald, et al. Reminders to Physicians from an Introspective Computer Medical Record.
Annals of Internal Medicine, 1984;100:130-138.
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[RG]
Physician Order
entry- (POE)
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Computer based POE
Gopher order entry
• Were first to succeed with order entry
– 20 million orders at Wishard since 1986
• POE provides better options for delivering
influencing patient care
• Even non fixed (not patient specific)
content can have an effect
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Gopher physician Users
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Cost Savings
CHF example
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Preventive POE inpatient POE
reminders 2001
(Dexter et al.)
60%
51%
50%
40%
36%
36%
32%
27%
30%
19%
reminders
control
20%
10%
0.80%
1%
0%
pnevx
flu shot
SQ Hep
ASA
Dexter PR, Perkins S, Overhage JM et al. A Computerized Reminder System to Increase the Use of
Preventive Care for Hospitalized Patients. N Engl J Med 2001;345:965-970.
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City Wide RMRS Functions
• CARE deliver clinical information when
needed for emergency care (NLM
supported study)
• Public health seek out reportable conditions
from laboratory data evidence, equivalence
duplicate cases, organize and deliver to
public health
• Research molecular biologic epidemiology
through Pathology samples ( National
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Cancer institute
Whole city
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About 1.3 million people
Five hospital systems and their clinical facilities
Fourteen separate hospital facilities
All four homeless care clinics
450 K emergency room visits per year
State and county public health
Three uses of community data repository
– Direct patient care
– Public health
– Research
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County Health Department
Quest
State Board of Health
LabCorp
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INPC all 5 city institutions
# HL7 message streams
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# NCPDP streams
#DICOM streams
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# rows/observations stored
2 (Agfa PACs, GE PACs)
436 million
# text reports stored
11, million
# CPOE orders stored
22 million (est)
# radiology images stored
Studies= 1 million
images=50 million (est)
480 thousand
# EKG tracings stored
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Clinical use
• At Wishard and Clarian total of
2.5 million accesses per month
by more than 4000 different clinical users
• Emergency Department physicians can look at
records from all institution as one merged
record when patients present at the Emergency
department
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Monthly volumes
# HL7 messages per month
5,491,882
# OBX results per month
5,803,541 + ___
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Uses in public health (all based on
HL7 messages)
• Automatically scan HL7 lab messages for
reportable disease
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Look at test code
Look at normal flag *
Look at result
Send those that =>reportable condition
• Faster by 8 days, more complete by 2 fold
• Immunization reporting
• Tumor registry
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Reportable disease example
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Outcomes
• Reliable
– Real time delivery
– 100%received (for participants)
• Reporting completeness (capture/recapture)
– Found nearly twice as many cases from the index
hospitals as found by the usual methods
• Reporting timeliness (versus result date)
– 8.4±15.4 days faster than HD – case finding
– 1.4±2.0 days faster than hospital case finding
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INPC Use in research
• Help in writing and planning grant
applications
– How many patients of a given kind are
available in the database
– What are their characteristics
• Help in recruiting patients to clinical trials
(see next slide)
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Use in research – grist for
epidemiologic studies
• Mahon BE, Rosenman MB, Kleiman MB.
• Maternal and infant use of erythromycin
and other macrolide antibiotics as risk
Factors for infantile hypertrophic pyloric
stenosis.
J Pediatr. 2001 Sep;139(3):380-4.
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Research – Shared Pathology
Informatics Network (SPIN)
• Pathology departments store tissue as paraffin
blocks for 10-15 years
• Protein, DNA and even MRNA can be identified
in these specimens
• Clinical repository can identify cancer patients
with specific characteristics
– E.g. short and long survivors of small cell lung cancer
• Can get from the record to pathology report and
the tissue blocks to answer biologic questions
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Research SPIN
• Auto coding of pathology reports
• Free text searching of pathology reports
• Peer-to-peer links between many nodes
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Boston
Pittsburgh
UCLA
All hospitals in Indianapolis
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Future
• Don’t think we will see monoliths every where.
Rather, message coupled systems
• For every system pushed into monolith 1-2 new
ones pop up at our institution.
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Prosolve cardiac echo
Witt cath lab system
_____Endoscopy system
Otter transplant system
______ ICU system
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Future
• Strong common/replicated master files
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Patient master ( Easy in GB)
Provider master ( may be described in dec 03)
Orderables master
Result master
Geographic location master
Printer locations
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Evidence based coding
• Selected structured data collection
• Hopefully – evidence based
• We need to find out which variables are
predictive or decisive
– Stiels Ottawa Ankle Rule
• Narrative continues to reign
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Leap in amount of non-structured
non text data
• Digital voice
– Speech understanding ( has to be successful
some time.
• Photos
• Video – record the whole encounter
(Charlie Safran)
• Scanned documents (To get totally
electronic record )
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Predictions
• Preempt disease rather than perfect
desperation care
– Empty the hospitals
– A major disease, e.g diabetes will be cured
• Community-based clinical systems
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Wireless- everybody, everywhere to
everyplace - (WEEE)
• Clinical data and info services as available as the
air
– Real time alerts and updates to Provider carried
systems
– Hi-grade video conferencing between provider and
patient.
• More care in lower acuity settings, Home health care replaces
other forms if more care shifted to lower acuity settings
– Wireless patient monitoring direct to provider systems
– Image reading (radiology, pathology) from afar
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Evidence based coding
• Hopefully – evidence based data collection
• First determine which variables are
predictive or decisive in guidelines
• Stiels Ottawa Ankle Rule
• Miles to go before mostly coding
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Leap in amount of non-structural
data
• Digital voice
– Speech
• Photo and video – record the whole
encounter (Charlie Safran)
• Scanned data
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Some
Observations
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The Keyboard Lives
• For order entry and note writing is the
fastest entry mechanism available
– Faster than mousing
– Faster than hand writing recognition
– Faster than thumb typing (but it is faster than
hand writing recognition
• All new MDs can type.
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Paper lives
• Input: you can’t avoid scanning
documents if you want a complete
record
• Output: 1 trillion laser printed pages n
2001, printer vendors predict 6 trillion
pages in 2006
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Paper lives
• Paper generated by computer may be with us
forever
• Paper is Light weight and portable
• Extra-ordinary resolution
– Best UXGA 1600x1200
– Page (@ 2400 dpi) 18,000 x 24,000
• Printers getting cheaper and better all of the time
• Easy to annotate
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The prefect PDA or “carried
computer” not here yet
• Screen too small
• Lacks a keyboard – the king of input
• Most clinical applications need wireless
connection
• But battery life too short (or box too big
when battery adequate )
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Our wireless invention:
The Popcorn Man’s “PDA”
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[RRInput]
Radio Link
Tablet Computers
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Tomorrows Cyborg wireless
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Ski mask wearable computer
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Cool wearable computer
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