Clinical Information Systems I

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Clinical Information Systems I

• NLM Medical Informatics Course
• Woods Hole, MA
• June 3, 2009

W. Ed Hammond, Ph.D., FACMI, FAIMBEProfessor
Emeritus, Duke UniversityChair, Health Level
Seven
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Clinical Information System

• Computer-based system that is designed for
  collecting, storing, manipulating, and making
  available clinical information for healthcare
  delivery process.
• May be limited to a single area (laboratory
  system, pharmacy system, imaging system, etc.) or
  they may be widespread and include virtually all
  aspects of clinical records (e.g. electronic
  medical records)
• Provide a clinical data repository that stores
  clinical data such as patients history of
  illness and interactions with care providers.
• Includes service functions such as Hospital
  Information Systems (HIS), functional systems
  (ADT, scheduling), departmental systems (LIS,
  RIS, PIS), Computerized Physician Order Entry
  systems (CPOE), ePrescribing systems

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HIT Stimulus target

• Inclusion of 36.5 b to create nationwide network
  of EHRs
• Can HIT improve health and health care?
• Can HIT save 77.8 b each year through universal
  use of HIT?
• What enables this dream?
• What is meaningful use of EHR?
• What are the components?

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Why is HIT a high priority?

• Patient safety
• Increased concerns related to safety of
  prescription drugs
• New emphasis on eliminating Healthcare Affiliated
  Infections
• Demand for quality pay related to performance
  and outcomes
• Cost containment in face of increasing costs of
  healthcare
• Efficient and effective health care delivery a
  must
• Health surveillance, biodefense and natural
  disaster increased mandatory reporting
  requirements
• Accommodating an aging and mobile population
• Effective management of chronic disease
• Equal access to care - uninsured
• Consumer sophistication and knowledge in health
  mobility
• Increasing importance of multiple uses of data
  translational medicine
• Movement from illness care to wellness care
• Practice of medicine that is predictive,
  personalized and pre-emptive

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Why is HIT a high priority?

• Resources are becoming limited
• Decreasing number of providers
• Smaller hospitals disappearing
• Long waits for appointments
• Few walk-in appointments available
• Changing models for healthcare
• Consumer driven health care
• Health savings accounts
• Shopping mall clinics, Doc in Box clinics
• Wal-Mart, Google and Microsoft movement into
  healthcare
• Changes in doctors information gathering skills
• Increase in options for testing and treatment
• Limited connectivity among providers with
  multiple providers involved in care
• The Healthcare Gamble who calls the play?

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Why is HIT a high priority?

• Volume of data about a patient has increased
  tremendously over the past decades
• Increasing number of diagnostic tests
• Increasing numbers and modality of images
• Genetic testing
• Access to data at place and time of decision
  making is critical
• Informed decision requires data
• Reusable data is a must
• From bytes to kilobytes to megabytes to gigabytes
  to terabytes to

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Why is HIT a high priority?

• Sources and amount of knowledge have increased
  exponentially over the past decades
• Amount of new knowledge introduced each year
  would take more than 200 years to assimilate into
  ones practice reading and understanding two
  papers each night
• Undergraduate and graduate education is based on
  out of date concepts
• Continuing medical education is inadequate
• We cant learn fast enough to be effective
• New knowledge requires new skills and new
  understanding
• Current model is evidence-based medicine, so we
  need evidence

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In the past

• Patients went to their doctors only when they
  were sick.
• Patients were not permitted to see their own
  records, and most did not want to.
• Doctors thought patients were not able to
  understand their diseases or treatments, which
  were often not even revealed to the patient.
• Doctors made all the decisions, usually not
  sharing options for treatment.

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Now

• Focus is changing from illness care to wellness,
  prevention, and preemptive care
• Patient has access to record by law
• Patient involved in decision-making about
  treatment
• Google and Internet source of knowledge
• Patients arrive at doctors office with stack of
  paper
• TV commercials suggest drugs and say ask your
  provider encouraging consumerism
• Personal Health Records are becoming more common

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A Bit of History

• After almost 50 years of development of the
  electronic medical record, we seem to be
  struggling with many of the same problems today.
• During that same period, technology has made
  unbelievable progress new drugs, new
  treatments, new tests, communication satellites
  with almost instant world communication,
  transportation advances with rapid and easy world
  travel, creation of a global community.
• Applications in healthcare have not kept pace
  with the technology.

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What have we missed?

• We have designed a system that mimics the paper
  based system we have not taken advantage of
  technology we have not stated or understood the
  problems we want to solve.
• We have yet to answer the simple question What
  is the purpose of the Electronic Health Record,
  and how can it most effectively be used?
• Legacy is overpowering. We are dominated by the
  past we have not been bold enough to tempt the
  marketplace with new vision.

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A meaningful use vision

• A ubiquitous infrastructure that permits the
  creation of an Electronic Health Record in which
  all relevant data about an individual is
  aggregated across regional, state and national
  boundaries.
• This EHR serves all sites, views, presentations
  and purposes relating to health and health care.
• With a single data entry, the EHR meets all data
  reporting requirements as well as health care.
  Its every thing for every body.
• The EHR becomes an active partner, not just a
  passive data repository.

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A meaningful use vision

• Comprehensive data for patient care
• Integrates data with knowledge for cognitive
  support of both providers and patients
• Accommodate heterogeneity of many sites of care
• Empower persons to become involved in the
  healthcare
• Provide operational value through aggressive
  interaction with patient and provider
• The vision depends on understanding what problems
  you are trying to solve at the moment and at that
  location.

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CIS is about

• Data and data management
• The right data and only the right data
• Complete, aggregated, timely, trustworthy,
  unambiguous, reusable, logically accessible
• Event driven displays, logically driven
• Knowledge and knowledge management
• Evidence-based, up-to-date, appropriate,
  integrated into work flow, human and computer
  useable
• Processes and work flow
• Effectively and efficiently combines data with
  knowledge to enable optimum human decision-making
• Monitor decisions and outcomes and provide safety
  checks, feedback and recommendations
• Integrate data collection, presentation and
  decision support transparently into care delivery
  process

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Value

• Data is reusable provides value for multiple
  secondary uses
• Analysis of patient conditions, treatments,
  outcomes, demographics and environment produce
  new knowledge that is automatically fed back into
  the care process.
• Models of care are produced that permit
  projections for improved outcomes, reduced costs,
  higher quality.

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Intensive Care
Primary Care
Inpatient
What is common and what is different among these
sites of care? How do we effectively put this
package together?
Electronic HealthRecord
Specialist Care
Centralized vsFederated
Home Health
Emergency Care
Nursing Home(LTC)
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The Current EHR

• Fragmented patient records
• Incomplete and unreliable data
• Record is unstructured location of data varies
  across records
• Poor user interfaces and inadequate data capture
• Passive participant in care process
• Data recorded after the fact
• Data storage reflects particular application and
  cannot easily be used independently
• Retrieval similar to paper record
  responsibility is on user to find critical data.
  The needle remains hidden in the hay stack!

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The Electronic Health Record

• Architecture designed for fast and varied
  retrieval and presentation independent of
  collection modality anticipates query
• Purpose is to enhance and enable the care of the
  individual reusability of data is also a goal
• Content focused on informational value contains
  only data contributing to current and future
  health of person store only what varies with
  patient data warehouse satisfies complete and
  permanent storage for legal, other purposes
• Structured for unambiguous clarity, understanding
  and interoperability
• Support common core throughout varied sites of
  care
• Patient-centric one person, one EHR
• Rich in functionality varies with site
• Includes workflow and process management

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So the EHRS must

• Support multiple clinical domains and therapeutic
  areas
• Contain imbedded Decision Support
• Filter and screen superfluous data present data
  appropriate for circumstances
• Support both push and pull data interchange
• Provide data that is reusable
• Enhance belief of data integrity, sound decision
  support, competent workflow management, and
  provide adequate privacy and security
• Become a part of the patient care team and
  provide data and give advice supported by
  literature when and where appropriate

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What we must have

• Architecture of EHR that can support a variety of
  users and uses.
• Requires independence of data from application
  set
• Data must be interoperable it must be
  automatically reusable it must be capable of
  integrating with new data to produce new value
  and understanding.
• Granularity of data must start at lowest levels
  to permit effective computer analyses and
  understanding
• Reevaluate patient care and treatment as new data
  enters incorporating old data

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And more

• Effective and timely disease management with a
  personalized approach
• Knowledge driven filters for presentation and
  exchange of data
• Proactive recommendation of actions for both
  providers and patients
• Determine factors that impact health including
  social, economic, and environmental situation.
  Focus on reducing impact of negative factors.
• Influence the way providers practice medicine it
  must change.

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Structured Data Storage

• Demographics (including living situation,
  occupation, )
• Summary Problem List
• Procedures
• Studies (laboratory, radiology, diagnostic tests,
  )
• Therapies (prescription drugs, immunizations,
  blood products, alternative medicines,
  over-the-counter drugs, )
• Allergies, adverse events, drug reactions
• Subjective Physical Findings (history, physical
  exam)
• Encounter (place, date_time, providers, problems,
  procedures, studies, therapies, SP, supplies,
  disposition)
• Providers involved in care
• Scheduling
• Protocols and disease management, trigger event
  flags
• Patient education record

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A Mistake to Avoid
Too much is worse than none!
MOREDATA
MORE INFORMATION
?
Solution requires intelligent filtering of data
rule-based data interchange
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EHR

• Demographics
• Why important?
• Includes demographics, living environment,
  occupation, family history, preferences, quality
  and nature of life, stress and pain, geocoding
• Clinical Data
• Why important and what content?
• Includes laboratory tests, diagnostic tests,
  diagnostic images, subjective and physical
  findings, diseases, behavior

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EHR

• Treatments
• Why important?
• Understand why choices made define expected
  results
• Outcomes
• Why important?
• Feed back to influence treatment and enhance
  knowledge and understanding of disease and
  related factors
• The EHR must contain everything anyone might need
  as part of the healthcare process.

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Functional Components for CIS
Decision Support
Reports
ExternalSystems
PlanningPhase
Data
Transfer
Store
Presen-tation
Collection
EHR Functions
Data Exchange
Billing
What is required to provide the interoperable
connectivity?
Query
A suite of standards!
Other Systems
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How do we know what we want?

• Start with defining use cases, story boards or
  scenarios in order to understand actors,
  interactions, required data elements, data flow,
  trigger events, work flow, and decision support
  required.
• Use cases are created by many groups including
  HITSP, HL7, IHE, CDISC, caBIG, VA, DOD, FDA, CDC,
  
• Package as Domain Analysis Model

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Establish a common base

• Start with a common Reference Information Model
  on which all data items, entities, acts, roles
  and relationships are defined. ISO/HL7 RIM is a
  global standard. CEN 13606
• Data models BRIDG, CDISC, caBIG

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Data elements

• Fundamental component for data interchange
• Key attributes include
• Unique persistent identifier code ISO OIDs,
  UMLS, other ?
• Precise definition validated by domain experts
• Single terminology assigned to data element
  derived from controlled vocabulary
• Data types (HL7/CEN/ISO)
• Standard units (ISO/HL7)
• Classifications
• Defined value set
• Synonyms
• Other attributes
• Centrally maintained globally distributed free
  to users dynamically maintained appropriate
  tools
• ISO 11179 underlying standard

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The Terminology Dilemma

• SNOMED CT (clinical terminology)
• LOINC (laboratory tests)
• RxNorm (orderable clinical drug codes and
  formulations, mapped in UMLS)
• Structured Product Labeling dosing, potential
  interactions, etc.
• VA NDF-RT (therapeutic classification,
  components, mechanism of action, physiologic
  effect, diseases treated)
• FDA terminology sets (dosage form, packaging,
  routes, application methods)
• MedDRA adverse events
• ICD-9 or ICD-10 for reimbursement and clinical
• CPT procedures
• ICPC primary care
• MEDCIN clinical terminology
• IEEE medical devices
• Local terminologies
• Over 200 different terminologies to choose from.

Mapping is a workable solution but costs extra,
is never synchronized, and loses information.
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An approach to semantic interoperability
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Compound data elements

• Attributes similar to data elements
• Examples include blood pressure, heart murmur,
  titers
• Expressed as
• Templates (HL7)
• Archetypes (openEHR)
• Common Message Element Type (CMET)
• Use XML syntax
• Clinical Example
• Blood Pressure
• Systolic
• Diastolic
• Arm
• Position of patient
• Cuff size

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Complex data elements

• Attributes similar to data elements
• Examples include drug sensitivity, microbiology
  results, body mass index, pulmonary functional
  tests
• Administrative such as name, address, telephone
• Extended into data groupings
• patient admit profile
• TB screen
• Well-baby workup
• Clinical trial component
• Trigger-driven data transport profiles
• Data required when a patient is transferred from
  hospital to nursing home
• Disease Management Profiles

34
Document standards

• Clinical Statements
• Clinical Document Architecture (CDA)
• Radiology reports
• Patient summary
• Discharge summary
• Referrals
• Claims attachments
• Infectious Disease Reports
• Continuity of Care Document (CCD)
• Structured Documents

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ltsectiongt ltcode code"101155-0"
codeSystem"2.16.840.1.113883.6.1"
codeSystemName"LOINC"/gt lttitlegtAllergies and
Adverse Reactionslt/titlegt lttextgt ltlistgt
ltitemgtltcontent ID"A1"gtPenicillin -
Hiveslt/contentgtlt/itemgt ltitemgtAspirin -
Wheezinglt/itemgt ltitemgtCodeine - Itching and
nausealt/itemgt lt/listgt lt/textgt ltentrygt
ltobservation classCode"OBS" moodCode"EVN"gt
ltcode code"247472004" codeSystem"2.16.840.1.113
883.6.96" codeSystemName"SNOMED CT"
displayName"HIves"gt ltoriginalTextgtltrefere
nce value"A1"/gtlt/originalTextgt lt/codegt
ltentryRelationship typeCode"MFST"gt
ltobservation classCode"OBS" moodCode"EVN"gt
ltcode code"91936005" codeSystem"2.16.840.1.
113883.6.96" codeSystemName"SNOMED
CT" displayName"Allergy to
penicillin"/gt lt/observationgt
lt/entryRelationshipgt lt/observationgt
lt/entrygt lt/sectiongt
CDA R2
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Continuity of Care Document (CCD)
ltResultsgt ltResultgt ltCCRDataObjectIDgt
2.16.840.1.113883.19.1 lt/CCRDataObjectIDgt
ltDateTimegt ltTypegt ltTextgtAssessment
Timelt/Textgt lt/Typegt ltExactDateTimegt
200004071430 lt/ExactDateTimegt
lt/DateTimegt ltTypegt ltTextgtHematologylt/Tex
tgt lt/Typegt ltDescriptiongt ltTextgtCBC
WO DIFFERENTIALlt/Textgt ltCodegt
ltValuegt43789009lt/Valuegt
ltCodingSystemgtSNOMED CTlt/CodingSystemgt
lt/Codegt lt/Descriptiongt ltStatusgtltTextgtFinal
Resultslt/Textgtlt/Statusgt
ltsectiongt ltcode code"30954-2
codeSystem"2.16.840.1.113883.6.1"
codeSystemName"LOINC"/gt lttitlegtLaboratory
resultslt/titlegt lttextgt CBC (04/07/2000)
HGB 13.2 WBC 6.7 PLT 123 lt/textgt ltentrygt
ltobservation classCode"OBS" moodCode"EVN"gt
ltid root"2.16.840.1.113883.19"
extension"1"/gt ltcode code"43789009"
codeSystem"2.16.840.1.113883.6.96"
codeSystemName"SNOMED CT"
displayName"CBC WO DIFFERENTIAL"/gt
ltstatusCode code"completed"/gt
lteffectiveTime value"200004071430"/gt
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Communications standards

• W3C, OMG, OASIS, IETF, HL7 others
• Include XML,TCP/IP, HTTP, Web services, SOAP,
  CCOW
• Supported by schemas, XSL, OCL, OWL, GIS
• Web services Web 2.0, Web 3.0
• WIFI standards
• RFID standards GS1

38
Data transport standards

• HL7 V2 and V3 for data and document transport
• DICOM for imaging
• HL7, NCPDP for prescription and related data
• HL7, X12N for claims data
• IEEE for medical device, sensors
• OASIS for business data
• IHE XDS
• Document standards (CDA, CCR, CCD)

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HL7 v2.x Syntax
MSH\REGADTMCMIFENG199112311501ADTA04A
DT_A01000001P2.4 EVNA04199901101500199901
10140001199901101410 PID191919GENHOSMR37
1-66-9256USSSASS 253763MASSIEJAMESA19560
129M171 ZOBERLEINISHPEMINGMI49849"" (9
00)485-5344(900)485-5344SHL70002CHL700061
0199925GENHOSAN 371-66-9256 NK11MASSIEEL
LENSPOUSEHL70063171 ZOBERLEINISHPEMINGMI49
849"" [phone](900)545-1234(900)545-1200
EC1FIRST EMERGENCY CONTACTHL70131 NK12123
Industry WayShepemingMI49849(900)545-1200
EMEMPLOYERHL7013119940605PROGRAMMERACME
SOFTWARE COMPANY PV1OO/R0148ADDISON,JAMES
0148ADDISON,JAMESAMB 0148ADDISON,JAMES
S1400AGENHOS199501101410
PV2199901101400
199901101400 ROLADCPHL704430148ADDISON,JAME
S OBXNM3141-9BODY WEIGHTLN62kgF OBX
NM3137-7HEIGHTLN190cmF DG11190815B
IOPSYACODE00 GT11MASSIEJAMES""""""""
171 ZOBERLEINISHPEMINGMI49849"" (900)485-5
344(900)485-5344SESELFHL70063371-66-925
MOOSES AUTO CLINIC 171 ZOBERLEINISHPEMINGMI4
9849""[phone] IN100HL70072BC1BLUE
CROSS171 ZOBERLEINISHPEMINGM149849"" (900)
485-53449050 OK
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Model-based Development
HL7 Framework
HL7 Specification
RIMDatatypesData elementsVocabularyTemplatesC
linical Statements

• V3 Messaging
• CDA Specifications
• System Oriented Architecture

Core Structured Content
40
41
Message instance
lt?xml version"1.0"?gt lt!DOCTYPE Ballt SYSTEM
"Ballot_C00_RIM_0092Da_1.dtd" gt ltBalltgt
ltdttm V"1999120523570100"/gt ltvote V"A"
S"HL7001" R"3.0" PN"Abstain"/gt
ltvotesOn_PropsdItmgt ltstandrdLevlInd
V'T'/gt ltpropsdBy_OrgnztnAsCommttegt
ltnm V"Humble Task Group"/gt
ltisAsubdvsnOf_OrgnztnAsCommttegt ltnm
V"Grand Committee"/gt lt/isAsubdvsnOf_Orgn
ztnAsCommttegt ltpartcpesAsPrimryIn_Stkhldr
Affltngt lt_StkhldrAffltngt
lttype V"X" S"HL7004" R"3.0" PN"XXX"/gt
lthasSecndryPartcpnt_PrsnAsCommtteContctgt
lthas_PrsnNamegt
ltpnmgt ltG V"George"
CLAS"R"/gt ltG V"Woody"
CLAS"C"/gt ltG V"W."
CLAS"R I"/gt ltF
V"Beeler" CLAS"R"/gt
lt/pnmgt lt/has_PrsnNamegt
lt/hasSecndryPartcpnt_PrsnAsCommtteContctgt
lt/_StkhldrAffltngt
lt/partcpesAsPrimryIn_StkhldrAffltngt
lt/propsdBy_OrgnztnAsCommttegt
lt/votesOn_PropsdItmgt
ltcastBy_VotngMembr T"OrgnztnlReprsntv"gt
ltOrgnztnlReprsntvgt ltisRoleOf_PrsnAsVotrgt
lthas_PrsnNamegt ltpnmgt
ltG V"George" CLAS"R"/gt
ltG V"W." CLAS"R I"/gt
ltF V"Beeler" CLAS"R"/gt lt/pnmgt
lt/has_PrsnNamegt
lthas_PrsnNamegt ltpnmgt
ltG V"Woody" CLAS"C"/gt ltG
V"W." CLAS"R I"/gt ltF
V"Beeler" CLAS"R"/gt lt/pnmgt
lt/has_PrsnNamegt lt/isRoleOf_PrsnAsVo
trgt ltsponsrdBy_OrgnztnAsHL7Membrgt
ltnm V"Mayo Clinic"/gt
ltemailAddrssTxt vhl7_at_mayo.edu/gt
lt/sponsrdBy_OrgnztnAsHL7Membrgt
lt/OrgnztnlReprsntvgt lt/castBy_VotngMembrgt lt/Ball
tgt
Source W. Beeler
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Decision support

• Knowledge reference framework and knowledge
  representation
• Arden Syntax, Protégé, PRODIGY, vEMR, GELLO
• Clinical Guidelines
• Guideline Interchange Format (GLIF) HL7
• Guideline Elements Model (GEM) ASTM
• Disease Management Protocols
• Evidence-based Care Plans
• Infobutton HL7

43
EHR standards

• Functional Requirements
• HL7 Draft Standard for Trial Use -2004
• Site variation functional profiles
• Content standards
• Structure/architecture
• Screens/presentation/icons
• Document Registration, IDs, and Naming

44
Medical and personal health devices

• Interface standards for medical devices
• Cable connected
• Infrared
• Wireless
• Simple to sophisticated devices
• Sensors
• Terminology
• Safety
• Integration of SDOs IEEE,CEN,DICOM, HL7, ISO

45
Identifiers

• Provider identifier
• National Provider Identifier HIPAA
• Facility Identifier
• Employer Identifier
• IRS tax identifier
• Person Identifier
• Debate Unique identifier vs identifying
  parameters
• Master Patient Index (local, regional, national)
• Record Locator Service

46
Supporting standards

• Implementation manuals (HITSP, HL7)
• Standard developers
• System designers
• Implementers
• Users
• Service-oriented architecture (HL7/OMG)
• CCOW
• Tool sets (HL7)
• Data element/terminology servers
• Transitional tools
• Message/document creators

47
Application profiles

• Integration profiles (IHE)
• End to end information flow
• Defined domain by domain
• Includes concepts of persistent objects
• Examples
• Integrating the Healthcare Environment IHE
• EHRVA Roadmap
• ELINCS
• CHI

48
Security/privacy Interoperability

• Security, Privacy and Confidentiality
• Authentication
• Authorization
• Role Based Access
• Access logs
• Audit Control
• Digital signature
• PKI
• Integrity
• Non-repudiation
• Encryption
• De-identification standards
• Probability of risk vs value
• ISO, CEN, HL7, others outside of health care

49
Privacy

• No person should be harmed by the release of
  health-related data
• No person should be denied proper treatment as a
  result of privacy concerns
• Unique personal identifiers do not mean privacy
  is invaded may be the opposite.
• There is a social responsibility to share data.

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Arden Syntax GELLO GLIF GEM Info buttons
ISO, CEN, HL7, IHE, CDISC, DICOM, IEEE, IHTSDO,
openEHR, IHE, LOINC, WHO/ICD,
Decision Support
TODAY
PlanningPhase
Data
Transfer
Store
Collection
ElectronicHealthRecord
Story boards Use cases RIM MDF DAM BRIDG SOA
Data Elements Data types Units CMETS Templates Ar
chetypes Templates Clinical Statements CDA CDD CT
S CDASH
XFORM Templates CDA Medical Devices
HL7 v2 HL7 v3 CEN 13606 XDS IEEE DICOM
CEN 13606 ISO
EHR FM PHR FM CCOW Genomics ISO
Identifiers
Profiles
Privacy and Security Standards
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Multiple Views of EHR

• Institutional view
• Site specific (inpatient, outpatient, emergency,
  long term, home)
• Data contained is defined by institutional
  requirements but derived from common source
• Provider centric
• Shared view The Essential EHR
• Aggregated and complete view of patient
• Supports push and pull scenarios
• Data centric
• Personal view
• Appropriate clinical data organized around
  personal health plan
• Management of persons health
• Supports a personal health plan and provides
  decision support specific to person
• Patient centric

52
Creation of aggregated EHR
Institutional EHR
Personal Health Record
Institutional EHR
The PatientEHR
Institutional EHR
Component of Population Health Record
53
Download Process
Sensitive DemographicData
DoubleEncryptionSiliconEncoder
ID
ID
HL7 Message
Identifying Data, name, address, etc.
Encrypted ID
Identifying Data, Translated (e.g. Zip).
Aggregated SummaryPopulationEHR
Summary Data
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What is behind this model?

• Standards
• Infrastructure to support aggregation of data
  into a single patient record which requires
• Infrastructure to support a regional network
• Infrastructure and linkage of regional networks
  to provide a virtual national network
• A business case based on supported facts and
  includes a financial model that balances rewards
  with costs
• A workable process that permits us to reach the
  destination in doable chunks
• Understanding and creating the necessary linkages
  among stakeholders
• State efforts blended into a common process that
  will support interoperability among states

55
These views must serve

• Real-time connectivity to provide appropriate and
  controlled access to aggregated patient data.
• Disease registries permit the monitoring and
  assurance of high quality care.
• Research databases are derived for specific
  purposes and for specific periods of time.
• Reimbursement is derived from clinical data,
  ideally in real time.
• Accreditation, credentialing and statistical
  reporting are derived products.
• The data warehouse contains all data for legal
  and archiving purposes.
• Support consumer driven healthcare
• Mandatory reporting such as immunizations, HAI,
  etc.

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EHR Interoperability Diagram
Derived from master data element registry
Billing/Claims
Profile
EnterpriseData Warehouse
PersonalEHR
PersonalEHR
Profile
Disease Registry
PatientEncounter
Provider EHRDatabase
Institution EHRDatabase
Disease Registry
Profile
Disease Registry
ResearchDatabase
SummaryEHR
Profile
ResearchDatabase
Profile
ResearchDatabase
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Institutional EHR

• Presents a provider-centric view of the patients
  record
• Record contains patient data as well as
  intellectual content from provider of care
  serves multiple purposes may contain notes of
  provider only.
• Patient should have access to data and be able to
  identify errors and require correction of errors
• Content is driven by the institutional needs and
  varies from site to site
• Should contain all data important for patients
  care plus other data required by the institution
• Constitutes the billing record
• There is a need to interchange data with other
  sites at which patient receives care
• EHRS support full functionality for site care and
  management

58
The Inpatient View

• Deals with acute events and data has mostly
  immediate value for decision making and
  intervention. After intervention occurs, data
  has less value. (Short persistence)
• Required functionality deals primarily with
  service activities ordering, results review,
  admission and discharge
• CPOE systems particularly valuable to support
  services
• Real-time decision support valuable
• Inpatient version of ePrescribing, unit dose
• Patient monitoring, medical device component of
  IT support
• More tolerance for additional time required for
  IT activities
• Administrative support provides value to
  physicians rounding data
• Intensive care even more acute. High payoffs for
  decision support very short persistence of data

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The Inpatient View

• Presentation of data for direct patient care
• Ease documentation requirements
• Evidence-based clinical pathways/guidelines/protoc
  ols
• Multiple views of data, usually time-oriented
• Automatic creation of discharge summaries
• Task and workflow management
• Automatic linkage to task management
• Coupled to scheduling for radiology and
  diagnostic tests, e.g.
• Patient location, patient status
• Asynchronous communication among healthcare
  providers and workers

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Outpatient view

• Data vary over a longer period of time. Data
  have a longer persistence.
• Trend analyses are important.
• Outpatient ePrescribing valuable medication
  history key.
• Focus on prevention and management of chronic
  disease.
• Primary responsibility, with patient, for the
  patients overall health, i.e., medical home
• Educational and behavioral modification
• Depends on integration of data from multiple
  sources
• Provider overhead for IT critical

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Shared or Population View

• A summary record (essential EHR) from all sites
  and sources of care RHIO EHR
• Linkage of data for new sites of care as well as
  base for population surveillance, research,
  quality, analysis
• Data arrives as identified data, available as
  de-identified
• Data source for authorized providers provides
  connectivity
• Provides
• Utilization data
• Accurate and timely statistics about health and
  disease in population
• Accurate reporting of events, disease and
  outcomes
• Early discovery of outbreaks, new diseases,
  bioterrorist attacks
• Immunizations, infectious disease tracking
• Creation of on-the-fly randomized clinical
  trials
• With geocodes, permits understanding statistics
  of health, spread of disease

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Personal Health Record

• Permitting the patient to view an institutions
  EHR is NOT a PHR
• PHR has three components
• Clinical data that will be similar to the summary
  health record plus data that is entered directly
  or by sensor into the PHR. Clinical data is
  downloaded from sites of care. Data may be
  uploaded to site EHRs.
• Management of a persons health including prompts
  for appointments, medication refills, screening
  tests, immunizations, etc. Decision support
  algorithms suggest what provider should be doing
  in terms of frequency of visit, tests, etc.
• Access to knowledge that is tailored to a
  persons needs and is driven by clinical data.
• May be located at a site of care, at a PHR
  provider or on the persons personal computer.
  Backup issues are important.

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Feedback loop
Personalize Health
Measurements
Risk Assessment
Personal Health Plan
PATIENT
PHYSICIAN
Outcome Tracking
Home Enhancement Tools
HEALTHCARE TEAM
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Regional Center

• Accommodates 3 to 5 million persons
• Contains summary, aggregated data
• Is a local database
• Available 24/7
• Contains linkages to other centers so patients
  crossing boundaries of regions can be aggregated
• De-identified data available for local or global
  queries and analysis

65
Regional Healthcare Information Organizations
Estimate approximately 100 such centers at
implementation cost of 3m each and operational
cost of 1 M.
RHIO

• Each RHIO provides backup for other RHIOs.
• MPI identifies home RHIO

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Regional Health Information Organizations

• Regional collaboration of multi-stakeholder
  organizations working together to connect
  healthcare communities with the goal of improving
  quality of care, safety and efficiency
• Typical objectives
• Develop community-wide health information
  exchange
• Create healthcare portal with interoperable
  applications
• Create a training and support infrastructure to
  ensure adoption of applications
• Engaging payers in programs that align incentives
  appropriately

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National Healthcare Information Networks (NHIN)

• To provide a secure, nationwide, interoperable
  health information infrastructure that will
  connect providers, consumers, and others involved
  in supporting health and healthcare.
• E-health information to follow the consumer, be
  available for clinical decision making, and
  support appropriate use of healthcare information
  beyond direct patient care so as to improve
  health
• De-identified regional data can be analyzed
  nationally in aggregate. There is a national MPI
  which permits authenticated and authorized access
  to RHIOs for legal health-related purposes.
• Security and privacy are top priorities.

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A minimal EHR system

• Simple design. Minimum system supports
  demographics, lab, meds, brief history and
  physical, appointments, encounters, reimbursement
  and limited decision support.
• Component design so enhancements can be added as
  desired.
• EHR contents are interoperable with larger, more
  complex systems.
• Make systems maintenance free and simple to use.

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An EHR For All The World

• Use Service Oriented Architecture approach
  design components that can be easily connected.
• Determine immediate problems to be solved then
  implement those components to meet those goals.
• Keep it simple do in manageable chunks grow
  systems as needs expand and new problems can be
  engaged

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Moving into the future
The Vision
The Centerpiece of HIT EHR
Data CreationData Collection Data
Interchange Data Aggregation
Proactive interpretation of data to direct
behavior to enable quality care.
Real-time integration of knowledge to direct and
control collection of data.
Includes the service functions HIS, CPOE,
ePrescribing, billing
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Creative vision

• Rather than using technology to identify medical
  errors, use technology to prevent medical errors.
• Real time analysis of data to direct safe and
  quality care.
• Dashboard displays at each level to focus on
  priority interventions.
• Stop errors before they happen
• Order timely and effective testing for disease
• Proactive presentation of data with understanding
  of next event.

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What else do we want?

• A system that helps not hinders
• A system that assures patient safety and insures
  quality care
• A system that supports public health
• Health surveillance
• Epidemiology data in my area of care
• Disease prevalence by region, age , gender, race,
  social status
• A system that enables transitional medicine
  shorten time from bench top to bedside

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Why Global?

• Maximize use of available resources common
  effort and share amplification of productivity
• Enhances understanding of the problems
• Share in creation and use of knowledge clinical
  trials should be ubiquitous
• Funding for research should be global and shared
  cost should not limit availability
• Mobility of disease disease knows no borders
• Mobility of people
• Preserve culture
• It just makes sense the world is one!

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What the future must bring

• An EHR designed to take full advantage of
  technology and embraces new concepts
• Push technology that delivers what the provider
  needs in form, time, content, and based on the
  next event
• Dashboard presentations based on closed loop
  systems. Heads-up displays instant awareness.
• Providers not only accept EHR but change the way
  they practice medicine (a necessity)
• Connectivity and completeness
• Enables accessibility wherever the patient is
• Reusability
• Establish and track metrics for health outcomes,
  quality of care, performance, access,
  disparities, and efficiency
• Permits projection for resource requirements for
  health care

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What does HIT have to do with world health and
world peace?

• HIT contributes to higher quality of life
• HIT enables equality of life
• HIT provides equal access to care and treatment
  based on current knowledge
• HIT enables education, provides jobs and
  contributes to ability to work thus contributing
  to society
• Solving health problems involves solving food
  problems
• Good hygiene, healthy behavior, immunizations
• Focus on problems in health then solve them