The Computable Patient Record; eMR 5.0 The Next Generation · 2018-05-03 · The Computable Patient...

Family Medicine Forum 2014 Workshop Saturday November 15th 2014

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The Computable Patient Record; eMR 5.0 The Next Generation J. Hughes; S. Simkus; A. Singer; M. Cotran; SYMBA The title of this workshop is based on the definition of the Gartner Fifth Generation electronically enabled medical record (eMR) called the “Mentor”

1st: The Collector - simple systems that provide a site-specific solution for the need to access clinical data which is imported through scanning or other forms of aggregation

2nd: The Documenter - basic systems that clinicians use at the point of care to adequately document rather than merely access clinical data

3rd: The Helper - Systems that include episodic and encounter data and use decision support tools to assist clinicians, functional in at the minimum both ambulatory and inpatient settings

4th: The Partner - Advanced systems that provide more decision support capabilities and that are operational and accessible across the continuum of care, and providing sufficient credibility as to become the patient's legal medical record

5th: The Mentor - Complex and fully integrated systems that include all previous capabilities and that are a main source of decision support in guiding patient care for both clinicians and consumers

The average eMR in Canada today functions at a level that is stuck between the first and third generations. Clinicians have unreasonable expectations for their eMRs because the profession has not taken the time and effort to specify what is required of these complex applications and have been offered electric versions of the paper record. “The problems of healthcare are rapidly approaching crisis proportions… The application of computer technology offers hope, but… will require a

much greater commitment than is presently true of the medical academic community.”

G. Octo Barnett 1969 (Founder Massachusetts General Hospital Computer Laboratory)


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To be satisfied with our eMRs the clinical information and process content of the medical record must be specified sufficiently to make it computable;

• To get past the document manger EMR and achieve the “quality and productivity revolutions” seen elsewhere in society with computer technology we need machine “computation” of the medical record

S: (n) calculation, computation, computing (the procedure of calculating; determining something by mathematical or logical methods) AND We must reinvent the processes of clinical information gathering, storing, processing and retrieval; this is the science of “Informatics”

• “merely automating the form, content and procedures of the current patient records will perpetuate their deficiencies and will be insufficient to meet emerging user needs”

• R.S. Dick;; E.B. Stein: “The Computer Based Patient Record;; An Essential Technology for Health Care”;; Institute of Medicine, National Academy of Science 1991

To achieve this reinvention we must not only study what is;

• “If communities were the size of cells and if hospitals, pharmacies, laboratories, patients and physicians were the size of sub cellular particles,

• no doubt they would be the subjects of a great deal of research, and much more would be known about their relationships and pathophysiology.” Weed, Lawrence;; “Medical Records, Medical Education, and Patient Care”;; The Press of Case Western Reserve University; 1969

BUT ALSO realize that this healthcare “system” we work in is not a system but a cottage industry devoid of any standards for clinical process or information content.

National Academy of Sciences “BUILDING A BETTER DELIVERY SYSTEM

A New Engineering/Health Care Partnership”


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Proctor P. Reid, W. Dale Compton, Jerome H. Grossman, and Gary Fanjiang, Editors 2005

“provides a framework and action plan for a systems/informatics approach to health care delivery based on a partnership between

engineers and health care professionals” This is the same realization that the NHS has come to after spending 12 billion pounds on eMRs.

National Health Services Joint WG 2012

“Technical standards alone do not ensure the ability for information systems to transfer interpretable health data around the NHS so that they can be reliably manipulated and understood.” “… this problem can be considerably simplified by the clinical professions agreeing on standard clinical representations for the content of medical/healthcare records.” A 5th Generation eMR requires that we create standards for the clinical information and process content of the medical record; “Two hundred years ago enlightened physicians understood that empiricism needed to be replaced by a more formal and testable way to characterize disease and its treatment. The tool they used then was the scientific method. Today we are in an analogous situation. Now the demand is that we replace the organizational processes and structures that force the arbitrary selection amongst treatments with ones that can be formalized, tested, and applied rationally.”

“Four rules for the reinvention of health care” Enrico Coiera, BMJ 2004;328:1197-1199 (15 May),

THAT utilize 1) Standard unambiguous medical terminology

• S: (n) terminology, nomenclature, language (a system of words used to name things in a particular discipline)

• e.g. the “Systematized Nomenclature of Medicine;; Clinical Terms” (SNOMED CT)


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2) Clinical Information Models

What is a Model?

“Man tries to make for himself in the way that suits him best a simplified and intelligible picture of the world and thus to over come (sig. understand) the world of experience, for which he tries to some extent to substitute this cosmos (sig. picture) of his. This is what the painter, the poet, the speculative philosopher and the natural scientist do, each in his own fashion... one might suppose that there are any number of possible systems... all with an equal amount to be said for them; and this opinion is no doubt correct, theoretically. But evolution has shown that at any given moment out of all conceivable constructions one has always proved itself absolutely superior to all the rest.” Einstein, A. “The World as I See It” (1931)

3) and the will to do a better job

• “If we accept the limits of discipline and form as we keep data in the medical record, the physician’s task will be better defined

• …and the art of medicine will gain freedom at the level of interpretation and be released from the constraints that disorder and confusion always impose.” Weed, Laurence; 1968

The choice is ours, We can turn this;


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into this;


6

At the end of this session, participants will be able to: -define informatics and its application to achieve safer more effective and efficient clinical practice -recognize the difference between computable and non computable clinical record content -articulate the informatics requirements necessary for an eMR to be a computable medical record Context The most common thing a doctor deals with on a daily basis is information. It has been fifty years since Laurence Weed defined the information requirements necessary for a medical record to be computable; twenty five years since Dick and Stein identified clinical information computability as necessary to achieve improved safety, efficiency and effectiveness in healthcare and fifteen years since Starfield et al decried the lack of information management standards in clinical care and the resultant


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morbidity. The failure of electronically enabled medical records to achieve information computability jeopardizes the adoption of eMRs and prevents the improvements in healthcare that should have already been achieved. The science of medical information has been declared a U.S. American Board Certified Medical Specialty. It is a mature science and holds the answer to achieving the computable patient record. This session will introduce the fundamentals of informatics and teach participants how to identify and use informatics in their clinical practice. The following are a complete slide set for the workshop. Not all slides will be used.

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pow

erofa

compu

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cord

zThisdatash

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wayto

goin

term

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quire

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gree

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ata

li

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tit

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meaningfulinformation(ie

CPCSSN

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ote??

Basic

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uiremen

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Com

puterͲ

basedPatie

ntRecord

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try

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tath

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beexchangedwith

otherusers

with

outthe

needform

anualdatareͲentry.

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useclinicaldecision

supp

ort

with

rulesthata

reim

ported

and

theserules

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dwillworkbe

causedataisstandardize

d

Emerging

Trend

s•

With

interope

rableEH

Rsystem

sandintegrated

decision

sup

portand

careplanning

tools,clinicians

willbebetterabletocoo

rdinatethebe

stpossib

lepatientcareacrossallpartso

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organiza

tion.

–Aph

ysicianmayhavetore

view

200

new

docum

entsaday

Plti

hlth

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itd

it

did

tifi

tik

ft

ik•

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latio

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althm

anagem

ent:Thereisagreatd

rivetowardidentifying

atͲriskorfu

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po

pulatio

ns,d

evelop

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careplansa

ndim

provingcommun

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highe

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oing

sowill

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ance.

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sup

portand

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lswillhelpph

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anageinform

ationandmon

itorthe

outcomesof

patie

ntswith

chron

iccon

ditio

nslikeCOPD

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ord

iabetes,according

toare

portfrom

theAg

ency

forH

ealth

careQualityandRe

search(A

HRQ).

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alize

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icine:The

evolutio

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med

icinerequ

iresh

ealth

careto

overcom

ethebarriersofinterop

erability,stand

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acyandpred

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goal,

accordingtoare

portfrom

theBroo

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eamlessand

rapidflo

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lif

tii

ldi

ilii

lt

dli

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id

(fh

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inform

ation,includ

inggeno

mic,clinicaloutcome,and

claim

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becomemoreefficient,effe

ctive,and

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alize

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fo/blog/eh

rsͲgoing

ͲwidelyͲim

plem

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lpful/

11

Lind

berg

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edsthe

helpof

compu

tertechn

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scompu

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theirind

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rpatientsinthesameho

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8

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ouldperform

tasksa

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rph

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ingthem

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ph

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extra,timeͲconsum

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lessitdire

ctly

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livery.

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ouldhelpph

ysiciansviewpatient

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ationmorequ

icklyandefficiently.And

theysh

ouldsu

pport–

notinterferewith

–ph

ysiciando

cumentatio

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nd

py

psoun

d,accurateeviden

ceͲbased

decision

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fo/blog/eh

rsͲ

goingͲwidelyͲim

plem

entedͲwidelyͲhe

lpful/

EHRweaknessesͲ

workflow

interrup

tionsand

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rability

•Clinicalworkflowinterrup

tionsand

interope

rabilityaretw

oofth

emostsignificantw

eaknessesw

ithinEHR

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dhil12

6i

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im

plem

entatio

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tclinicalworkflowbecauseth

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unableto

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majority

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dents.Physic

iansareund

er

pressureto

captureaneverͲin

creasin

gstackofinform

ation

oneverypatie

ntknow

ingthat

onlyapo

rtionof

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oneverypatient,kno

wingthatonlyapo

rtionofth

at

inform

ationrelatestoadiagno

sticortreatmen

tdecision

.•

https://www.clinicalkey.com/in

fo/blog/eh

rsͲgoing

ͲwidelyͲ

implem

entedͲwidelyͲhe

lpful/

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orsm

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ysiciansbelieveth

atEHR

ven

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sightofclinicalneedsfo

rworkflowfu

nctio

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ibili

di2014

f150

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rability,accordingtoa2014surveyof1

50

providersrep

ortedinHealth

ITOutcomes.

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anoverwhe

lmingim

perativetocom

pleteMU

certificatio

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etest.”

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manufacturershavebe

comesofo

cusedon

ensuringtheir

softw

areisMUͲcertifiedthatm

anyhavelostsighto

fthe

functio

nalitythatistrulyim

portanttohe

althprovide

rs,”

says

Health

ITOutcomes

edito

rin

chiefK

enCo

ngdo

nsaysHealth

ITOutcomes

edito

rͲinͲchiefKen

Con

gdon

.•


fo/blog/eh

rsͲgoing

ͲwidelyͲ

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entedͲwidelyͲhe

lpful/

12

Physiciandissatisfactio

nwith

EHR

sis

rampant

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ackon

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sofcom

puterized

do

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tatio

n,includ

ingdataentryand

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Sh

if

li

dd

supp

ort.Suchusageissuesofte

ntransla

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duced

timeforclinicalcare,dataanalysisandeviden

ceͲbased

de

cisio

nͲmaking,according

toa2013repo

rtfro

mRAN

DandtheAm

erican

HospitalA

ssociatio

n(AHA

).•

Physicians’com

plaintsrangefrom

dataen

try,usability,

inefficiency,andlesstimeforp

atientcare,to

limite

ddata

exchangebetweenEH

Rsand

erosio

nofclinical

documen

tatio

ndo

cumen

tatio

n.•


fo/blog/eh

rsͲgoing

ͲwidelyͲ

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Med

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otherclinicians

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portanttoknow

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izem

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13

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Tabu

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14

Normaliza

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owsner

&Tufte

1994

SituationalA

waren

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The Computable Patient Record; eMR 5.0 The Next Generation · 2018-05-03 · The Computable Patient...

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Transcript of The Computable Patient Record; eMR 5.0 The Next Generation · 2018-05-03 · The Computable Patient...