Architectuurcongres 20110623
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Transcript of Architectuurcongres 20110623
EPD ontwikkeling:Standaardisatie en Samenhang
Dr Jan A. Hazelzet
Kinderarts-Intensivist&
CMIO Erasmus MC
ICT Architectuur congres, Nieuwegein, 23 Juni 2011
Men neme een architect…Recept voor een goed zorgsysteem
Nieuwegein, 23 juni 2011
Congres ‘Architectuur in de Zorg’
ERASMUS MC Sophia Children’s Hospital
50% Pediatric Intensivist ≈ 1400 admissions/y
28 + 6 beds
Age: 0-18 y
Staff:
12 intensivists / 4 fellows
≈ 120 fte. nurses
50% CMIO
Strategic planning
Clinician’s perspective IT-Governance
Clinical Documentation
Interoperability
Regional Information Exchange
Liaison Medical <=> Informatics
IT in personalized integrated Health Care
HealthCare
Quality
Documentation
Knowledge
Cohesion
The Quality gap
Health care is not as Safe
Effective
Efficient
Patient centered
Timely
Equitable
as it should beCommittee on Quality of Health Care in America, 2001
Crossing the Quality Chasm: A New Health Care System for the 21st Century
To err is human: Building a safer health care systemLinda T. Kohn et al. 2000
The Quality gap
Health care is not as Safe “Do not harm the patient”
Effective “Do the right thing in the right patient”
Efficient “Don’t waste money”
Patient centered “Do we know what the Patient needs”
Timely “Don’t waste time”
Equitable “Don’t discriminate”
as it should beCommittee on Quality of Health Care in America, 2001
Crossing the Quality Chasm: A New Health Care System for the 21st Century
NEJM 2010; 363:2124-34
Landelijk EPD
200620072008200920102011
Meaningful EHR Functionalities:
Structured and coded clinical documentation
Workflow and clinical decision support
Knowledge management services
e-Prescribing
Healthcare information exchange, data access, quality reporting
Personal health records
…enabling a safe, patient-centric, high-quality healtcare system that optimizes patient outcomes
Meaningful EHR Functionalities:
Structured and coded clinical documentation
Workflow and clinical decision support
Knowledge management services
e-Prescribing
Healthcare information exchange, data access, quality reporting
Personal health records
…enabling a safe, patient-centric, high-quality healtcare system that optimizes patient outcomes
Meaningful EHR Functionalities:
Structured and coded clinical documentation
Workflow and clinical decision support
Knowledge management services
e-Prescribing
Healthcare information exchange, data access, quality reporting
Personal health records
…enabling a safe, patient-centric, high-quality healtcare system that optimizes patient outcomes
Uniformity
HIT-Enabled Health ReformAchieving Meaningful Use
2009 2011 2013 2015HIT-Enabled Health Reform
Mea
ning
ful U
se C
riter
ia
HITECH Policies 2011 Meaningful
Use Criteria (Capture/share
data)2013 Meaningful
Use Criteria(Advanced care processes with
decision support)2015 Meaningful
Use Criteria (Improved Outcomes)
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Hospital Meaningful Use Objectives Over Time
Meaningful Use Incentives by Adoption Year
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Meaningful User 2009 2010 2011 2012 2013 2014 2015 2016 Total
Incentive
2011 $ 18,000 $ 12,000 $ 8,000 $ 4,000 $ 2,000 $ 44,000
2012 $ 18,000 $ 12,000 $ 8,000 $ 4,000 $ 2,000 $ 44,000
2013 $ 15,000 $ 12,000 $ 8,000 $ 4,000 $39,000
2014 $ 12,000 $ 8,000 $ 4,000 $ 24,000
2015 + $ Penalties
Health Outcomes Policy Priority
Improve care coordination
Engage patients and families
Improve population and public health
Improve quality, safety, efficiency, and
Reduce health disparities
Ensure adequate privacy and security protections for personal health information
Wensen patiënt in de tijd van e-Health
Transparantie van prestaties van zorgverleners
Inzicht in eigen medische gegevens
Zelf regelen van het delen / uitwisselen van deze informatie
Toevoegen van informatie
Adequate voorlichting algemeen en op maat
Contact met arts via e-mail
Afspraken maken via internet
Zinvolle alerts t.a.v. diagnostiek en behandeling
Zelf management: documentatie van thuis metingen
…….
Idealized concept of a PHR system
J Am Med Inform Assoc. 2008;15:729-736
Wensen dokters in de tijd van e-Health
Verlenen van veilige, effectieve en evidence-based zorg met informatie geintegreerd in de klinische workflow
Actuele, relevante, complete en accurate patiënten gegevens
Curves, beelden, lab gegevens etc. kunnen hergebruiken
Documenteren van patiënten contacten (telefoon, e-mail, chat etc.)
Webspreekuur
Ondersteuning verwijzingen
E-consult
……
Huidige werkelijkheid
10’ per patiënt tijdens spreekuur
Onvolledige informatie
Geen overzicht
Verwarring
DBC afhandeling
Landelijke registraties
Administratie, brieven etc.
Niet patiënt gericht
Ontoegankelijk voor de patiënt
….
Commerciële EPD “pakketten” of “Suites”
EMR
Erasmus EPD (Elpado) nu
•Familie anamnese•Alerts•Vaccinaties •Allergie•Procedures •Sociale anamnese•Voorgeschiedenis
•Allergie•Familie anamnese•Voorgeschiedenis•Alerts•Vaccinaties •Sociale anamnese
•Voorgeschiedenis•Allergie•Familie anamnese•Alerts•Vaccinaties •Sociale anamnese•Probleemlijst
Digitaal: 40% artsen, 70% verpleegkundigenHybride, dan wel volledig papier
Specialisme 1 Specialisme 2 Specialisme 3
Specialisme georiënteerdi.p.v. Patiënt centered
Basisdossier
Tussendossier•Voorgeschiedenis•Allergie•Familie anamnese•Alerts•Vaccinaties •Sociale anamnese•Probleemlijst
Alle Specialismen
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Basisdossier= eenheid van taal
???
српско писано говор је ћepиулица. даби особа потпуно разумила-черилицу или койи говор, питаотац треба да разумиjе говор, граматику, семантику, од тога говора. да би компютор превео cваку горе спомометну део за корист здравовен-свене сексиjе, било би велико изазиваные.
EMR A EMR B
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Component
Vocabulary
Semantics
Grammar
Challenges - Language
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Component Standard
Vocabulary Code sets, terminologies, ontologies
Semantics Data model
Grammar Content
Challenges - Language
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Component Standard Has “words” for…
Vocabulary Code sets, terminologies, ontologies
Diseases, procedures, specimen types, occupations, drugs, chemicals, anatomy, etc.
Semantics Data model Definitions, Drugs, chemicals, brand names, etc.
Grammar Content Clinical observations, including lab tests, vital signs, EKG measurements, etc.
Challenges - Language
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Component Standard Has “words” for… Examples
Vocabulary Code sets, terminologies,ontologies
Diseases, procedures, specimen types, occupations, drugs, chemicals, anatomy, etc.
SNOMED-CT,LOINC, RxNorm, GO (genes)
Semantics Data model Definitions, Drugs, chemicals, brand names, etc.
HL7 RIM, open EHR, DCM…
Grammar Content Clinical observations, including lab tests, vital signs, EKG measurements, etc.
HL7 2.x, NCPDP, Continuity of Care Record/CCD
Challenges - Language
Open International Standards
Grammatics: Structure: CCR Vocabular: Terms: SnoMed, LOINC, RxNorm, NANDA, GO Semantics: Definitions HL7v3, Open EHR, Archetypes, DCM etc. Images: Radiology, ECG: IHE, DICOM ……………
Journal of AHIMA 2009; 80: 44-50.
View the Complete Set of HITSP Deliverables
www.HITSP.org
Continuity of Care Record (CCR)
Continuity of Care Record Wat is het? Kern data set van de meest relevante en actuele feiten van de
gezondheidstoestand van een patiënt.
Vervaardigd door een zorgverlener aan het eind van een bezoek.
Met deze voor de volgende zorgverlener toegankelijke informatie kan de zorg doorgaan.
Kan vervaardigd, getoond en verstuurd worden. Op papier en electronisch
Kerngegevensset (CCR)
NAW gegevens Recente afspraken Problemen / diagnoses Betrokken zorgverleners Verzekeringsgegevens Vaccinaties Allergieën en alarmen Familie anamnese Sociale anamnese
Doorgemaakte ingrepen Medische apparatuur Functionele status Vitale parameters Labresultaten Behandelbeperkingen Medicatielijst Behandelplan
http://en.wikipedia.org/wiki/Continuity_of_Care_Record
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Conceptual Model of the CCR
Document Identifying Information“From/To” info re Provider/ClinicianReason for Referral/Transfer
Patient Identifying Information
Insurance and Financial InfoHealth Status of PatientDiagnosis/Problems/ConditionsAdverse Reaction/AlertsCurrent MedicationsImmunizationsVital SignsLab ResultsProcedures/Assessments
Extension
Care Documentation
Extension
Optional Extension
Extension Eligibility, Co-payment, etc.
Med. Specialty-specific Info
Disease Management-specific Info
Extension
Extension
Extension
Extension
Extension
Extension
Institution-specific information
Med. Specialty-specific Info
Disease Management-specific Info
Personal Health Record Info Documented by the Patient
Care Documentation for Payers (Attachments)
Personal Health Record Info Documented by the Patient
Care Plan Recommendation
Optional Extension
1
2
3
4
5
6
Mandated Core Elements of the CCRVersion 6– 10/31/03
Allergie / alert
Probleemlijst
Problem Oriented Medical Record
Probleem 1, 2, 3….Subjectief
Objectief
Evaluatie
PlanDx
Rx
Vx
Medicatie veiligheid
Presentatie Anne de Roos Medicatieoverdracht NVZA, KNMP
Medicatie veiligheid
Collins et al., J Biomed Inform 2011
Medische literatuur: PubMed MESH
• SnoMed• LOINC• RxNorm• MESH
SnoMed CT
http://www.ihtsdo.org/snomed-ct/snomed-ct0/
Methods Inf Med 2010; 49: 349–359
Potential benefits and strengths of SNOMED-CT
Consistent terminology: across all disciplines and domains; (inter)nationally
Comprehensive terminology: covers most needs of electronic documentation; constant growth, postcoordination, crossmapping
Point of care terminology: concurrent coding, live search, help with decision support, overall enhanced patient care
Terminology of CIS: same terms used across the entire health system, ER, OR, ICU, and health records; Minimizing duplicate data entry, Ease of coding, re-use of data, Improved data quality, Use of contents of free text data (NLP)
Internationally recognized and maintained: consistent patient records for research, prerequisite for international health record, Dynamic terminology with frequent updates
Adapted from: Journal Critical Care 2010; 25: 364.e1–364.e9
Survey HIT vendors 2008: only 30% had license, 6% was using it
Journal of Critical Care 2010: 25: 364
http://snomed.dataline.co.uk/
LOINC
Medicatie: RxNorm
Patient & de Zorg
Algemene Ziekenhuizen
AcademischeCentra
Patient
Categorale Ziekenhuizen
Ouders
Huisartsen
Revalidatie
Verpleeghuizen
Thuis zorg
Data Structure for EPD (1)
Demographics Content: HL7 2.x for messaging, CCD for document summaries
Vocabulary: HITSP Harmonized code sets for gender, marital status
Problem List Content: HL7 2.x for messaging, CCD for document summaries
Vocabulary: SNOMED-CT
Medications Content: NCPDP script for messaging, CCD for document
summaries
Vocabulary: RxNorm and Structured SIG
Adapted from blog John Halamka
Data Structure for EPD (2)
Allergies Content: HL7 2.x for messaging, CCD for document summaries
Vocabulary: UNII for foods and substances, NDF-RT for medication class, RxNorm for Medications
Progress Notes and Other Narrative Documents (History and Physical, Operative Notes, Discharge Summary)
Content: HL7 2.x for messaging, CCD for document summaries
Vocabulary: CDA Templates
Departmental Reports (Pathology/Cytology, GI, Pulmonary, Cardiology etc.)
Content: HL7 2.x for messaging, CCD for document summaries
Vocabulary: SNOMED-CTAdapted from blog John Halamka
Data Structure for EPD (3)
Laboratory ResultsContent: HL7 2.x for messaging, CCD for document summariesVocabulary: LOINC for lab name, UCUM for units of measure, SNOMED-CT for test ordering reason
MicrobiologyContent: HL7 2.x for messaging, CCD for document summariesVocabulary: LOINC for lab name/observation
Administrative Transactions (Benefits, Referrals, Claims) Content: X12Vocabulary: X12, CAQH CORE
Adapted from blog John Halamka
Nieuwe Uitdagingen
Determinanten van ons phenotype
Health
Environs
LifestyleDNA
“Equal but not the same”“Equal but not the same”
Leefstijl
Risico factoren per Patient
0
2
4
6
8
10Roken
Overgewicht
Activiteit
Voeding
AlcoholStress
Cholesterol
Bloeddruk
Nefropathie
1‐mrt‐09 1‐mrt‐10
Medical content in EMR
http://www.mapofmedicine.com/www.pkc.com
www.affymetrix.com
Research: From clinical notes to structured phenotypes
NATURE REVIEWS GENETICS 2011; 12: 417- 428
Two archetypal workflows in EHR-driven genomic research
NATURE REVIEWS GENETICS 2011; 12: 417- 428
Integratie van Health Care en Research
Information technology for patient safetyQual Saf Health Care 2010;19(Suppl 2):i25ei33
Gebruiksvriendelijk, modern, intuitief, supporting
Conclusies
Conclusies
Conclusies