nhprc conference october 2006c. arnott smith © 2006 the ontology of the operating room modeling...

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NHPRC Conference October 2006 C. Arnott Smith © 2006 The ontology of the operating room Modeling medical records for the HIPAA-Aware EAD

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NHPRC Conference October 2006

C. Arnott Smith© 2006

The ontology of the operating room

Modeling medical records for the HIPAA-Aware EAD

The medical record: A capsule history

Ancestors of the modern record Case records (19th c.) Bedside chart Physician order Financial ledger

Electronic? Not yet 10% penetrance in best studies 21% of systems capture >75% of information 75% of systems are hybrid

International and federal standards enroute

What it contains

Conglomeration of clinical documents Voice dictation Primarily qualitative, narrative text

Typical cancer patient record (2001): 80% = 6 unique document types Average of 68 documents/patient

Structure little-studiedFocus here: OR Notes

Definitions

“Loosely structured document” “documents that have much in common” (Essin,

1993) Contain elements (document parts)

Example: Description element

The patient was placed supine on the operating table. The left neck was prepped and then draped in sterile fashion. A transverse incision was made over a palpable lymph node in the left neck. Platysma was divided with cautery. The lymph node was dissected from its surrounding tissue by dividing its attachments betweenclamps and ligating them with silk ties. The specimen was sent directly to Hematopathology.

Example: Description label

DESCRIPTION: The patient was placed supine on the operating table. The left neck was prepped and then draped in sterile fashion. A transverse incision was made over a palpable lymph node in the left neck. Platysma was divided with cautery. The lymph node was dissected from its surrounding tissue by dividing its attachments between clamps and ligating them with silk ties. The specimen was sent directly to Hematopathology.

Earliest standard

American College of Surgeons (ACS)1918: Minimum Standards for HospitalsSpecified optimal content for operative

reportsQuality control initiative for certifying

surgeons

Data

20 OR Notes, 3 time periods, various surgeons’ documentation

Halsted, 1895-1926

Blalock, 1946-1951

EMR, 2001

Method

Reviewed by 2 coders for Total elements in 20 documents Unique elements in 20 documents Elements occurring across 3 collections Elements with HIPAA-regulated content

(18 categories for deidentification) And without

Results

1895-1926

1946-1951

2001

354

238

304

Total elements

Results

1895-1926

1946-1951

2001

111

16

33

Total unique elements

Results

1895-1926

1946-1951

2001

18

12

15

Average elements per document

R: 7-47 R: 8-13

R: 12-19

Results

Elements common to 3 collections, 1895-2001 Anesthesia Type (Ether) Identifier (10903) Operation Description

Operation Type (Anastomosis) Patient Name (Mrs. Catherine A. Smith)

Results

1895-1926

1946-1951

2001

88

85

70

Elements with HIPAA content: “Name”

Results

1895-1926

1946-1951

2001

63

31

65

Elements with HIPAA content: “Date”

Results

1895-1926

1946-1951

2001

39

42

40

Elements with HIPAA content: “Any other unique .. Number..”

Results

HIPAA-Sensitive Elements

Any Other NumberAny Other Number

Any Other Number

Date

Date

Date

NameName

Name

0

20

40

60

80

100

Halsted Blalock EMR

Collection

Num

be

r of

ele

men

ts

Results

Elements common to 3 collections, 1895-2001 Anesthesia Type (Ether) Identifier (10903) Operation Description

Operation Type (Anastomosis) Patient Name (Mrs. Catherine A. Smith)

Results

Elements common to 3 collections, 1895-2001 Anesthesia Type (Ether) Identifier (10903) Operation Description

Operation Type (Anastomosis) Patient Name (Mrs. Catherine A. Smith)

Implications for an EAD finding aid

Attribute: “HIPAA” Equals restricted (not viewable) Allow (no problem) Verify (may or may not be viewable)

Catherine Arnott Smith, PhDAssistant Professor

School of Library and Information Studies

University of Wisconsin-Madison

[email protected]