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
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
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
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