what the dormouse said;

What the dormouse said;

Bio-medical Informatics; Systems Engineering; Ontologies and other things you didn’t know about EMRs

by

John Hughes

and

Michel Lortie

January 2011

Information in the Service of Health

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Medbase Research – Confidential and Proprietary Information


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Standards for Accreditation of Residency Training Programs Page 1 9

• Each residency program must demonstrate a commitment to integrating the tools of information management into patient care, teaching and research.

• This will require that the program have an organized approach to promoting the use of, and fostering the teaching of informatics.

• Essential elements of this commitment will include:• 1. Providing residents and faculty with ready access to the tools of

information management in the areas where they usually conduct patient care.

• 2. Developing, implementing and evaluating a resident curriculum and faculty development program in family medicine informatics.


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National Academy of Sciences“BUILDING A BETTER DELIVERY SYSTEM

A New Engineering/Health Care Partnership”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”


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HiRES Project - Mission Statement

The advancement of research, education and service in healthcare through the

application of systems engineering and biomedical informatics principles

“information in the service of health”


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What is Informatics?

S: (n) information science, informatics, information processing, IP (the sciences concerned with gathering, manipulating, storing, retrieving, and classifying recorded information)

http://wordnetweb.princeton.edu/


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http://wordnetweb.princeton.edu/perl/webwn?o2=&o0=1&o7=&o5=&o1=1&o6=&o4=&o3=&s=informatics&i=0&h=0#c

http://wordnetweb.princeton.edu/perl/webwn?o2=&o0=1&o7=&o5=&o1=1&o6=&o4=&o3=&s=information+science

http://wordnetweb.princeton.edu/perl/webwn?o2=&o0=1&o7=&o5=&o1=1&o6=&o4=&o3=&s=information+processing

http://wordnetweb.princeton.edu/perl/webwn?o2=&o0=1&o7=&o5=&o1=1&o6=&o4=&o3=&s=IP

What are systems?• S: (n) system, scheme (a group of

independent but interrelated elements comprising a unified whole)

• e.g. a “healthcare system”



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http://wordnetweb.princeton.edu/perl/webwn?o2=&o0=1&o7=&o5=&o1=1&o6=&o4=&o3=&s=systems&i=1&h=000000000#c

http://wordnetweb.princeton.edu/perl/webwn?o2=&o0=1&o7=&o5=&o1=1&o6=&o4=&o3=&s=system

http://wordnetweb.princeton.edu/perl/webwn?o2=&o0=1&o7=&o5=&o1=1&o6=&o4=&o3=&s=scheme

What is Engineering?

S: (n) engineering, engineering science, applied science, technology (the discipline dealing with the art or science of applying scientific knowledge to practical problems)



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http://wordnetweb.princeton.edu/perl/webwn?o2=&o0=1&o7=&o5=&o1=1&o6=&o4=&o3=&s=engineering&i=1&h=00000#c

http://wordnetweb.princeton.edu/perl/webwn?o2=&o0=1&o7=&o5=&o1=1&o6=&o4=&o3=&s=engineering+science

http://wordnetweb.princeton.edu/perl/webwn?o2=&o0=1&o7=&o5=&o1=1&o6=&o4=&o3=&s=applied+science

What is Ontology?

• S: (n) ontology ((computer science) a rigorous and exhaustive organization of some knowledge domain that is usually hierarchical and contains all the relevant entities and their relations)

• S: (n) ontology (the metaphysical study of the nature of being and existence)



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What is an EMR?

• an evolving concept defined as a systematic collection of electronic health information about individual patients or populations.

• It is a record in digital format that is capable of being shared across different health care settings, by being embedded in network-connected enterprise-wide information systems.


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Why is this man upset?

• There is growing pressure from the public– The public is using computers - why are

their medical records on paper?


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A Failure of Systems

Mortality

• “More than 98,000 Americans die and more than one million patients suffer injuries each year as a result of broken health care processes and system failures.” (IOM, 2000; Starfield, 2000);


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A Failure of SystemsMorbidity

• “…little more than half of patients receive known ‘best practice’ treatments for their illnesses and less than half of physician practices use recommended processes for care” (Casalino et al., 2003; McGlynn et al., 2003)


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A Failure of SystemsWaste

• “…thirty to forty cents of every dollar spent on health care, or more than a half-trillion dollars per year, is spent on costs associated with “overuse, underuse, misuse, duplication, system failures, unnecessary repetition, poor communication, and inefficiency” (Lawrence et al, “Building a Better Delivery System: A New Engineering/Health Care Partnership”; The National Academies Press 2005)


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A Failure of SystemsAn opportunity?

• “…the cost of the failure to take advantage of the tools, knowledge, and infrastructure that have yielded quality and productivity revolutions in many other sectors of the economy has been enormous.” (“Building a Better Delivery System: A New Engineering/Health Care Partnership”; The National Academies Press 2005)


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Paper vs Computers

• It is hard to believe that this ‘performs better than computer records’


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Or is it?• “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


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Isn’t this what we want?Information in the Service of Health

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EMR Generations

The Helper

The Partner

The Mentor


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EMR Generations1st: 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 settings4th: 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


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The Computable Medical Record• To get past the document manger EMR and

achieve the “quality and productivity revolutions” seen elsewhere in society we need “computation”

• S: (n) calculation, computation, computing (the procedure of calculating; determining something by mathematical or logical methods)


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The Computable Medical Record

But • Cancer is more complicated than a bank

overdraft• We are not born with an instruction manual and

set of blue prints• In fact the human being is the most complex

entity in the known universe


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The Computable Medical Record

“I don't know who discovered water but it certainly wasn't a fish.”

Marshall McLuhan


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Information; the water we swim in• In attempting to arrive at the truth, I have applied

everywhere for information, but in scarcely an instance have I been able to obtain hospital records fit for any purposes of comparison.

• If they could be obtained, they would enable us to decide many other questions besides the one alluded to.

• Nightingale, Florence; “Notes on a Hospital” 1873


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Merck Manual


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The Tsunami of Information• The scientific method is under threat due to its

own success• 4 exabytes (4.0 x 10^19) of unique information

was generated in the last 12 months• Health practitioners are being swamped by a

tsunami of clinical research


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

“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.”


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Foundations in the Weeds“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


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Solutions

• real improvement in outcomes will occur only when clinical systems reconfigure themselves specifically to address the needs and concerns of chronically ill patients (Wagner EH. “Chronic disease management: what will it take to improve care for chronic illness?” Eff Clin Pract. 1998;1:2-4)


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“Make it so Number One”• This journey to reinvent health care begins by

recognizing that to design health services, we need to understand systems.

• The behavior of a system emerges out of the interaction of its components, and the more components there are, the harder it is to predict the outcome of a seemingly simple change.

• The nature of complex systems such as health care means that simple fixes will always have unexpected consequences.


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The Therac 25 Disaster• Between June 1985 and January 1986 six

patients were killed or massively overdosed by radiation therapy because

• The software designers did not understand that many of the assumptions that were left implicit in the specifications would quickly become invalid in slightly changed circumstances and would lead to catastrophic failure.


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How do unexpected consequences occur?

‘‘When I use a word,’’ Humpty Dumpty said in a rather scornful tone, ‘‘it means just what I choose it to mean—neither more nor less.’’

‘‘The question is,’’ said Alice, ‘‘whether you can make words mean so many different things.’’

‘‘The question is,’’ said Humpty Dumpty, ‘‘which is to be master—that is all.’’

“Alice's Adventures in Wonderland”;1865 Charles Lutwidge Dodgson (aka Lewis Carroll).


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So how do we avoid implicit assumptions?

1. Unambiguous terminologies,

2. Systems models of our processes

3. Knowledge ontologies


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What is a 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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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)


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What is an Ontology?

• A multi-axial relational hierarchy that veridically represents a portion of reality (POR)


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The Ogden and Richards (1923) semiotic triangle

How do we model clinical reality


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The three levels of realityFrom Werner CEUSTERShttp://www.org.buffalo.edu/RTU

1. The world exists ‘as it is’ prior to a cognitive agent’s perception thereof;


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Reality existed before any observation

• Humans had a brain well before they knew they had one.

• Trees were green before humans started to use the word “green”.

RAnd also most structures in reality are there in advance.


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Three levels of realityFrom Werner

CEUSTERShttp://www.org.buffalo.edu/RTU


2. Cognitive agents (human beings) build up ‘in their minds’ cognitive representations of the world such as concepts;


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From Werner CEUSTERShttp://www.org.buffalo.edu/RTU

The ontology author or observer’s brain (B) acknowledges the existence of some Portion Of Reality (POR)

R

B


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From Werner CEUSTERShttp://www.org.buffalo.edu/RTU

R

BSome portions of reality

escape his attention.


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Three levels of realityFrom Werner CEUSTERShttp://www.org.buffalo.edu/RTU


2. Cognitive agents (human beings) build up ‘in their minds’ cognitive representations of the world;

3. To make these representations publicly accessible in some enduring fashion, we create representational artefacts such as words or numerals that are fixed in some medium (e.g. a word in a patient’s chart).


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He represents only what he considers relevant; From Werner CEUSTERShttp://www.org.buffalo.edu/RTU

RO

B

#1

RU1B1

RU1O1

RO

B

#1

RU1B1

RU1O1

• Both RU1B1 and RU1

O1 are representational units referring to #1;

• RU1O1 is NOT a

representation of RU1B1;

• RU1O1 is created through

concretization of RU1B1

in some medium.


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Beware of Terminologies

• These concretizations or TERMS are not supposed to represent the cognitive perceptions or concepts but rather the Portion of Reality that has been observed;

• We should not be in the business of concept representation.

• Both SNOMED CT and HL7 are full the ambiguities resulting from this error.


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5572 04/07/1990 26442006 closed fracture of shaft of femur

5572 04/07/1990 81134009 Fracture, closed, spiral


5572 12/07/1990 9001224 Accident in public building (supermarket)

5572 04/07/1990 79001 Essential hypertension

0939 24/12/1991 255174002 benign polyp of biliary tract



47804 03/04/1993 58298795 Other lesion on other specified region


298 22/08/1993 2909872 Closed fracture of radial head




PtID Date ObsCode Narrative

0939 20/12/1998 255087006 malignant polyp of biliary tract

Three references of hypertension for the samepatient denote three times the same disease.

If two different fracture codes are used in relation to

observations made on the same day for the same patient, they

might refer to the same fracture

The same type of location code usedin relation to three different events might or might not refer to the samelocation.

If the same fracture code is used for the

same patient on different dates, then these codes might or might not refer to the

same fracture.

The same fracture code used in relationto two different patients can not refer tothe same fracure.

If two different tumor codes are usedin relation to observations made on differentdates for the same patient, they may still refer to the same tumor.

Using terminology codes alone does not prevent ambiguities as to what is described: How many

disorders are listed?


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G in G outGarbage in Garbage out

OrGarbage in Gospel out

• For machine computation purposes the record should use code numbers specific to each instantiation of a given universal.


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To make explicit reference to the concrete individual entities relevant to the accurate description of each patient’s condition, therapies, outcomes, etc.

Differnetiating an instance from a universal using Referent Tracking


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78

Referent Tracking Differentiating an

instance from a universal By introducing an

Instance Unique Identifier (IUI) for each relevant particular (individual) entity


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• The fundamental motivation for the design and philosophy of the Problem-Oriented Medical Record (POMR) is the belief that the medical record is the central medium of communication and the first repository of knowledge in the practice of clinical medicine.

• “Medical records, medical education, and patient care: The problem-oriented record as a basic tool;” Weed, Lawrence L. 1970


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“Data Discipline”“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


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13th International Congress on Medical Informatics; September 2010

Cape Town, South Africa

what the dormouse said;

Documents

proprietary informationwhat

service of healthinformation

n information science

engineering science

n engineering

information processing

teaching of informatics

recorded information