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





e-Prescribing








e-Prescribing




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


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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.


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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


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


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


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

Health & Medicine

Architectuurcongres 20110623