James "Jim" Arthur Lovell, Jr., (born March 25, 1928)
One of the reasons I am doing this work is to better understand how we can give clinicians more of what they want by understanding what the practical constraints are to what they want.
One of the problems is how to implement effective use of terminology within a HIT pattern of data gathering
Patient has morbidity Sees GP/presents to ER Clinician (GP/Other) records notes in any preferred manner These notes are stored in the clinical EMR system A classification or terminology is applied as per the context/standards/ policy of the location But need to share the information To share need to use a terminology for contextual interop of data … e.g. SNOMED Apply to patient data (say CDA) By using OOXML we are able to embed the CDA in a human readable format and distribute
Drop-down – pre-populated, generally static, easier to control from IUT perspective Free Text – better for clinician, very bad for interop and IT control Hybrid – usually cumbersome and “not the best” of both worlds above
Riddel and Webber (1973) “…one of the most intractable problems is that of defining problems and of finding where in the complex causal networks the trouble really lies…”
Westbrooke et al (2007) Wicked problems are dynamic with multiple sets of complex, interacting issues that evolve in an emergent social context.
ICD-10(AM) 34000 entries (A00.0 [“Cholera due to Vibrio cholerae 01, biovar cholerae”] to Z99.9 [“Dependence on unspecified enabling machine and device”]) Source: NCCH Usyd ICD-10-AM book
No-one seems to look at the value within the infrastructure to provide a common platform for clinician noting purposes. If we look at the complex scenario of clinical noting with terminology and at infrastructure then we can suggest that clinical noting follows the commoditized processes of word processing software. If this is taken as a possibility then can we use commoditized word processing software to accept clinical noting while allowing us to embed contexutalisation data (in the form of terminology) and a clinical contextualisation structure on the data (in the form of CDA, etc) We should aim to remove the “Guru” syndrome requirements in HIT.
“sCCOW” is “simplified” CCOW – currently CCOW may be too complex and not versatile enough for many controlled environments. It may be possible to simplify the process using process engines and contextualisaiton based upon patient-clinician time-in-motion studies.
Making Terminology Work
Making Terminology work
Driving in situ use of wicked
classification schemes with
Werner van Huffel
Regional Strategist, Microsoft APAC
The Author is an employee of Microsoft and undertaking health Informatics field studies.
Masters degree in Health Information Management (Health Informatics) [HIM-HI], University of Sydney,
Raphael Mastier (Microsoft, France)
Marc Horowitz (HealthLanguage, Global)
Andrew Kirby (Microsoft, UK)
Neil Jordan (Microsoft, Global)
Brian Levy (HealthLanguage, USA)
“…Houston, we've had a problem...”
- Apollo 13, Lovell J. A. , 1970
Clinicians wanted this
Why is this work being done?
Due to MANY
• What is Wicked about classification?
• Why commoditized software?
• Referral Process
• Discharge Summary
• Rx Distribution
2 (+ a bit) ways of data entry
Source: “Smart Forms” in an Electronic Medical Record: Documentation-based Clinical
Decision Support to Improve Disease Management; SCHNIPPER J L, et al; J Am Med Inform
Assoc. 2008;15:513–523. DOI 10.1197/jamia.M2501.
Source: Plug-and-Play XML: A Health Care Perspective; SCHWEIGER R, et al; J Am Med Inform
Source: An Applied Evaluation of SNOMED CT as a Clinical Vocabulary for the
Computerized Diagnosis and Problem List; Wasserman H, et al; AMIA Symposium
Proceedings 2003; pp 207.
Dropdown Lists Free Text
Hybrid (the bit)
• Riddel and Webber (1973)
• Westbrooke et al (2007)
• Summarized paraphrase:
– A fuzzy solution space in which the problem locus is
• As one thing is solved another introduces itself and, potentially, re-
influences the original point from this the current solution was derived.
HPI service IHI service
Health messaging Clinical Communications Clinical Terminologies
Without the “guru-needed” syndrome
ICD <-> SNOMED
Clinical Data container
CDA, CCR, CCD, Archetype, …?
Why Commoditized software?
• Because it is part of the infrastructure
• Has the container abilities required
• Had the technology extensibility needed
Wicked clinical system
Concept Demonstrator (Demo time)
MS Word 2007+
• Terminology (HLi)
• ID services
• Decision Support
Language Engine (LE)
Commoditized Clinical noting:
Embedded Machine readable structures for data mining
combined with Human readable formats for knowledge
gathering using Commoditized software
Guru’s are important
CCR CEN 13606
Doctors don’t work like this
There are many standards that can be incorporated
We may be trying to stuff too much in
Not stress tested within an evidence based evaluation framework
There are a wicked number of ways to solve the clinical noting problem
“If an idea seems new to an individual, it is an innovation”
- Diffusion of Innovations 5th Ed, Rogers E., 2003