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Situation
“Improper data and non-availability of medical information results in
extraordinary hards...
eindia.eletsonline.com
Guiding Principle # 1
The Patient is mobile
• AFMS is not a geographically spread out collection of...
eindia.eletsonline.com
Guiding Principle # 2
• In Banking, Railways, Airlines, or Stock Market
– Few Things a million time...
eindia.eletsonline.com
Industry Solution
• Database
Relational Databases
• RDBMS (Relational Database Management Systems)
eindia.eletsonline.com
Question # 1
A patient is referred from Command Hospital (WC) to Army
Hospital (R&R). He carries pa...
eindia.eletsonline.com
Question # 2
A patient goes on discharge from Army Hospital (R&R)
to MH Mathura and then 403 Field ...
eindia.eletsonline.com
Question # 3
A soldier who was admitted to Army Hospital (R&R)
five years back is to proceed on ret...
eindia.eletsonline.com
Question # 4
A Court of Law asks for the medical records of a patient
admitted ten years back. The ...
eindia.eletsonline.com
Question # 5
Three years hence a new clinical sub-specialty is
formed, certain new procedures are i...
eindia.eletsonline.com
Nothing was working
• US Dept. of Commerce study
– health care is the 4 th most info reliant indust...
eindia.eletsonline.com
Sunil Shroff, head of Urology at the Sri Ramachandra
Medical College and Research Institute, Chenna...
eindia.eletsonline.com
2009
 The biggest cost will be paying and training the
labour force needed to create the network.
...
eindia.eletsonline.com
Paradigm Shift
2005
Query Based Architecture
(Uses only Databases)
replaced by
Messaging Architectu...
eindia.eletsonline.com
US National - Reordering
• HIPAA (Health Information Portability & Accountability Act)
• April 27, ...
eindia.eletsonline.com
eindia.eletsonline.com
Speech Extract
• The Department of Defense (DOD) is working with the Department
of Veterans Affairs...
eindia.eletsonline.com
HL7
Messaging Standard
Ver 2.3 - 1997 (proprietary)
Ver 3.0 - Current (XML based)
RIM (Reference In...
eindia.eletsonline.com
HL7
The Clinical Context Management Specification (CCOW)
Ver 1.0 - Jul 1999
Ver 1.3 - Current
Arden...
eindia.eletsonline.com
Clinical Document
CDA is specifies the syntax and supplies a framework for
specifying the full sema...
eindia.eletsonline.com
Properties of CD
• Defines a clinical document as having the following six
characteristics:
– Persi...
eindia.eletsonline.com
Persistence
 Continues to exist in an unaltered state, for a time
period defined by local and regu...
eindia.eletsonline.com
Human Readability
 Human readable, guarantees that a receiver of a
CDA document can algorithmicall...
eindia.eletsonline.com
Potential for Authentication
 Constitutes an assemblage of information that is
intended to be lega...
eindia.eletsonline.com
Context
 Establishes the default context for its contents
eindia.eletsonline.com
Wholeness
 Authentication of a clinical document applies to
the whole and does not apply to portio...
eindia.eletsonline.com
Stewardship
 Maintained by an organization entrusted with its
care
eindia.eletsonline.com
HL 7 - RIM
• In order to develop a healthcare messaging standard, there needs to
be agreement on wh...
eindia.eletsonline.com
• LOINC
Logical Observation Identifiers Names and Codes
College of American Pathologists
American C...
eindia.eletsonline.com
HL7 CDA Levels
• In any large healthcare organisation levels of IT
adoption will vary
• AHRR – stat...
eindia.eletsonline.com
HL 7 - CDA - Levels
Concept of “Incremental Semantic Interoperability”
Three Levels (all files in X...
eindia.eletsonline.com
CDA = header + body
• CDA Header
Metadata required for document discovery,
management, retrieval
• ...
eindia.eletsonline.com
One Question
These are Not ISO Stds
But they are the largest most advanced bodies
When ISO std is f...
eindia.eletsonline.com
Indian Standards
• IT Act 2000
• Digital Signatures
• Secure Electronic Record
• Govt of India Poli...
eindia.eletsonline.com
IT Budget
Sector Percentage
Financial Services 11
Insurance 8
Consumer Services 7
Wholesale Trade 6...
eindia.eletsonline.com
US - VA
Parameter Nos
Community based outpatient clinics 784
VA Hospitals 152
Nursing Homes 135
Vet...
eindia.eletsonline.com
US - DOD
• Provides medical care and assistance to 9.6 million
active duty service members, their f...
eindia.eletsonline.com
US DOD – VA Spending
• VA Vista - US$ 3.09 billion (over about 25 years)
(In 2006, VistA received t...
eindia.eletsonline.com
Translational Research
• Bench-to-bedside research
• Heavily dependent on Medical Informatics
• All...
eindia.eletsonline.com
Stage Cumulative Capabilities
US
2010
(N=5281)
Canada
2010
(N=639)
Stage 0 All three ancillaries no...
eindia.eletsonline.com
US
• Jan 2009 - Barack Obama elected President
• Feb 2009 – American Recovery and Reinvestment Act
...
eindia.eletsonline.com
US
• The law defines a meaningful user as a physician who:
– Uses a certified EHR in a meaningful m...
eindia.eletsonline.com
US
• Penalties
– 2015: -1 percent of Medicare allowed charges
– 2016: -2 percent
– 2017: -3 percent...
eindia.eletsonline.com
GAO Report
US DOD - Department of Defense
• In 1988 the US started its own electronic health record...
eindia.eletsonline.com
GAO Report
US DOD - Department of Defense
• The lack of an integrated system perpetuated the
relian...
eindia.eletsonline.com
• In November 2005, the Assistant Secretary of Defense
for Health Affairs announced a change in the...
eindia.eletsonline.com
• When fully deployed, AHLTA was envisioned to provide the
department with a modernized health info...
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Hospital CIO Conclave- Mainstreaming IT in India Hospitals- Col Sanjay Patole, Army R&R Hospital

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Transcript of "Hospital CIO Conclave- Mainstreaming IT in India Hospitals- Col Sanjay Patole, Army R&R Hospital"

  1. 1. eindia.eletsonline.com Situation “Improper data and non-availability of medical information results in extraordinary hardship for a lot of serving and ex-service personnel, who end up finding their records lost, unable to get their benefits processed in a timely fashion. There are innumerable instances, about serving and ex-service personnel, who were finding it almost impossible to get the benefits that they had earned despite the fact that their disabilities or their needs were evident for all to see.
  2. 2. eindia.eletsonline.com Guiding Principle # 1 The Patient is mobile • AFMS is not a geographically spread out collection of numerous hospitals • AFMS is a large geographically spread out, 30,000 bedded hospital • RAP - ADS - FSC - GH - ZH - CH - AHRR - MH Kirkee - ALC – QMTS • When a patient is admitted in a large hospital close to 80% of his medical record is from other centres
  3. 3. eindia.eletsonline.com Guiding Principle # 2 • In Banking, Railways, Airlines, or Stock Market – Few Things a million times • Healthcare – Text, Audio, Video, Images, Graphs, Values – Patient >> Study >> Series >> Findings Million things a Million times
  4. 4. eindia.eletsonline.com Industry Solution • Database Relational Databases • RDBMS (Relational Database Management Systems)
  5. 5. eindia.eletsonline.com Question # 1 A patient is referred from Command Hospital (WC) to Army Hospital (R&R). He carries paper records, X-Rays, CT- Scans etc from that hospital as well as other subsidiary hospitals and records of the past ten years from various hospitals. How does this patient’s record enter into the system at Army Hospital (R&R) without any repetitions of any tests (the aim of a reduced health care budget) ?
  6. 6. eindia.eletsonline.com Question # 2 A patient goes on discharge from Army Hospital (R&R) to MH Mathura and then 403 Field Hospital, what does she carry in the name of her medical records, so that they can be correctly interpreted there without any specialized application software other than for DICOM ?
  7. 7. eindia.eletsonline.com Question # 3 A soldier who was admitted to Army Hospital (R&R) five years back is to proceed on retirement and his medical record is required by his AMA and in the Record Office to ascertain the extent and attributability of his gunshot wound before proceeding on Pension. What record would be sent to the Record Office ?.
  8. 8. eindia.eletsonline.com Question # 4 A Court of Law asks for the medical records of a patient admitted ten years back. The Radiologist who signed the CT Scan report has got posted out. The Pathologist has retired, the Surgeon has left the Army and vanished into the Himalayas. What record would be submitted to the Court of Law ?
  9. 9. eindia.eletsonline.com Question # 5 Three years hence a new clinical sub-specialty is formed, certain new procedures are invented in existing specialties and a new equipment has been invented/designed among many other things. How will these be incorporated into the system ?
  10. 10. eindia.eletsonline.com Nothing was working • US Dept. of Commerce study – health care is the 4 th most info reliant industry sector after • telephone & telegraph • radio & television • security brokerage • Yet the slowest to adopt IT • What was wrong ?
  11. 11. eindia.eletsonline.com Sunil Shroff, head of Urology at the Sri Ramachandra Medical College and Research Institute, Chennai, points out another instance of a `digital divide' between the so-called `computer pundits' who haven't the faintest clue of the medical field and the healthcare sector they try to address. ‘The Hindu’ March 03, 2005
  12. 12. eindia.eletsonline.com 2009  The biggest cost will be paying and training the labour force needed to create the network.  Labourers will have the extremely difficult task of designing a system that “thinks like a physician” Luis Castillo Senior Vice President Siemens Healthcare
  13. 13. eindia.eletsonline.com Paradigm Shift 2005 Query Based Architecture (Uses only Databases) replaced by Messaging Architecture (Models the Real World) (Utilizes local Databases & Messages) End product is a digitally signed .xml file)
  14. 14. eindia.eletsonline.com US National - Reordering • HIPAA (Health Information Portability & Accountability Act) • April 27, 2004, the President signed Executive Order 13335 (EO) • HHS • AHIC (American Healthcare Information Committee) • ONCHIT • Contracts – HITSP and others Standards Protocols Security • Obama AHIC abolished HITECH Act part of Recovery Act
  15. 15. eindia.eletsonline.com
  16. 16. eindia.eletsonline.com Speech Extract • The Department of Defense (DOD) is working with the Department of Veterans Affairs (VA) to create a new electronic-health record (EHR) system that will include health care information for veterans from the time they enter military service through their retirement. • The two departments are working together to build the Joint Virtual Lifetime Record, which will standardize the way the agencies share electronic medical information.
  17. 17. eindia.eletsonline.com HL7 Messaging Standard Ver 2.3 - 1997 (proprietary) Ver 3.0 - Current (XML based) RIM (Reference Information Model) incl ICD, LOINC, SNOMED Clinical Document Architecture KONAArchitecture - 1996 Patient Record Architecture - 1998 ANSI / HL7 Release 1.0 - 2000 ANSI / HL7 Release 2.0 - 2005
  18. 18. eindia.eletsonline.com HL7 The Clinical Context Management Specification (CCOW) Ver 1.0 - Jul 1999 Ver 1.3 - Current Arden Syntax a language for organizations that require or develop systems that automatically assist physicians in decisions and alerts MLMs in CDSS - Jul 1999
  19. 19. eindia.eletsonline.com Clinical Document CDA is specifies the syntax and supplies a framework for specifying the full semantics of a clinical document A CDA can be a Discharge Summary Referral (CCR is one such) Progress Note Imaging Report Admission & Physical Public Health Report … any content that carries a signature
  20. 20. eindia.eletsonline.com Properties of CD • Defines a clinical document as having the following six characteristics: – Persistence – Human readability – Potential for authentication – Context – Wholeness – Stewardship • A CDA Document has a Header & a Body
  21. 21. eindia.eletsonline.com Persistence  Continues to exist in an unaltered state, for a time period defined by local and regulatory requirements
  22. 22. eindia.eletsonline.com Human Readability  Human readable, guarantees that a receiver of a CDA document can algorithmically display the clinical content of the note on a standard Web browser
  23. 23. eindia.eletsonline.com Potential for Authentication  Constitutes an assemblage of information that is intended to be legally authenticated as a single entity
  24. 24. eindia.eletsonline.com Context  Establishes the default context for its contents
  25. 25. eindia.eletsonline.com Wholeness  Authentication of a clinical document applies to the whole and does not apply to portions of the document without the full context of the document
  26. 26. eindia.eletsonline.com Stewardship  Maintained by an organization entrusted with its care
  27. 27. eindia.eletsonline.com HL 7 - RIM • In order to develop a healthcare messaging standard, there needs to be agreement on what data will be included in the messages. What data elements need to be represented? How are those data elements related to each other? What activities are involved in the healthcare process? How are those activities related to the data elements of healthcare? • Therefore the RIM (Reference Information Model) ICD LOINC SNOMED - CT Relationships, Context etc
  28. 28. eindia.eletsonline.com • LOINC Logical Observation Identifiers Names and Codes College of American Pathologists American Clinical Laboratory Association Regenstrief Institute RELMA > 41,000 ‘Observation Terms’ • SNOMED - CT Systematized Nomenclature of Medicine College of American Pathologists for a perpetual license National Library of Medicine (NLM) U.S. Department of Health and Human Services for ULMS > 3,70,000 Concepts
  29. 29. eindia.eletsonline.com HL7 CDA Levels • In any large healthcare organisation levels of IT adoption will vary • AHRR – state-of-the-art • Refer Mayo Clinic – state-of-the-art • MH Mathura – Intermediate • ADS – Basic • RAP – Nil (just a laptop) • How does a Clinical Document from AHRR get read in an RAP and vice versa ?
  30. 30. eindia.eletsonline.com HL 7 - CDA - Levels Concept of “Incremental Semantic Interoperability” Three Levels (all files in XML) Level 1 - Header Structured, Body can be any word document, scanned image etc Level 2 - Header & Body both structured but structure applied upto section level. e.g. Clinical Note, Lab Result, etc Level 3 - Complete structuring as per RIM therefore fully machine processible and can support true CDSS using MLMs
  31. 31. eindia.eletsonline.com CDA = header + body • CDA Header Metadata required for document discovery, management, retrieval • CDA Body Clinical report Discharge Summary Referral Progress Note H&P Public health report … any content that carries a signature
  32. 32. eindia.eletsonline.com One Question These are Not ISO Stds But they are the largest most advanced bodies When ISO std is formed, it will be based on these Joint Commission is a not-for profit body
  33. 33. eindia.eletsonline.com Indian Standards • IT Act 2000 • Digital Signatures • Secure Electronic Record • Govt of India Policy on Open Standards and guidelines on e- governance (notified by the Govt of India, Ministry of Communications and Information Technology, notification No. 2(32)/2009/EG-II dated 12 Nov 2010) • International Open Standards • Recursively Open Standards • Govt of India, ‘Interoperability Framework for e-Governance Version 2.4’, • Details of every protocol, file format etc - .odt, .xml, http
  34. 34. eindia.eletsonline.com IT Budget Sector Percentage Financial Services 11 Insurance 8 Consumer Services 7 Wholesale Trade 6 Business Services 6 Retail 4 Healthcare 2 2009 - Healthcare Information Technology – Global Trends, Common Challenges ; H Stephen Lieber, President & CEO HIMSS
  35. 35. eindia.eletsonline.com US - VA Parameter Nos Community based outpatient clinics 784 VA Hospitals 152 Nursing Homes 135 Veteran Population 22,658,000 Healthcare attendance 5,500,000 Independent licensed healthcare practitioners 53,000 Total Healthcare Workers 180,000
  36. 36. eindia.eletsonline.com US - DOD • Provides medical care and assistance to 9.6 million active duty service members, their families, and other eligible beneficiaries • 135,000 personnel in approximately 700 Army, Navy, and Air Force medical facilities • The department’s fiscal year 2010 budget for providing health care services was about $49 billion
  37. 37. eindia.eletsonline.com US DOD – VA Spending • VA Vista - US$ 3.09 billion (over about 25 years) (In 2006, VistA received the Innovations in American Government Award from Harvard University’s Ash Institute for Democratic Governance and Innovation because it has led to reduced errors and provided cost savings in VA’s delivery of health care) • US DOD AHLTA - US$ 4.3 billion (over about 13 years)
  38. 38. eindia.eletsonline.com Translational Research • Bench-to-bedside research • Heavily dependent on Medical Informatics • All major multicentre studies utilise controlled vocabularies • Use of SNOMED-CT, LOINC etc and Std formats enables faster collation • AI systems can then machine read records based on programmed parameters • When AHRR does cutting edge Cardiac, Liver, Bone Marrow, Onco treatments, its dept of IT should not let it down when it comes to Translational Research
  39. 39. eindia.eletsonline.com Stage Cumulative Capabilities US 2010 (N=5281) Canada 2010 (N=639) Stage 0 All three ancillaries not installed 10.1 % 29.0 % Stage 1 Ancillaries – Lab, Rad, Pharmacy - all installed 7.1 % 12.1 % Stage 2 CDR, Controlled Medical Vocabulary, CDS, may have Document Imaging, HIE capable 14.6 % 23.5 % Stage 3 Nursing/clinical documentation (flow sheets), CDSS (error checking), PACS available outside Radiology 49.0 % 33.0 % Stage 4 CPOE, CDSS (clinical protocols) 10.5 % 2.2 % Stage 5 Closed loop medication administration 4.5 % 0.0 % Stage 6 Physician documentation (structured templates), full CDSS (variance & compliance), full R-PACS 3.2 % 0.5 % Stage 7 Complete EMR; CCD transactions to share data; Data warehousing; Data continuity with ED, ambulatory, OP 1.0 % 0.0 %
  40. 40. eindia.eletsonline.com US • Jan 2009 - Barack Obama elected President • Feb 2009 – American Recovery and Reinvestment Act – Health Information Technology for Economic and Clinical Health Act (HITECH Act) – Formally codifies the ONCHIT – US $ 20 billion development of a robust health information technology (IT) infrastructure • 13 Jan 2010 - 45 CFR Part 170 - Interim Final Rule • 28 Jul 2010 - 45 CFR Part 170 - Final Rule • 27 Aug 2010 - Effective
  41. 41. eindia.eletsonline.com US • The law defines a meaningful user as a physician who: – Uses a certified EHR in a meaningful manner, which includes the use of electronic prescribing (e-prescribing) – Uses a certified EHR that can accommodate the electronic exchange of health information to improve quality – Submits information on clinical quality measures, as chosen by the Health and Human Services (HHS) Secretary • Incentives – First payment year: $18,000 in 2011 or 2012; $15,000 in 2013; $12,000 in 2014 – Second payment year: $12,000 – Third payment year: $8,000 – Fourth payment year: $4,000 – Fifth payment year: $2,000
  42. 42. eindia.eletsonline.com US • Penalties – 2015: -1 percent of Medicare allowed charges – 2016: -2 percent – 2017: -3 percent • Certified EHR – 7 certification Agencies - HIMSS – All vendors have to get certified • Similar to FDA – Cannot use a non-FDA drug or procedure – Cannot use a non-ONCHIT EHR application • Open Source applications for the country ( ? IPR)
  43. 43. eindia.eletsonline.com GAO Report US DOD - Department of Defense • In 1988 the US started its own electronic health record system to support all of its hospitals and clinics, called the Composite Health Care System (CHCS). • “CHCS was facility-centric, in which each facility stored only its own medical information for patients using different data standards. Therefore, if a medical provider wanted to obtain complete information about a patient, a query would have to be made to each of the CHCS locations—a time- and resource- intensive activity. • Additionally, when a patient moved to another region, the electronic records did not transfer across the CHCS locations because of the different data standards at each location.”
  44. 44. eindia.eletsonline.com GAO Report US DOD - Department of Defense • The lack of an integrated system perpetuated the reliance on paper-based records, leading DOD to pursue a comprehensive electronic health care record. • To this end, in 1997, the department initiated the CHCS II. It had planned to divide the system acquisition into seven software releases to be delivered incrementally by June 2006 at an estimated cost of US$4.3 billion (in 1998 dollars).
  45. 45. eindia.eletsonline.com • In November 2005, the Assistant Secretary of Defense for Health Affairs announced a change in the name of the system from CHCS II to AHLTA (Armed Forces Health Longitudinal Technology Application). • DOD has initiated efforts to improve system performance and enhance functionality and plans to continue its efforts to stabilize the AHLTA system through 2015 GAO Report US DOD - Department of Defense
  46. 46. eindia.eletsonline.com • When fully deployed, AHLTA was envisioned to provide the department with a modernized health information system that would generate and maintain a comprehensive, lifelong, computer-based patient record for every soldier, sailor, airman, and marine; their family members; and others entitled to DOD military health care. The electronic health record was expected to give health care providers real-time access to individual and military population health care information, thus facilitating clinical decision support and rationale for care rendered to U.S. service members worldwide. However, after more than a decade of effort to deliver this system, the department has recently begun planning for a new electronic health record system.” GAO Report GAO-11-50, October 2010

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