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Architectuurcongres 20110623

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Architectuurcongres 20110623

  1. 1. EPD ontwikkeling:Standaardisatie en Samenhang Dr Jan A. Hazelzet Kinderarts-Intensivist & CMIO Erasmus MC ICT Architectuur congres, Nieuwegein, 23 Juni 2011
  2. 2. Congres ‘Architectuur in de Zorg’ Men neme een architect… Recept voor een goed zorgsysteemNieuwegein, 23 juni 2011
  3. 3. 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 ExchangeLiaison Medical <=> Informatics
  4. 4. IT in personalized integrated Health Care Quality Health Cohesion Documentation Care Knowledge
  5. 5. The Quality gapHealth care is not as Safe Effective To err is human: Building a safer health care system Efficient Linda T. Kohn et al. 2000 Patient centered Timely Equitableas it should be Committee on Quality of Health Care in America, 2001 Crossing the Quality Chasm: A New Health Care System for the 21st Century
  6. 6. The Quality gapHealth 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 be Committee on Quality of Health Care in America, 2001 Crossing the Quality Chasm: A New Health Care System for the 21st Century
  7. 7. NEJM 2010; 363:2124-34
  8. 8. Landelijk EPD 2006 2007 2008 2009 2010 2011
  9. 9. Meaningful EHR Functionalities: …enabling a safe, patient-centric, high-quality healtcare system that optimizes patient outcomes 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
  10. 10. Meaningful EHR Functionalities: …enabling a safe, patient-centric, high-quality healtcare system that optimizes patient outcomes 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
  11. 11. Meaningful EHR Functionalities: …enabling a safe, patient-centric, high-quality healtcare system that optimizes patient outcomes Structured and coded clinical documentation Workflow and clinical decision support Uniformity Knowledge management services e-Prescribing Healthcare information exchange, data access, quality reporting Personal health records
  12. 12. HIT-Enabled Health Reform Achieving Meaningful Use 2009 2011 2013 2015 HIT-Enabled Health ReformMeaningful Use Criteria HITECH Policies 2011 Meaningful Use Criteria (Capture/share data) 2013 Meaningful Use Criteria (Advanced care processes with 2015 Meaningful decision support) Use Criteria (Improved Outcomes) 14
  13. 13. Hospital Meaningful Use Objectives Over Time
  14. 14. Meaningful Use Incentives by Adoption YearMeaningful Total User 2009 2010 2011 2012 2013 2014 2015 2016 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 16
  15. 15. 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
  16. 16. 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 …….
  17. 17. Idealized concept of a PHR system J Am Med Inform Assoc. 2008;15:729-736
  18. 18. 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 ……
  19. 19. 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 ….
  20. 20. Commerciële EPD “pakketten” of “Suites”
  21. 21. EMR
  22. 22. Erasmus EPD (Elpado) nu Specialisme georiënteerd i.p.v. Patiënt centered •Familie anamnese Tussendossier •Alerts •Voorgeschiedenis •Allergie •Vaccinaties •Voorgeschiedenis •Allergie •Familie anamnese •Allergie •Allergie •Familie anamnese •Voorgeschiedenis •Procedures •Familie anamnese •Alerts •Alerts •Sociale anamnese •Alerts •Vaccinaties •Vaccinaties •Voorgeschiedenis •Vaccinaties •Sociale anamnese •Sociale anamnese •Sociale anamnese •Probleemlijst Basisdossier •Probleemlijst Specialisme 1 Specialisme 2 Specialisme 3 Alle SpecialismenDigitaal: 40% artsen, 70% verpleegkundigen Hybride, dan wel volledig papier
  23. 23. 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 26
  24. 24. Challenges - LanguageComponentVocabularySemantics Grammar 27
  25. 25. Challenges - LanguageComponent StandardVocabulary Code sets, terminologies, ontologiesSemantics Data model Grammar Content 28
  26. 26. Challenges - LanguageComponent Standard Has “words” for…Vocabulary Code sets, Diseases, terminologies, procedures, ontologies 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. 29
  27. 27. Challenges - LanguageComponent Standard Has “words” for… ExamplesVocabulary Code sets, Diseases, SNOMED-CT, terminologies, procedures, LOINC, RxNorm, ontologies specimen types, GO (genes) occupations, drugs, chemicals, anatomy, etc.Semantics Data model Definitions, Drugs, HL7 RIM, open chemicals, brand EHR, DCM… names, etc. Grammar Content Clinical observations, HL7 2.x, NCPDP, including lab tests, Continuity of vital signs, EKG Care Record/CCD measurements, etc. 30
  28. 28. 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 ……………
  29. 29. Journal of AHIMA 2009; 80: 44-50.
  30. 30. View the Complete Set of HITSP Deliverables www.HITSP.org
  31. 31. Continuity of Care Record (CCR)
  32. 32. Continuity of Care RecordWat 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
  33. 33. Kerngegevensset (CCR) NAW gegevens  Doorgemaakte ingrepen Recente afspraken  Medische apparatuur Problemen / diagnoses  Functionele status Betrokken zorgverleners  Vitale parameters Verzekeringsgegevens  Labresultaten Vaccinaties  Behandelbeperkingen Allergieën en alarmen  Medicatielijst Familie anamnese  Behandelplan Sociale anamnese http://en.wikipedia.org/wiki/Continuity_of_Care_Record
  34. 34. 38
  35. 35. Conceptual Model of the CCR1 Document Identifying Information “From/To” info re Provider/Clinician Optional Reason for Referral/Transfer Extension2 Patient Identifying Optional Information Extension3 Extension Eligibility, Co-payment, etc. Insurance and Financial Info4 Health Status of Patient Extension Med. Specialty-specific Info Diagnosis/Problems/Conditions Adverse Reaction/Alerts Current Medications Extension Disease Management-specific Info Immunizations Personal Health Record Info Vital Signs Extension Documented by the Patient Lab Results Procedures/Assessments Extension Med. Specialty-specific Info5 Care Documentation Extension Disease Management-specific Info Extension Institution-specific information Extension Care Documentation for Payers (Attachments) Extension Personal Health Record Info Documented by the Patient6 Care Plan Recommendation Version 6– 10/31/03 Mandated Core Elements of the CCR
  36. 36. Allergie / alert
  37. 37. Probleemlijst
  38. 38. Problem Oriented Medical Record  Probleem 1, 2, 3…. Subjectief Objectief Evaluatie Plan Dx Rx Vx
  39. 39. Medicatie veiligheid Presentatie Anne de Roos Medicatieoverdracht NVZA, KNMP
  40. 40. Medicatie veiligheid
  41. 41. Collins et al., J Biomed Inform 2011
  42. 42. Medische literatuur: PubMed MESH
  43. 43. • SnoMed• LOINC• RxNorm• MESH
  44. 44. SnoMed CT http://www.ihtsdo.org/snomed-ct/snomed-ct0/
  45. 45. Methods Inf Med 2010; 49: 349–359
  46. 46. 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
  47. 47. Journal of Critical Care 2010: 25: 364
  48. 48. http://snomed.dataline.co.uk/
  49. 49. LOINC
  50. 50. Medicatie: RxNorm
  51. 51. Patient & de ZorgPatient Huisartsen Algemene Ziekenhuizen RevalidatieOuders Academische Verpleeghuizen Centra Thuis zorg Categorale Ziekenhuizen
  52. 52. 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
  53. 53. Data Structure for EPD (2) 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-CT Adapted from blog John Halamka
  54. 54. Data Structure for EPD (3) Laboratory Results Content: HL7 2.x for messaging, CCD for document summaries Vocabulary: LOINC for lab name, UCUM for units of measure, SNOMED-CT for test ordering reason Microbiology Content: HL7 2.x for messaging, CCD for document summaries Vocabulary: LOINC for lab name/observationAdministrative Transactions (Benefits, Referrals, Claims) Content: X12 Vocabulary: X12, CAQH CORE Adapted from blog John Halamka
  55. 55. Nieuwe Uitdagingen
  56. 56. Determinanten van ons phenotype DNA Lifestyle Environs Health
  57. 57. “Equal but not the same”
  58. 58. Leefstijl
  59. 59. Risico factoren per Patient Roken 10 Nefropathie 8 Overgewicht 6 4 Bloeddruk 2 Activiteit 0 Cholesterol Voeding Stress Alcohol 1‐mrt‐09 1‐mrt‐10
  60. 60. Medical content in EMR www.pkc.com http://www.mapofmedicine.com/
  61. 61. www.affymetrix.com
  62. 62. Research:From clinical notes to structured phenotypes NATURE REVIEWS GENETICS 2011; 12: 417- 428
  63. 63. Two archetypal workflows in EHR-drivengenomic research NATURE REVIEWS GENETICS 2011; 12: 417- 428
  64. 64. Integratie van Health Care en Research
  65. 65. Information technology for patient safety Qual Saf Health Care 2010;19(Suppl 2):i25ei33
  66. 66. Gebruiksvriendelijk, modern, intuitief, supporting
  67. 67. Conclusies
  68. 68. Conclusies
  69. 69. Conclusies

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