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Patient Summaries in the Emergency Department

  1. 1. Patient Summaries in the Emergency Department Catherine Chronaki Secretary General HL7 Foundation, Brussels, Belgium Contact: euoffice@HL7.org Funded under H2020-643889
  2. 2. 2 HL7 Foundation: who we are.. HL7 the best and most widely-used eHealth standards since 1986 HL7 v2, Clinical Document Architecture, HL7 FHIR 19 National Affiliates in Europe (~38 wordwide) European HL7 foundation established in 2010 European Funded Research Projects eHGI, Antilope, Semantic Healthnet, Trillium Bridge, Expand, Trillium-II PHC34: ASSESS CT, OpenMedicine, eStandards Annual HL7 in Europe Newsletter Website: www.HL7.eu eHealth policy & Research eHealth stakeholders group; mHealth Guidelines; ENISA expert group EFMI council (2012-): eHealth Week EFMI Board (2016) HIMSS Europe SDO Joint Initiative Council HL7 Vision: A world in which everyone can securely access and use the right health data when and where they need it. Patient summaries in the Emergency Department 25.Sep.2017
  3. 3. 3 Pros and cons Source: HIMSS Insights 2015 25.Sep.2017 Patient summaries in the Emergency Department
  4. 4. 4 Emergency department as decision environment High decision density Decision fatigue Throughput pressure Wide range of illnesses Diagnostic Uncertaintly Narrow time windows Interruptions and distractions Shift work/sleep disruption Shift changes cognitive decline at the end of a shift 30% Diagnostic Error in ED Radiology 5% Missed injuries 12% Cardiovascular 19% Respiratory 30% Overall ~16% Patient summaries in the Emergency Department 25.Sep.2017 Source: Dr. Pat Croskerry, Emergency London; https://www.youtube.com/watch?v=GFE6D5460oE It’s not about what we know, it’s about how we think!
  5. 5. 5 International Patient Summary (IPS) Implementation Guide: Purpose & Scope Goal: identify the required clinical data, vocabulary and value sets for an international patient summary. Scope: “The IPS specification shall focus on a minimal and non-exhaustive Patient Summary, which is specialty-agnostic and condition- independent, but still clinically relevant.” The primary use case is to provide support for cross- border or cross-juridictional emergency and unplanned care: Cross-jurisdictional patient summaries (through adaptation/extension for multi-language and realm scenarios, including translation). Emergency and unplanned care in any country, regardless of language. Value sets based on international vocabularies that are usable and understandable in any country. Data and metadata for document-level provenance. 5 25.Sep.2017 Patient summaries in the Emergency Department
  6. 6. 6 European Patient Summary Guidelines, Nov 2013, rev 2016 25.Sep.2017 Patient summaries in the Emergency Department
  7. 7. 7 Patient Summary Guideline EU patient summary guideline defines patient summary as the “minimum set of information needed to assure healthcare coordination and continuity of care” Emergency or unplanned care refers to “the range of healthcare services available to people who need medical advice, diagnosis and/or treatment quickly and unexpectedly” Types of EHR summaries Emergency data set Continuity of care record Encounter report Discharge summary 2nd opinion Clinical patient summary Disease specific summaries Around the world many variants of the same basic types of patient summaries HL7 Consolidated CDA seven document types, seven of which were consolidated in CCDA 25.Sep.2017Patient summaries in the Emergency Department
  8. 8. 8 Patient summary as Health data navigator Think of the Patient summary as a window to a person’s health or dashboard: Medications, allergies, vaccinations, problems and procedures, labs, diagnostic imaging, recent or planned encounters, implantable devices advance directives “Bring the Power of Platforms to Health Care” using data to drive: administrative automation, networked knowledge, and resource orchestration [Bush & Fox, HBR November 2016] eStandards need to help build trust unlock the power of health data facilitate decision support navigate the health system 25.Sep.2017 Patient summaries in the Emergency Department
  9. 9. 9 eStandards can unlock data for trust & flow Today:Massive health data accumulated in silo EHR systems for documentation Need to move from passive documentation to active use of information and knowledge creation: activation! Patient summaries defined at the macro level for cross-border exchange for emergency or unplanned care at a national level. Need to address communities and individuals! Standards and profiles address a predefined exchange of information. Need flexible use of available content and structure, recognizing national, regional or local jurisdictions: trust & flow! Patient summaries in the Emergency Department 25.Sep.2017
  10. 10. 10 Connected Care and the Patient Experience 25.Sep.2017Patient summaries in the Emergency Department http://surescripts.com/connectedpatient/default.html
  11. 11. 11 USA: Connected Care and the Patient Experience 25.Sep.2017Patient summaries in the Emergency Department http://surescripts.com/connectedpatient/default.html
  12. 12. Global Community of Practice social value • Bridge patient summary initiatives Governance learning resources mobile Health Patient Summaries 25.Sep.2017 Patient summaries in the Emergency Department
  13. 13. • Quality assurance • Health goals • Early warnings Can we use patient summaries to unlock patient data?
  14. 14. 14 Triage bots in NHS111 Apps refers the patient to hospital or recommends next-day GP appointment NHS England: alternative mechanism for integrated urgent care reduce pressure on the NHS Dr Chaand Nagpaul, the British Medical Association GP committee chairman, was skeptical: “the app would rely “slavishly” on algorithms and could not replace the judgement of trained clinicians.” GPs: too risk averse! 25.Sep.2017Patient summaries in the Emergency Department NHS111: 15m calls a year, Can AI help? London Central and West Unscheduled Care Collaborative (LCW), a GP-led not-for-profit organization Babylon offers subscription based remote GP consultation service 300K users in 2016 But no access to health records! 14
  15. 15. Sharing Data in the US Between Different EHRs  ~40% of systems are sharing data  ~30% of physicians can find the data  ~20% of the time data is integrated into the physician workflow  ~10% of the time the data has an impact on patient care  Challenges of sharing summary documents 15
  16. 16. 16 25.Sep.2017 Patient summaries in the Emergency Department
  17. 17. 17 USA: ED and Health information Exchange 25.Sep.2017 Patient summaries in the Emergency Department
  18. 18. 18 Emergency data sets 25.Sep.2017 Patient summaries in the Emergency Department http://aktin.art-decor.org source: Kai Heitmann https://tinyurl.com/y7assld4
  19. 19. 19 Patient Summaries in Norway 25.Sep.2017 Patient summaries in the Emergency Department
  20. 20. 20 Patient summary initiatives Scotland Emergency Record Greece Crete (~2010): Pilot of emergency record for frequent users National (recent): medication record France UK Luxemburg China Spain Sweden Portugal 25.Sep.2017 Patient summaries in the Emergency Department Questions: 1) Automated or manual entry 2) Single or multiple source/custodian 3) Patient access 4) Patient generated data 5) Privacy: Opt-in / option out 6) Business case 7) Added value services
  21. 21. 21 What do we need to make it happen with standards and interoperability? Co-create make it real by standards Governance scale for large-scale deployment Alignment flourish in sustainable ways Patient summaries in the Emergency Department 25.Sep.2017 21
  22. 22. 22 25.Sep.2017Patient summaries in the Emergency Department 22
  23. 23. mhm@medcom.dk euoffice@HL7.org www.trilliumbridge.eu Patient summaries in the Emergency Department EvaluateBridge HarmonizeGuide

Editor's Notes

  • Good morning, ladies and gentlemen.
    How we can use patient summaries / medical histories/ data in the emergency room to improve decision making: quality and speed?
  • 30% cognitive decline, Decision ; rational mind observing your intuitive mind…
    Dual process: analytical and intuitive thinking
  • The patient feels sick and seeks healthcare in a country that is not his/her country of origin.
    The most frequent situation is that the health professional has no prior clinical information
    about that patient and it is not expected that his visit will be repeated. They will not normally
    have a language in common.
  • .Establishing incentives for high quality recording or assembly of patient summary data can directly improve data insights guiding interventions with direct impact on increased productivity, and patient satisfaction. Note that the concept of health system navigators is not new. It was first introduced by Harold Freeman in 1990. Assisted by medical students, patients are able to navigate the logistical, emotional, and frequently cultural barriers of receiving care. Patients are assisting in assessing the situation and choices, articulate objectives, evaluate alternatives and reach decisions. In the end, healthcare is analog and human touch is paramount. Digital health tools can help fill the intention gap!
    http://www.hpfreemanpni.org/
  • Systems of record – SQL / CDA/CCD /
    Systems of differentiation – IHE Profiles / PCHA/Continua Profiles
    Systems of innovation – FHIR / OpenEHR Archetypes

    Data drive a wave of automation aspiring to improve care
    forge connections of health & wellness, medical research, and clinical decision support.
    Healthcare systems can rely on digital technologies to
    sustain costs, improve access, provide quality care facing dwindling resources and increasing demand
    offer mobile patient- and provider-facing apps
    mix patient-generated data with provider medical notes
    use data to shape personalized care pathways
    provide just-in time access to health services in person or online

    Health information technology standards are at the core of the compass, to tap the potential of shared aggregate data and sustain trust.
  • A more digitally connected doctor would make millions of people breathe a sigh of relief.

    Unnecessary paperwork and phone calls make Americans dread visiting the doctor more than other everyday tasks.
    We argue that citizens need a digital health compass to unlock the power of their health information, drive their engagement in personal health information management, and identify the most suitable health services for the situation at hand. With increasing quantity and uneven quality of health data, patient summaries could be the starting point to write an individual’s health story.

    Lots of paper. An average visit is 15 minutes of which
    5 minutes is paper work and 6 minutes is verbally sharing health data.

    Patients get used to doctors with digital technology they think they are organized innovative and compettant. Are more open if they can communication with email or text. Fill paper work online, receives tests and medical records online, schedule appointments online.

  • Americans say doctors still walk into most appointments without critical information about their patients
  • Establish the case for the international patient summary as a citizen’s right and enabler of safe care.
    Validate the global role of the international patient summary in different contexts
    Consult with key stakeholder groups to identify needs, and use cases to promote the international patient summary
    Assess key enablers and success factors for benefit realization in adopting international patient summary standards
  • This workshop will:
    Introduce the aims of the Trillium II project
    Present approaches from three different countries: Denmark, USA
    Collect input on the International Patient Summary among participants
    Open a discussion on how to assess, bridge and harmonizing relevant initiatives around the globe in an effort to attract new members to GC-DHIP and create a network effect that will nurture innovation and fuel creativity with global standards serving as infrastructure for interoperability.
  • Jan 2017: https://www.digitalhealth.net/2017/01/babylon-health-to-power-nhs-111-with-ai-triage-bot/
    A chatbot will now answer NHS 111 inquiries from more than a million Londoners as the health system looks for new ways to manage the growing health burden.
    NHS England has announced a new deal between health app company Babylon Health and North Central London CCGs, which will be testing an “NHS 111 powered by Babylon”.
    The app is essentially an chatbot drive by clinically-based algorithms that will triage patients without human intervention based on reported symptoms, a process that NHS England claims will take as little as two minutes.
    Based on the symptoms and its own algorithms, the app could refer the patient to hospital or recommend a GP appointment the next day.
    In a statement, NHS England said: “The app will provide an alternative mechanism of accessing integrated urgent care and connecting patients to clinicians, and will aim to reduce pressure on the NHS during the busy winter period and beyond.”
    “It will tell people where to go and who to see, as close to their home as possible, so they can make the right choices.”
    However, doctors have already expressed concerns about the reliance on algorithms and self-reported symptoms for determining the severity of a person’s illness.
    Dr Chaand Nagpaul, the British Medical Association GP committee chairman, told the Guardianthe app would rely “slavishly” on algorithms and could not replace the judgement of trained clinicians.

    While this is the first-time NHS 111 has relied solely on an AI to field patient inquiries, non-clinical call staff already rely on computer algorithms to make triage decisions.
    This had led to widespread criticism, with GPs calling for the “shipwreck” service to be scrapped entirely in 2015, claiming it was pumping up demand unnecessarily by being too risk adverse.
    The London pilot is being run through London Central and West Unscheduled Care Collaborative (LCW), a GP-led not-for-profit organisation that already runs the local NHS 111 service. It will cover the boroughs of Camden, Islington, Enfield and Barnet.
    Starting this month, it will run for six months, although patients living in the area will still be able to use the NHS 111 telephone service.
    Digital Health News understands it is one of four pilots planned this year to test how artificial intelligence can be used to ease pressure on NHS 111, a service that receives about 15 million calls a year.
    LCW chief operating officer Adam Duncan said the organisation would conduct a “robust” assessment of the apps value in improving the NHS 111 service.
    “The use of the app could also reduce the demand on NHS 111 during the most busy periods, whilst retaining the high quality and accessible service.”
    Babylon is chiefly known as a subscription based remote GP consultation service which provides video consultations through your phone for a monthly fee or a one-off payment.
    However, in June last year the company launched a AI triage tool, likely to be the model for the new NHS 111 chatbot app, pitting it against real clinicians in a demonstration.
    During the trial, the AI tool usually gave different, and more cautious, advice than the clinician.
    Babylon chief executive Ali Parsa said the pilot would help put “accessible healthcare into the hands of everyone”.
    “We should all be proud that our NHS is now becoming a pioneer in adopting cutting edge technology to deliver a timely and accurate digital triage service.”
    The pilots come after health secretary Jeremy Hunt announced an expansion of the NHS 111 service to include a new online “triage service”, for less serious health problems, in September last year.
    An online NHS 111 triage service has been announced by the government before, most recently in 2015.
    AI triage tool for 50million pounds; 300K users, June 2016
    https://www.digitalhealth.net/2016/06/babylon-health-launches-new-ai-triage-tool/
     
    AI function was pitted against 20 nurses and 15 junior doctors in 102 clinical scenarios.
    A panel of GPs found the doctors gave the correct triage advice 77.5% of the time, nurses 73.5% of the time, and the babylon AI 90.2% of the time.
  • The point is that barriers to current data sharing will also exist for sharing and use of patient summaries.
  • To develop, deliver, test and deploy standards sets which are properly adapted to a dynamic healthcare system, we need a constant flow of interaction between three types of activities:

    Co-creation between all relevant stakeholders
    to make it real using standards

    A supportive and appropriate governance system
    to make it scale toward large-scale deployment

    The flexibility to adapt and align as needs and requirements change
    to make it stay in a sustainable way
  • Co-create: identify situations of patient summary use beyond emergency and unplanned care
    Bridge: patient summary projects and initiatives identifying good and bad practices
    Validate: Develop, Collect, Assess learning resources to validate content
    Engage: mobile Health community to foster innovation & inform health policy
    Contribute: feedback to standards organizations improving patient summary standards

    The purpose of the Global community for digital health innovation practice is to identify relevant projects and use cases of interest that will help validate and promote the use of international patient summary standards in demonstrations, readiness exercises, and other pilot projects.
    Founding members of GC-DHIP are members of the Trillium-II consortium that have committed to pilot project demonstrations.
    Additional organizations and pilot projects implementing patient summaries are invited to join.
    eHealth programs of Luxenburg (eSante), Catalonia, Spain (TicSalut), Denmark (MedCom), Portugal (SPMS), Sequoia (US), HSPC (US) are part of the steering committee of GC-DHIP and Henrique Martins, is the first chairman.
    The community has also close connections to the eHealth Digital Services Infrastructure services established under the Connected Europe Facility.
    Why join?
    Be part of a global community and exchange knowledge with other countries
    If you know about Patient Summaries
    If you are curious about Patient Summaries
    If you want to influence an International Patient Summary
    If you want to be part of an international effort with local impact

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