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  • Rex OsbornHIMSS 2009 Middle EastPresentationTransparency in Healthcare Technology; A Clinical Informaticist & Strategist ApproachImagine an HCIT environment where clinical data barriers no longer impeded collaboration, where data elements are managed, unified in a common language, & shared no matter your clinical discipline or specialty.Learning Objectives: How to leverage your existing HCIT solutions How interoperability and integration via standards can allow unification of data elements Using practical HCIT logic, how to share unified data into existing EHR or newly invested EHR solutions (EHR = Electronic Health Record)The Future of Healthcare: There is growing evidence that the current health systems of nations around the world will be unsustainable if unchanged over the next 15 years. Globally, healthcare is threatened by a confluence of powerful trends – increasing demand, rising costs, uneven quality, misaligned incentives. If ignored, they will overwhelm health systems, creating massive financial burdens for individual countries and devastating health problems for the individuals who live in them.The attitude that all healthcare should be local is dangerously provincial and, in extreme cases, xenophobic. The days when healthcare sectors operate in silos must end. New solutions are emerging from beyond traditional boundaries and innovative business models are being formed as healthcare becomes globalized. These solutions are changing the way the Chinese think about financing hospitals, Americans recruit physicians, Australians reimburse providers for care, Europeans embrace competition, and Middle Eastern governments build for future generations.In a world in which economies are globally interdependent and the productivity of nations relies on the health of its citizens, the sustainability of the world’s health systems is a national competitive issue and a global economic imperative. Moreover, there is a moral obligation to create a global sustainable health system. The stakes could not be higherThe idea of sustainability is subject to many interpretations. It is often used in the context of environmental protection and renewal of natural Clinicians. One comprehensive definition can be found in Paul Hawkin’s book, The Ecology of Commerce: “Sustainability is an economic state where the demands placed upon the environment by people and commerce can be met without reducing the capacity to provide for future generations.” This definition applies in profound ways to healthcare. At the current rate of consumption and at the current level of thinking, the healthcare organizations of today will be unable to meet demand in the future. Our health systems will be unsustainable.A new model is required, and DOHMS has a unique opportunity as a global leader of change to create a federated model that allows a pluralistic population access to the best healthcare technology solutions available with a clinical foundation that incorporates IT standards, transparency and interoperability allowing the patient and the clinician to work as a collaborative team. Thereby mitigating risk for patients as well as clinicians, managing community health and asserting intelligent management tools to provide all stakeholders a better understanding of ways to improve and manage their health. When Health is absent, Wisdom cannot reveal itself, Art cannot become manifest, Strength cannot be exerted, Wealth is useless & Reason powerless.Herophiles, 300 B.C.The Healthcare Enterprise: A system where all computers in a healthcare system's various Hospitals, clinics, GP’s (General Practitioner) and specialty Centre's are connected to exchange information. Enterprise based applications are dramatically changing the business of healthcare. They are redefining everything from the way information flows to how people and healthcare organizations interact. The challenges across the Enterprise include; business processes to quality of patient care. Care is provided across multiple entities, from the general practitioner through the specialist to the Hospital, these entities are defined as the Healthcare Enterprise. HCIT vendors must provide solutions in this niche that simplifies administration, enables Integrated Patient Centric Care, enhances physician information, personifies interoperability, and maintains continuity of care thereby empowering clinicians & patients by giving them more choice and greater access to information. The transformation from a traditional healthcare organization to an Enterprise savvy provider of solutions means leveraging the internet for business processes and patient care suites of solutions. This will require a re-thinking of existing business models, workflow re-engineering as well as a safe harbor of patient data. It involves becoming more connected, and more flexible to react faster to change. The question is no longer when the Internet will impact the business of healthcare, but how the industry will adopt the technology to get the most out of the Internet, streamline and build new innovation into business processes, simplify and improve the healthcare experience for both the patient as well as the clinician.
  • HCIT Sustainability Pressures & Considerations; VisionCollaboration. Payers, hospitals, physicians, and community service organizations are working together to foster standardization and adoption of technology and process changes. They are teaming to enhance access and portability of healthcare services. They are coming together to realign incentives to accomplish mutual goals.Consumerism. Providers are reorganizing themselves in a patient-centric continuum through care management approaches. Payers are developing consumer-oriented benefits plans. Pharmaceutical and life sciences companies are using new pharmacogenomic discoveries to pursue personalized medicine.Technology assessment and dissemination. Payers, providers and community organizations are coming together on a regional and/or national basis to establish infrastructure and communications standards. They are developing incentives that will distribute the risks and rewards more evenly. Payers and research organizations are evaluating technology relative to productivity and lifespan.Transparency. New payment and reporting methods are emphasizing safety, performance and accountability for health organizations across all industry sectors. Payers and providers are participating in pay-for-performance programs. Industry trade groups are establishing quality and safety standards. Governments are establishing reporting mechanisms and requirements.Portfolio management. Hospitals, pharmaceutical companies, life science organizations, and payers are increasingly called upon to manage their service portfolios in a balanced, fiscally responsible manner. Governments are calling for rational approaches to regional service planning. Providers are organizing and allocating services to meet consumers’ needs for access, manage quality of care, and reduce duplication and inefficiency.Manpower management. New models of developing, recruiting and retaining manpower are developing to address the root causes of gaps in service and impending future needs.
  • COST – HCIT Solutions Are Expensive To Select, Implement, Adopt & Support LEGACY SYSTEMS – Existing Investments Have To Be Upgraded, Integrated, Displaced/Replaced, Migrated & Converted INTEGRATION - Best Of Breed/Disparate/Closed & Even Open Solutions Require Considerable Investment, Talent & Monies DATA SHARING & INTEROPERABILITY – Data Is Needed Across The Patients Continuum, Not Just In A Single Environment, Crossing This Chasm Mitigates Risk For Clinician As Well As For The Patient STANDARDS- Adoption Of Integration, Interoperable & Compatibility Standards As Well As Nomenclature/Data Dictionary (Vocabulary) Significantly Impacts Data Sharing, Access & Interoperability ACCESS – Device Strategy, Mobility, Remote Access as well as Rural Clinical Data Availability is a Complex Proposition SECURITY – Risk Mitigation, Auditing, Access, Control & Privacy DATA INTEGRITY** – Who Owns The Data? WORKFLOW – Enhance It, Don’t Break It! ADOPTION – Practical Adoption, Sustainable And Self Dependent Model &… TALENT – Clinicians to Plan, Manage, Execute & Support HCIT
  • Chronic Disease Management: is the concept of reducing healthcare costs and/or improving quality of life for individuals with chronic disease conditions by preventing or minimizing the effects of a disease through integrative care. CDM can also be called care management, disease management, health management programs, or disease self-management.Point of Care; Access to Clinical Data: Access to care is relegated to the foundation belief that all clinically relevant data should be available @ the point of care (Where the clinician and the patient convene). The goal of “access to care” is to define, shape and sequence the processes and activities which maximize coordination of care across the continuum of patient care. Over time, patients may receive a range of care in multiple settings from multiple providers. For this reason it is important for a health system to view the patient care it provides as part of an integrated system of settings, services, health care practitioners and care levels. Access to care/Data Sharing enables continuity of care. Point of care is where the clinician as well as the patient converge / meet / advocate.Patient Safety: Patient Safety (PS**) is the avoidance, prevention, and amelioration of adverse outcomes or injuries stemming from the processes of healthcare. These events include "errors," "deviations," and "accidents.“ Patient safety is a subset of healthcare quality. The goal of Patient Safety is to reduce preventable medical mistakes and improve the quality and affordability of healthcare. Top Five GoalsImprove the accuracy of patient identificationImprove the communication between clinicians & patientsImprove the safety of medication(s)Eliminate wrong site, wrong patient, and wrong procedure surgeryAccurately & comparatively reconcile medications across the continuum of carePatient Empowerment: The idea that patients are active participants in their care. The health care industry is learning that patients' involvement and empowerment are essential to improving their overall health, and patients are demanding more say in their care.Clinical Pathways: Clinical Pathways is a formal process description of how a clinical team should handle a specific clinical case, leading to a more consistent team based approach that increases quality and efficiency of the process. The goal of Clinical Pathways; Improve care through more standardized processes and better coordination, Improve care documentation, Improve care measurement by linking process and outcomes through the variance management system & Improve communication between the care team members.Clinical Content Management: is a strategy leveraging technologies employed in the Clinical IT industry for managing the capture, storage, archiving, security, revision control, retrieval, distribution, data mining, preservation and destruction of clinical data elements (content). Cost Containment: Cost Containment is a variety of strategies or methods whose primary goal is to control the rising cost of healthcare, thus making health care more affordable. These strategies and methods may include, but are not limited to information technology, government regulation, managed care programs, payment policies, global budgets, rate setting, consumer education, and utilization management. As costs rise the result is that more and more hospitals, medical clinics, and other healthcare providers and payers are looking for solutions and services that will help them to control expenses and reduce [manage] costs. Patient Population Management: is the study of the sources and correlates variability in patient complaints, problems, diagnosis, and diseases. This allows at the administrative level targeting new services and or Clinicians for a patient population. Life Sciences: industry offers a technology infrastructure that reduces complexity, streamlines information flow, and improves productivity for the next generation of pharma & bi-science solutions. Knowledge Driven Life Sciences helps pharmaceutical professionals streamline operations and improve their decision making. Reference - Patient Safety; Reference Material: Released Reports…Preventing Medication Errors: Quality Chasm Series Jul 20,2006 Medicare's Quality Improvement Organization Program: Maximizing Potential Mar 09,2006Performance Measurement: Accelerating Improvement Dec 01,2005 Improving the Quality of Health Care for Mental and Substance-Use Conditions: Quality Chasm Series Nov 01,2005Quality Through Collaboration: The Future of Rural Health Nov 01,2004 1st Annual Crossing the Quality Chasm Summit: A Focus on Communities Sep 14,2004Patient Safety: Achieving a New Standard for Care Nov 20,2003 Keeping Patients Safe: Transforming the Work Environment of Nurses Nov 04,2003Key Capabilities of an Electronic Health Record System Jul 31,2003 Health Professions Education: A Bridge to Quality Apr 08,2003 Priority Areas for National Action: Transforming Health Care Quality Jan 07,2003Fostering Rapid Advances in Health Care: Learning from System Demonstrations Nov 19,2002 Leadership by Example: Coordinating Government Roles in Improving Health Care Quality Oct 30,2002 Envisioning the National Health Care Quality Report Mar 30,2001 Crossing the Quality Chasm: A New Health System for the 21st Century Mar 01,2001 To Err is Human: Building A Safer Health System Nov 01,1999 Ensuring Quality Cancer Care Apr 01,1999
  • 65% of patients in the US are Outpatient, of those 56% are seen in the ER / ED From 2003 to 2006, US healthcare spending increased by $363 billion to reach $2.1 trillion, or nearly $6,800 per capita. To put this into context, during this three-year period, healthcare costs increased by more than what the United States spent on oil and gasoline in total during all of 2006 when energy prices began to reach new highs.In 2006 alone, the United States spent twice as much on healthcare as it did on food—and more than China’s citizens consumed altogether. Not only does the United States spend a great deal on healthcare in absolute terms, but the nation also spends far more than expected, given the relative level of wealth of the United States MORE… US Healthcare Stats Chronic diseases account for 70% of all deaths in the United States. Hospitalizations for pregnancy-related complications occurring before delivery account for more than $1 billion annually. The direct and indirect costs of diabetes is $174 billion a year. Each year, arthritis results in estimated medical care costs of nearly $81 billion, and estimated total costs (medical care and lost productivity) of $128 billion. The estimated direct and indirect costs associated with smoking exceed $193 billion annually. In 2008, the cost of heart disease and stroke in the U.S. is projected to be $448 billion. The estimated total costs of obesity was nearly $117 billion in 2000. Cancer costs the nation an estimated $89 billion annually in direct medical costs. Nearly $98.6 billion is spent on dental services each year. GLOBAL HEALTHCAREGlobalization has radically altered the business model for service and manufacturing industries. Health, traditionally regarded as a local industry, is becoming global as well. It’s changing the way the Chinese think about financing hospitals, Americans recruit physicians, Australians reimburse providers for care, Europeans embrace competition, and Middle Eastern governments build for future generations.“No country has got all the healthcare answers. Whilst different health systems inevitably reflect local societal and political realities, there are valuable lessons to be learned from observing how other health economies make things happen.” In England, for example, we have learnt the lesson that those health economies which reward providers on the basis of quality and productivity get more of both. That’s what the NHS is now aiming to do, both for primary care and hospital services,” said Simon Stevens, President, UnitedHealth Europe and visiting professor of health policy, London School of Economics (and the UK Government’s Health Policy Adviser 1997-2004).Fundamental: Global education about health issues began in the 1950s with the founding of WHO and the acknowledgement that fundamental health improvement begins with public health initiatives such as clean water and immunization. Many Europeans adopted a belief in “solidarity” around publicly funded access to care. Discovery: From the 1970s through the 1990s, healthcare costs spiraled upwards, fueled by increasing demand and medical advances. Pharmaceutical companies were the first to broaden their reach as the need to innovate and compete prompted them to seek global partners and pipelines. Today, the global pharma model continues to expand as companies race to develop genetically targeted drugs and stem cell research. More clinical trials are moved outside the U.S. and Europe to territories where costs are lower. For example, pharmaceutical companies are moving trials to India, which has the world’s largest pool of diabetics, many of whom have never received drugs for treatment, simplifying patient enrollment and trial management. Pharma’s reach has fueled the need for globally harmonized regulations, a difficult but critical effort spearheaded by the European Union (EU) and foreshadowing the need for broader standards in other health arenas.Reactive: Between 1990 and 2010, health systems begin considering a variety of global solutions to local problems. Labor shortages? Ramp up international recruiting. Filipino, Caribbean and South African nurses are aggressively recruited by England and the U.S., where the process was facilitated by a more permissive visa policy for registered nurses. By some estimates, Filipino nurses can earn up to nine times in England what they would earn at home, which has fueled the exodus of an estimated 250,000 nurses, sparking fears of a brain drain at home. “Most of the international medical graduates in the U.S. come from India, Pakistan, the Philippines and other English-speaking countries. Although physicians from Africa do not represent a significant share of the physicians coming to America, the loss of any physicians could be a problem for some African countries. One-fourth of U.S. physicians received training in foreign medical schools. Short of money? Hospital systems in more than 50 countries, including Australia, Brazil, Sweden, Malaysia and UAE, are creating public/private partnerships to build new hospitals and clinics. Doubts about quality? Accreditation agencies with global reach are selling services globally. Need to cut costs or expand services? Outsource to foreign health service firms. Known as “nighthawking,” some American hospitals have turned to companies in Australia, Israel, India, Switzerland and Lebanon to read CT scans overnight.HCIT Vision : Beginning in 1997, health spending had been accelerating as a percent of Gross Domestic Product (GDP) among Organization for Economic Co-operation and Development (OECD) countries. In 2005, the cumulative health spending of 24 OECD countries was $3.1 trillion USD. Multiple sources estimate that health spending for OECD countries will more than triple to $10 trillion by 2020.Healthcare organizations and governments around the world are urgently seeking solutions to temper costs while balancing the need to provide access to safe, quality care. Yet, conventional approaches are failing, even in the most advanced nations of the world – throughout Europe, Asia, the Middle East, Australia, Canada and the United States. Solution Drivers for Change; Transferable LessonsSystem - Industry standards and government regulations are the solutions over which individual organizations have the least direct influence. However, healthcare organizations must devote some Clinicians and participate in national policy debates in order to create a more sustainable health system.1. Collaborate across traditional sectors and territory boundaries2. Determine what care or benefits are basic to public health and structure an insurance system for the rest3. Use regulation to encourage and strengthen competition4. Organize care from the patient’s point of view: establish a patient-centric continuum of care5. Think small6. Anticipate ways to deliver care to patients who increasingly move and travel Finance - Organizations must concentrate on improving their financial position in order to meet global challenges. These solutions will be based in both revenue and expense areas, as well as knowing when and how to make investments. 1. Make consumers more personally responsible for the cost of seeking care2. Put prices on the menu; disclose charges3. Learn from existing systems when designing performance-based reimbursement4. Incentivize clinicians for outcomes, not activity, through pay-for-performance models 5. Design financial incentives to anticipate cream-skimming6. Access new sources of capital through public-private partnerships People - Ultimately, healthcare is delivered by people for people. The capacity for staff to accept and embrace change will make or break solutions because people are the implementers. Organizations that can help their people manage change will be at an advantage in the global health system. 1. Establish shared incentives to accomplish mutual goals2. Make wellness the preferred, if not mandated, lifestyle3. Train workers in new technologies 4. Leverage nursing more widely5. Challenge conventional training models to create new Clinicians and roles that meet future needs Process - Process redesign to increase efficiency and efficacy will be a required competency in the fast changing healthcare environment. Exploiting new technologies, clinical developments and globalization will require process change for organizations to be efficient and nimble. 1. Reinforce clinicians’ roles as facilitators of appropriate care2. Reach agreement on quality standards3. Make error reporting voluntary and anonymous4. Publish or perish: report performance to enhance transparency and knowledge sharing5. Leverage quality to move the market6. Listen to consumers Technology - New medical technologies and new ways to capture and use medical data are just a few examples of how technology can make health systems better. Health organizations will need to choose wisely within limited budgets when it comes to how and what technology they buy. 1. Invest in a shared IT infrastructure2. Leverage technology to eliminate duplication and administrative inefficiencies3. Make technology a reason to collaborate4. Move information, not people5. Customize care to patients’ genetic needs 6. Value technology’s impact on productivity and lifespan
  • FACTOID: US HCIT Market $39.5 Billion 2008 (Datamonitor)Electronic Medical Record EMRAn electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within one Healthcare organization. Electronic Health Record EHRAn electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one Healthcare organization.Personal Health Record PHRAn electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be drawn from multiple sources while being managed, shared, and controlled by the individual. The electronic health record (EHR) is the focus of efforts throughout the health industry to employ the most comprehensive information available to best inform the care delivery process. The definition recognizes that health-related information about a patient is available in multiple locations and systems and that, if presented through a common and user-friendly interface, this information can improve the ability of clinical personnel to support the best possible diagnosis, treatment, and health management decisions for and with an individual. The ability to aggregate comprehensive information, whether physically within one record or virtually from records in multiple locations, is currently limited. Technical standards and common vocabularies for medical terms have yet to be agreed upon let alone implemented for many different types of data originating from many diverse sources. The potential for digitizing information and thus making it available to all involved in Healthcare will improve over time, in step with progress in the interoperability of information and the increased adoption of EHRs within the delivery system. In the past, a person’s medical history was recorded primarily to document how clinicians in a single care organization treated that person’s health needs during a clinical encounter. EHRs will help Healthcare providers move to a more efficient way of organizing and sharing information beyond the scope of one organization or single encounter. EHRs take advantage of advances in computer performance and electronic communication to present a patient-focused view of an individual’s health information recorded by various provider facilities—such as physician offices, hospitals, long-term care facilities, behavioral health centers, home-based care, laboratories and pharmacies—and authorized clinicians, such as physicians, nurses, social workers and others involved in an individual’s care. EHRs will allow the recorded narratives, newly added observations and test results for a patient to be brought together from multiple settings and locations of care providers into one health record. In addition, information from administrative sources may also be included, such as: claims data from health plans; formulary and medication data from pharmacy benefit managers, and demographic data. It is expected that the information contained in an EHR be maintained in a secure manner that protects the confidentiality of the individual’s information. The scope of this definition is limited to the content and characteristics of the underlying record, not on the systems that perform functions enabling data in the record to be used for various purposes. Thus it is different from, and cannot be equated with, establishing detailed functional standards or criteria.
  • 3 Practice Spaces / Environments IP - OP & GPSilos of Information in each Practice SpaceLack of collaboration between the spacesLack of incentive & cooperative tools between spacesNo continuity of care between spaces for PatientsEach space possesses systems that are often proprietary & lack interoperability capabilitiesCurrent System does not mitigate risk for patients or cliniciansMedicine is practiced without interoperability & data availabilityData is dynamic and requires a multi media and real time approach; High Acuity Systems have initiated more of an efforts to combine multi media with dynamic clinical data and yet again this data is kept in a silo…Definition: Patient Focused Care; Following the patient across their personal continuum of care. Patient Care (n) :  1. An at home solution that encourages your independence and improves your quality of life 2. Reliable, dependable assistance focused on your needs 3. A unique combination of professional expertise and personal commitment. Continuum of CareSix Principles of Continuum-Based Care: A set of unifying principles forms the basis for using levels of care along the Continuum of Healthcare encounters, episodes of care, specialty procedures and treatments for an episode of illness/injury be it acute, or chronic.. The underlying principles are: 1. The Continuum of Care describes coordinated levels of care designed for persons who present with a medical condition and/or clinical diagnosis and/or persons needing therapy related to a range of medically-related problems. 2. Patient placement in a level of care along the Continuum of Care is determined by an individualized treatment plan based upon the matching of patient needs with service attributes. Usually initiated by a gatekeeper i.e. General Practitioner (GP)3. Access to care at all levels of intensity is maximized through efficiencies of clinical process and effective management of Clinicians. 4. Clinical decision-making must be collaborative and shared across the continuum to maintain continuity of care. Primary decisions on course of action for patients are between clinicians and the patient, this partnership is fundamental. 5. Treatment offered along the Continuum of Care requires active involvement of the service, departmental and multi-discipline team and patient with both community and family Clinicians. 6. Finally, due to the matching of patient needs with targeted interventions, the provision of treatment in the most appropriate, least restrictive environment, and the reliance on patient education, Clinicians, family and community support systems, this enables the Continuum of Care process, and allows the HC system to adhere to financial policies in providing quality care in a cost effective manner.
  • COMMON MEDICAL VOCABULARY: Clinical vocabularies, terminologies or coding systems, are structured list of terms which together with their definitions are designed to describe unambiguously the care and treatment of patients. Terms cover diseases, diagnoses, findings, operations, treatments, drugs, administrative items etc., and can be used to support recording and reporting a patient's care at varying levels of detail, whether on paper or, increasingly, via an electronic medical record. A nomenclature is a relatively simple system of names; a vocabulary is a system of names with explanations of their meanings; a classification is a systematic organisation of things into classes, and a thesaurus (such as MeSH) is designed to index medical literature and support search over bibliographic databases. But many of the terms used in this field can prove difficult to define accurately, and their use in practice can be inconsistent. Medical coding and classification systems form part of current moves towards implementing a standardised "language for health": a common (computerized) medical language for global use. The US Institute of Medicine 2003 report, Patient Safety: Achieving a New Standard for Care, highlights the importance of terminologies to healthcare and provides the following summary of their purpose and a likely outcome of current efforts in the field: "If health professionals are to be able to send and receive data in an understandable and usable manner, both the sender and the receiver must have common clinical terminologies for describing, classifying, and coding medical terms and concepts. Use of standardized clinical terminologies facilitates electronic data collection at the point of care; retrieval of relevant data, information, and knowledge; and reuse of data for multiple purposes (e.g., disease surveillance, clinical decision support, patient safety reporting). "No single terminology has the depth and breadth to represent the broad spectrum of medical knowledge; thus a core group of well-integrated, non-redundant clinical terminologies will be needed to serve as the backbone of clinical information and patient safety systems." UMLSThe integration of standardised medical terminologies into a single, unified knowledge representation system has formed a key area of applied informatics research in recent years. The Unified Medical Language System (UMLS) is the most advanced and most prominent effort in this direction, bringing together within its Metathesaurus a large number of distinct source-terminologies. The UMLS Semantic Network, which isdesigned to support the integration of these source-terminologies, has proved to be a highly successful combination of formal coherence and broad scope. We argue here, however, that its organization manifests certain structural problems, and we describe revisions which we believe are needed if the network is to be maximally successful in realizing its goals of supporting terminology integration.
  • Patient Centric Care:1. Patients are whole persons. They have roles beyond those determined by their disease. They are family members, workers and members of a community. All these roles need to be taken into account when providing them with health care. (Continuum of Care based Medicine)2. Since patients are not medical professionals, the definition of care they bring to the hospital and clinic environment is vital in how our clinicians care for the patient. The patients feelings of vulnerability must be addressed. The best patient is one that has an understanding of their problem and confidence in the clinician providing care. (Patient Portals)3. Patients experience therapeutic presence, which means that the caregiver is there for them when needed throughout the process of care. This requires that the clinicians is both informed and in lock step with colleagues on the best way to treat and guide the patient throughout the process of care across the continuum. (EHR = Electronic Health Record, Continuity of Care & Clinician Portals)4. The patient is a full partner in their care and an integral part of the care team. The patient's medical condition is discussed with the patient and the patient is involved in making treatment decisions. Communication with the patient is based on his or her level of understanding, and the patient is fully informed about all aspects of his or her condition and care. (Patient Portals & Dynamic Clinical Pathways)5. The patients family are involved in the patient's care and are made to feel welcome in the care environment, be that a hospital, clinic or home setting. (Consumer Portals)6. The patient being a whole person means that the needs of family are met as well. The patient's family relationships do not become unimportant simply because the patient is ill or in the hospital or clinic. We often hear that patients are more concerned about how their spouse is coping than they are about their own health. (Consumer & Patient Portals)7. The patient experiences competence and continuity of care as the clinicians appointed to provide care are informed purveyors of care. The patient must have trust and confidence in caregivers and believe that they are working as a coordinated team. (EHR, Advanced Clinicals, Clinician Portals & Continuity of Care)8. There must be open, honest and respectful sharing of information. The patient, and those whom the patient has authorized, must be able to access information and to expect clear and understandable answers to relevant clinical questions as they arise. (EHR, EBM = Evidence Based Medicine, OBM = Outcomes Based Medicine, Dynamic Clinical Pathways)9. When possible, patients are given choices and schedules are tailored around patient needs. Itineraries of care allow the patient to know where they are supposed to be, when and why. (Enterprise Scheduling, Consumer Portals & Patient Portals)10. The patient’s complete history and clinical experience is recorded, and available for future treatments and clinical encounters. All results, treatment plans, education, discharge / disposition planning, registries, guidelines, clinical notes and procedural documentation can be archived, distributed where and when needed and reported on. (EHR, Clinical Data Center) Healthcare IT Pressures; The changing face of Medicine & how it is practiced and perceivedHospital (acute) levelConsolidation of hospitals and local hospital facilities (centres of excellence)Increased competition amongst hospitals (at least in liberalised model)Emphasis on more complex proceduresGreater risk of patient litigationImpact of foreign workers on costs/overheadsPressure to reduce length of stayGreater dependency on ICU, CCU & NICU bedsShift from Accidents & Emergency to trauma unitsMovement of care and procedures to settings outside of the hospital (specialty clinics)Evolution of Diagnostics & Treatment Centres and day surgeryNeed for improved coordination with services and other settingsEncouragement of hospital information systems, especially clinical systems Increasing provision of information and overall declining qualityGP (outpatient) levelAn increasing requirement to use electronic communication (e.g. for governemnt cost accounting purposes), often based on the introduction of patient and professional cardsThe availability of a subsidised infrastructure Adoption incentives so GP’s are part of the continuum rather than an isolated data siloIncreased gatekeeper role24hour/7days a week service expectation by patientsMany more patient encountersChanging patterns of care activitiesGP workload becoming increasingly clericalIncreased participation in care chains and better coordination needed with hospitals or care servicesGrowing co-operation amongst community care professionals, problems currently at boundary with social careMany community players needing to share patient dataChanging interaction with patients (requiring doctors to have up-to-date information)
  • Continuum of care, Cradle to Grave Model…. Where the data comes from… What do we want to do with the data?In a prototypical client server architecture data resides in a traditional, direct-attached storage model, erratically distributed across the enterprise. This model breeds silos of information and has variably served us well within proximity and connectivity of feeder systems. This is true for applications for which multiple computers serve the same purpose with the same clinical data. Again this model has worked reasonably well for less complex environment; however, it has had some predictable limitations as an enterprise strategy for managing critical clinical data. In many environments there are multiple management, point of capture, and input channels making it increasingly difficult to administer storage and apply consistent data governance policies. An array of disparate storage platforms and configurations are served by different management tools, further adding to the cost of managing the clinical data. Furthermore, data is duplicated throughout the infrastructure, leading to versioning, transfer, and synchronization challenges. This in turn has made it increasingly difficult for healthcare organizations to ensure adequate protection of clinically critical data. Reducing the costs of managing and administration of storage is the premier reason for data consolidation. Multiple studies by storage vendors have indicated what types of storage models are best deployed across a healthcare enterprise, the most scalable solutions and redundant storage options are readily available from these vendors. So, rather than taking a technically focused opportunistic approach to consolidating storage and data, lets take some time to focus on the clinical basis. Therefore if we “start with the end in mind” what do clients want to achieve with data consolidation? This paper is being written with the end user in mind, namely the clinicians. What value does data consolidation have in store for them as well as their administrative management?Define Patient Continuum Focused Care:Sustained partnership between patient and physician that transcends multiple illness episodes and evolves into a relationship characterized by trust, loyalty, and a sense of responsibility.HCIT Sustainability Pressures & Considerations; VisionCollaboration. Payers, hospitals, physicians, and community service organizations are working together to foster standardization and adoption of technology and process changes. They are teaming to enhance access and portability of healthcare services. They are coming together to realign incentives to accomplish mutual goals.• Consumerism. Providers are reorganizing themselves in a patient-centric continuum through care management approaches. Payers are developing consumer-oriented benefits plans. Pharmaceutical and life sciences companies are using new pharmacogenomic discoveries to pursue personalized medicine.Technology assessment and dissemination. Payers, providers and community organizations are coming together on a regional and/or national basis to establish infrastructure and communications standards. They are developing incentives that will distribute the risks and rewards more evenly. Payers and research organizations are evaluating technology relative to productivity and lifespan.Transparency. New payment and reporting methods are emphasizing safety, performance and accountability for health organizations across all industry sectors. Payers and providers are participating in pay-for-performance programs. Industry trade groups are establishing quality and safety standards. Governments are establishing reporting mechanisms and requirements.Portfolio management. Hospitals, pharmaceutical companies, life science organizations, and payers are increasingly called upon to manage their service portfolios in a balanced, fiscally responsible manner. Governments are calling for rational approaches to regional service planning. Providers are organizing and allocating services to meet consumers’ needs for access, manage quality of care, and reduce duplication and inefficiency.Manpower management. New models of developing, recruiting and retaining manpower are developing to address the root causes of gaps in service and impending future needs.
  • Leveraging OECD Banking Transparency ATM to Bank Transactional Data to HCIT ConceptPeople in OECD countries are comfortable and familiar with monetary banks. That’s a good thing because without people willingly depositing their money into banks, there would be no banking system as we know it. Without a healthy monetary banking system our economies would be comparatively dysfunctional, and our personal lives would be critically deficient in opportunities.This is not unlike the requirements we need as a foundation for HCIT. We looked at how transparent banking has t be to compete as well as to be adopted. Today millions of people conduct business in banks as well as over the most available infrastructure conduit “The Internet.”Banking & Healthcare: Take the gathering and delivery of your medical records to a physician. Let’s say that the physician needs only your health records for the last 10 years. What happens next? Her office becomes a dumping ground of confusing data or in some cases paper (or, practically the same thing, scanned images of medical information) from different sources, different specialties, and for time periods beginning with your birth. Suddenly, the physician is an information banker for your information whether she likes it or not. Granular information ownership holds forth the promise of a single, integrated system from which that physician may precisely draw.Consolidating Patient Data: Central RepositoryConsolidating clinical data from disparate systems across the enterprise is more than an exercise in data storage alone. Clinical data consolidation is a complex strategy that requires planning and realization that storing data for redundancy or disaster recovery is merely a first step for data warehousing, data aggregation and intelligence mining of critical data elements. Healthcare Organizations are increasingly taking on clinical data consolidation to help rationalize IT infrastructure investments, reduce IT cost, and take advantage of newer innovative technologies. The challenge anymore is not so much based upon the storage technology; many vendors today can meet and even exceed your expectations with dynamically scalable solutions. However, it is finding the right vendor partner to provide you a full array of services to get the data where it needs to be and to be managed in such a way that the data can be distributed across the enterprise via disparate systems that make up the clinicians point of care. Providing clinician’s relevant clinical data from across the patient’s continuum of care is paramount in the enhancement of patient safety and for the realization of true continuity of care. The challenge for consolidating clinical data is based upon migration, conversions, reconciling, managing and ultimately distribution of these clinical data elements across the “patients’ continuum of care. ELEMENTS1. Security: A physically safe place to store money. Also, government regulations insure continuity of depositswhen banks go bankrupt. – HEALTHCARE; HCIT seeks security, privacy as well as confidentiality, not unlike any financial institution would….2. Credibility: Banks handle people’s money like they say they will in order to continue maintaining andattracting deposits. HEALTHCARE; HCIT must provide credible data and must maintain data integrity3. Incentive: An important dynamic operates here. Banks compensate customers so they can be compensated when they loan funds at higher market interest rates to third parties for financing consumer and commercial purchases. Tougher,,,, HEALTHCARE; HCIT must create a win win situation, when our product are implemented in a thoughtful and workflow centric way balancing how clinicians work and what patients need and expect we have discover that we will have a higher degree of adoption i.e. success.. We incentive healthcare legislatively to invest in to HCIT for the better of the patent as well as to mitigate risk for the clinicians… 4. Control: Customers deposit their money, withdraw it or transfer it when they choose. HEALTHCARE; HCIT we call this access to care & access to data and interoperability.5. Convenience: Banks provide on-site tellers, off-site automatic teller machines and on-line Internet bankingto increase on-demand access. HEALTHCARE; HCIT must provide for access to care as well as access to information leveraging existing technologies as well as exploring more innovative ways to balance customer service not just with our patients but with our clinicians as well form the HCOT perspective both are our customer. With convenience adoption and acceptance will resonate.6. Integration: Banks provide a critical component to a very complex web of communications involved in oureveryday transactions. HEALTHCARE; HCIT deems integration, adoption of standards to be a key area where we must improve and evolve to meet the needs of our patients and to serve our clinicians. At the same time integration allows interoperability, interconnectivity as well as ways to translate the nomenclature to allow a seamless transparency for clinically relevant data across the foundation of the continuum.7. Verification: By regulation and by practice, banks verify that monies deposited with them are legal tenderand not counterfeit. HEALTHCARE; HCIT Requires that data’s integrity is maintained… The Data Challenge: Legacy hospital information systems – while providing adequate support for patient care and administration -- are poorly suited for meeting the information needs of clinicians, administrators and staff. Data requests from GP’s, Clinics, Specialist, and Hospitals often cannot be serviced in a timely manner. Also, those clinician entities and clinical departmental systems installed at various times over the last twenty years are rarely compatible. Thus, creation of a dataset suitable for analysis often demands time-consuming data manipulation such as conversion, migration, merging, data manipulation, data aggregation / mining, archiving for business continuity (BC) as well as disaster recovery (DR). Furthermore it also means that data reports from a single system cannot meet the needs of the patient population as a whole. Medicine does not start nor start at a single institution any longer. Solutions to such problems include development of software, unifying vocabularies, classification of data and assessments as to what data should and must be shared for comprehensive data reporting and transparent access across the continuum of care. The interface with these issues expressed is the easy part as standards like HL7 are a foundation for common communication and interoperability or relevant clinical data. What remains is a tool to abstract multiple episodes of care and their data sources to provide a single ubiquitous view of the patient longitudinal medical record via their existing clinical conduit i.e. user interface (UI). The data that cannot be presented will then need a conduit (usually a bi-directional web-based portal to elaborate on what data you have and what data you will ultimately need to render a treatment follow a pathway or offer a referral to a colleague. Disparate data must be assessed for clinical value, must be classified and unified via existing standards to provide a single enterprise level conduit for data dissemination to occur across your enterprise.
  • Portals immediate impact will be paramount for proliferation of the PHR: A Personal Health Record (PHR) is a confidential and easy-to-use tool for managing information about your health. A PHR is usually an electronic file or record of your health information and recent services, such as your medical conditions, allergies, medications, and doctor or hospital visits that can be stored in one place, and then shared with others, as you see fit. You control how the information in your PHR is used and who can access it. PHRs are usually used on the Internet so that you can look up your information wherever you are.WHY?People are concerned to find themselves at the center of the healthcare ecosystem today because they must navigate a complex web of disconnected interactions between providers, hospitals, insurance companies & government agencies. The focus of a Personal Health Record (PHR) is to empower people to lead healthier lives by being more involved with their health. PHR solutions today allow people to collect their private health information on their terms & for companies across the health industry to deliver compatible tools & services built on the person’s selected PHR provider. HIMSS calls the PHR a ePHR (electronic Personal Health Record) - An electronic Personal Health Record ("ePHR") is a universally accessible, layperson comprehensible, lifelong tool for managing relevant health information, promoting health maintenance and assisting with chronic disease management via an interactive, common data set of electronic health information and e-health tools. The ePHR is owned, managed, and shared by the individual or his or her legal proxy(s) and must be secure to protect the privacy and confidentiality of the health information it contains. It is not a legal record unless so defined and is subject to various legal limitations.
  • Introduction GCDV Concept: Once data is made available within the GCDV, the data is classified, and standardized, catalogued and provided with rules based logic on its availability to disparate systems. The data is now monolithic, and is attached to the patient, their medical record number (ID, enterprise ID, cross referenced “EMPI) and is translated yet again for a PHR (Personal Health Record). The difference between a EHR for clinicians and a PHR for patients is vocabulary and frame of reference. This essentially is the foundation for linking regional and national systems that have leveraged and invested in to legacy and technologies that simply do not interoperate and provide a continuum of care view or aspect capability. With clinical content and data management tools reporting, mining and data aggregation is secure and enabled. The GCDV works much like an EMPI actively or passively with the existing MPI’s, the GCDV simply communicates with the CDR (Clinical Data Repository) and would be capable of providing more clinical relevant data and deeper components of the EMR. Communication protocols are created with top vendors. Agreements are made with each individual site where communication is required so that data governance is adhered and applied. Data ownership is only debatable with vendors, sites are the gatekeepers, and the patients data of course belong to the patient. No longer can HCIT vendors hold data hostage and sites will have the inalienable right to manage and share data as needed to secure quality continuum based care. GCDV enables this ability and right.Global Healthcare Challenges a Catalyst for ChangeScientific progress in biomedical research Technological innovations in diagnosis, treatment, and clinical informaticsChanging clinical practice (as influenced by the two vectors listed above)Institutional and managerial strategies that bring innovation to the patientContinued erosion of acute beds giving way to ambulatory treatment centresThe most powerful long‑term vector for change will be the maturation of scientific inquiry in cell biology and genetics; progress in these areas will generate the most far‑reaching effects in reshaping the healthcare delivery system. The payoffs of biomedical research investments will be based upon OBM (Outcomes Based Medicine), EBM (Evidence Based Medicine) and the CDS (Clinical Decision Support) solutions that feed clinicians as they coach their client down a patient centric dynamic clinical pathway. The management of these pathways across the continuum of care where all clinical and medicinal interventions occur will require a compass; This voyage cannot be made without clinical data content and its appropriate management.These technologies will enable physicians to extend their therapeutic and protective powers beyond the walls of their offices and hospitals. Computerized systems providing continuous medication and patient monitoring will reduce the need to hospitalize patients, perhaps dramatically. The patients of the 21st century will be connected to their physicians, specialist or hospitals by webs of telemetry similar to those used in cellular communications; perhaps these communication webs will be coordinated or monitored by computer systems that could trigger responses in advance of crises.Therefore changing medical technology will make it possible for the home or the residential community to re-emerge as the primary site of clinical care; Just as it was at the beginning of the 20th century. As a result, medical care in 2037 may become less obtrusive and more woven into the fabric of everyday life. The great catalyst for change will be the embracement of internet based technology and existing IT standards, as medical standards appear to be an effort to shape the way vendors develop rather than looking at existing technologies that achieve the same goal. At the same time, the maturation of artificial intelligence applications in medicine may enhance, perhaps dramatically, the productivity of clinicians, and it may improve patient safety as well. Although research into the medical applications of artificial intelligence (the use of large clinical data bases and interactive software for support of diagnostic decisions) has been under way for more than 20 years. In fact 1984 marked the first time that a commercially available product incorporating artificial intelligence became available for hospital use.In the years ahead, “intelligent” clinical informatic systems will become the hospital’s operating core, interacting with all clinicians in diagnostic decision-making and patient management. These systems will monitor patient conditions on a real‑time basis, allow collaboration, tracking physiological signs and incorporating test results, comparing patient responses against profiles gleaned from vast clinical data bases (clinical content management & decision support systems using evidence based medicine), and assisting the patient care team in evaluating and planning patient care. The most rigorous application of computer‑assisted care will be in the intensive care unit, where monitoring technologies are most sophisticated and where integration of patient information and decision-making is required critically. Dynamic clinical pathways will provide patient specific and historical clinical decision support aid for the clinician. This will occur across the continuum providing a common framework for collaboration for clinician interactions as well as outcomes management for chronic disease management and registries designed for research and post visit evidence based medicine.Nano-technology will also provide appropriate direct organ transfer of medications and interactions i.e. artificial isles of langerhan for diabetes management. This will require additional tele-monitoring of patients and active participants with their corporate sponsored or government mandated Patient Health Record. All chronic disease participants and terminal patients will be required to be wired via home, computer and self monitors for nutrition, medication, education and lifestyle management.Physicians will use artificial intelligence systems to complement and to extend their diagnostic capabilities. By the early 2009, a patient’s first encounter with a new physician or health plan may take the form of responding to a diagnostic inquiry program linked by telephone or home computer to the physician’s office. This will frame the first face‑to‑face meeting between patient and physician with a detailed, structured clinical background.Referrals of patients to specialists or admitting patients to hospitals will be accompanied by machine-to‑machine transmittal of clinical information that’s necessary for therapy. Clinical information systems will combine text, sound, multi media and images in new storage and retrieval modes, which will replace paper medical records, Information transmittal will contain both high‑resolution visual images of specimens or affected body parts as well as voice, structured or written commentary from the consultant.Welcome to the hospital of 2037…. As treatment advances divert large numbers of patients from the inpatient hospital setting, and as life‑support and maintenance technologies enable patients to carry on their lives away from hospitals and nursing homes, the hospitalized population will shrink to perhaps half its current size by the early part of the next century, despite an aging population. The hospitalized population will be incredibly frail and costly to treat, exhibiting acuity levels comparable to or higher than patients in today’s hospital intensive care units.The physical hospital will be much smaller and infinitely more complex technically. A 400‑bed facility will be considered large, and the young people of the future will marvel at the 1,000‑ to 1,500‑bed facilities that began emptying out during the 1980s and 1990s.By 2037, today’s hospital will be converted (by technology and by changing delivery patterns) into the high‑tech, critical care hub of a dispersed network of smaller clinical facilities, physician offices, and remote care sites. These networks will be knit together by “intelligent” clinical information systems and by both air and ground critical care transportation systems. The economic boundaries of the system will be defined by the coverage of financing packages tied to the provision of care within the system. Each metropolitan area will boast multiple competing systems, whose networks may stretch out as far as 200 miles from the core facility.HCIT’s Role: The nature of how patients navigate through the healthcare continuum today lacks innovation and creativity. HCIT vendors challenge will be to provide clinicians with the ability to track care across the continuum, following the patient rather than following a clinician. These services will be provided by colleagues and collaborative services based on the internet as the primary conduit of data elements. The patient lies at the center of a complex interaction of medical science, clinical care, care coordination, social support, prevention, lifestyle management, and decision making. The first step will be to assist and participate actively in breaking down the barriers that exist today for a diverse solution capable of bridging the continuum spectrum in a logical and effective manner.
  • Standards are vital to HCIT as well as the future of deployed clinical solutions; The current range of HCIT standards run a wide gamut and span several tiers of the healthcare IT industry. There is a real need today for focused coordination of these initiatives to leverage the synergies, to continue to promote harmonize vocabularies, to enable interoperability & to support consistent and uniformed data standards across the continuum of care. HCIT Standards: Standards are vital to HCIT as well as the future of deployed clinical solutions; The current range of HCIT standards run a wide gamut and span several tiers of the healthcare IT industry. There is a real need today for focused coordination of these initiatives to leverage the synergies, to continue to promote harmonize vocabularies, to enable interoperability & to support consistent and uniformed data standards across the continuum of care. Standards Used in HCIT:Accredited Standards Committee (ASC) X12 Insurance Subcommittee (X12N) Implementation Guides Version 004010 plus Addenda 004010A1 - http://www.x12.org/Accredited Standards Committee (ASC) X12 Standards Release 004010 - http://www.x12.org/American Society for Testing and Materials (ASTM) Standard Specification for Continuity of Care Record (CCR) - ASTM International, Committee E31 on Healthcare Informatics: EMR / EHR vendors can use the organization's data security and privacy standards, but it is best known for the Continuity of Care Record uniform patient summary. http://www.astm.org - http://www.astm.org/cgi-bin/SoftCart.exe/COMMIT/COMMITTEE/E31.htm?E+mystoreCouncil for Affordable Quality Health Care (CAQH) Committee on Operating Rules for Information Exchange (CORE) Phase I Operating Rules - http://www.caqh.org/Federal Medication Terminologies - http://www.ncvhs.hhs.gov/061012p2.pdfHealth Level Seven (HL7) Version 3.0 Continuity of Care Document (CCD) - http://www.hl7.org/Health Level Seven (HL7) Version 3.0 Clinical Document Architecture (CDA/CDA R2 – HIS = IHE- Integrating the Healthcare Enterprise) - http://www.hl7.org/ & http://www.ihe.net/ - http://ihe.univ-rennes1.fr/organization/news.phpHealth Level Seven (HL7) Version 2.5 - http://www.hl7.org/Health Level Seven (HL7) EHR System Functional Model Draft Standard for Trial Use (DSTU) 0 http://www.hl7.org & http://www.providersedge.com/ehdocs/ehr_articles/HL7_EHR_System_Functional_Model-DSTU.pdfIntegrating the Healthcare Enterprise (IHE) Laboratory Technical Framework Supplement 2006-2007 Revision 1.0 - http://www.ihe.net/ - http://ihe.univ-rennes1.fr/organization/news.phpIntegrating the Healthcare Enterprise (IHE) Patient Care Coordination (PCC) Technical Framework Revision 1.0 - http://www.ihe.net/ - http://ihe.univ-rennes1.fr/organization/news.phpLogical Observation IdentifiersNames and Codes (LOINC®) - http://www.regenstrief.org/National Council for Prescription Drug Programs (NCPDP) SCRIPT Standard Version 8.1 - http://www.ncpdp.org/main_frame.htmUMLS (Uniformed Medical Language System) - http://www.nlm.nih.gov/research/umls/umlsmain.html (US) & http://umlsks.nlm.nih.gov/kss/servlet/Turbine/template/admin,user,KSS_login.vm (UK)DICOM (Digital Imaging & Communications in Medicine) - http://medical.nema.org/MeSH (Medical Subject Headings) - http://www.nlm.nih.gov/mesh & SnoMed CT - http://www.nlm.nih.gov/research/umls/Snomed/snomed_main.html - http://www.snomed.org/documents/snomed_overview.pdfIHE XDS (Cross-Enterprise Document Sharing) - http://www.ihe.net/ & http://ihe.univ-rennes1.fr/organization/news.php - http://www.ihe.net/Events/xds-i_demo_rsna2006.cfmHealth Information Exchange (HIE) – Europe http://www.hi-europe.info/wire/default.htm & US http://www.ehealthinitiative.org/default.mspx a part of the eHealth Initiative, agreed data exchange (data sharing across the continuum)RxNorm - http://www.nlm.nih.gov/research/umls/rxnorm/index.html & http://www.nlm.nih.gov/research/umls/presentations/2004-amia-poster-ob.pdf & http://www.ncvhs.hhs.gov/050201p5.pdfISO International Organization of Standards (Suisse) - http://www.iso.ch/iso/en/stdsdevelopment/tc/tclist/TechnicalCommitteeDetailPage.TechnicalCommitteeDetail?COMMID=4720CORBA (Common Object Request Broker Architecture) - http://www.corba.orgOMG (Object Management Group) http://www.omg.org/EHR-Lab Interoperability and Connectivity Standards (ELINCS): An emerging standard for reporting laboratory test results with future plans for a lab test ordering standard - http://www.elincs.orgSource: http://www.medicity.com/WhitePaper/Page3.aspStructured versus Unstructured Data: Structured data (also called discrete data) means information that can be stored, quantified, and evaluated in relationship to other data elements. The term structured data is used in contrast with free-form data or blob data which can be stored and sometimes searched, but cannot preserve or represent relationships with other stored information. For example, voice dictation—stored as transcribed text strings, formatted documents or sound files—is blob data. As a text string or document it can be searched for the occurrence of key words. As a sound file it can be indexed and retrieved by descriptors, but cannot be searched. In contrast, a spread sheet—an example of structured data—with the same information, preserves it in a form so that automated analysis can correlate one information item with another and tally the results for all similarly captured notes.Discrete data has great value if it can be efficiently collected. It populates a database of patient histories that can then be mined for all of the rich information that it contains. It offers statistical evidence for improving every aspect of the care equation. Source: Rex OsbornConclusion: Resolution is standardization of clinical data elements as well as inevitable new UI’s (web based portals for example across the continuum) that structure all data for legacy systems that do not meet the standards being proposed or are capable of meeting those standards. Cost will be the major road block for adoption of new standards, even if the standards can improve delivery of care immediately. Workarounds and workflow adaptation (workarounds) will occur @ the point of care requiring GP (General Practitioners) to login to multiple products / solutions to retrieve data that should be available and is available in multiple databases across the continuum. The real weakness today no matter the degree of sophistication of the solutions is the inability for clinicians to collaborate and corroborate no matter their physical location. The marketing ploy of “data where and when you need it most” only counts if that vendors products are everywhere you are. Unfortunately a single vendor seldom has solutions across the patients continuum of care, therefore tactically clients should demand better integration, smarter interoperability and transparency of data distribution and communications. How to Push for Standards… Gain an advisor, partner, not a consultant that has no skin in the game. Shared risk is a fraternity.1. Standards-definition efforts driven by market needs and urgency.2. Adopt standards within products promptly Demonstrate interoperability – both within, and between, enterprisesStandards and interoperability certification“Without standards… How can we get clinical data from a wide variety of vendors/systems/solutions in to a harmonic database that is shared between the General Practitioners, Clinics, Hospitals, Skilled Nursing facilities as well as Long Term Care?”Source: http://www.nlm.nih.gov/research/umls/umlsdoc_intro.htmlDefinition: UMLS - The Unified Medical Language System (UMLS) facilitates the development of computer systems that behave as if they "understand" the language of biomedicine and health. To that end, NLM produces and distributes the UMLS Knowledge Sources (databases) and associated software tools (programs). Developers use the Knowledge Sources and tools to build or enhance systems that create, process, retrieve, and integrate biomedical and health data and information. The Knowledge Sources are multi-purpose and are used in systems that perform diverse functions involving information types such as patient records, scientific literature, guidelines, and public health data. The associated software tools assist developers in customizing or using the UMLS Knowledge Sources for particular purposes. The lexical tools work more effectively in combination with the UMLS Knowledge Sources, but can also be used independently. Source: http://www.regenstrief.org/medinformatics/loinc/Definition: LOINC - The purpose of the LOINC® database is to facilitate the exchange and pooling of results, such as blood hemoglobin, serum potassium, or vital signs, for clinical care, outcomes management, and research. Currently, most laboratories and other diagnostic services use HL7 to send their results electronically from their reporting systems to their care systems. However, most laboratories and other diagnostic care services identify tests in these messages by means of their internal and idiosyncratic code values. Thus, the care system cannot fully "understand" and properly file the results they receive unless they either adopt the producer's laboratory codes (which is impossible if they receive results from multiple sources), or invest in the work to map each result producer's code system to their internal code system. LOINC codes are universal identifiers for laboratory and other clinical observations that solve this problem.Source: http://www.nlm.nih.gov/pubs/factsheets/mesh.htmlDefinition: MeSH – MeSH (Medical Subject Headings) is the National Library of Medicine's controlled vocabulary thesaurus. It consists of sets of terms naming descriptors in a hierarchical structure that permits searching at various levels of specificity.MeSH descriptors are arranged in both an alphabetic and a hierarchical structure. At the most general level of the hierarchical structure are very broad headings such as "Anatomy" or "Mental Disorders." More specific headings are found at more narrow levels of the eleven-level hierarchy, such as "Ankle" and "Conduct Disorder." There are 22,997 descriptors in MeSH. In addition to these headings, there are more than 151,000 headings called Supplementary Concept Records (formerly Supplementary Chemical Records) within a separate thesaurus. There are also thousands of cross-references that assist in finding the most appropriate MeSH Heading, for example, Vitamin C see Ascorbic Acid. These additional entries include 24,050 printed see references and 112,012 other entry points.Source: http://www.snomed.org/ & http://www.snomed.org/snomedct/documents/snomed_ct_user_guide.pdfDefinition: SnoMed - SNOMED Clinical Terms® (SNOMED CT®), is the universal health care terminology that makes health care knowledge usable and accessible wherever and whenever it is needed. This strong foundation is leading the health care industry in building a seamless infrastructure of worldwide care while integrating an overwhelming amount of clinical data.
  • Consolidating Patient Data: Central RepositoryConsolidating clinical data from disparate systems across the enterprise is more than an exercise in data storage alone. Clinical data consolidation is a complex strategy that requires planning and realization that storing data for redundancy or disaster recovery is merely a first step for data warehousing, data aggregation and intelligence mining of critical data elements. Healthcare Organizations are increasingly taking on clinical data consolidation to help rationalize IT infrastructure investments, reduce IT cost, and take advantage of newer innovative technologies. The challenge anymore is not so much based upon the storage technology; many vendors today can meet and even exceed your expectations with dynamically scalable solutions. However, it is finding the right vendor partner to provide you a full array of services to get the data where it needs to be and to be managed in such a way that the data can be distributed across the enterprise via disparate systems that make up the clinicians point of care. Providing clinician’s relevant clinical data from across the patient’s continuum of care is paramount in the enhancement of patient safety and for the realization of true continuity of care.The challenge for consolidating clinical data is based upon migration, conversions, reconciling, managing and ultimately distribution of these clinical data elements across the “patients’ continuum of care.
  • Gis2009 Hydrabad Osborn New

    1. 1. Rex Osborn;Clinical Informatic Idea Architect
    2. 2. SECTIONS
    3. 3. HEALTHCARE CHALLENGES FACTOID: In the US; The medical care costs of people with chronic diseasesaccount for more than 75% of the nation’s $2.8 Trillion USD medical care costs
    4. 4. EMR vs EHR There are components of data classifications that are most associated with an EHR; 1. Integrated view of the data 2. Access to knowledge sources 3. Physician order entry & clinical data entry 4. Integrated communication support & 5. Clinical decision supportFMSU CONFIDENTIAL - 13 September 2006
    5. 5. COMMON “HCIT”DENOMINATORS
    6. 6. HCIT EVOLUTION Level 4 Continuum Focused Continuity of Care Continuum Focused; Continuity of Care & PHR/CCR Reduces barriers betweenClinical & Financial Value Level 3 GP / Specialist & Hospital Clinicians Ambulatory & Acute ACIS - CPOE & EMR Prevalence - Enterprise Inclusive w/ ACIS, IT Standards Based CPOE & EMR Focus Uniformed & Structured Data Elements & Level 2 Healthcare Standards Classification are optional (low full Adoption rate) Innovation: IDN Focused IDN Based HIS vendors Initiated Clinical, >> Chronic Disease Admin & Innovation: Management Level 1 Financial Integration >> Clinical >> Outcomes based Pathways Medicine >> Clinical >> Patient Legacy Innovation: Decision Support Empowerment Non-Scalable >> Bi-Directional >> Point of Care Solutions Integration Devices (Access) Patient Focused Care “Heavy Financial >> Standards >> Internet Dependence Via & Administration Discussion >> Evidence Based EHR for Clinicians Programs” Initiated (1980’s) Medicine PHR for Patient 9 Complexity, Diversity & Comprehensiveness
    7. 7. Defining; HCIT UTOPIA 10
    8. 8. PATIENT UTOPIA 11
    9. 9. MEDICINE UTOPIA 12
    10. 10. CRADLE to GRAVE
    11. 11. 15
    12. 12. INTEROPERABILITY & TRANSPARENCY 16
    13. 13. INTERFACE Portals VS Engines Portals are empty vessels; Conduits for source data Rarely leveraging a relational DB. Lack intelligence to categorize or unify medical language & do not consider clinical relevance Challenged by multiple Pt ID domains & no clinical decision support Is a wonderful conduit for a unified view, coupled with an intelligent eCDR Can provide a unified view Primarily “Uni” directional, seldom interactional FUTURE: Will become essential tool for clinicians, payors / Govt & patients
    14. 14. LEVERAGE STANDARDS1. Leverage existing integration standards2. Uniformity of data and communication protocols, IT standards3. Promote harmonization of medical vocabulary, allowing a translation level of registry services to provide easier cataloguing & distribution4. Support ANY IT standard that will break down barriers between clinicians 20
    15. 15. Cerner GE Eclipsys AGFA LIS Critical Rad & PPM Ambulatory CIS RIS Care Cardio EMR PACS EMR Rx Units PACS • Lab Results • Clinical Notes • Clinical Notes • Clinical Notes • Lab Referrals • Clinical Docs • Clinical Docs • Clinical Docs • Rad Dx Rpt • Assessment • DICOM • DICOM • Results • Physiological • Rad Referrals • Results • DICOM SR • DICOM SR • Orders • Monitors • Rx Scripts • Orders • Care Plans • Pathways • eRx • Referrals Enterprise Dynamic “Results” EBM, CDS,Images EDMS Data D/W OBM & CDM CDR 21
    16. 16. THE IDEA A real time clinical data collector, master distributor & manager of all clinical data across the healthcare collective. The Global Clinical Data Archive, provides seamless interoperability between existing and future clinical informatic solutions. The GCDV provides transparency distribution of all clinical data elements in the appropriate nomenclature andontology across the patient continuum of care. The GCDV breaks down barriers between clinicians, enables true connectivity, reduces medical errors and makes your clinical IT solutions better. GCDV makes your healthcare IT environment work! 23
    17. 17. = WORLD CLASS NATIONAL HEALTH Dubai Abu Dhabi UAE Ministry of Health Object Replication Clinical Data Conduits Clinical Data Clinical Data Clinical Data RDBMS – GCDV Manager & UMLS Managers RDBMS – GCDVManager & UMLS Region(s) 1 & 2 National Region(s) 1, 2, 3, 4, 5 6&7 24

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