“Nursing Interventions and Outcomes in Three Older Populations” Effectiveness Study

Project Consultant MeetingUniversity of Iowa College of Nursing

February 10-11, 2003

Advanced Controlled Medical TerminologyWireless Palm-based Access to Health Information

James J. CiminoColumbia University Department of Medical Informatics

Advanced Controled Medical Terminology:The Medical Entities Dictionary (MED)

• Columbia Presbyterian Medical Center

• Health data repository since 1988

• Multiple uses of data

• Automated decision support

• Merger with New York Hospital

New York Presbyterian HospitalClinical Information Systems Architecture

DatabaseInterface

Research

Administrative

Alerts & Reminders

Reformatter

Database Monitor

Clinical Database

Medical Logic Modules

Medical Entities Dictionary

Results Review

. . .. . .Radiology LaboratoryDischarge

Summaries

Reformatter Reformatter

Central Controlled Terminology

MED Structure

MedicalEntity

PlasmaGlucose

Test

LaboratorySpecimen

PlasmaSpecimen

AnatomicSubstance

Plasma Substance

Sampled

Part of

Has S

pecimen

Substance Measured

LaboratoryProcedure

CHEM-7

LaboratoryTest

Event

DiagnosticProcedure

Substance

BioactiveSubstance

Glucose

Chemical

Carbo-hydrate

The MED Today

• Concept-based (73,000)

• Multiple hierarchy (90,000)

• Synonyms (180,000)

• Translations (125,000)

• Semantic links (134,000)

• Attributes (175,000)

Applications of the MED

• Communicating terminology changes

• Data modeling to support clinical applications

• Terminology management

• Conceptual mapping for decision support

• Problem-based views of the EMR

• Translation to link to information resources

K#1 = 4.2K#1 = 3.3

K#2 = 3.2

K#1 = 3.0

Retrieving Results Individually

K#1

K#2

K#3 = 2.6

K#3

K#1 = 4.2K#1 = 3.3

K#2 = 3.2

K#1 = 3.0

Retrieving Results by Class

K#1

K#2

K

K#3

K#3 = 2.6

Supporting Clinical Applications: Example: Summary Reports

Chem20 Display

Lab Display

Plasma Glucose Test

Serum Glucose TestFingerstick Glucose Test

Lab Test

Intravascular Glucose Test

DOP Summary

WebCIS Summary

Maintenance: “Pushing” a Term

MedicalEntity

LaboratoryTest

PlasmaGlucose

Test

BioactiveSubstance

Glucose

Carbo-hydrate

ChemistryTest

Chem-7Glucose

Test

Chem-20Glucose

Test

StatGlucose

Test

Chemical

Maintenance: “Pushing” a Term

MedicalEntity

LaboratoryTest

PlasmaGlucose

Test

BioactiveSubstance

Glucose

Carbo-hydrate

ChemistryTest

Chem-7Glucose

Test

Chem-20Glucose

Test

StatGlucose

Test

StatGlucose

Test

Chemical

Maintenance: “Pushing” a Term

MedicalEntity

LaboratoryTest

PlasmaGlucose

Test

BioactiveSubstance

Glucose

Carbo-hydrate

ChemistryTest

Chem-7Glucose

TestStat

GlucoseTest

Chem-20Glucose

Test

StatGlucose

Test

StatGlucose

Test

Chemical

Maintenance: Finding a New Class

MedicalEntity

LaboratoryTest

Hepatitis BCore Antigen

Chemical

ChemistryTest

CoreAntigenHBC

Antigen

Maintenance: Finding a New Class

MedicalEntity

LaboratoryTest

Hepatitis BCore Antigen

Chemical

ChemistryTest

CoreAntigen

Hepatitis BCore Antigen

Test

HBC

Antigen

MedicalEntity

LaboratoryTest

Hepatitis BCore Antigen

Chemical

ChemistryTest

CoreAntigenHBC

Antigen

Maintenance: Automated Classification

MedicalEntity

Drug

PharmacologicSubstance

Sulfameth-oxizole

Chemical

Antibiotic

Bactrim"S1", "65"

Trimethoprim/Sulfamethoxizole

PreparationsTrimeth-

oprim

Septra"S1"

Sulfa Allergy"S1"

AllergyClass

TrimethoprimAllergy

"65"

Terminology and Automated Decision Support

• Data monitor checks for triggering conditions

• Medical Logic Modules decide if warning conditions are present

• Message sent to appropriate channel

• Decision support concepts are more general than clinical data

• MED provides mapping

• Example: Tuberculosis culture result

Automated Decision SupportExample: “Positive” TB Cultures

• Alert checks for late results of TB tests

• IF Result Not Equal “No Growth”…

• One day, an apparent epidemic of positive results…

…but checking the lab shows

“No Growth to Date”

How the Lab Fooled the Alert

• Alert looked for results = “No Growth”

• Lab started reporting “No Growth to Date”

• “No Growth to Date”<> “No Growth”

• Solution: Use the controlled terminology to map all No-Growth-like lab terms into a single class, and have the alert logic refer to the class.

How We Outsmarted the Lab(Before)

No Growth

Medical Logic Module

No Growth to Date

No Growth after ...

How We Outsmarted the Lab(After)

No Growth

No Growth after 48 Hours

No Growth after 72 Hours

“No Growth” Results

No Growth after 24 Hours

No Growth to Date

Medical Logic Module

Lab :1/1/99 Cardiac Enzyme Test

Radiology :2/23/99 Chest X Ray

Radiology :2/28/96 Head CT

Lab :12/28/96 Sickle Cell Test

Admission :3/14/96 Stroke

Admission :2/14/98Angina

Lab :1/1/99 Blood Type Test

Radiology :2/1/97 Knee X Ray

Discharge :1/15/99 CHF

MedicalRecord

Problem-Oriented Views of the EMR

Chest X ray

IntravascularCK Test

CreatineKinase

Chest X ray 2 View

Cardiac Enzyme

CongestiveHeart Failure

Angina

Heart Disease

Chest

Admission :2/14/98Angina

Lab :1/1/99 Cardiac Enzyme Test

Radiology :2/23/99 Chest X Ray

Discharge :1/15/99 CHF

Heart MED

Translations with the MED

Gentamicin

InjectableGentamicin

Gentamicn Sensitivity

Test

SerumGentamicin

Level

GentamicinToxicity

EtiologyMeasures

Sensitivity

Substance Measured Has ingredient

is-a

IntravascularGentamicin

TestsSummaryReports

DecisionRule

ExpertSystem

DrugInformation

Linking to Expert Systems

Linking to Expert Systems

Linking to Expert Systems

Wireless Palm-based Access to Health Information:The Palm-Based Clinical Information System (PalmCIS)

• Lack of information contributes to errors

• Inadequate communication contributes to errors

• Multimodal studies of information and communication

• PalmCIS

• Virtual Whiteboard

• Infobuttons

Studies of Information and Communication

• Modalities– questionnaires– focus groups– observational studeis

• Information needs:– nurses: diagnoses, labs, policies, drug information,

educational materials– physicians: diagnoses, labs, notes, disease

management, prescribing

• Communication needs:– nurses: who’s the doctor?– physicians: who’s the nurse?

PalmCIS• Hand-held, wireless platform

– Kyocera SmartPhone– Sprint PCS– Eudora Web

• Security– HTTPS– Login/ID– SecureID– IP Address– Device ID

• Clinical Data– WebCIS Functions– Shortcuts

PalmCIS

PalmCIS

PalmCIS

PalmCIS

• Matches patients, teams, and roles

• Notes added to team-member’s “to do” list

• Answers “Who’s taking care of…?”

• Asynchronous communication channel

• Data capture/display interfaces

• Scheduling systems

Virtual Whiteboard

Virtual Whiteboard

• Context-specific information needs

• Access to Internet resources– PubMed– Micromedex

• Access to Palm-based applications– Epocrates

Infobuttons

Infobuttons

Infobuttons

Infobuttons

Status Report

• Applications built

• Pilot testing with physicians and NPs

• Collecting scheduling info

• Clinical study planned