Intro to Medical Informatics Nature of Medical Data 6.872/HST950 Lecture# 21 Implications of Health Care Organization for Informatics • Money determines much – Medicine spends 1-2% on IT, vs. 6-7% for business overall, vs. 10-12% for banking – “Bottom line” rules, therefore emphasis on • Billing • Cost control • Quality control, especially if demonstrable cost savings • Retention and satisfaction (maybe) – Management by accountants 3 Who Keeps Records? •Doctor •Nurse • radiologist • Office staff, • pharmacist admissions • patient • Administrator • physical therapist • lab personnel Outline • Recall context of current medical practice • History of medical record keeping • Organization of medical records • Computerized medical records –Why – Key issues – Failures and successes • Current approaches 2 Why Keep Records? • Basis for historical record • Communication among providers • Anticipate future health problems • Record standard preventive measures • Identify deviations from the expected • Legal record • Basis for clinical research 4 Forms of Clinical Data • Numerical Measurements • Coded (?) discrete data – Lab data – Family history – Bedside measurements – Patient’s medical history – Home instrumentation – Current complaint • Recorded signals (e.g., • Symptoms (patient) ECG, EEG, EMG) • Signs (doc) – Physical examination • Images (X-ray, MRI, CAT, – MedicationsUltrasound, Pathology, • Narrative text…) • Genes (SNPs, – Doctor’s, nurse’s notes expression arrays, – Discharge summaries pedigrees, …) – Referring letters 5 6 Harvard-MIT Division of Health Sciences and TechnologyHST.950J: Medical ComputingPeter Szolovits, PhD10987654321Intro to Medical Informatics 8 POMR Data Base Problem List Plans (by problem) Progress Notes (by problem) diagnostic, therapeutic, patient education The Data Base The Problem List • “those features in the patient’s psychobiological • Identifying information (name, age, sex, race, religion, insurance info, makeup that require continuing attention”etc.) • Patient profile (occupation, education, marital status, children, – Social historyhobbies, worries, moods, sleep patterns, habits, etc.) – Risk factors • Medical history – Chief complaints – Symptoms – History of present illness – Physical findings– Past medical history – Review of systems – Lab tests – Family history • Causally organized; e.g., GI bleeding caused by– Medications • Physical examination duodenal ulcer appears under the ulcer • Laboratory data and physiologic tests (complete blood count, electrocardiogram, chest x-ray, creatinine, urinalysis, vital capacity, tonometry, etc.) 9 10 Organization of Data • Doctor’s journal (traditional) • Time order of collection, per patient (Mayo) • Source of data • Problem-Oriented Medical Record (POMR) (L. Weed, 1969) – Notes organized by problems – SOAP: subjective, objective, assessment, plans 7 11 Example Problem List Nov 1973 Unemployment June 1973 SLE June 1973 �#9Apr 1973Proteinuria June 1973 �#9Mar 1973Pleurisy June 1973 �#9Mar 1973Arthralgias Mar 1973 �Cholecystectom y Oct 1972Gallstones 1960S/P pyelonephritis 1958Penicillin allergy 1958Recurrent bronchitis 1953Hypertension DateInactiveDateActiveNo Problem-Related Plans • Diagnostic: lab tests, radiology studies, consultations, continued observations, … • Therapeutic: medications, diet, psychotherapy, surgery, … • Patient education: instruction in self-care, about goals of therapy, prognosis, … 12Intro to Medical Informatics Plans per problem 1. Diarrhea Dx: • stool for occult blood, culture, ova, and parasites, microscopic fat; and muscle fibers • Sigmoidoscopy • Barium enema if persistent Rx: Avoid foods that exacerbate Ed: Informed that more info is needed to make a diagnosis, will aim for symptomatic therapy for now. 13 Progress Notes • Subjective: interval history, adherence to program • Objective: physical findings, reports of lab, x-ray, other tests • Assessment: Appraisal of progress, interpretation of new findings, etc. • Plan: Dx, Rx, Ed. 15 POMR characteristics • Augment with data flow sheets • Importance of clinical judgment • Benefits: – Communication among team members, explicitness – Education and audit – Clinical research Plans per problem (cont.) 2. Pyuria Dx: •BUN • Repeat urinalysis • Urine culture 3. Obesity Rx: 1500 kcal diet, Weight Watchers Ed: Dangers of obesity cited. Goal: 170 lbs. 14 Example SOAP Note #3 RHD with mitral stenosis S: 2 flight dyspnea, mild fatigue. No orthopnea, hemoptysis, ankle edema. Child has strep throat. O: BP 120/70. P 78 regular Neck veins normal, lungs clear. Grade iii diastolic rumble, wide opening snap, P2 slightly ↑ A: Stable. Catheterization still not indicated. Risk of strep throat present. P: Dx: Cardiac fluoroscopy Rx: Continue chlorothiazide and penicillin V 250mg b.i.d.—2 weeks Ed: Reinstructed about antibiotic coverage for tooth extractions, sched. for next month. (Will contact oral surgeon.) 16 POMR evidence • Difficult adoption • Some duplication • Some doctors liked it • Paper-based POMR slow, computer-based maybe faster • Demand-oriented MR: by time, by source, by problem, etc. Dynamic arrangement. 17 18Intro to Medical Informatics Mayo experience • Paper records, mostly • Pneumatic tube delivery, therefore limited size • Formal procedures for reaping and organizing records at discharge • Comprehensive index 19 Paper record: Strengths • Familiar; low training time • Portable to point of care • No downtime • Flexibility; easy to record subjective data • Browsing and scanning – Find information by unanticipated characteristics (e.g., Dr. Jones’ handwriting) The Computer-based Patient Record • IOM Study: Dick, R. S. and Steen, E. B., Eds. (1991). The Computer-Based Patient Record: An Essential Technology for Health Care. Washington, D.C., National Academy Press. • Made strong case for CPR • Recommended CPRI (Institute), but it never caught on • Today’s standards grow more out of communication standards: HL7 (labs) and DICOM (digital images) Paper record: Weaknesses • Content: missing, illegible, inaccurate – E.g., one hospital study: 11% of tests
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