Nature of Medical Data 6.872/HST950 Peter SzolovitsOutline • 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 approachesImplications 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 accountantsWhy 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 researchWho Keeps Records? • Doctor • Nurse • radiologist • Office staff, • pharmacist admissions • patient • Administrator • physical therapist • lab personnelForms of Clinical Data • Numerical Measurements – Lab data – Bedside measurements – Home instrumentation • Recorded signals (e.g.,ECG, EEG, EMG) • Images (X-ray, MRI, CAT, Ultrasound, Pathology, …) • Genes (SNPs, expression arrays, pedigrees, …) • Coded (?) discrete data – Family history – Patient’s medical history – Current complaint • Symptoms (patient) • Signs (doc) – Physical examination – Medications • Narrative text – Doctor’s, nurse’s notes – Discharge summaries – Referring lettersOrganization 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, plansPOMR Data Base Problem List Plans (by problem) Progress Notes (by problem) diagnostic, therapeutic, patient educationThe Data Base • Identifying information (name, age, sex, race, religion, insurance info,etc.) • Patient profile (occupation, education, marital status, children,hobbies, worries, moods, sleep patterns, habits, etc.) • Medical history – Chief complaints – History of present illness – Past medical history – Review of systems – Family history – Medications • Physical examination • Laboratory data and physiologic tests (complete blood count,electrocardiogram, chest x-ray, creatinine, urinalysis, vital capacity, tonometry, etc.)The Problem List • “those features in the patient’s psychobiological makeup that require continuing attention” – Social history – Risk factors – Symptoms – Physical findings – Lab tests • Causally organized; e.g., GI bleeding caused by duodenal ulcer appears under the ulcerExample Problem List No Active Date Inactive Date 1 Hypertension 1953 2 Recurrent bronchitis 1958 3 Penicillin allergy 1958 4 S/P pyelonephritis 1960 5 Gallstones Oct 1972 Cholecystectomy Mar 1973 6 Arthralgias Mar 1973 #9 June 1973 7 Pleurisy Mar 1973 #9 June 1973 8 Proteinuria Apr 1973 #9 June 1973 9 SLE June 1973 10 Unemployment Nov 1973Problem-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, …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.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.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.Example SOAP Note #3 RHD with mitral stenosis S: 2 flight dyspnea, mild fatigue. No orthopnea, hemoptysis, ankleedema. Child has strep throat. O: BP 120/70. P 78 regularNeck 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.—2weeks Ed: Reinstructed about antibiotic coverage for tooth extractions,sched. for next month. (Will contact oral surgeon.)POMR characteristics • Augment with data flow sheets • Importance of clinical judgment • Benefits: – Communication among team members, explicitness – Education and audit – Clinical researchPOMR 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.Mayo experience • Paper records, mostly • Pneumatic tube delivery, therefore limited size • Formal procedures for reaping and organizing records at discharge • Comprehensive indexThe Computer-based Patient Record • IOM Study: Dick, R. S. and Steen, E. B., Eds.(1991). The Computer-Based Patient Record: An Essential Technology for HealthCare. Washington, D.C., National Academy Press. • Made strong case for CPR • Recommended CPRI (Institute), but it nevercaught on • Today’s standards grow more out ofcommunication standards: HL7 (labs) andDICOM (digital images)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)Paper record: Weaknesses • Content: missing, illegible, inaccurate – E.g., one hospital study: 11% of tests were repeats to replace lost information – Too thick (1.5 lbs avg.) – Fail to capture rationale – Incomprehensible to patients and familiesSample paper record defects • 75% of face sheets had no dischargedisposition, 48% no principal Dx • Agreement between
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