Intro to Medical Informatics©2004, Peter Szolovits and MIT 11Nature of Medical Data6.872/HST950Peter Szolovits2Outline• 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 approaches3Implications 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 accountants4Why 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 research5Who Keeps Records?•Doctor•Nurse• Office staff, admissions• Administrator• physical therapist• lab personnel• radiologist• pharmacist• patient6Forms 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 lettersIntro to Medical Informatics©2004, Peter Szolovits and MIT 27Organization 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, plans8POMRData Base Problem ListPlans(by problem)Progress Notes(by problem)diagnostic, therapeutic,patient education9The 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.)10The 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 ulcer11Example Problem ListNov 1973Unemployment10June 1973SLE9June 1973Æ#9Apr 1973Proteinuria8June 1973Æ#9Mar 1973Pleurisy7June 1973Æ#9Mar 1973Arthralgias6Mar 1973ÆCholecystectomyOct 1972Gallstones51960S/P pyelonephritis41958Penicillin allergy31958Recurrent bronchitis21953Hypertension1DateInactiveDateActiveNo12Problem-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, …Intro to Medical Informatics©2004, Peter Szolovits and MIT 313Plans per problem1. DiarrheaDx: • stool for occult blood, culture, ova, and parasites, microscopic fat; and muscle fibers• Sigmoidoscopy• Barium enema if persistentRx: Avoid foods that exacerbateEd: Informed that more info is needed to make a diagnosis, will aim for symptomatic therapy for now.14Plans per problem (cont.)2. PyuriaDx:•BUN• Repeat urinalysis• Urine culture3. ObesityRx: 1500 kcal diet, Weight WatchersEd: Dangers of obesity cited. Goal: 170 lbs.15Progress 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.16Example SOAP Note#3 RHD with mitral stenosisS: 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, P2slightly ↑A: Stable. Catheterization still not indicated. Risk of strep throatpresent.P: Dx: Cardiac fluoroscopyRx: Continue chlorothiazide and penicillin V 250mg b.i.d.—2weeksEd: Reinstructed about antibiotic coverage for tooth extractions,sched. for next month. (Will contact oral surgeon.)17POMR characteristics• Augment with data flow sheets• Importance of clinical judgment• Benefits:– Communication among team members, explicitness– Education and audit– Clinical research18POMR 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.Intro to Medical Informatics©2004, Peter Szolovits and MIT 419Mayo experience• Paper records, mostly• Pneumatic tube delivery, therefore limited size• Formal procedures for reaping and organizing records at discharge• Comprehensive index20The Computer-basedPatient 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)21Paper 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)22Paper 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 families23Sample paper record defects• 75% of face sheets had no discharge disposition, 48% no principal Dx• Agreement between encounter