HL7-UK 2003 ConferenceHealthcare Interoperability Past Efforts-Present Benefits-Future Prospects Clement J. McDonald, M.D. December 11, 2003
Work of many Regenstrief faculty • Mike Barnes, M.D. • Paul Dexter, M.D. • Burke Mamlin, M.D. • Mick Murray, PharmD. • Marc Overhage, M.D., Ph.D. • Susan Perkins, Ph.D. • Gunther Schadow, M.D. • Bill Tierney, M.D.
Where we were in early 80’s • Building our own systems to collect data • Lab • Pharmacy • Scheduling system • Horrible batch and cobbled interfaces to collect data from other institutions systems
What to do? • Impossible except for nutty people • We needed an easier way • Standards…
Plea for standards help • 1981 1st rejection of grocer’s paper • 1983 (Jan.) Grocer paper published 1 • 1983 (Nov.) Plea for standards at fall SCAMC meeting 2 • 1984 (Nov.) A discussion of the draft proposal for data exchange standards for clinical laboratory results. 3 • McDonald CJ, Park BH, Blevins L. Grocers, physicians, and electronic data processing. AMA Cont Med Ed Newsletter 1983; 12:5‑8. • McDonald CJ. Standards for the transmission of diagnostic results from laboratory computers to office practice computers ‑‑ an initiative. Proc Annu Symp Comput Appl Med Care 1983; 123‑24. • McDonald CJ, Wiederhold G, Simborg DW. A discussion of the draft proposal for data exchange standards for clinical laboratory results. Proc Annu Symp Comput Appl Med Care 1984; 406‑13.
1984 SCAMC Fall Symposium • Panel Members: • Clement McDonald, M.D. • Gio Wiederhold, Ph.D. • Donald W. Simborg, M.D. • Ed Hammond, Ph.D. • Fredrick R. Jelovsek, M.D. • Ken Schneider, M.D.
1984 Proposal- Familiar? FIGURE 1 Patient 1 (general information about patient) Battery 1 (information about first battery reported/requested) Result 1 (information about the first result of battery 1) Result 2 (information about the second result of battery 1) Result n (information about the last result of battery 1) Battery 2 (information about battery 2) Result 1 (information about the first result of battery 2) Result 2 (information about the second result of battery 2) Result n (information about the last result of battery 2) Battery n (information about the last battery for the first patient) Result 1 (information about the first result of the last battery) Patient 2 (all of the structure repeats) Patient N
Pleas answered • 1988 ASTM 1238-88 4 • 1989 HL7 published version 2.0 5 • 1990 SCAMC – Progress, Promises and the Conductors Wand 6 (4) Standard Specification for Transferring Clinical Laboratory Data Messages Between Independent Computer Systems. Annual Book of ASTM Standards; Philadelphia, PA, 1988. (5) Health Level Seven, Version 2.0. An application protocol for electronic data exchange in healthcare environments. Ann Arbor, Michigan: Health Level Seven, 1989. (6) McDonald CJ. Standards for the electronic transfer of clinical data: progress, promises, and the conductor's wand. Proc Ann Symp Comput Appl Med Care. 1990;14:9-14.
Music & words 1990 • MIDI to orchestra what HL7 is to EMR
1995-2003 • Messages fairly good • Could get HL7 result messages working in 1-3 weeks • Vendors knew the standard • Most “BAD” messages due to conscious placement of right info in “wrong” field
Example bad messages • Value, units, normal ranges, flags, and performance site put ALL in OBX-5 • Value and units both jammed into OBX-5 • OBX-5 says “see comment” - everything jammed into following NTE • Whole report (many test results) jammed into single OBX-5
Life good but not perfect • Codes for the same question (observation) different every where • Need most-Standard question (observation) codes • If answer is text- all’s well • If answer is numeric - all’s well • If answer is a code (but come with text representation) – not perfect, OK
LOINC standard for codes • First meeting – 1994 • Select group of interested parties • Mayo medical laboratories • CORNING MetPath (since merged with SHF to become Quest) • University of Washington • Indiana University/Regenstrief Institute • University of Utah (Intermountain Healthcare) • Veterans Administration • University of Ghent Belgium
LOINC Actual • Identifies the observation (OBX3 and OBR4) • The question not the answer • First file distributed April 1995 (6000 terms) • Now 34,000 terms • Battery structures • Hierarchy • Synonym • Free Mapping and browsing program • Free for all uses – url: http://www.loinc.org/ McDonald CJ, Huff SM, Suico JG, Hill G, Leavelle D, Aller R, et al. LOINC, A Universal Standard For Identifying Laboratory Observations: A 5-Year Update. Clin Chem 49:4; 624-633
Wishard the oldest and the broadest coverage • Data beginning in 1972 • Since early 80’s • All laboratory data • All pharmacy (in patient and out) • All dictation • All diagnostic studies ( radiology, cardiac, etc) • Al encounters ( with DX's and procedures etc) • Coded clinical information from largest clinics ( OB and Medicine and med subspecialty • Since late 80’s • All- physician entered orders • Recently – Inpatient vitals, MD note entry, etc.
VISIT INFORMATION From registration system Courtesy of HL7 VITAL SIGNS DATA FROM AUTOMATIC BP- PULSE – TEMPERATUREcourtesy of HL7
Chest x-ray 12 bit, 1024 x 1247 resolution
Chest x-ray 12 bit, 2048 x 2494 (full) resolution
Trade offs between JPEG and JPEG2000 • JPEG decodes much faster (5X) • JPEG Compresses “small” images (e.g. CT and MRI as well as JPEG200 • JPEG2000 compresses large films (chest x-rays) (2000 x 2700) 12 bit depth by 5 x better • Use JPEG for “small” CT and MRI images and JPEG 2000 for large plain films.
Scanned images • Courtesy of TIFF
Telemedicine Courtesy of: • H232 • IPSEC • MPEG 1
IT is ALL in the Standards • HL7 (most) • DICOM (to capture uncompressed images from PACS • NCDP (Prescriptions from outpatient pharmacy • JPEG , JPEG 2000 for storing clinical images in Clinical Repository • IP (Everywhere) • JPEG, MPEG 1 • Code Standards Currently Used: • CPT • ICD • LOINC • CDO-3
Guard Rails • Improve preventive care from 30% to 400% over control state (1) • Improve drug dosing and reduce errors in drug prescribing • Increase required corollary orders 5%-64% (e.g. test Vancomycin levels when giving Vancomycin) 1. McDonald CJ, Hui SL, Smith DM, Tierney WM, Cohen SJ, Weinberger M. Reminders to physicians from an introspective computer medical record. Annals of Internal Medicine1984; 100:130‑138. 2. Overhage JM, Tierney WM, Zhou XH, McDonald CJ. A Randomized Trial of “Corollary Orders” to Prevent Errors of Omission. JAMIA 1997;4:364-375.
Preventive Reminders Percent Response McDonald, et al. Reminders to Physicians from an Introspective Computer Medical Record. Annals of Internal Medicine, 1984;100:130-138. [RG]
Computer based POEGopher order entry • Were first to succeed with order entry • 20 million orders at Wishard since 1986 • POE provides better options for delivering influencing patient care • Even non fixed (not patient specific) content can have an effect
Cost Savings CHF example
Preventive POE inpatient POE reminders 2001(Dexter et al.) Dexter PR, Perkins S, Overhage JM et al. A Computerized Reminder System to Increase the Use of Preventive Care for Hospitalized Patients. N Engl J Med 2001;345:965-970.
City Wide RMRS Functions • CARE deliver clinical information when needed for emergency care (NLM supported study) • Public health seek out reportable conditions from laboratory data evidence, equivalence duplicate cases, organize and deliver to public health • Research molecular biologic epidemiology through Pathology samples ( National Cancer institute