Bringing the technology of FedEx parcel tracking to the Electronic Health Record (EHR) 1/2 0.

Bringing the technology Bringing the technology of FedEx parcel tracking of FedEx parcel tracking to the to the Electronic Health Electronic Health Record (EHR)Record (EHR)

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Barry SmithBarry Smith

• Director, (US) National Center for Ontological Research – leader on ontology projects for US Army

• Founding Coordinating Editor of the OBO (Open Biomedical Ontologies) Foundry project

• Consultant to German Federal Health Ministry on ontology projects

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Principal Investigator◦ Protein Ontology◦ Infectious Disease Ontology

Scientific Advisor◦ Gene Ontology (world’s most successful

ontology)◦ Ontology for Biomedical Investigations

(OBI)◦ Cleveland Clinic Semantic Database in

Cardiothoracic Surgery3

Barry SmithBarry Smith

Barry Smith: FundingBarry Smith: Funding

• Work funded by European Union, US, Austrian and Swiss National Science Foundations, Volkswagen Foundation, Humbolt Foundation

• Winner of $3 million Wolfgang Paul Prize from German Government

• National Center for Biomedical Ontology $18 million collaboration of Stanford University, The Mayo Clinic and Smith’s group at University at Buffalo

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What is tracking What is tracking technology?technology?

The use of unique IDs (e.g. bar codes) in order to track items as they move through a system.

◦ Logistics

◦ Manufacturing

◦ Transportation of merchandise

◦ Handling of evidence in a criminal investigation

◦ Etc.

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What does tracking What does tracking technology do for the technology do for the businesses who use it?businesses who use it?

FEDEX◦ Coordination: With parcel tracking FEDEX links

different activities to the parcel itself as it moves through the system.

FEDEX activities:◦ Receiving◦ Addressing◦ Billing◦ Scheduling◦ Delivering ◦ Locating (in transit)◦ Relocating (if lost)◦ Restituton (in case of loss) 6/

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Tracking technologyTracking technology

Allows the customer (sender and recipient)

◦ to inform himself of the process of a parcel through the system

◦ to influence this process in case of need

Tracking allows coordination of many different tasks without mixing up information about one parcel and another.

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Tracking technology is Tracking technology is already used as a matter of already used as a matter of course forcourse for• bank and credit card transactions• cargo and logistics• conveyor belt manufacturing• mp3 files (for Digital Rights

Management)• archeological specimens• forensic evidence tracking

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Why should medicine Why should medicine adopt it?adopt it? Patients

◦ grow older or change domicile◦ change health care provider◦ need specialist care.

Because there is no unified ID system in the various health care institutions, all kinds of opportunities to ensure continuity of care are lost.

Even where a reliable system of patient IDs exists, there is no ID system for◦ the patient’s disorders◦ the patient’s documents◦ the many other items relevant to patient health,

recorded always in a general way9/

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Two levels to this Two levels to this problemproblem

the level of what is general◦ the patient record systems used by different

healthcare providers use different terms for the same general kinds of entities on the side of the patient (here ontology comes in)

the level of what is particular◦ tracking technology is not employed to link

the different patient record systems together

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Real world example Real world example (true story)(true story)

Person P with complaint X

◦ Went out of town and became sick.

◦ Attended a series of different healthcare providers

◦ Informed each in turn that he had a quite specific ailment which needed urgently a quite specific kind of treatment.

◦ In part, at least, because the tracking mentality is so alien to the medical world, each new set of healthcare providers insisted on re-diagnosing from scratch.

◦ The process wasted time and almost killed him.

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The Electronic Health The Electronic Health RecordRecord

Currently the Electronic Health Record is standardly conceived as a digitalized record of what the doctor thought, saw or did◦ what tests he did◦ what medicines he prescribed◦ what hypotheses he formulated

In the US, the record is primarily used to support hospital billing needs

In other countries it is used as an aid to diagnosis

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Currently the Electronic Currently the Electronic Health Record is focused Health Record is focused on the doctoron the doctorData is organized according to which doctors

saw the patient, not according to the problems which were treated, creating data clumps which are very often isolated from each other

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This blocks continuity of This blocks continuity of carecareDifferent hospitals used different record

systems

If, in contrast, you have a health record which

◦ tracks the patient,◦ and the patients different problems,◦ and treatments

through time, then you can

◦ glue together the records of the patient at different times

◦ create an easily accessible and re-usable history. 14

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The Electronic Health The Electronic Health RecordRecord

Still works with general terms for almost all the entities recorded

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The story The story of Jane of Jane SmithSmith

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Jane’s favourite supermarket

July 4th, 1990July 4th, 1990 Jane goes Jane goes shoppingshopping

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The freezer section of Jane’s favourite supermarket

The only available warning sign used outside

An injured upper leg

A visit to the A visit to the hospitalhospital

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Diagnosis: Diagnosis: severe spiral severe spiral fracture of the femurfracture of the femur

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General types General types and and particular instancesparticular instances

General type◦ Fracture◦ Headache◦ human being◦ Death◦ fall◦ accident

Particular instances◦ Mary’s fracture◦ my current headache◦ Me◦ Reagan’s death◦ Mary’s fall◦ Jim’s accident last Wednesday

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Kinds of codes in the Kinds of codes in the EHREHR• The EHR uses specific codes (alphanumeric

ID’s) for:◦ Patients (for example your Social Security Number)◦ Physicians (standardly assigned by the hospital)◦ Times (date, time of day)◦ Places (each hospital will use a different ID system e.g.

for buildings)

• But it uses general ‘observation codes’ (‘obscodes’) for everything else.

• The obscodes are taken from standardized clinical terminologies

• The record tells us that there is some particular fracture – an instance of the general class ‘fracture’ – but which one? 21

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Examples of observation codes Examples of observation codes used in the EHRused in the EHR

5572 04/07/1990 26442006 closed fracture of shaft of femur

5572 04/07/1990 81134009 Fracture, closed, spiral


5572 12/07/1990 9001224 Accident in public building (supermarket)

5572 04/07/1990 79001 Essential hypertension

0939 24/12/1991 255174002 benign polyp of biliary tract



47804 03/04/1993 58298795 Other lesion on other specified region


298 22/08/1993 2909872 Closed fracture of radial head




PtID Date ObsCode Narrative

0939 20/12/1998 255087006 malignant polyp of biliary tract

PtID = Patient ID

ObsCode = Observation Code

• taken from SNOMED (Systematized Nomenclature

of Medicine)


5572 04/07/1990 81134009 Fracture, closed, spiral




0939 24/12/1991 255174002 benign polyp of biliary tract



47804 03/04/1993 58298795 Other lesion on other specified region


298 22/08/1993 2909872 Closed fracture of radial head




PtID Date ObsCode Narrative

0939 20/12/1998 255087006 malignant polyp of biliary tract

ProblemsProblems

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Enormous problems Enormous problems with current practiceswith current practices

It is difficult to count the number of (numerically) different diseases, disorders, medical problems in a given patient

This produces bad statistics on:◦ Incidence◦ Prevalence◦ Cost

It is difficult to identify outcomes (and thus determine value added)◦ Is this the same disorder now as that which was

recorded 3 years ago? 24

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Enormous problems Enormous problems with current practiceswith current practices

Suppose the doctor sees several patients all of whom complain of nasty viral warts.

He sees in all their records that they all ‘visited swimming pool’

◦ but the records do not tell him that they all visited the same swimming pool

◦ swimming pools are not identified via unique IDs.

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unique numerical IDs for all concrete individual entities relevant to the diagnosis and therapy of each patient

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The solutionThe solution

This proposal can be This proposal can be implemented harmlesslyimplemented harmlessly

The Fedex-style tracking layer would in 99% of the cases work behind the scenes◦ would not force everybody to speak a new

language◦ or to learn new technology.

Only in very rare cases would it require intervention from the doctor/coder◦ but these are precisely the cases where the

referent tracking data is of most help to both the doctor and the patient

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It can be implemented It can be implemented incrementallyincrementally

For example, test it first◦in the hospital’s blood bank services◦in the hospital’s organ transplant

services

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In medicineIn medicine

The treatment of general types (diabetes, fracture, death) is dealt with quite successfully by medical terminologies and ontologies

The treatment of particular instances is still underdeveloped

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Solution: Referent Solution: Referent TrackingTracking

Method: introduce Unique Identifiers for each relevant particular◦ for Mary’s fracture◦ John’s heart◦ Jim’s tumor

Result: An ever growing map of clinical cases, and of their interrelations to other clinical cases

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Services provided by our Services provided by our solutionsolution

◦ automatic generation of IDs for particulars

◦ automatic assignment of these IDs to the particulars which need to be referred to in the EHR

◦ repository for all the Ids

◦ Database of statements relating the corresponding particulars to the types recorded in the EHR

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Advantages of the Advantages of the solution solution

Referent tracking can solve a number of problems in an elegant way

Existing coding systems and technologies can be used for the implementation

The IDs are generated by software behind the scenes, so that normal coding practices can continue as before

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Because the same patient often attends different hospitals using different coding systems the use of common ID repositories will gradually lead to automatic mappings between terminologies

Thus, the big problem of continuity of care in a world where different hospitals have different EHRs and thus use different terminologies will be resolved.

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As IDs come to be associated with a plurality of codes from different coding systems

We can run statistical tests to find outliers◦ codes which were misapplied◦ or ill-defined

Or we can test and enhance rules for reasoning postulated by coding systems such as SNOMED-CT

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Over time, the ID repository will come to serve as a benchmark of correctness for coding systems, allowing automatic step-by-step improvements

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Bringing the technology of FedEx parcel tracking to the Electronic Health Record (EHR) 1/2 0.

Documents

successful ontology

biomedical ontology

barry smith slide

ontology projects

particular tracking

patient health

case of need tracking

different terms