Governance of clinical information and the role of Electronic Health Records in service delivery Royal College of Physicians, London, November 2007 Dr.

Governance of clinical information and the role of Electronic Health

Records in service delivery

Royal College of Physicians, London, November 2007

Dr Dipak KalraCentre for Health Informatics and Multiprofessional Education

(CHIME)

University College London

[email protected]

Royal College of Physicians, London, November 2007

Dr Dipak KalraCentre for Health Informatics and Multiprofessional Education

(CHIME)

University College London

[email protected]

Drivers for integrating health information• Manage increasingly complex clinical care

• Connect multiple locations of care delivery

• Support team-based care

• Deliver evidence-based health care

• Improve safety• reduce errors and inequalities

• reduce duplication and delay

• Improve cost effectiveness of health services

• Underpin population health and research

• Empower and involve citizens

• Protect patient privacy

Purposes requiring a semantically computable EHR• Manage increasingly complex clinical care

• Connect multiple locations of care delivery

• Support team-based care

• Deliver evidence-based health care

• Improve safety• reduce errors and inequalities

• reduce duplication and delay

• Improve cost effectiveness of health services

• Underpin population health and research

• Empower and involve citizens

• Protect patient privacy

Clinical decision making needs to combine health records and medical knowledge

Descriptions,findings,

intentions

Professionalism and accountability

Health Records

Prompts,remindersBio-sciences

Diseases and treatments

Medical Knowledge

Pathologicalprocesses

Evidence ontreatment

effectiveness

Clinical outcomesEpidemiology

Clinical audit

Care plans

Research

Trustworthy inferences require these to be represented faithfully and consistently

Making safe inferences from EHR data• Can a single observation be interpreted:

• is it clear what coding scheme was used?

• are there qualifiers or co-ordinated terms to modify the meaning?

• is it clear which measurement units, normal ranges etc. apply to the data?

• does historical meaning stay the same?

Hepatitis, acute,- amoebic- due to poison- infective- syphilitic, secondary

Nomenclature of disease,

1948

SNOMED-CT2006

“Hepatitis due to infection”

infective hepatitis now includes syphilis

Clinical knowledge evolves!

Making safe inferences from EHR data• Can a single observation be read:

• is it clear what coding scheme was used?

• are there qualifiers or co-ordinated terms to modify the meaning?

• is it clear which measurement units, normal ranges etc. apply to the data?

• does historical meaning stay the same?

• Can the correct inferences be made about the observation: • is there enough context in order to know what was meant by the

author when the observation was first created?

• is this contextual information (meta-data) in a standardised form?

If we query the EHR

List of diagnoses and List of diagnoses and procedures procedures

Procedure Appendicectomy1993

Diagnosis Acute psychosis2003

Diagnosis Meningococcal meningitis1996

Procedure Termination of pregnancy1997

Diagnosis Schizophrenia2006

Can we safely interpret a diagnosis without its context?

Clinical interpretation context

“They are trying to kill me”

Symptoms

Reason for encounter Brought to ED by family

Mental state exam Hallucinations

Delusions of persecution

Disordered thoughts

Management plan Admission etc.....

Diagnosis Schizophrenia

Working hypothesis Certainty

Emergency Department Seen by junior

doctor

Junior doctor,emergency situation,a working hypothesis

soschizophrenia is

not areliable diagnosis

Data archive management

EHRdata

life-cycle

Professionalaccountability

Medical knowledge and health culture

Life-longEHR

Clinicalencounter

Clinical contextsMedico-legal contexts

Potential interpretation contexts

schizophreniaschizophrenia

Examples of clinical interpretation context• within the overall clinical story

• past, present

• intended treatments, planned procedures

• clinical circumstances of an observation• e.g. standing, fasting

• presence / absence / certainty of the finding

• hypotheses, concerns

• a diagnosis for a relative • but not the patient!

• confidence and evidence• seniority of the author

• justification, clinical reasoning, guideline references

Examples of medico-legal context• Authorship, responsibilities, signatories

• Dates and times• occurrence, clinical encounter, recording, schedules, intentions

• Information subjects• whose record is this? (who is the patient?)

• about whom is this observation? (e.g. family history)

• who provided this information?

• Version management

• Access privileges• which need to be defined in ways that can be interpreted across

organisational and national boundaries

• Consents

Point of care delivery

Continuing care

(within the institution)

Long-term shared care

(regional national, global)

TeachingResearch

Clinical trials

explicit consent

EducationSecondary research

EpidemiologyData mining

de-identified

+/- consent

Public healthHealth care

managementClinical audit

implied consent

Governance requirements

•faithfulness

•completeness

•medico-legal integrity

•standards conformance

•consistent semantics

•privacy management

Clinical data life-cycle

Citizen in the community

Clinical trials,functional genomics,

public health databasesEHR repositories

Clinical devices,instruments

Clinical applications

Decision support, knowledge managementand analysis components

Mobile devices

Personnel registers,security services

The role of EHR interoperability standards

Date: 1.7.94

WhittingtonHospital

Healthcare Record

John Smith DoB: 12.5.46

ISO/EN 13606

openEHR.org

EHR archetypes

openEHR / 13606 Archetypes: a shared library of clinical data structures

openEHR / 13606 Archetypes: a shared library of clinical data structures

Equivalent expressions ?

•<Presenting symptom> = <Headache>

•<Headache present> = <True>

•“Have you been getting headaches?”: “Yes”

•<Headache symptom>

Conclusions

• Contextual information is essential for the safe interpretation of health records

• EHR interoperability standards provide a means of representing and communicating this context in a consistent way

• Archetypes provide a means of systematising EHR data structures and content

• True semantic interoperability is harder to achieve, but is on the European roadmap

• This must be our goal to support knowledge-driven health care