1. EPD ontwikkeling:
Standaardisatie en Samenhang
Dr Jan A. Hazelzet
Kinderarts-Intensivist
&
CMIO Erasmus MC
ICT Architectuur congres, Nieuwegein, 23 Juni 2011

2. Congres ‘Architectuur in de Zorg’
Men neme een architect…
Recept voor een goed zorgsysteem
Nieuwegein, 23 juni 2011

3. ERASMUS MC Sophia Children’s Hospital
 50% Pediatric Intensivist
 ≈ 1400 admissions/y
 28 + 6 beds
 Age: 0-18 y
 Staff:
 12 intensivists / 4 fellows
 ≈ 120 fte. nurses
 50% CMIO
 Strategic planning
 Clinician’s perspective
 IT-Governance
 Clinical Documentation
 Interoperability
 Regional Information Exchange
Liaison Medical <=> Informatics

4. IT in personalized integrated Health Care
Quality
Health
Cohesion Documentation
Care
Knowledge

5. The Quality gap
Health care is not as
 Safe
 Effective To err is human: Building a
safer health care system
 Efficient
Linda T. Kohn et al. 2000
 Patient centered
 Timely
 Equitable
as it should be
Committee on Quality of Health Care in America, 2001
Crossing the Quality Chasm: A New Health Care System for the 21st Century

6. The Quality gap
Health care is not as
 Safe “Do not harm the patient”
 Effective “Do the right thing in the right patient”
 Efficient “Don’t waste money”
 Patient centered “Do we know what the Patient needs”
 Timely “Don’t waste time”
 Equitable “Don’t discriminate”
as it should be
Committee on Quality of Health Care in America, 2001
Crossing the Quality Chasm: A New Health Care System for the 21st Century

7. NEJM 2010; 363:2124-34

8. Landelijk EPD
2006
2007
2008
2009
2010
2011

11. Meaningful EHR Functionalities:
…enabling a safe, patient-centric, high-quality healtcare
system that optimizes patient outcomes
 Structured and coded clinical documentation
 Workflow and clinical decision support
 Knowledge management services
 e-Prescribing
 Healthcare information exchange, data access, quality reporting
 Personal health records

12. Meaningful EHR Functionalities:
…enabling a safe, patient-centric, high-quality healtcare
system that optimizes patient outcomes
 Structured and coded clinical documentation
 Workflow and clinical decision support
 Knowledge management services
 e-Prescribing
 Healthcare information exchange, data access, quality reporting
 Personal health records

13. Meaningful EHR Functionalities:
…enabling a safe, patient-centric, high-quality healtcare
system that optimizes patient outcomes
 Structured and coded clinical documentation
 Workflow and clinical decision support
Uniformity
 Knowledge management services
 e-Prescribing
 Healthcare information exchange, data access, quality reporting
 Personal health records

14. HIT-Enabled Health Reform
Achieving Meaningful Use
2009 2011 2013 2015
HIT-Enabled Health Reform
Meaningful Use Criteria
HITECH
Policies
2011 Meaningful
Use Criteria
(Capture/share
data)
2013 Meaningful
Use Criteria
(Advanced care
processes with 2015 Meaningful
decision support) Use Criteria
(Improved
Outcomes)
14

15. Hospital Meaningful Use Objectives Over Time

16. Meaningful Use Incentives by Adoption Year
Meaningful Total
User
2009 2010 2011 2012 2013 2014 2015 2016
Incentive
2011 $ 18,000 $ 12,000 $ 8,000 $ 4,000 $ 2,000 $ 44,000
2012 $ 18,000 $ 12,000 $ 8,000 $ 4,000 $ 2,000 $ 44,000
2013 $ 15,000 $ 12,000 $ 8,000 $ 4,000 $39,000
2014 $ 12,000 $ 8,000 $ 4,000 $ 24,000
2015 + $ Penalties
16

18. Health Outcomes Policy Priority
 Improve care coordination
 Engage patients and families
 Improve population and public health
 Improve quality, safety, efficiency, and
 Reduce health disparities
 Ensure adequate privacy and security protections for personal health
information

19. Wensen patiënt in de tijd van e-Health
 Transparantie van prestaties van zorgverleners
 Inzicht in eigen medische gegevens
 Zelf regelen van het delen / uitwisselen van deze informatie
 Toevoegen van informatie
 Adequate voorlichting algemeen en op maat
 Contact met arts via e-mail
 Afspraken maken via internet
 Zinvolle alerts t.a.v. diagnostiek en behandeling
 Zelf management: documentatie van thuis metingen
 …….

20. Idealized concept of a PHR system
J Am Med Inform Assoc. 2008;15:729-736

21. Wensen dokters in de tijd van e-Health
 Verlenen van veilige, effectieve en evidence-based zorg met informatie
geintegreerd in de klinische workflow
 Actuele, relevante, complete en accurate patiënten gegevens
 Curves, beelden, lab gegevens etc. kunnen hergebruiken
 Documenteren van patiënten contacten (telefoon, e-mail, chat etc.)
 Webspreekuur
 Ondersteuning verwijzingen
 E-consult
 ……

22. Huidige werkelijkheid
 10’ per patiënt tijdens spreekuur
 Onvolledige informatie
 Geen overzicht
 Verwarring
 DBC afhandeling
 Landelijke registraties
 Administratie, brieven etc.
 Niet patiënt gericht
 Ontoegankelijk voor de patiënt
 ….

23. Commerciële EPD “pakketten” of “Suites”

24. EMR

25. Erasmus EPD (Elpado) nu
Specialisme georiënteerd
i.p.v. Patiënt centered
•Familie anamnese Tussendossier
•Alerts •Voorgeschiedenis
•Allergie •Vaccinaties •Voorgeschiedenis •Allergie
•Familie anamnese •Allergie •Allergie •Familie anamnese
•Voorgeschiedenis •Procedures •Familie anamnese •Alerts
•Alerts •Sociale anamnese •Alerts •Vaccinaties
•Vaccinaties •Voorgeschiedenis •Vaccinaties •Sociale anamnese
•Sociale anamnese •Sociale anamnese •Probleemlijst
Basisdossier
•Probleemlijst
Specialisme 1 Specialisme 2 Specialisme 3 Alle Specialismen
Digitaal: 40% artsen, 70% verpleegkundigen
Hybride, dan wel volledig papier

26. Basisdossier= eenheid van taal
српско писано говор је ћepиулица. даби
особа потпуно разумила-черилицу или
койи говор, питаотац треба да
разумиjе говор, граматику, семантику,
од тога говора. да би компютор
превео cваку горе спомометну део за ???
корист здравовен-свене сексиjе, било
би велико изазиваные.
EMR A EMR B
26

27. Challenges - Language
Component
Vocabulary
Semantics
Grammar
27

28. Challenges - Language
Component Standard
Vocabulary Code sets,
terminologies,
ontologies
Semantics Data model
Grammar Content
28

29. Challenges - Language
Component Standard Has “words” for…
Vocabulary Code sets, Diseases,
terminologies, procedures,
ontologies specimen types,
occupations, drugs,
chemicals, anatomy,
etc.
Semantics Data model Definitions, Drugs,
chemicals, brand
names, etc.
Grammar Content Clinical observations,
including lab tests,
vital signs, EKG
measurements, etc.
29

30. Challenges - Language
Component Standard Has “words” for… Examples
Vocabulary Code sets, Diseases, SNOMED-CT,
terminologies, procedures, LOINC, RxNorm,
ontologies specimen types, GO (genes)
occupations, drugs,
chemicals, anatomy,
etc.
Semantics Data model Definitions, Drugs, HL7 RIM, open
chemicals, brand EHR, DCM…
names, etc.
Grammar Content Clinical observations, HL7 2.x, NCPDP,
including lab tests, Continuity of
vital signs, EKG Care Record/CCD
measurements, etc.
30

31. Open International Standards
 Grammatics: Structure: CCR
 Vocabular: Terms: SnoMed, LOINC, RxNorm, NANDA, GO
 Semantics: Definitions HL7v3, Open EHR, Archetypes, DCM etc.
 Images: Radiology, ECG: IHE, DICOM
 ……………

32. Journal of AHIMA 2009; 80: 44-50.

33. View the Complete Set of HITSP Deliverables
www.HITSP.org

34. Continuity of Care Record (CCR)

35. Continuity of Care Record
Wat is het?
 Kern data set van de meest relevante en actuele feiten van de
gezondheidstoestand van een patiënt.
 Vervaardigd door een zorgverlener aan het eind van een bezoek.
 Met deze voor de volgende zorgverlener toegankelijke informatie kan
de zorg doorgaan.
 Kan vervaardigd, getoond en verstuurd worden. Op papier en
electronisch

36. Kerngegevensset (CCR)
 NAW gegevens  Doorgemaakte ingrepen
 Recente afspraken  Medische apparatuur
 Problemen / diagnoses  Functionele status
 Betrokken zorgverleners  Vitale parameters
 Verzekeringsgegevens  Labresultaten
 Vaccinaties  Behandelbeperkingen
 Allergieën en alarmen  Medicatielijst
 Familie anamnese  Behandelplan
 Sociale anamnese
http://en.wikipedia.org/wiki/Continuity_of_Care_Record

38. 38

39. Conceptual Model of the CCR
1 Document Identifying Information
“From/To” info re Provider/Clinician Optional
Reason for Referral/Transfer Extension
2 Patient Identifying Optional
Information Extension
3 Extension Eligibility, Co-payment, etc.
Insurance and Financial Info
4 Health Status of Patient Extension Med. Specialty-specific Info
Diagnosis/Problems/Conditions
Adverse Reaction/Alerts
Current Medications Extension Disease Management-specific Info
Immunizations Personal Health Record Info
Vital Signs Extension
Documented by the Patient
Lab Results
Procedures/Assessments
Extension Med. Specialty-specific Info
5 Care Documentation
Extension Disease Management-specific Info
Extension Institution-specific information
Extension Care Documentation for Payers
(Attachments)
Extension Personal Health Record Info
Documented by the Patient
6 Care Plan Recommendation
Version 6– 10/31/03
Mandated Core Elements of the CCR

40. Allergie / alert

42. Probleemlijst

43. Problem Oriented Medical Record
 Probleem 1, 2, 3….
Subjectief
Objectief
Evaluatie
Plan
Dx
Rx
Vx

44. Medicatie veiligheid
Presentatie Anne de Roos Medicatieoverdracht NVZA, KNMP

45. Medicatie veiligheid

47. Collins et al., J Biomed Inform 2011

49. Medische literatuur: PubMed MESH

50. • SnoMed
• LOINC
• RxNorm
• MESH

52. SnoMed CT
http://www.ihtsdo.org/snomed-ct/snomed-ct0/

53. Methods Inf Med 2010; 49: 349–359

55. Potential benefits and strengths of SNOMED-CT
 Consistent terminology: across all disciplines and domains; (inter)nationally
 Comprehensive terminology: covers most needs of electronic
documentation; constant growth, postcoordination, crossmapping
 Point of care terminology: concurrent coding, live search, help with decision
support, overall enhanced patient care
 Terminology of CIS: same terms used across the entire health system, ER,
OR, ICU, and health records; Minimizing duplicate data entry, Ease of coding,
re-use of data, Improved data quality, Use of contents of free text data (NLP)
 Internationally recognized and maintained: consistent patient records for
research, prerequisite for international health record, Dynamic terminology with
frequent updates
Adapted from: Journal Critical Care 2010; 25: 364.e1–364.e9
Survey HIT vendors 2008: only 30% had license, 6% was using it

56. Journal of Critical Care 2010: 25: 364

57. http://snomed.dataline.co.uk/

58. LOINC

59. Medicatie: RxNorm

64. Patient & de Zorg
Patient
Huisartsen Algemene
Ziekenhuizen
Revalidatie
Ouders Academische Verpleeghuizen
Centra
Thuis zorg
Categorale
Ziekenhuizen

66. Data Structure for EPD (1)
 Demographics
 Content: HL7 2.x for messaging, CCD for document summaries
 Vocabulary: HITSP Harmonized code sets for gender, marital
status
 Problem List
 Content: HL7 2.x for messaging, CCD for document summaries
 Vocabulary: SNOMED-CT
 Medications
 Content: NCPDP script for messaging, CCD for document
summaries
 Vocabulary: RxNorm and Structured SIG
Adapted from blog John Halamka

67. Data Structure for EPD (2)
 Allergies
 Content: HL7 2.x for messaging, CCD for document summaries
 Vocabulary: UNII for foods and substances, NDF-RT for medication
class, RxNorm for Medications
 Progress Notes and Other Narrative Documents (History and Physical,
Operative Notes, Discharge Summary)
 Content: HL7 2.x for messaging, CCD for document summaries
 Vocabulary: CDA Templates
 Departmental Reports (Pathology/Cytology, GI, Pulmonary,
Cardiology etc.)
 Content: HL7 2.x for messaging, CCD for document summaries
 Vocabulary: SNOMED-CT
Adapted from blog John Halamka

68. Data Structure for EPD (3)
 Laboratory Results
Content: HL7 2.x for messaging, CCD for document summaries
Vocabulary: LOINC for lab name, UCUM for units of measure,
SNOMED-CT for test ordering reason
 Microbiology
Content: HL7 2.x for messaging, CCD for document summaries
Vocabulary: LOINC for lab name/observation
Administrative Transactions (Benefits, Referrals, Claims)
Content: X12
Vocabulary: X12, CAQH CORE
Adapted from blog John Halamka

69. Nieuwe Uitdagingen

70. Determinanten van ons phenotype
DNA
Lifestyle
Environs
Health

71. “Equal but not the same”

72. Leefstijl

73. Risico factoren per Patient
Roken
10
Nefropathie 8 Overgewicht
6
4
Bloeddruk 2 Activiteit
0
Cholesterol Voeding
Stress Alcohol
1‐mrt‐09 1‐mrt‐10

74. Medical content in EMR
www.pkc.com
http://www.mapofmedicine.com/

75. www.affymetrix.com

76. Research:
From clinical notes to structured phenotypes
NATURE REVIEWS GENETICS 2011; 12: 417- 428

77. Two archetypal workflows in EHR-driven
genomic research
NATURE REVIEWS GENETICS 2011; 12: 417- 428

78. Integratie van Health Care en Research

79. Information technology for patient safety
Qual Saf Health Care 2010;19(Suppl 2):i25ei33

80. Gebruiksvriendelijk, modern, intuitief, supporting

82. Conclusies

83. Conclusies

84. Conclusies