iHT2 Health IT Summit in Seattle 2012 – Case Study “EMR Usability & NLP”

Case Study
EMR Usability & NLP

Thomas H. Payne, MD, FACMI
Medical Director, IT Services
UW Medicine
Clinical Associate Professor
Departments of Medicine, Health Services, and Biomedical Informatics & Medical Education
University of Washington

IHT2, Seattle, 8/22/12 tpayne@u.washington.edu
Thursday, August 23, 12

Topics today

• The story of moving from paper to electronic notes

• NLP and clinical decision support

• 3 examples: NLP in UW Medicine EMRs

• Summary and discussion

2 tpayne@u.washington.edu

5 reasons doctors have trouble with EMRs

• Time requirement to enter notes and write orders

• What notes look like and contain

• Changed interaction with patients

• Expense to buy and operate

• Makes it harder to be a doctor


4,500

4,000 —Deaths
—Billions of passengers-km
3,500

3,000

2,500

2,000

1,500

1,000

500
1918

1928

1938

1948

1958

1968

1978

1988

1998

2008
Source: Aircraft Crashes Record Ofﬁce, Geneva (http://www.baaa-acro.com/)

The Geography of Transportation Systems. http://people.hofstra.edu/geotrans/eng/ch3en/conc3en/airfatalities.html. tpayne@u.washington.edu

tpayne@u.washington.edu

Tools for structured note entry


Problems with structured note entry

• Training requirement higher

• In our experience, most physicians don’t like to write with them.

• Most physicians don’t like to read them (except narrative portion).

• Important detail may be lost.


What hath we wrought?


More attractive Less attractive

Payne TH, Patel R, Beahan S, Zehner J. The physical attractiveness of electronic physician notes. 10 tpayne@u.washington.edu
AMIA Annu Symp Proc., 2010:622-626.


Why is narrative text valuable?

• Narrative contains history, details of history and exam, and most importantly
the thinking of the clinician. (This is a rare overlap between needs of
reimbursement, clinical care, teaching, and research.)

• Each note contains kernels of truth. Templates, direct entry aids, copy/paste
can hide them.

• In UW Medicine there are electronic notes from ~1.4 million visits and
68,000 admissions each year → great potential to improve decision-making
and to learn.


Hardware you already own

Broca’s area

auditory auditory
association
Graphic credit: Prof.Genevieve B. Orr
http://www.willamette.edu/~gorr/classes/cs449/brain.html

Sound to text

“45 year old female
with pulmonary
sarcoidosis…”


Speech technologies are mainstream


Med reconciliation accurate?


Early signs of sepsis?

Other recommendations within
imaging reports?


Broader differential?
Appropriate care?
Code status in EMR accurate?

In compliance with billing rules?


Sound to meaning

“45 year old female Parent/Child (Relationship Type)
with pulmonary Sarcoidosis (disorder) {31541009 ,
sarcoidosis…” SNOMED-CT }

Natural language processing
A subﬁeld of artiﬁcial intelligence and
computational linguistics. It studies the
problems of automated generation and
understanding of natural human languages


Analysis of UHC Core Measures data within
UW Medicine

All 3
Current availability of data elements HF AMI OPPS SCIP
measures

Structured, codiﬁed, machine-readable format 3 (17%) 6 (15%) 1 (11%) 10 (15%)

Free text from canonical single source 9 (50%) 11 (28%) 6 (67%) 26 (39%)

Free text from canonical multiple sources 1 (6%) 1 (3%) 0 (0%) 2 (3%) 85%
Handwritten documentation, human
5 (28%) 22 (55%) 2 (22%) 29 (43%)
interference required

Analysis of 67 metrics reported to University Healthcare Consortium for heart failure (HF), acute myocardial infarction (AMI), and outpatient surgical care improvement project (OPPS SCIP) metrics. Together, these measures
include 67 distinct metrics that require reporting to UHC. Supporting data in source systems (ORCA EMR, echocardiology, Docusys OR system, Reg/ADT, and other systems) for reporting these 67 metrics were analyzed.

Slide courtesy of Tony Black, Biomedical Informatics Core, Institute of
Translational Health Sciences, University of Washington


QA Tools: Required Clinical Variables by Anticipated Accessibility
Accessible n Percentage Hard to Access n Percentage

Demographics 482 100 Disease-speciﬁc history 142 30
Diagnosis 346 72 Care site 133 28
Prescription 167 35 Physical exam 67 14
Past medical history 148 31 Refusal 60 13
Procedure date 117 24 Patient education 53 11
Lab date 81 17 Social history 52 11
Problem/chief complaint 57 12 Treatment 25 5
Vital sign/weight/height 46 10 Diagnostic test result 18 4
Allergy 42 9 Imaging result 17 4
Lab result 38 8 Contraindication 15 3
Medication history 28 6 Pathology 11 2
Diagnostic test date 22 5 Family history 11 2
Imaging date 22 5 ECG result 6 1
Medications, current 13 3 X-ray result 2 <1
Vaccination 9 2
X-ray date 6 1
EKG date 6 1

American Journal of Medical Quality, Vol. 24, No. 5, Sep/Oct 2009

ness in gathering the patient’s one virtue of com
history, findings from the physi- tems is that they
cal examination, and other data. corded informatio
Can Electronic Clinical Documentation Help Prevent
Diagnostic Errors?
Because information from pa- formats. Designer
Gordon D. Schiff, M.D., and David W. Bates, M.D.
tients’ previous clinical encoun- leverage the “visu
Tinvest nearly $50technology testsquality without adversely discouraging independent data
he United States is about to many questions about it persist. ing physicians from the patient,
tersbillion in For example, can it bebe more read- assessment, and
health information
and improve will leveraged to gathering and capabilities of EH
country to a tipping availablethe quality of electronic notes vision a redesigned documenta-
ily point with Will with electronic than the aggregation,
4
(HIT) in an attempt to push the affecting clinicians’ efficiency? perpetuating errors. But we en-

puterized records, which are records, degraded by the wide- to elec-
paper ex- or will it be shifting approaches to improving diagno- patient’s weight o
respect to the adoption of com- be better than that of paper notes, tion function that anticipates new

pected to improve the quality and spread use of templates and cop- sis, not one that relies on the pu-
tronic systems could substantial-diagnosticians” of for instance)
1
reduce the costs of care. A fun- ied-and-pasted information? tative “master tion,
damental question is how best A fundamental part of deliv- past eras. The diagnostic process
to design electronicimprove clinicians’ is get- must be made reliable,emphasis or disp
ly health rec- eringthe diagnosis right. Unfor- and electronic documentation will
good medical care knowledge not heroic,
ords (EHRs) to enhance clinicians’ ting
workflow and the quality of care. tunately, diagnostic errors areproblem
about thecommon, outnumbering medica- be key toand clinicians will to facilitate rap
patient. The velopers this effort. Systemsneed as de-
Although clinical documentation
of having too much information The second way
plays a central role in EHRs and tion and surgical errors as causes to reconceptualize documentation
occupies a substantial proportion of outpatient malpractice claims workflow as part of the next gen-

tion practices have now surpassingbut we believe ers will need to lead by adopting
is largely been multiple benefits, that of having can foster thought
3
of physicians’ time, documenta- and settlements. EHRs promise eration of EHRs, and policymak-

dictated by billing and legal re- that one key selling point is their a more rational approach than
quirements. Yet the primary role potential for preventing, become in- in which billingserving as a p
too little, and it will mini- the current one, is by
of documentation should be to mizing, or mitigating diagnostic codes dictate evaluation and man-
clearly describe creasingly difficultevidencereview and providers are forced
and communicate errors. Admittedly, to to agement all nicians, together
what is going on with the patient. support the existence of such a to focus on ticking boxes rather
Electronic prescribing patient information than on thoughtfully document succinc
themedication benefit is currently lacking, and ing their clinical thinking.
appears that is document-
to reduce the rate of our hypothesis runs counter to
errors, but the other benefits of the sentiments and claims of There are numerous ways in
electronic records are less clear.2 many physicians, who argue that which EHRs can diminish diag-
We must ensure that electronic electronic documentation in its nostic errors (see table). The first
clinical documentation works ef- current incarnation is time-con- lies in filtering, organizing, and
fectively to improve care if more suming and can degrade diag- providing access to information.
benefits are to be achieved. Yet nostic thinking — by distract- Making accurate diagnoses has

N ENGL J MED 2010; 362:1066-9 tpayne@u.washington.edu

CT CHEST VENOUS PROTOCOL
CT ABDOMEN / PELVIS
INDICATION
Motorcycle crash.
Comparison: Trauma series same date and outside noncontrast CT chest abdomen and pelvis same date.
PROCEDURE:
Reconstruction thickness: 2.5mm. Interval: 2.5 mm
Superior extent: Thoracic inlet. Inferior extent: Ischial tuberosities
Intravenous contrast: Positive.
Oral contrast: Not used.
MPR's: Coronal, Chest, Abdomen and Pelvis, venous.

FINDINGS: **** CHEST ****
Aorta and great vessels: Normal for a venous phase study.
Mediastinal hematoma: Absent
Pericardial fluid: Absent
Endotracheal tube: Absent
Intercostal tubes: Absent
Right lung: Mild dependent upper lobe consolidation likely represents atelectasis.
Left lung: Partial collapse of the left upper lobe. Mild basal atelectasis is also present.
IMPRESSION:
Right pneumothorax: Absent
Left pneumothorax: Moderate left pneumothorax, increased compared to the prior outside study.
Multiple left rib fractures and left clavicular fracture.
Right pleural fluid: Absent
Moderate of thefluid: Absent left rib fracturesleft present:is partially collapsed.
Left pleural pneumothorax. The
Bones
left thorax: Multiple are
lung
Right sacral fracture and 4left7 pelvic ring disruption and 12. There is a minimally displaced mid shaft fracture of the left clavicle. Please refer to dedicated CT pelvis for details.
Segmental 2nd, anterolateral to minimally displaced, posterior 11 with associated small extraperitoneal hematoma.
ThereNo right sidedof the Thoracic spine for details. right kidney, which may be secondary to a 4-mm renal calculus at the level of the distal ureter. Delayed abdominal
chest fractures identified.
is mild hydronephrosis of the
Spine: See CT
radiograph is recommended.
**** ABDOMEN AND PELVIS ****
Liver: Normal
Small amount of fluid surrounding the gallbladder, and nonspecific finding of uncertain clinical significance.
Spleen: Normal
Comment: Normal ducts: Normal. A small amount of fluid is noted surrounding the gallbladder, of uncertain significance.
Gallbladder and bile
Pancreas:
Small left hemothorax.
Portal veins: Normal
Abdominal aorta and branch vessels: Normal
Left apical extrapleural is mild right hydronephrosis and ureteral dilatation. At the level of the pelvis (2/215), there is a radiodense structure, which could
Kidneys and ureters there hematoma associated with rib fractures.
The above described fluid next to4 the gallbladder may simply represent the gallbladder wall. No definite fluid around the gallbladder or liver is
represent a renal calculus which measures mm.
Adrenal glands: Normal
identified. duodenum and small bowel: Normal.
Stomach,
BetterColon: Normal on and retroperitoneum: Normal right pelvic calcification described above, which is external to the ureter and represents a phlebolith. No
visualized
Mesentery, omentum
CT cystogram, is the
evidence of ureteral calculi.
Appendix:Not visualized
Right adnexalIVC:Normal
Aorta and
Lymph Nodes:
Normal
cyst. Recommend nonemergent pelvic ultrasound for further evaluation to exclude cystic ovarian neoplasm.
Small hiatal Normal
Bladder: hernia.
Uterus and ovaries: There is a right hypodense and well demarcated adnexal mass, which measures 2.8 cm in diameter.
High-densitypelvic ultrasound.
Consider fluid is present posterior and adjacent to the inferior aspect of the descending colon. This is contiguous with the pelvic retroperitoneal
hematoma,Right sacral fracture A small amountdisruption is again visualized. noted. refer to dedicated bony pelvis CT for details. extension ofextravasation.
Bones: and given the absence of abnormalities ofPlease colon most likely represents There is left parasymphyseal and
peri-acetabular hematoma.
and pelvic ring
of presacral hematoma also
the No definite intraperitoneal fluid is identified. No obvious active the retroperitoneal hematoma, which is not
increased inintraperitoneal fluid or prior study.
No free size since the air present.
Subcutaneous tissues and body wall: There is left gluteal subcutaneous hematoma.
IMPRESSION:
Multiple left rib fractures and left clavicular fracture.
Moderate left pneumothorax. The left lung is partially collapsed.
Right sacral fracture and left pelvic ring disruption with associated small extraperitoneal hematoma. Please refer to dedicated CT pelvis for details.
There is mild hydronephrosis of the right kidney, which may be secondary to a 4-mm renal calculus at the level of the distal ureter. Delayed abdominal radiograph
is recommended.
Small amount of fluid surrounding the gallbladder, and nonspecific finding of uncertain clinical significance.
Comment:
Small left hemothorax.
Left apical extrapleural hematoma associated with rib fractures.
The above described fluid next to the gallbladder may simply represent the gallbladder wall. No definite fluid around the gallbladder or liver is identified.
Better visualized on CT cystogram, is the right pelvic calcification described above, which is external to the ureter and represents a phlebolith. No evidence of
ureteral calculi.
Right adnexal cyst. Recommend nonemergent pelvic ultrasound for further evaluation to exclude cystic ovarian neoplasm.
Small hiatal hernia.
High-density fluid is present posterior and adjacent to the inferior aspect of the descending colon. This is contiguous with the pelvic retroperitoneal hematoma,
and given the absence of abnormalities of the colon most likely represents extension of the retroperitoneal hematoma, which is not increased in size since the
prior study.
Discussed with admitting surgical service at 8:30 p.m.


Show term detail

I clicked on AML. This window shows that
‘AML’ was recognized as a monocytic
leukemia, SNOMED code 100744006.


NLP can help clinical decision support

• Summarization

• Enhanced search

• Extracting key encoded information from narrative, such as problem lists but
potentially far more

• Focus our attention on needs that might be overlooked

• As narrative text grows, so does the need for NLP


July 2009 tpayne@u.washington.edu
ICN: 006764


NLP tagging, then CMS E/M rules applied

E/M assigned by Code estimated by
nCode MD

Phrase recognized
and assigned
SNOMED code

Narrative text—dictation, directly entered, or
combination—is run through engine to tag SNOMED
phrases. CMS algorithm used to assign E/M code
suported by the note.

11/14/09
28

NLP improves E/M Financial Management

accuracy and RVUs CODE OF CONDUCT
Your coding questions answered

Natural language processing
• After calibration, 94% concordance improves coding accuracy
between human coders and system Process enables group to provide rapid feedback to physicians and
identify problems

• Feedback within 3 seconds on each M any physicians find rules for
assigning accurate E&M codes
within three seconds and remained accu-
rate, according to an ongoing audit.

note written challenging1 and ask for feedback. Since
coding clinical notes is an essential compo-
nent of billing for professional medical
During our test, NLP increased coding
accuracy, provided rapid, regular feedback
to physicians on their performance, and
services and is required for payer compli- identified problems that might other-

• With improved compliance comes
ance, we used natural language processing wise have been difficult to identify. For
(NLP) to assign E&M codes to electronic example, if a note was complete except
clinical notes and to provide coding feed- for the absence of the chief complaint,

revenue
back. NLP is a subfield of computer science the level supported by the note would be
that studies problems of automated genera- lower and the reason for this would be in
tion and understanding of natural human the feedback screen. We believe this tool
languages. will increase compliance with billing rules,
Over the last two years, the University assist in practitioner education and reduce
of Washington (UW) Medicine tested NLP billing costs.
By Thomas H. Payne, MD, (shown
to assign E&M codes to electronic clinical It has been well-accepted by physicians here) medical director, Information
notes for billing professional services. and compliance professionals, who are Technology Services, UW Medicine,
Seattle, tpayne@u.washington.
We compared accuracy with coding by accustomed to the nCode, an applica-
edu; Aidan Garver-Hume, systems
practitioners (mostly physicians) and tion used to apply NLP techniques to analyst and programmer, Information
coding experts, and assessed practitioner professional fee billing. It also satisfied Technology Services, UW Medicine,
Seattle, aiding@u.washington.edu;
acceptance, impact on labor costs and physician requests for feedback on coding
Sheila Kirkegaard, practice plan
the educational mission of our physician performance. administrator, Fred Hutchinson Cancer
practice plan. Research Center, Seattle, skirkega@
fhcrc.org; Jamie Sweeney, charge capture
This work was conducted under the Billing workflow supervisor, UW Physicians, Seattle,
auspices of UW Physicians, our group prac- jsweeney@uwp.washington.edu;
tice plan in the outpatient and inpatient Prior to this project, physician and Michael Ash, MD, RPh, vice president of
provider strategy, Cerner Corporation,
Blood and Marrow Transplant Service of nonphysician providers (NPPs) who bill
Kansas City, mash@cerner.com; K.K.
Seattle Cancer Care Alliance (SCCA), a for services completed paper fee sheets Kailasam, director and distinguished
cancer care hospital and clinic created by with codes for outpatient visits. Several engineer, Cerner Corporation, Kansas
the UW, Seattle Children’s Hospital and
Fred Hutchinson Cancer Research Center.
applications were developed including
an electronic fee sheet (eFeesheet) and an
City, kkailasam@cerner.com; Candace
L. Hall, solution manager, Cerner
Corporation, Kansas City, chall@
The clinic serves patients considered for interactive screen that replaced the paper cerner.com; Mika N. Sinanan, MD,
PhD, professor, Department of Surgery,
hematopoietic cell transplantation and fee sheet. It appears after a physician
Thursday, August 23, 12 those undergoing or recovering from the signs a note and permits rapid entry of an
UW, president, UW Physicians, Seattle,

Summary

• We need to better match EMRs with human strengths and workflow.

• Much of the clinical note content clinicians create is in narrative.

• That content can help us make better decisions, esp if aided by NLP.

• NLP today fits into the workflow of EMRs to capture important content
from narrative.


iHT2 Health IT Summit in Seattle 2012 – Case Study “EMR Usability & NLP”

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iHT2 Health IT Summit in Seattle 2012 – Case Study “EMR Usability & NLP”