Electronic Health Record

Transcription

1 e- Electronic Health Record in European Context Electronic Health Record A contemporary perspective Mikuláš Popper NÁRODNÉ CENTRUM ZDRAVOTNÍCKYCH INFORMÁCIÍ NATIONAL HEALTH INFORMATION CENTER popper@nczisk.sk

2 INTRODUCTION HEALTH RECORDS NL EXPRESSIONS ELECTRONIC HEALTH RECORD HUMAN-COMPUTER NL COMMUNICATION - A HISTORICAL ILLUSTRATION A CONCEPTUAL BACKGROUND FOR A KNOWLEDGE BASED EHR SYSTEM AN ILLUSTRATING EXAMPLE

3 ICT & MEDIA & TRANSPORTATION MEANS MAKE OUR GLOBE SHRINKING SHRINKING SHRINKING

4 WHILE CURRENT WORLD POLICIES AND ECONOMIC CONDITIONS CREATE INCREASING DOMESTIC & INTERNATIONAL MOBILITY OF PEOPLE ACROSS DIVERSE LANGUAGE DOMAINS GROWING COMMUNICATION BARRIERS

5 NEWLY EMERGING DIMENSIONS FOR GENERATING HEALTH RECORDS VIRTUALLY ACCOMPANYING MOBILE CITIZENS WHEN MOVING AMONG HEALTH SERVICE PROVIDERS AMONG FACILITIES IN ONE BUILDING AMONG DIVERSE ESTABLISHMENTS COUNTRYWIDE CROSS-BORDERS

6 INTRODUCTION HEALTH RECORDS NL EXPRESSIONS ELECTRONIC HEALTH RECORD HUMAN-COMPUTER NL COMMUNICATION - A HISTORICAL ILLUSTRATION A CONCEPTUAL BACKGROUND FOR A KNOWLEDGE BASED EHR SYSTEM AN ILLUSTRATING EXAMPLE

7 MEDICINE IS AN INFORMATION INTENSIVE DOMAIN HEALTHCARE SERVICE PROVIDERS SHOULD HAVE AT HAND ALL RELEVANT PATIENT RELATED HEALTH INFORMATION WHEN AND WHERE NEEDED

8 NATURAL LANGUAGE HAS A KEY ROLE IN MEDIATING RELEVANT INFORMATION TO REFLECT PERSON S S HEALTH STATE IS THE MOST COMMON MEANS FOR RECORDING AND CONVEYING INFORMATION IN HEALTH RECORDS

9 NOVA DAYS THE ADVANTAGE OF PROCESSING AND COMMUNICATING RELEVANT HEALTH RELATED INFORMATION IN NL IS WELL UNDERSTOOD PARTICULARLY THE ADVANTAGE OF MEDICAL RECORDS INTEROPERABILITY IN SPITE ORIGINATING ON DIVERSE PLATFORMS AND EVEN ACROSS DIFFERENT LANGUAGE DOMAINS THIS IS A MATTER ATTRACTING ACADEMIC AND SCIENTIFIC BODIES, NATIONAL GOVERNMENTS EUROPEAN COMMISSION - LSP

10 INTRODUCTION HEALTH RECORDS - NL EXPRESSIONS ELECTRONIC HEALTH RECORD HUMAN-COMPUTER NL COMMUNICATION - A HISTORICAL ILLUSTRATION A CONCEPTUAL BACKGROUND FOR A KNOWLEDGE BASED EHR SYSTEM AN ILLUSTRATING EXAMPLE

11 HEALTH RECORD IS A DOCUMENT (SET OF DOCUMENTS) ACCUMULATING HEALTH RELATED INFORMATION RECORDED BY HEALTHCARE PROVIDERS AS A RESULT OF HIS/HER CONTACT WITH PATIENT OR TO HIM/HER BELONGING SPECIMEN

12 HEALTH RECORD IS A KEY INFORMATION CARRIER A VEHICLE FOR SHARING HEALTH RELATED INFORMATION AMONG DIVERSE ACTORS IN HEALTHCARE RELATED SERVICES MEDICAL HISTORY (CURRENT ILLNESS, FAMILY HISTORY, WORKING AND SOCIAL HISTORY) OBJECTIVE EXAMINATION (ASPEXY,, AUSCULTATION, PALPATION, PERCUSION) RESULTS OF FUNCTIONAL DIAGNOSTICS, BIOCHEMICAL AND HEMATOLOGIC EXAMINATIONS, IMAGING, MONITORING AND OTHERS

13 QUALITY OF A HEALTH RECORD IS GIVEN BY RELIABILITY OF ITS CONTENT BY COMPLETENESS AND CONSISTENCY OF ITS CONTENT BY ITS ACCESSIBILITY WHEN AND WHERE NEEDED BY READINESS AND EASINESS TO REVEAL ALL RELEVANT FACTS IN IT

14 ELECTRONIC FORM OF HEALTH RECORD IS A VERY PROMISING WAY TO MEET ALL PREVIOUSLY LISTED REQUIREMENTS

15 ElectronicHealthealth Record REPOSITORY OF INFORMATION ON HEALTH HISTORY AND CURRENT STATE OF A SUBJECT OF CARE, IN COMPUTER PROCESSABLE FORM AND DIGITALLY SHARABLE

16 EHR IS IS ACTUALLY A RATHER COMPLEX SOFTWARE SYSTEM

17 SOME OF THE ITS COMPONENTS HAVE IMPORTANT SUPPORTIVE ROLE e.g. FOR DATA SECURITY, PATIENT PRIVACY PROTECTION, IDENTIFICATION OF PERSONAL ACCESS RIGHTS, MAINTAINING LOGS FOR ANY ACCESS REFERENCING SHARED DATA MODELS FOR INTEROPERABILITY POINTERS TO ALL OR SELECTED RECORDS OF A GIVEN PATIENT IN ALL NETWORK NODES (PHYSICAL LOCATIONS, REPOSITORIES) WHERE RECORDS ARE STORED AND MAINTAINED

18 THE CORE OF THE EHR SYSTEM IS COMPRISED FROM DECLARATIVE AND PROCEDURAL COMPONENTS

19 THEY CORRESPOND TO A KIND OF DOMAIN KNOWLEDGE, PARTICULARLY TO A STRUCTURED SYSTEM OF CONCEPTS REFERENCED BY LEXICAL UNITS, FORMAL RULES TO COMPOSE FROM THEM DIVERSE MORE COMPLEX DATA STRUCTURES TO CONVEY COMPUTER TREATABLE MEANING, RULES FOR THEIR CONTEXT DEPENDED INTERPRETATION, etc

20 DESIGN OF THOSE IS FACILITATED BY ALREADY AVAILABLE SOPHISTICATED SOFTWARE TOOLS BEING THEORETICALLY WELL GROUNDED INTRODUCED IN WHAT FOLLOWS To be noted: Many related development efforts are under the auspice of EuroRec in European extent and National ProRec establishments in EU member states

21 INTRODUCTION HEALTH RECORDS - NL EXPRESSIONS ELECTRONIC HEALTH RECORD HUMAN-COMPUTER NL COMMUNI- CATION - A HISTORICAL ILLUSTRATION A CONCEPTUAL BACKGROUND FOR A KNOWLEDGE BASED EHR SYSTEM AN ILLUSTRATING EXAMPLE

22 THE FOLLOWING ILLUSTRATION IS AIMING AT PROVIDING A FLAVOR FOR THE FOLLOWING EXPLANATIONS IT IS AN EXCERPT BASED ON THE ARTICLE J. WEIZENBAUM: ELIZA - A Computer Program For the Study of Natural Language Communication Between Man and Machine. In Communications of the Association for Computing Machinery, vol. 9, no.1, January

23 EXCERPT FROM A REAL HUMAN (PROBAND( PROBAND) AND COMPUTER DIALOG Men are all alike. In what way? They re always bugging us about something other. Can you think of a special example? Well, my boyfriend made me come here. Your boyfriend made you come here

24 He says I m Im depressed much of the time. It s s true. I am unhappy. I am sorry to hear you are depressed. Do you think coming here will help you not to be unhappy? I need some help, that much seems certain. What would it mean to you if you got some help?

25 Perhaps I could learn to get along with my mother. My father. You are like my father in some way. Tell me more about your family. Your father. What resemblance you see? You are not very aggressive but I think you don t t want me to notice that. What makes you think I am not very aggressive?

26 You don t t argue with me. You are afraid of me. My father is afraid of everybody. Bullies. Why do you think I don t argue with you? Does it please you to believe I am afraid of you? What else comes to mind when you think of your father? Does that have anything to do with the fact that your boyfriend made you come here?

27 INTRODUCTION HEALTH RECORDS - NL EXPRESSIONS ELECTRONIC HEALTH RECORD HUMAN-COMPUTER NL COMMUNICATION - A HISTORICAL ILLUSTRATION A CONCEPTUAL BACKGROUND FOR A KNOWLEDGE BASED EHR SYSTEM AN ILLUSTRATING EXAMPLE

28 (1.a) DECLARATIVE COMPONENT OF THE SOFTWARE SYSTEM ONTOLOGY IS A THEORETICALLY GROUNDED FORMALISMS (MEANS) [BASED ON DESCRIPTIVE LOGICS] THAT ENABLE SYMBOLIC (FORMAL) REPRESENTATION OF EMPLOYED INTERRELATED TERMINOLOGY (VOCABULARY) TO CONVEY MEANINGS AND REPRESENTING KNOWLEDGE

29 (1.b) DECLARATIVE COMPONENT OF THE SOFTWARE SYSTEM ONTOLOGY THE CONSIDERED MEANS YIELD NOMENCLATURES: STANDARDIZED CANONIZED VOCABULARY OF SPECIFIC LANGUAGE DOMAINS MAKING POSSIBLE TO REFER CONCEPTS (ENTITIES), SHARE THEIR DESCRIPTIONS, EXERCISE LOGICAL SEMANTICS AND REASONING ALGORITHMS WITH WELL UNDERSTOOD PROPERTIES AND COMPUTATIONAL COMPLEXITY

30 (2.a) DECLARATIVE COMPONENT OF THE SOFTWARE SYSTEM ARCHETYPES ARE STRUCTURED COMBINATIONS OF TERMS TO SET UP MODELS / PROTOTYPES TO REPRESENT ENTITIES, THEIR ROLE AND/OR FUNCTION THOUGH NOT EXCLUSIVELY WITH A CLEAR CUT CATEGORICAL POWER THE CORRESPONDING DATA STRUCTURES REFER TO CONCEPTS WITH THEIR (MOSTLY) INTERRELATED ATTRIBUTES AND RELATED CONTEXTUALLY INFLUENCED CONSTRAINED VALUES THEY MAY TAKE 30

31 (2.b) DECLARATIVE COMPONENT OF THE SOFTWARE SYSTEM ARCHETYPES THE ATTRIBUTES MIGHT HAVE THEIR OWN SPECIFIC ATTRIBUTES WITH ASSOCIATED RULES (CONSTRAINTS) SO THAT THEY MAY IMPLY SPECIFIC LOCAL PROCEDURES - FUNCTIONALITIES openehr ARCHETYPES ARE MODELS OF CLINICAL OR OTHER DOMAIN-SPECIFIC CONCEPTS [e.g. SYMPTOMS, SIGNS, DIAGNOSES, ETIOLOGY,, etc.]

32 ONTOLOGY AS A KIND OF VOCABULARY ARCHETYPES AS STRUCTURED COMBINATION OF TERMS REPRESENTING MEANING EMPLOYING INSTRUCTIONS FOR CREATION MEANINGFUL STRUCTURES

33 THE PROCEDURAL COMPONENT IS ASSOCIATED BY A NUMBER OF PROCESSES ENABLING PUTTING DOWN / UPDATE ATTAINED INFORMATION IN A STRUCTURALLY CORRECT, COMPLETE, CONSISTENT, SUITABLE, AND MEANINGFUL FORM TO STORE, MAINTAIN, AND SHARE THE RECORDS IN A CONTROLLED WAY TO USE, EXERCISE, RETRIEVE, COMPOSE RECORDS PURPOSEFULLY FOR DIVERSE AIMS -IN ADVANCED CASES- TO INDICATE POSSIBLE DATA INTERPRETATIONS, TO INFER SUGGESTIONS, INSTRUCTIONS, ARRANGEMENTS FOR FURTHER ACTIVITIES 33

34 TEMPLATES FORMAL SPECIFICATIONS DEFINING A PARTICULAR AGGREGATION OF ARCHETYPES AND ASSOCIATED PROCESSES e.g. CONTEXTS, PURPOSES, CLINICAL DOMAIN, etc. ENABLE SPECIFICATION OF CONSTRAINS IMPOSED ON COMPONENT ARCHETYPES TO MAKE THEM 'FIT FOR PURPOSE ASSIGNING DEFAULT (EXPECTED) VALUES, MANDATORY AND FACULTATIVE ITEMS SCREEN FORMS, REPORTS, OR MESSAGES

35 THE BACKGROUND OF TEMPLATES SYMPTOM SYMDROM DG FACTS FROM EHR ATTRIBUTES EXPECTING VALUES

36 A GENERIC DIAGNOSE TEMPLATE AN ILLUSTRATION inconsistent findings excluding evidences attributes development forms/stages severity disease severity life/health threatening potential diagnosing approaches (e. g. evidence-based, by exclusions, by treatment) typical clinical image pattern (bonded findings) DIAGNOSE conceptual, causal, case-based, analogical reasoning expected obligatory and/or facultative findings etiology pathophysiology generalizations specializations diagnoses with similar clinical image occurrence limits expected treatment outcome

37 ILLUSTRATION OF A GENERIC DIAGNOSIS ARECHETYPE NAME of the disease: IS-A-CASE CASE-OF: more general diagnose(s) ) if any GENERALIZES: a list of diagnoses if any DIFFERENTIATE: diagnoses with similar clinical image OBLIGATORY FINDINGS: a list [X-from[ from-y] FACULTATIVE FINDINGS: a list [X-from[ from-y] EXCLUDING/INCONSISTENT FINDINGS: a list ATTRIBUTE (development stage): a list of permitted expressions ATTRIBUTE (disease severity): a list of permitted expressions ETIOLOGY: a list of agents/factors

38 NAME: DUODENAL ULCER IS-A-CASE CASE-OF: FINDINGS: PAIN OF: PEPTIC STOMACH ULCER LOCALIZATION: upper part of the abdomen below the tip of the xiphoid process mostly to the right of the midline CAUSED/PROVOKED: meals consumption OCCURRENCES: between one to four hours after meal intake, rarely r in morning before breakfast RELIEVED: by milk and other protein foods intake and/or by taking antacids CAUSES/PROVOKES: sometimes awakens at night LAB: very high gastric acid secretion ENDOSCOPY and/or X-RAY: X positive findings INCONSISTENT (CHALLENGING) FINDINGS: PAIN LOCALIZATION: above the xiphisternal junction ETIOLOGY: long lasting psychical stress, Helicobacter pylori ETIOLOGY: PARTICULAR DIAGNOSIS ARECHETYPE A FRAGMENTAL ILLUSTRATION

39 A GENERIC FINDING TEMPLATE AN ILLUSTRATION specificity / sensitivity +/- predictiveness attributes subsumption reliability false positivity/negativity environmental factors methods, expenses, preparation, planning evidence/proof for, associates/pointer to FINDING facility and time requirements ACQUISITION affinity to, appealing to, consistent with bonding patterns inconsistent with discriminates among generalization specialization language substitute risks, constraints, patient s stress

40 ILLUSTRATION OF A GENERIC FINDING ARECHETYPE NAME of the FINDING: RELATES TO: object, organ, tract, system, function, behavior CATEGORY: symptom, observation (sign), functional examination, physical examination result, lab-value, imaging, endoscopy,,, therapeutic consequence INCONSISTENT WITH: ONSET/DURATION LOCALIZATION if-needed SPECIFICATION if-needed DYNAMICS INTENSITY if-needed DYNAMICS CHARACTER if-needed DYNAMICS WHAT HAS PRECEDED WHAT IS ACCOMPANYING CAUSES OCCURS FREQUENCY if-needed DYNAMICS AMOUNT if-needed DYNAMICS COLOR if-needed EXTENT ODOR If-needed INTENSITY GETTING WORTH RELIEVED BY if-needed DYNAMICS

41 PARTICULAR FINDING ARECHETYPE A FRAGMENTAL ILLUSTRATION - PAIN LOCALIZATION if-needed DETAILING if-needed DYNAMICS INTENSITY if-needed DYNAMICS CHARACTER if-needed DYNAMICS ONSET DURATION OCCURS if-needed OCCURRENCE TIMES PRECEDED/CAUSED PROVOKED IS ACCOMPANIED CAUSES IT GETS WORSE if-needed SPECIFICATIONS RELIEVED BY if-needed SPECIFICATIONS

42 PAIN ILLUSTRATION - LOCALIZATION

43 PAIN ILLUSTRATION - INTENSITY VERY MILD MILD MODERATE STRONG SEVERE UNBEARABLE

44 PAIN ILUSTRATION INTENSITY DYNAMICS CONSTANT INCREASING INTENSITY GETTING WORTH WEAKENNING, FADE VANISH CEASE

45 PAIN ILLUSTRATION CHARACTER, NATURE SPASM, CRAMP PRESSING PULSING RUBBING, CUTTING STABBING BURNING SQUEEZING CONVULSIVE CONTUSIVE

46 PAIN ILLUSTRATION ONSET BEFORE A WHILE SEVERAL MINUTES SEVERAL HOURS A DAY (YESTERDAY) SEVERAL DAYS A WEEK SEVERAL WEEKS\ A MONTH SEVERAL MONTHS

47 PAIN ILLUSTRATION DURATION SEVERAL SECONDS SEVERAL MINUTES SEVERAL HOURS SEVERAL DAYS SEVERAL WEEKS SEVERAL MONTHS

48 PAIN ILLUSTRATION OCCURRING TIME/SEASON IN NIGHT IN MORNING DURING THE DAY IN EVENIING IN COURSE OF WORKING DAYS IN COURSE OF NON BUSINESS DAYS DURING SPRING SUMMER AUTUMN

49 PAIN ILLUSTRATION OCCURRING TIMES FIRST TIME SECOND TIME THIRD TIME REPEATEDLY UNDER THE CONDITION

50 PAIN ILLUSTRATION OCCURRING TIMES DYNAMICS REPEATS WITH CONSTANT FREQUENCY REPEATS WITH INCREASING FREQUENCY REPEATS WITH LESSER FREQUENCY

51 INTRODUCTION HEALTH RECORDS - NL EXPRESSIONS ELECTRONIC HEALTH RECORD HUMAN-COMPUTER NL COMMUNICATION - A HISTORICAL ILLUSTRATION A CONCEPTUAL BACKGROUND FOR A KNOWLEDGE BASED EHR SYSTEM AN ILLUSTRATING EXAMPLE

52 A FRAGMENT FROM AN EHR The patient, male, age 54, a long distance truck driver for more than 10 years, claims perceiving pain (the patient signifies the location by pointing slightly below the tip of the xiphoid process), which is usually spreading (points to a narow area a bit to the right of the midline). It occurs about 2 to 3 hours after eating, sometimes the pain awakens him at night and very seldom in morning before breakfast. After consuming milk and other protein foods the pain ceases. The same holds after taking antacids,, THE PARSER IN THE PROCEDURAL COMPONENT OF THE EHR SYSTEM SEARCHES FOR KEY WORDS, i.e. NAMES OF FINDINGS AND VALUES OF 21. ATTRIBUTES TO IDENTIFY SEMANTIC CASES

53 Let s consider now a fragment from an EHR record: The patient, male, age 54, a long distance truck driver for more than 10 years, claims perceiving pain (the patient signifies the location by pointing slightly below the tip of the xiphoid process), which is usually spreading (points to a narow area a bit to the right of the midline). It occurs about 2 to 3 hours after eating, sometimes the pain awakens him at night and very seldom in morning before breakfast. After consuming milk and other protein foods the pain ceases. The same holds after taking antacids,, SYMPTOM CONCEPT LOCALIZATION OCCURRENCE PROVOKED CAUSES RELIEVED BY THEN IT TRIES TO MATCH THESE WITH THE IDENTIFIED AND IMPLIED CONCEPTS, ARCHETYPES

54 NAME: DUODENAL ULCER IS-A-CASE CASE-OF: FINDINGS: PAIN OF: PEPTIC STOMACH ULCER LOCALIZATION: upper part of the abdomen below the tip of the xiphoid process mostly to the right of the midline CAUSED/PROVOKED: meals consumption OCCURRENCES: between one to four hours after meal intake, rarely in morning before breakfast RELIEVED: by milk and other protein foods intake and/or by taking g antacids CAUSES/PROVOKES: sometimes awakens at night LAB: very high gastric acid secretion ENDOSCOPY and/or X-RAY: X positive findings INCONSISTENT (CHALLENGING) FINDINGS: PAIN LOCALIZATION: above the xiphisternal junction ETIOLOGY: long lasting psychical stress, Helicobacter pylori ETIOLOGY: PARTICULAR DIAGNOSIS ARECHETYPE A FRAGMENTAL ILLUSTRATION

55