09- Networking and Health Information Exchange- Unit 7- Supporting Standards for EHR Application-...

Networking and Health Information Exchange

Supporting Standards for EHR Application

Lecture cThis material Comp9_Unit7c was developed by Duke University, funded by the Department of Health and Human Services,

Office of the National Coordinator for Health Information Technology under Award Number IU24OC000024..

Supporting Standards for EHR ApplicationLearning Objectives

1. Understand the clinical decision support standard Arden Syntax (Lecture a)

2. Understand standards for clinical guidelines (Lecture b)

3. Understand object-oriented expression language for clinical decision support – GELLO (Lecture b)

4. Understand the clinical decision support standard Infobutton (Lecture c)

5. Understand disease management (Lecture c)6. Understand other clinical decision support

applications (Lecture c)

Health IT Workforce Curriculum Version 3.0/Spring 2012

Networking and Health Information Exchange Supporting Standards for EHR

Application Lecture c

Supporting Standards for EHR ApplicationLearning Objectives

7. Understand other standards that help to support networking and reporting requirements as well as functionality to optimize the connectivity among heterogeneous systems deployed within a single enterprise (Lecture d)

8. Understand single sign-on standards and the HL7 Clinical Context Object Workgroup (CCOW) standard (Lecture d)

9. Understand regulatory standards (Lecture d)10. Understand issues relating to person identifiers, master

patient indices, and record locator services (Lecture d)

Infobutton

4Health IT Workforce Curriculum Version 3.0/Spring 2012

• Context-sensitive links embedded within a clinical information system to allow easy retrieval of relevant information

• Functions by generating and sending queries to CDSS using data from EHRs

• CIS displays button next to data such as a diagnosis or abnormal lab data– When clicked, Infobutton formulates a query – Based on context of the interaction

• Including patient demographics, activity being performed, and user role

Infobutton Manager

• Software that supports implementation of Infobuttons in an application independent manner

• Application passes parameters to the Infobutton Manager which generates an HTML document with a set of natural language questions that are hyperlinks to clinical information resources

Information Resources• Many resources available

– Micromedex– MDConsult– UpToDate– Medline Plus

• Access different– http://resource1/com/search = “azithromycin” AND dose– http://resource2.com/query = “azithromycin” [Mesh Terms] AND

dose [All Fields]– http”//resource3.com/searchConcept = 3333 ^ azithromycin filter

= 11 ^ dosage

HL7 Infobutton Standard

• Implementations– XML based– URL based

• Terminologies supported– RxNorm– LOINC– SNOMED-CT– MeSH

Example of InfoButton

Source: www.infobuttons.org

Source. www.infobutton.org

Source: Shared by Dr. James Cimino

Disease Management• Includes all data and treatments related to

a particular disease• Tracks events

– Reminders for required tests– Identifies patients whose goals are not

reached– Tracks compliance– Compares patients

• Manages Workflow11Health IT Workforce Curriculum

Version 3.0/Spring 2012Networking and Health Information Exchange

Lecture c

Example of Disease Management System

Source: Dr. W. Ed Hammond

Order Entry Standards

• Sharing knowledge• Patient focused• Meets auditing requirements

Pseudo-code

Heparin is started and adjusted according to the patient's weight and the last APTT

IF starting heparin drip THEN

Give kg based bolus. Adjust the dose by protocol

IF APTT < 35 THEN

Give 80/kg bolus and increase drip by 4 units/kg.h

Repeat APTT in 6 hours

Vanderbilt CPOE Example 1

Source: Dr. William W. Stead of Vanderbilt CPOE System

Vanderbilt CPOE Example 2

Source: Dr. William W. Stead of Vanderbilt CPOE System

CARE - Regenstrief

IF TODAY IS NOT AFTER 10/1 & BEFORE 12/31OR "FLU SHOT LAST" IS AFTER 8/1OR LAST "REFUSED FLU INJ" WAS = 1 & SINCE 1 YEAR AGOOR "DRUG ALLERGIES" WAS = "SERUM ALRGY"

THEN EXIT

IF "AGE" IS GT 65 THEN Consider use of "flu shot AB" if no egg allergy because age places patient in high risk category AND EXIT

IF "X LAST" WAS = ASTHMA" V "COPD" OR "CHEST X-RAY LAST" WAS = "COPD" THEN Consider giving "flu shot AB" if no egg allergy because patient's lung disease places him in high risk category. R:2124 AND EXIT

Example provided by: Dr. Clement McDonald

Calculation of Framingham Risk

Framingham Heart Study

Source: Stroke After Atrial Fibrillation, n.d.

Create the Decision Tree• Define the decision problem• Identify the decision alternatives• List the possible clinical outcomes of each of the

decision alternatives• Represent the sequence of events leading to the clinical

outcomes by a series of chance nodes and decision nodes

• Choose a time horizon for the problem• Determine the probability of each chance outcome• Assign a value to each clinical outcome

– Preference– Utility– Payoff

Simple Decision Tree

Source: W. Ed Hammond, PhD.

Operate

Do not operate

Disease present

Disease absent

Outcome; Treatment with disease

Outcome; Treatment without disease

Outcome; Treatment with disease

Outcome; Treatment without disease

Standard gamble

Source: Slide set from W. Ed Hammond (original source unavailable)

What is Evidence-based Practice?• Traditional conceptualizations

– Research utilization– Clinical trials-based– Clinical practice guidelines

• Application of domain knowledge to patient care– Evidence as a continuum

PEPID – Clinical Guidelines

Source: Slide courtesy of Dr. Suzzane Bakken (original source unavailable)

Cochrane Database of Systematic Reviews

WebCIS Instrument, Currie et al.

Risk Assessment Toolkit

Cancer Risk - Diet

Risks for Developing Colon Cancer

Summary – Lecture c

• Presented the HL7 InfoButton standard – Feature that provides context-sensitive access to key

knowledge.

• Showed InfoButton’s value – Easy to implement and use– Can be used for almost any purpose– Provides trusted links to key knowledge resources.

• Also illustrated several of the knowledge resources available on the Internet

References – Lecture c

References Slide 17: Source: Courtesy of Dr. Clem McDonaldAcknowledgment: Some of the material in this unit was taken from HL7 at www.hl7.org.

ImagesSlide 8: What are Infobuttons? (n.d.). Retrieved February 24, 2012, from NIH Laboratory for Informatics Development,

National Library of Medicine, University of Utah Department of Biomedical Informatics, and Columbia University Department of Biomedical Informatics website: http://www.infobuttons.org/

Source: Slide set from W. Ed Hammond (original source unavailable)Slide 10: Source: Courtesy of Dr. James Cimino Slide 12: Source: Dr. W. Ed HammondSlide 15: Source: Courtesy of Dr. William W. Stead of Vanderbilt CPOE System Slide 16: Source: Courtesy of Dr. William W. Stead of Vanderbilt CPOE SystemSlide 18: Source: Slide set from W. Ed Hammond (original source unavailable)Slide 19: Stroke After Atrial Fibrillation. (n.d.). Retrieved February 24, 2012, from Framingham Heart Study website:

http://www.framinghamheartstudy.org/risk/strokeatrial.html Slide 21: Source: W. Ed Hammond

References – Lecture c

ImagesSlide 22: Source: Slide set from W. Ed Hammond (original source unavailable)Slide 24: Source: Slide courtesy of Dr. Suzzane Bakken (original source unavailable)Slide 25: Browse Databases and Tools. (n.d.). Retrieved February 24, 2012, from Essential Evidence Plus website:

http://www.essentialevidenceplus.com/content/poems Slide 26:Source: Courtesy of Suzzane Bakken, Columbia University

Welcome to the Risk Assessment Toolkit. (n.d.). Retrieved October 2, 2006, from MD Anderson Cancer Center website: www.cra.developerlabs.net

Cancer Risk Toolkit, My Diet. (n.d.). Retrieved October 2, 2006, from MD Anderson Cancer Center website: www.cra.developerlabs.net

Your ten-year and lifetime chance of developing colon cancer. (n.d.). Retrieved October 2, 2006, from MD Anderson Cancer Center website: www.cra.developerlabs.net

09- Networking and Health Information Exchange- Unit 7- Supporting Standards for EHR Application-...

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