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April 10, 2009

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Loraine Lawson

Excellent piece. I posted about it at IT Business Edge, so hopefully you'll get some traffic off our site.
http://www.itbusinessedge.com/cm/blogs/lawson/is-it-capable-of-building-a-national-electronic-health-records-system/?cs=31858

Ognian Pishev

The following paragraph is a condensed description of the requirements for a proper data model in healthcare:

"The first problem with modeling healthcare data is that models must represent certain concepts (and not others) that will remain stable and true long enough to be built into computer software then used by healthcare providers and patients. Mr. Obama, have you noticed just how much knowledge has, is, and will be accumulating in the medical sciences? Knowledge is codified using words..."

So let's separate what is stable from what is changing or is likely to change. In order to do so openEHR (www.openEHR) defines a two-level modelling methodology and two sets of specifications - an information part and a knowledge part. The first one defines a stable reference model that describes the EHR as a container that holds compositions (documents) which in turn may have entries (observations, evaluations, instructions, etc.). Although the selection of entries is based on a certain model of decision making in healthcare, the model itself does not attempt to represent clinical knowledge. It comes from a variety of sources - terminologies, ontologies, classifications, measurement systems, etc. - and the application of computable knowledge representation to the information model is how data acquires its context-specific meaning. The full computable data models of clinical concepts are called archetypes: blood pressure is an archetype, so is a synoptic report, pathology lab result, etc.
The archetype is meant to represent all the clinical knowledge re. a certain concept. However, in order to make a practical use of archetype libraries we combine them in semantic templates, which, for example, may specify that we need the systolic and diastolic blood pressure, and the arterial, or the pulse, neither are we interested in discussing whether the patient was sitting, standing, etc.
In different circumstances, e.g. in sports medicine we may want to have a baseline reading and then repeat it every 5,10mins. Archetypes allow for different constraints in different templates, so long as we use the same basic clinical models. Once we've selected the template we can further enhance the semantics by querying available terminologies (SNOMED, ICD) and producing bindings to the terminology subsets that should be used with particular archetypes/templates. If our understanding of medicine is enriched, we can produce a new version of the archetypes, or in order to dig deeper, we can specialise them and so on.
The beauty of the openEHR approach which formed the basis of an international standard (CEN/ISO 13606) is that it produces fully computable EHRs that serve as the platform for application development. Semantic interoperability, which simply means that data captured by one application should be reusable by any other application without transformation, is based on archetype libraries freely available in the public domain. Archetypes are produced by clinicians who are the data modelers using a freely available Archetype Editor. ADL, the archetype definition language, is part of the international standard and every single bit of the openEHR specifications is available from the openEHR foundation.

Current discussions of EHRs in the US are describing the HOW and not the WHAT part. If we start by defining the semantics of medical data, then it will be fairly easy to specify a logical record architecture and provide health IT vendors with content specifications for shareable EHRs. It is up to them to design the implementation of a semantically interoperable EHR, which is the only meaningful way of providing for the "meaningful use" of IT in healthcare.

Christopher Fahey

It sounds to me like the problem is primarily one of user interface design. It sounds like almost no thought or effort or money was devoted to making the user interfaces actually useful to medical professionals. Every problem you've described sounds like one that is the direct result of letting systems engineers design the user interface.

By blaming the data model, I fear you are focusing attention on a symptom and not on the real underlying problem. The result will be that the data model will be improved endlessly, but the user interface for entering and retrieving the data will still be based on the technology and not on the humans.

Even a perfect data model is useless if the medical professionals can't use it.

To those of us in the user experience and interface design world, the failure of EHS is a profound tragedy because so much that you complain about can be solved if your industry would simply focus on the correct problem.

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I still prefer the old way when charts were hung at the bed of each patients bed containing detail of his health problems.

Glen

The archetype is meant to represent all the clinical knowledge re. a certain concept. However, in order to make a practical use of archetype libraries we combine them in semantic templates, which, for example, may specify that we need the systolic and diastolic blood pressure, and the arterial, or the pulse, neither are we interested in discussing whether the patient was sitting, standing, etc. http://www.hotfilemediafire.com

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The beauty of the openEHR approach which formed the basis of an international standard (CEN/ISO 13606) is that it produces fully computable EHRs that serve as the platform for application development. Semantic interoperability, which simply means that data captured by one application should be reusable by any other application without transformation, is based on archetype libraries freely available in the public domain.

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"a nation-covering, interoperable, secure, private, reliable, accurate, and instantaneous electronic healthcare data network is at best terrifying and at worst pernicious."i am in your side.

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The first one defines a stable reference model that describes the EHR as a container that holds compositions (documents) which in turn may have entries (observations, evaluations, instructions, etc.). Although the selection of entries is based on a certain model of decision making in healthcare, the model itself does not attempt to represent clinical knowledge.

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By blaming the data model, I fear you are focusing attention on a symptom and not on the real underlying problem. The result will be that the data model will be improved endlessly, but the user interface for entering and retrieving the data will still be based on the technology and not on the humans.

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Dear John et al.,

Hello, Kimia et al.

A reader whom I will call Doug wrote to ask that question. What is your answer for Doug?

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Accusing the data model Im afraid that we are focusing on the symptom and not the real underlying problems. The result is that the data model getting better, but the user interface for entering and searching the data is still based on technology rather than people.

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the USA government is trying to manage with all country's holes in the budget...

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If our nation simply accepts your vision while healthcare IT vendors collect a lion's share of the $20 billion stimulus bounty, individuals and businesses will pay higher medical costs, patients will receive inferior care, medical professionals will lose more of their precious time fighting IT systems instead of delivering better care, and you will be a one term president.

This is so true. I hope his message reach the president.

EMR

An electronic medical record is not just a typed record of the patient encounter, but an extremely useful decision support tool. The data can be entered into the EMR via any of the two general mechanisms: direct entry by the physician using point and click templates or transcription of dictated notes.

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