As we discussed HIE (Health Information Exchange) I keep going back to issues I have seen time and again. Junk in equal junk out.
“Will the real Slim Shady please stand up?”
This is what kept coming to mind every time we discussed Health Information Exchange. But first what is HIE?
HIE is the exchange of health information across systems. If you were in an accident in New York, the hospital could pull your records from your primary care physician in your hometown in Atlanta. The information is pulled online, sent to the ‘cloud’ (virtual storage), and then comes back down in a format that will work for the New York Hospital.
There are a multitude of concerns here that have been discussed by several people in the field.
1. How do you secure the cloud? How will it be HIPAA Compliant? How do you keep it from being easily hacked and ensure only those who should be pulling your records are pulling them?
2. How do you get the different systems to talk to each other? Each system has it’s own language. Yes there is SNOMED-CT that should be the verbiage used for problem lists, but it won’t be used for tests (ok ICD9 or ICD10 will help with this one), clinician notes (nothing to help with this one yet), etc. No one calls items the same thing. Even in the same hospital there are different terms for diagnosis, diet, etc. depending on who you ask. The Dietician calls it the Consistent Carbohydrate Diet. The Nurse knows it as the ADA Diet. The nutritionist who serves the food and the patient, knows it simply as the Diabetic Diet. If there is so much inconsistency within one organization on a simple item such as diet, then how will information be sent to a cloud and come out in a readable & useable form?
3. Supposing the issues above could solve, then lets move on to a bigger issue. ” Will the Real Slim Shady please stand up?”
This is the issue I keep coming back to. Patient Identifier. Even if you can get hospitals to agree to an HIE, and even if (BIG if here) you could solve most of the issues with terminology, how in the world do you solve the issue with incorrect records being tied together? Or making sure you have pulled all the information on that patient?
If you have a savvy patient who knows all of their past medical history, and may even carry their records to each hospital visit then you don’t have this issue. This issue is caused by those patients who cannot remember what hospitals and physicians offices they have used. It is an issue for people who do not have a unique identifier. Not everyone who is seen in US hospitals has a SSN.
Another issue is not everyone wants to have their medical records linked. I know the VA just used metadata tagging so that some information could be sent and other information could be excluded based on tags.
There is also the issue of people who don’t want to have the system share information across an exchange. They don’t want to be in any system.
So why does this matter? Well what happens when you are traveling by yourself. You are in a major car wreck. Your allergy bracelet (listing your deadly allergic to __) comes off in the wreck and your ID is still intact and the responders have enough information to pull your health record. The hospital in anticipation of your arrival uses the information the emergency responders have to pull your records. The only issue is someone has stolen your ID in the past. You made sure to cancel your credit cards and other items, but you didn’t check to see if anyone had used your ID at a hospital. The most recent visit at the hospital, is by the person who stole your ID & not you. You are transferred to the hospital, where they start treating you for your wounds. They start an IV with the medication your are deadly allergic to. You start crashing. Now are you crashing due to an internal bleed or another issue? The hospital does not know. Your records shows you have no allergies so it must be something else.
This is just one scenario that keeps coming to mind. I mean just think about the episode on House (even if you don’t agree with the medicine or think this has ever happened, it could). The patient kept crashing until they figured out they had the wrong patient records.
Am I suggesting implanting computer chips in everyone? Or maybe a tattoo with information? No. I am just saying don’t think technology will fix everything. As I said other day, technology on top of a bad process is still a bad process with bad outcomes. Do I know how to fix this issue? No. I know there are several people working on the issues I mentioned above. Your hospital may even be working on these issues now just within their hospital.
What do you think? Do you think we will be able to create an HIE? Do you think it will work? What about the issues above… how would you address these issues?
Just some thoughts to ponder on a lovely Thursday afternoon.
Oh the possibilities with using Semantic Medline. The demonstration of Semantic Medline really engaged the class. I now remember why I LOVE research. You could say it was the pretty colors or just the complete cool geeky way of correlating research. I wish it would have started with the visualization first then went into the details.
So what is Semantic Medline?
“Semantic MEDLINE is a prototype Web application that integrates PubMed searching, advanced natural language processing, automatic summarization, and visualization into a single Web portal. The application is intended to help manage the results of PubMed searches by identifying semantic predications in the citations retrieved.”
And here is what it looks like:
You may not be able to see it from this still photo, but you can actually click into each color line and term to see why it was linked to the original term. This is all done based on the MeSH terms.
In addition to getting the visual image, you can also see the abstract of the article:
This allows you to look at the visual picture of the connection and then go into the details and the data of why it is connected. Now why is this so awesome besides the pretty colors and patterns?
Imagine all the possibilities and the new heights research could reach……
Think of teaching. How this can be used to help students who are more visual learners grasp what cases Alzheimer’s Disease.The professor could do the search and then lead a discussion into the specific nodes, pulling up the literature that supports why it is related to the topic. It could even go into why the literature is reliable or not.
It access an extremely rich data mine of information and extracts it into a visual presentation. It could lead to new discovers of diagnosis, treatment, management, etc.
Genetics. It can show the connection between a gene and a specific disease. For instance, obesity alters the CLOCK gene, the alterations of to the CLOCK gene have the potential to cause cancer. This can be easily shown through the visualization of the MeSH terms in Semantic Medline.
MeSH. I am going to start teaching MeSH using Semantic Medline. Why? People respond extremely well to the visualization. It reminded me of why I enjoy research. It is piecing together a puzzle, and Semantic Medline pieces it together in a gorgeous data rich way. It makes me want to review terms all day long to find connections, determine if it has been written about before, and write articles. It makes me want to long to research (yes I am an odd duckling).
The only sad part is it is not available to all users yet. It is limited to those with a license to UMLS. It is also important to note that it is still in beta testing. So there are still some issues being worked out before it goes live. If you want to have access you will need to request a license to UMLS. It is free, all you have to do is complete a report once a year. So if you want to use this to teach students, do research, or just have fun with the graphics then you will need to sign-up first.
Can you imagine other ways it can be used? My head is still reeling with all the possibilities.
Of course this is all possible thanks to genius people like Marcelo Fiszman, M.D., who is also an excellent presenter. Excellent job!
This is what we learned in class today, and I mean that in the nicest way possible.
One of the presenters today, by J. Starren, discussed unintended consequences of implementing technology. He discussed how implementing new technology can interrupt or cause issues with current processes. Yes this is true. The other issue, which we have not discussed is when you implement technology on-top of a bad process only muddies the waters even more. What do I mean?
Hypothetical Scenario: Let’s say you have a process of filling out paper slips for lab for every item that is sent to lab. On this slip you indicate the specimen, patient data, and tests that need to be ran. When you implement the new EMR, you do away with the paper slips. Now only patient data is put on the specimen, and all orders are entered into the computer system screen which was built off the paper lab slip. Nursing has access to the system, so lab should too and why do nurses need this information filled out again?
It is the first day of implementation and about an 30 minutes into it when issue calls start coming in. Physicians are asking where their stat lab results are for patients and why the information is not showing up in the system. Nurses are now spending their time rewriting orders, calling lab, and some are actually going to lab. Lab meanwhile, is standing there like deer in the headlights. They have no idea what has just happened. They are trying to process orders without the information they previously received. The only person with access to the new system in lab is on vacation.
There are multiple possible issues with this hypothetical situation (I am making assumptions based on the information above):
- No one walked the lab process to determine if it is in fact done this way.
- No one confirmed the labs on the paper slip are actually orderable labs in the system.
- Lab was not involved in the process and now is receiving specimens without the information they were use to and do not have access to the system to look up the information.
- If no one reviewed the labs on the paper slip, then no one bothered to see if they could prefill specific items on the screen. IE, urine always defaults in the specimen field for Pregnancy Urine Test.
- No one worked with lab to create a glossary of orderable labs and what is included in each lab test.
- Lab was not even informed of the change.
Within 15 minutes of the first call, everyone has reverted back to paper. No worries lab had extra copies stored away in a cabinet.
Maybe I am thinking of the worse possible situation, but it illustrates what can happen when you take a bad process (not just the paper slips process but the lack of a process for making changes) and add technology onto it.
So how does this relate back to your baby is ugly? Well we discussed today how testing a system with someone you know does you know good. They will not admit when there are issues. It is the same for testing a process. You need to find an outside resource that is not involved in the process, has no ties, or influences to evaluate the process, database, program, etc.
Sometimes the best way to do this is get someone who is very resistant to change or against the idea and evaluate the process. If you are the one that designed the process, program, or other item, you may not be pleased with what you hear, but just remember it is constructive feedback. It is a little different than your baby is ugly. It is hard to hear, but you can fix the process/program.
I have had this issue lately. As I developed a process for order set development people have made suggestions for changes. I know changes are needed. I developed a process with parts that are constantly under change. So change is part of it. The issue is how it is addressed.
A stranger walks by and says your baby is ugly is actually better than you finding out your Aunt has been saying your baby is ugly every time you left the room. Why did the Aunt not tell you up front? Its hard. Some people do not take it as well. Personally, I want to hear if there are issues with a process/program so that it can improve. If I do not know the issues, then I cannot fix them. But these can be communicated in a nicer way than saying “your baby is ugly.” Constructive criticism is how you help others improve.
The other item is offer feedback to people directly instead of just criticizing. Don’t just say this is bad, I don’t want to change. Offer suggestions. Or say I am not sure how to fix this but it would be nice if..”.
All of this to say that technology will turn your processes upside. It sometimes is a good unintended consequence since it provides you time to review your processes. It can be an issue that does not go well if you do not take the time to evaluate the process and walk it in advance.
This is just something I have taken away from Woods Hole so far. I am sure as I reflect on my the presentation and my tweets I will have other take away items that I will post later.
Here is something else I’m taking away, wonderful morning walks with great views:
Today was the first day at the Woods Hole Biomedical Informatics Program. I say it was the first day but it was really a day of welcome and introductions.
Tonight we had a welcome reception where everyone introduced themselves. I learned a few interesting facts:
- Total number of people at this session=30
- 17 Librarians (tied for most librarians)
- 6 Physicians (least number of physicians)
- 6 Administrators
- 1 vendor
2. Each person brings a unique perspective
We have some who are just dipping their toes into Informatics, and others who have been working in the field of informatics for years. We have people who want to learn the basics to just have more knowledge, and others who want to know how to integrate this into their daily clinical life to improve patient care. There is one person (a GI fellow) with a great idea of reducing the amount of unnecessary CT scans to diagnosis GI issues using screening criteria built into an EMR system. It sounds like an intriguing idea and I am curious to learn more about the concept and if the class will help develop the concept.
I am still learning about all the people in our class and will be posting more as we move through each session. I will also tweet as much as I am able (yes @hurstej will probably tweet more than me even though she is not here).
Tonight as we introduced ourselves we discussed why we here and what we hoped to learn. As my post earlier today pointed out, my job description has changed. I am now officially part of Clinical Informatics. I still do all of the normal library work, but I also work on informatics projects. This is one of the main reasons I am here. I want to learn more about how to accurately incorporate appropriate technology into clinical settings. I am not sure the course will go over this specifically, but I am hoping to get some basic knwoledge to take back to my organization.
Of course I will be sharing this knowledge and information gathered with all of you. If you have a question about the courses, program, items I post, etc. please leave me a comment below or send me a message on twitter.
Note: For some reason I am having issues with various features in WordPress on the iPad. It must be the questionable iOS or that this is an Apple product (kidding Apple Fanboys). I do however apologize for the issues with spacing and other items.
She went to Woods Hole, MA, BioMedical Informatics program of course.
It has been almost 2 months since my last full blog post. Why so much delay between posts? I would like to say it is because I have so much to do (there is truth to this statement). The only issue is if The Krafty Librarian can find time to blog after working all day and then taking care of 3 kids… I should be able to find time too.
My only excuse is work. In the last few months I have been tasked with several new responsibilities including working part time in Clinical Informatics, and leading multiple (I think up to 80 now) order set projects that include EBM, project management and Knowledge management.
I now support three hospitals as a solo hospital librarian, while running CME and working on Clinical Informatics. So the truth of why I haven’t blogged lately is really because by the time I get home I do not want to look at another screen. I just cannot seem to bring myself to do it, but I will try to improve. Why?
Well, I have several projects currently in the works that would make excellent papers/posters and presentations. Including launching an iPad program for the residents that meant getting the EMR and Sharepoint to work on Safari, Working with clinicians on building CPOE, EBM for order sets, the difficulties of getting multiple EMR systems to work together, the changes to the medical library field for the solo hospital librarian, and something I call the domino effect (more to come later).
These are just a few topics that have been rattling around in my brain lately. Today at #woodsholebmi Ryan asked if I had submitted anything for MLA. The short answer is no. The long answer is typed above.
Even Heather commented on how quiet I have been on Twitter lately and how this was going to change with Woodshole. She is right. I have been quiet on Twitter lately due to work projects, and Woodshole will mean an increase in tweets. So if you follow me on Twitter, fair warning the next week will contain several tweets about Biomedical Informatics. The next week will also include several blog posts on Biomedical Informatics with a few others possibly thrown in for good measure. And if you are not familiar with these terms, do not worry. I will probably define several of thesse over the next week as I move through the course.
Thank you to all of my followers who are still reading my blog post despite a 2 month hiatus.
Medlibs Twitter Chat TONIGHT, July 26th, Thursday, at 9pm EST
Twitter chats typically have a set of questions/topics to go through, but then again it is also a fluid conversation. I cannot guarantee we will discuss all of the topics below but these are some items I thought would be great to discuss. So what are some of the items we might be discussing?
1. Introduction: name, title, organization
2. If you are involved with EMR, CPOE, EHR, Clinical Informatics or other aspects of Meaningful Use please explain briefly.
3. How did you get involved?
4. Why should medlibs get involved? In other words why is this so important to organizations?
5. Tips/advice for other medlibs on how to get involved?
6. Why is EBM(evidence based medicine) important?
7. How can medlibs help integrate EBM (evidence based medicine) into EMR/EHR/CPOE?
8. How can medlibs help with providing consumer/patient information?
9. Do you think medical librarians could be Clinical Informatics? Why or why not?
10. Do you see a place for medlibs to be knowledge managers (organizing the data)? Are you doing this?
11. What other ways does the government changes impact medlibs?
12. Anything else as we wrap up?
As we have done previously each item will be posted as Topic #1 and responses should lead with T1 and include the #medlibs hashtag. This will make it easier to follow the conversation. But then again remember this is a fluid discussion. So we could do away with the rules completely. Just think back to Mark Funk’s Janet Doe Lecture at MLA and imagine yourself in a coffee shop with a good cup of coffee to get the ideas flowing. Of course as in previous weeks drinks of all kinds are allowed to help encourage the fluid network!
Note: If you have specific items you think should be addressed in the discussion please leave a comment below or email me.