Health Enterprise Computing Long Term Care and Patient - - PowerPoint PPT Presentation

SLIDE 1

1 1

Health Enterprise Computing and Patient Identification

6.872/HST.950 February 13, 2003 Peter Szolovits

(with first half content from David Margulies)

Community Hospitals Home Health Long Term Care Tertiary Care Clinics Primary Care Docs Pharmacy Reference Lab Specialists XXX Health System

Integrated Delivery System... Integrated Delivery System...

Knowledge Knowledge Assets Assets Plan Plan Tertiary Tertiary Clinics Clinics Plans Plans PHO PHO PPO PPO MSO MSO Affiliations Affiliations Contracts Contracts IDS IDS PPO PPO Carve Carve-

• Outs

Outs Purveyors Purveyors PSO PSO THE GOVERNMENT THE ENROLLEE THE HOME THE EMPLOYER

Complexity now Complexity now within... within...

Context: Evolution of Clinical Computing...

• Focus evolved from automating AR process

in hospitals, to LAN-based SI of departmental systems, to enterprise clinical computing, toward region- and system-level process automation

• Changing healthcare organizational models

and economic models ---> changing clinical computing priorities and designs

SLIDE 2

2 2

Phase 2: LAN-based SI -- Automate Data Distribution to MDs...

Case Case Mix Mix Material Mgmt Material Mgmt Payroll Payroll General Ledger General Ledger Accounts Payable Accounts Payable Laboratory Laboratory Nursing Nursing Pharmacy Pharmacy Radiology Radiology Surgery Surgery Internal Medicine Internal Medicine Order Comm Order Comm ATDs ATDs Patient Acct Patient Acct

Entry Entry

Physician Physician

Phase 3: Data-based SI to Create an EMR...

Case Case Mix Mix Material Mgmt Material Mgmt Payroll Payroll General Ledger General Ledger Accounts Payable Accounts Payable Laboratory Laboratory Nursing Nursing Pharmacy Pharmacy Radiology Radiology Surgery Surgery Int Int Med Med

Order Comm Order Comm

ATDs ATDs Patient Acct Patient Acct Data Data Repository Repository “Electronic “Electronic Medical Medical Record” Record”

Paradigm 1 Paradigm 1 Paradigm 2 Paradigm 2

Pat Pat Acct Acct Laboratory Laboratory Nursing Nursing Pharmacy Pharmacy Radiology Radiology Surgery Surgery Int Int Med Med Order Order Comm Comm ATDs ATDs Viewer Viewer Document Document Expert Expert Systems Systems

Clinician’s System Clinician’s System

Interface Engine Interface Engine

Order Order Mgmt Mgmt

DATA REPOSITORY

Group Group-

• Patient

Patient Relationships Relationships Patient Patient-

• Provider

Provider Encounters Encounters Patient Patient-

• Provider

Provider Relations Relations Clinical Events: Clinical Events: Procedures, Results Procedures, Results & Documents & Documents Clinical Clinical Orders Orders Clinical Clinical Problems Problems Clinical Clinical Careplans Careplans Styles of Styles of Practice Practice Providers Providers & Other & Other Personnel Personnel Groups Groups Facilities Facilities & & Locations Locations Patients Patients Facility Facility-

• Group

Group Affiliations Affiliations Visits Visits Group Group-

• Provider

Provider Roles Roles Institutional Institutional Care Care Standards Standards & Protocols & Protocols

Settlement Settlement Membership Membership Care Care Team Team Int. Int. Med Med Rad Rad Lab Lab Pharm Pharm

Surgery Surgery

Account Account Plan Plan Design Design Discharge Discharge Dismiss Dismiss Episode Episode Activation Activation Authorization Authorization Health Health Status Status Mgt. Mgt. Community Community Care Care Self Self Care Care Evaluate Evaluate Assess Assess Plan Plan Act Act Schedule Schedule Refer Refer Visit Visit Activation Activation Mgt. Mgt. Team Team Health Health Mgt. Mgt. Health Health Record Record Measure Measure

Phase 4: Enterprise-level Clinical Process Automation...

SLIDE 3

3 3

Most Installations...

Dismiss Dischrg Follow- Up Account Plan Act Evaluate Assess Register Admit Check History Schedule Pharm Surgery Int Med Lab Rad Refer Care Care Team Team Medical Medical Record Record

Clinical Data Clinical Data Repository Repository Based... Based... Clinicians’ Clinicians’ Worksystem Worksystem Mayo Genesys SOM EMMC HMW …... Samaritan

Different Imperatives, Different IT Strategies

World World-

• Wide

Wide Community Community-

• Wide

Wide Multiple Facilities Multiple Facilities Critiqueing Critiqueing Scheduling Scheduling Common Clinical Ordering Common Clinical Ordering Electronic Chart Viewer Electronic Chart Viewer Clinical Data Repository Clinical Data Repository MPI/ADT Synchronization MPI/ADT Synchronization Independent Departmental Systems Independent Departmental Systems

Computer Computer-

• Based Patient Record

Based Patient Record Care Team Support Care Team Support

Evolutionary Stages

Departmental Departmental System System

Stages Stages

Virtual Virtual Database Database Integrated Integrated Database Database Computer Computer-

• Based

Based Patient Record Patient Record Care Process Care Process Intrarelation Intrarelation Pro Pro-

• Active

Active Management Management Concurrent Concurrent Event Event Critiquing Critiquing

Characteristics Characteristics Examples Examples

Access Directly Via Program Access Directly Via Program

• highly structured
• powerful

Workstation Access Via Network Workstation Access Via Network

distribution data

distribution data

disparate databases and user interface

disparate databases and user interface PathNet PathNet Laboratory Laboratory Information System Information System HL7 Query Tools HL7 Query Tools Copy Data into Central Depository Copy Data into Central Depository

relationships possible

relationships possible

common user interface

common user interface

multimedia

multimedia ORACLE ORACLE Control Access and Encode Control Access and Encode

nomenclature support

nomenclature support

security and audit control

security and audit control

data succession

data succession

date authenticity

date authenticity Open Clinical Open Clinical Foundation Data Foundation Data Repository Repository Diagnoses, Care Plans and Orders Diagnoses, Care Plans and Orders

context for results

context for results

expectations possible

expectations possible

requirements for records

requirements for records Operations Data Operations Data

care management

care management

fiscal management

fiscal management

EIS

EIS Normative Data and Rules Normative Data and Rules

extrapolations

extrapolations

management by protocol

management by protocol ProNet ProNet Orders Orders CareNet CareNet Plans Plans MRNet MRNet Operations Operations Open Management Open Management Foundation Data Foundation Data Repository Repository Discern Rules Discern Rules APACHE APACHE MEDIQUAL MEDIQUAL

Beyond the Enterprise: CHINs Valid needs, No Buyer...

Community Community Health Health Information Information Services Services

Physicians Clinics, HMOs Hospitals

Utility Providers

Repository

Core Services

• E-Mail

Database Systems

• Membership Server
• Health Plan Server
• Health Record Index
• Outcomes Management

Transaction Systems

• Scheduling Services
• Report Management
• Claims Consolidation
• Utilization Review

Business Systems

• Client Billing
• Financial Accounting

Core Services Core Services

• E

E-

• Mail

Mail Database Systems Database Systems

• Membership Server

Membership Server

• Health Plan Server

Health Plan Server

• Health Record Index

Health Record Index

• Outcomes Management

Outcomes Management Transaction Systems Transaction Systems

• Scheduling Services

Scheduling Services

• Report Management

Report Management

• Claims Consolidation

Claims Consolidation

• Utilization Review

Utilization Review Business Systems Business Systems

• Client Billing

Client Billing

• Financial Accounting

Financial Accounting Network Applications

• E-Mail

Database Application

• Membership
• Eligibility
• Health Record Access
• Outcomes Measurement

Transaction Applications

• Scheduling/Referrals
• Electronic Signature
• Claims Processing

Clinical Systems

• Case Management
• AHP Business Systems

Network Applications Network Applications

• E

E-

• Mail

Mail Database Application Database Application

• Membership

Membership

• Eligibility

Eligibility

• Health Record Access

Health Record Access

• Outcomes Measurement

Outcomes Measurement Transaction Applications Transaction Applications

• Scheduling/Referrals

Scheduling/Referrals

• Electronic Signature

Electronic Signature

• Claims Processing

Claims Processing Clinical Systems Clinical Systems

• Case Management

Case Management

• AHP Business Systems

AHP Business Systems External Organizations

SLIDE 4

4 4

Community Health Information Needs

Person Identification Server Membership Server Plan/Eligibility Server Health Record Server Resource Scheduling Server Care Protocol Server Commerce Server

Care Maps

• Defined and tested

clinical methods

• Specific paths through

map individualized

• Multiple opportunities

for triage and adaptation

– by planned choice – by risk – by availability – by length of trajectory – by cost – by new information Plan and manage

THE EYE OF THE CLINICIAN

External External Knowledge Knowledge Personal Personal Productivity Productivity Lab Lab Meds Meds Surgery Surgery Rad Rad Dietary Dietary Nursing Nursing NLM NLM Literature Literature Databases Databases Case Case Management Management CarePlans CarePlans Problems Problems MD MD RN RN Chart Chart Review Review Edit Edit Notes Notes Orders Orders Decision Decision Support Support

Electronic Medical Record Electronic Medical Record

CERNER CERNER CERNER CORPORATION CORPORATION CORPORATION

CPM CPM

Infosystem Infosystem Functional Functional Specifications Specifications

“EMERGING FROM THE COMMON “EMERGING FROM THE COMMON PROCESS MODEL” PROCESS MODEL”

SLIDE 5

5 5

CPM CPM

Enrollment Enrollment CMPI CMPI MPI MPI ADT ADT Register Register Identify Identify

• Clinician

Clinician

• Hospital

Hospital

IDENTIFY IDENTIFY

CPM CPM Rule Rule-

• Based Critiquing

Based Critiquing Focal AI Focal AI Bibliographic Bibliographic Case Case-

• Based Learning

Based Learning History & Physical History & Physical Assess Assess

ASSESS ASSESS

Heuristic Plan Redesign Heuristic Plan Redesign

PLAN PLAN

Managed Protocols Managed Protocols Plan Plan Task List Task List Standards Standards Protocols Protocols DRG/MDC DRG/MDC

Reed Classification System... Reed Classification System... UNLS... UNLS... Gabrielli Gabrielli... ... Medical Entities Dictionary... Medical Entities Dictionary...

Problem Problem-

• Oriented

Oriented SNOMED/ SNOMED/ ICD/CPT ICD/CPT Codifi Codifi-

• cation

cation

CPM CPM

ORDER/SCHEDULE ORDER/SCHEDULE

CPM CPM

Order Set Order Set Order Mgt. Order Mgt. Order Comm. Order Comm. Order Req. Order Req. Order Order Order Entry Order Entry Provider Cal. Provider Cal. Patient Appoint. Patient Appoint. Proc. Proc. Appoint. Appoint. Provider Provider Resource Resource Mgt. Mgt. Multi Multi-

• Disciplinary Care Plan

Disciplinary Care Plan Health Plans Health Plans System wide Resource System wide Resource Optimization Optimization Multi Multi-

• Resource

Resource Mgt. Mgt. Dynamic System Dynamic System Configurator Configurator Schedule Schedule

SLIDE 6

6 6

PERFORM PERFORM

MAR MAR Instrumentation Instrumentation Perform Perform Diagnostic Test Diagnostic Test Flowsheet Flowsheet

CPM CPM

Medical Device Interface Medical Device Interface Ubiquitous Ubiquitous

DOCUMENT DOCUMENT

Scanned Text & OCR Scanned Text & OCR Document Document Procedure Procedure Report Report Dictate & Dictate & Translate Translate Text Templates Text Templates Knowledge Templates Knowledge Templates Technology Technology Character Character Cell Cell Telephone Telephone Windows Windows Pen Pen-

• Based

Based Computing Gesture Computing Gesture Voice Recognition Voice Recognition Natural Language Processor Natural Language Processor

CPM CPM

ACCOUNT ACCOUNT

DRG DRG Govt Govt Insurance Insurance Bill Bill Charge Charge Account Account Patient Patient Acctg Acctg. . General General Ledger Ledger Retrospective Retrospective Case Case-

• Mix

Mix Mgt. Mgt. Managed Care Managed Care Capitation Capitation ‘At Risk’ Capitation ‘At Risk’ Capitation Actuarial Pricing Actuarial Pricing Activity Activity-

• Based

Based Costing Costing

CPM CPM

CERNER PROCESS MAP CERNER PROCESS MAP

Enrollment Enrollment CMPI CMPI MPI MPI ADT ADT Register Register

• Clinician

Clinician •

• Hospital

Hospital Rule Rule-

• Based Critiquing

Based Critiquing Focal AI Focal AI Bibliographic Bibliographic Case Case-

• Based Learning

Based Learning History & Physical History & Physical Heuristic Plan Redesign Heuristic Plan Redesign Managed Managed Protocols Protocols Task List Task List Standards Standards Protocols Protocols DRG/MDC DRG/MDC Reed Classification Syste Reed Classification Syste UNLS... UNLS... Gabrielli Gabrielli... ... Medical Entities Dictionary Medical Entities Dictionary Problem Problem-

• Oriented

Oriented SNOMED/ SNOMED/ ICD/CPT ICD/CPT Codifi Codifi-

• cation

cation Order Set Order Set Order Mgt. Order Mgt. Order Comm. Order Comm. Order Req. Order Req. Order Order Entry Entry Provider Cal. Provider Cal. Patient Appoint. Patient Appoint. Proc. Proc. Appoint. Appoint. Provider Provider Resource Mgt. Resource Mgt. Multi Multi-

• Disciplinary

Disciplinary Care Care Plan Plan Health Health Plans Plans System wide Resource System wide Resource Optimization Optimization Multi Multi-

• Resource Mgt.

Resource Mgt. Dynamic System Dynamic System Configurator Configurator MAR MAR Instrumentation Instrumentation Diagnostic Test Diagnostic Test Flowsheet Flowsheet Medical Device Interface Medical Device Interface Ubiquitous Ubiquitous Scanned Text Scanned Text & OCR & OCR Procedure Procedure Report Report Dictate & Dictate & Translate Translate Text Text Templates Templates Knowledge Knowledge Templates Templates Character Character Cell Cell Telephone Telephone Windows Windows Pen Pen-

• Based

Based Computing Gesture Computing Gesture Voice Voice Recognition Recognition Natural Natural Language Language Processor Processor Technology Technology DRG DRG Govt Govt Insurance Insurance Bill Bill Charge Charge Patient Patient Acctg Acctg. . General General Ledger Ledger Retrospective Retrospective Case Case-

• Mix

Mix Mgt. Mgt. Managed Managed Care Care Capitation Capitation ‘At Risk’ ‘At Risk’ Capitation Capitation Actuarial Actuarial Pricing Pricing Activity Activity-

• Based

Based Costing Costing

Assess Assess Plan Plan Order Order Sched Sched. . Perform Perform Account Account Identify Identify

CPM CPM

Document Document

SLIDE 7

7 7

CERNER PROCESS MAP CERNER PROCESS MAP

Enrollment Enrollment CMPI CMPI MPI MPI ADT ADT Register Register

• Clinician

Clinician •

• Hospital

Hospital Rule Rule-

• Based Critiquing

Based Critiquing Focal AI Focal AI Bibliographic Bibliographic Case Case-

• Based Learning

Based Learning History & Physical History & Physical Heuristic Plan Redesign Heuristic Plan Redesign Managed Managed Protocols Protocols Task List Task List Standards Standards Protocols Protocols DRG/MDC DRG/MDC Reed Classification Syste Reed Classification Syste UNLS... UNLS... Gabrielli Gabrielli... ... Medical Entities Dictionary Medical Entities Dictionary Problem Problem-

• Oriented

Oriented SNOMED/ SNOMED/ ICD/CPT ICD/CPT Codifi Codifi-

• cation

cation Order Set Order Set Order Mgt. Order Mgt. Order Comm. Order Comm. Order Req. Order Req. Order Order Entry Entry Provider Cal. Provider Cal. Patient Appoint. Patient Appoint. Proc. Proc. Appoint. Appoint. Provider Provider Resource Mgt. Resource Mgt. Multi Multi-

• Disciplinary

Disciplinary Care Care Plan Plan Health Health Plans Plans System wide Resource System wide Resource Optimization Optimization Multi Multi-

• Resource Mgt.

Resource Mgt. Dynamic System Dynamic System Configurator Configurator MAR MAR Instrumentation Instrumentation Diagnostic Test Diagnostic Test Flowsheet Flowsheet Medical Device Interface Medical Device Interface Ubiquitous Ubiquitous Scanned Text Scanned Text & OCR & OCR Procedure Procedure Report Report Dictate & Dictate & Translate Translate Text Text Templates Templates Knowledge Knowledge Templates Templates Character Character Cell Cell Telephone Telephone Windows Windows Pen Pen-

• Based

Based Computing Gesture Computing Gesture Voice Voice Recognition Recognition Natural Natural Language Language Processor Processor Technology Technology DRG DRG Govt Govt Insurance Insurance Bill Bill Charge Charge Patient Patient Acctg Acctg. . General General Ledger Ledger Retrospective Retrospective Case Case-

• Mix

Mix Mgt. Mgt. Managed Managed Care Care Capitation Capitation ‘At Risk’ ‘At Risk’ Capitation Capitation Actuarial Actuarial Pricing Pricing Activity Activity-

• Based

Based Costing Costing

Assess Assess Plan Plan Order Order Sched Sched. . Perform Perform Account Account Identify Identify

CPM CPM

Document Document

CERNER PROCESS MAP CERNER PROCESS MAP

Enrollment Enrollment CMPI CMPI MPI MPI ADT ADT Register Register

• Clinician

Clinician •

• Hospital

Hospital Rule Rule-

• Based Critiquing

Based Critiquing Focal AI Focal AI Bibliographic Bibliographic Case Case-

• Based Learning

Based Learning History & Physical History & Physical Heuristic Plan Redesign Heuristic Plan Redesign Managed Managed Protocols Protocols Task List Task List Standards Standards Protocols Protocols DRG/MDC DRG/MDC Reed Classification Syste Reed Classification Syste UNLS... UNLS... Gabrielli Gabrielli... ... Medical Entities Dictionary Medical Entities Dictionary Problem Problem-

• Oriented

Oriented SNOMED/ SNOMED/ ICD/CPT ICD/CPT Codifi Codifi-

• cation

cation Order Set Order Set Order Mgt. Order Mgt. Order Comm. Order Comm. Order Req. Order Req. Order Order Entry Entry Provider Cal. Provider Cal. Patient Appoint. Patient Appoint. Proc. Proc. Appoint. Appoint. Provider Provider Resource Mgt. Resource Mgt. Multi Multi-

• Disciplinary

Disciplinary Care Care Plan Plan Health Health Plans Plans System wide Resource System wide Resource Optimization Optimization Multi Multi-

• Resource Mgt.

Resource Mgt. Dynamic System Dynamic System Configurator Configurator MAR MAR Instrumentation Instrumentation Diagnostic Test Diagnostic Test Flowsheet Flowsheet Medical Device Interface Medical Device Interface Ubiquitous Ubiquitous Scanned Text Scanned Text & OCR & OCR Procedure Procedure Report Report Dictate & Dictate & Translate Translate Text Text Templates Templates Knowledge Knowledge Templates Templates Character Character Cell Cell Telephone Telephone Windows Windows Pen Pen-

• Based

Based Computing Gesture Computing Gesture Voice Voice Recognition Recognition Natural Natural Language Language Processor Processor Technology Technology DRG DRG Govt Govt Insurance Insurance Bill Bill Charge Charge Patient Patient Acctg Acctg. . General General Ledger Ledger Retrospective Retrospective Case Case-

• Mix

Mix Mgt. Mgt. Managed Managed Care Care Capitation Capitation ‘At Risk’ ‘At Risk’ Capitation Capitation Actuarial Actuarial Pricing Pricing Activity Activity-

• Based

Based Costing Costing

Assess Assess Plan Plan Order Order Sched Sched. . Perform Perform Account Account Identify Identify

CPM CPM

Document Document

CERNER PROCESS MAP CERNER PROCESS MAP

Enrollment Enrollment CMPI CMPI MPI MPI ADT ADT Register Register

• Clinician

Clinician •

• Hospital

Hospital Rule Rule-

• Based Critiquing

Based Critiquing Focal AI Focal AI Bibliographic Bibliographic Case Case-

• Based Learning

Based Learning History & Physical History & Physical Heuristic Plan Redesign Heuristic Plan Redesign Managed Managed Protocols Protocols Task List Task List Standards Standards Protocols Protocols DRG/MDC DRG/MDC Reed Classification Syste Reed Classification Syste UNLS... UNLS... Gabrielli Gabrielli... ... Medical Entities Dictionary Medical Entities Dictionary Problem Problem-

• Oriented

Oriented SNOMED/ SNOMED/ ICD/CPT ICD/CPT Codifi Codifi-

• cation

cation Order Set Order Set Order Mgt. Order Mgt. Order Comm. Order Comm. Order Req. Order Req. Order Order Entry Entry Provider Cal. Provider Cal. Patient Appoint. Patient Appoint. Provider Provider Resource Mgt. Resource Mgt. Multi Multi-

• Disciplinary

Disciplinary Care Care Plan Plan Health Health Plans Plans System wide Resource System wide Resource Optimization Optimization Multi Multi-

• Resource Mgt.

Resource Mgt. Dynamic System Dynamic System Configurator Configurator MAR MAR Instrumentation Instrumentation Flowsheet Flowsheet Medical Device Interface Medical Device Interface Ubiquitous Ubiquitous Scanned Text Scanned Text & OCR & OCR Dictate & Dictate & Translate Translate Text Text Templates Templates Knowledge Knowledge Templates Templates Telephone Telephone Windows Windows Pen Pen-

• Based

Based Computing Gesture Computing Gesture Voice Voice Recognition Recognition Natural Natural Language Language Processor Processor DRG DRG Govt Govt Insurance Insurance Bill Bill Charge Charge Patient Patient Acctg Acctg. . General General Ledger Ledger Retrospective Retrospective Case Case-

• Mix

Mix Mgt. Mgt. Managed Managed Care Care Capitation Capitation ‘At Risk’ ‘At Risk’ Capitation Capitation Actuarial Actuarial Pricing Pricing Activity Activity-

• Based

Based Costing Costing

Assess Assess Plan Plan Order Order Sched Sched. . Perform Perform Account Account Identify Identify

CPM CPM

Document Document

Technology Technology Proc. Proc. Appoint. Appoint. Diagnostic Test Diagnostic Test Procedure Procedure Report Report Character Character Cell Cell

CERNER PROCESS MAP CERNER PROCESS MAP

Technology Technology Enrollment Enrollment CMPI CMPI MPI MPI ADT ADT Register Register

• Hospital

Hospital Rule Rule-

• Based Critiquing

Based Critiquing Focal AI Focal AI Bibliographic Bibliographic Case Case-

• Based Learning

Based Learning History & Physical History & Physical Heuristic Plan Redesign Heuristic Plan Redesign Managed Managed Protocols Protocols Task List Task List Standards Standards Protocols Protocols DRG/MDC DRG/MDC Reed Classification Syste Reed Classification Syste UNLS... UNLS... Gabrielli Gabrielli... ... Medical Entities Dictionary Medical Entities Dictionary Problem Problem-

• Oriented

Oriented SNOMED/ SNOMED/ ICD/CPT ICD/CPT Order Set Order Set Order Mgt. Order Mgt. Order Comm. Order Comm. Order Req. Order Req. Provider Cal. Provider Cal. Patient Appoint. Patient Appoint. Provider Provider Resource Mgt. Resource Mgt. Multi Multi-

• Disciplinary

Disciplinary Care Care Plan Plan Health Health Plans Plans System wide Resource System wide Resource Optimization Optimization Multi Multi-

• Resource Mgt.

Resource Mgt. Dynamic System Dynamic System Configurator Configurator MAR MAR Flowsheet Flowsheet Medical Device Interface Medical Device Interface Ubiquitous Ubiquitous Scanned Text Scanned Text & OCR & OCR Text Text Templates Templates Knowledge Knowledge Templates Templates Windows Windows Pen Pen-

• Based

Based Computing Gesture Computing Gesture Voice Voice Recognition Recognition Natural Natural Language Language Processor Processor DRG DRG Retrospective Retrospective Case Case-

• Mix

Mix Mgt. Mgt. Managed Managed Care Care Capitation Capitation ‘At Risk’ ‘At Risk’ Capitation Capitation Actuarial Actuarial Pricing Pricing Activity Activity-

• Based

Based Costing Costing Proc. Proc. Appoint. Appoint. Diagnostic Test Diagnostic Test Dictate & Dictate & Translate Translate Telephone Telephone Govt Govt Insurance Insurance Bill Bill Patient Patient Acctg Acctg. .

• Clinician

Clinician Charge Charge General General Ledger Ledger

Assess Assess Plan Plan Order Order Sched Sched. . Perform Perform Account Account Identify Identify

CPM CPM

Document Document

Procedure Procedure Report Report Character Character Cell Cell Instrumentation Instrumentation Codifi Codifi-

• cation

cation Order Order Entry Entry

SLIDE 8

8 8

CERNER PROCESS MAP CERNER PROCESS MAP

Technology Technology Enrollment Enrollment CMPI CMPI MPI MPI ADT ADT Register Register

• Hospital

Hospital Rule Rule-

• Based Critiquing

Based Critiquing Focal AI Focal AI Bibliographic Bibliographic Case Case-

• Based Learning

Based Learning History & Physical History & Physical Heuristic Plan Redesign Heuristic Plan Redesign Managed Managed Protocols Protocols Task List Task List Standards Standards Protocols Protocols DRG/MDC DRG/MDC Reed Classification Syste Reed Classification Syste UNLS... UNLS... Gabrielli Gabrielli... ... Medical Entities Dictionary Medical Entities Dictionary Problem Problem-

• Oriented

Oriented SNOMED/ SNOMED/ ICD/CPT ICD/CPT Order Set Order Set Order Mgt. Order Mgt. Order Comm. Order Comm. Order Req. Order Req. Provider Cal. Provider Cal. Patient Appoint. Patient Appoint. Provider Provider Resource Mgt. Resource Mgt. Multi Multi-

• Disciplinary

Disciplinary Care Care Plan Plan Health Health Plans Plans System wide Resource System wide Resource Optimization Optimization Multi Multi-

• Resource Mgt.

Resource Mgt. Dynamic System Dynamic System Configurator Configurator MAR MAR Flowsheet Flowsheet Medical Device Interface Medical Device Interface Ubiquitous Ubiquitous Scanned Text Scanned Text & OCR & OCR Text Text Templates Templates Knowledge Knowledge Templates Templates Windows Windows Pen Pen-

• Based

Based Computing Gesture Computing Gesture Voice Voice Recognition Recognition Natural Natural Language Language Processor Processor DRG DRG Retrospective Retrospective Case Case-

• Mix

Mix Mgt. Mgt. Managed Managed Care Care Capitation Capitation ‘At Risk’ ‘At Risk’ Capitation Capitation Actuarial Actuarial Pricing Pricing Activity Activity-

• Based

Based Costing Costing Proc. Proc. Appoint. Appoint. Diagnostic Test Diagnostic Test Dictate & Dictate & Translate Translate Telephone Telephone Govt Govt Insurance Insurance Bill Bill Patient Patient Acctg Acctg. .

• Clinician

Clinician Charge Charge General General Ledger Ledger

Assess Assess Plan Plan Order Order Sched Sched. . Perform Perform Account Account Identify Identify

CPM CPM

Document Document

Procedure Procedure Report Report Character Character Cell Cell Instrumentation Instrumentation Codifi Codifi-

• cation

cation Order Order Entry Entry

CERNER PROCESS MAP CERNER PROCESS MAP

Technology Technology Enrollment Enrollment CMPI CMPI MPI MPI ADT ADT Register Register

• Hospital

Hospital Rule Rule-

• Based Critiquing

Based Critiquing Focal AI Focal AI Bibliographic Bibliographic Case Case-

• Based Learning

Based Learning History & Physical History & Physical Heuristic Plan Redesign Heuristic Plan Redesign Managed Managed Protocols Protocols Task List Task List Standards Standards Protocols Protocols DRG/MDC DRG/MDC Reed Classification Syste Reed Classification Syste UNLS... UNLS... Gabrielli Gabrielli... ... Medical Entities Dictionary Medical Entities Dictionary Problem Problem-

• Oriented

Oriented SNOMED/ SNOMED/ ICD/CPT ICD/CPT Order Set Order Set Order Mgt. Order Mgt. Order Comm. Order Comm. Order Req. Order Req. Provider Cal. Provider Cal. Patient Appoint. Patient Appoint. Provider Provider Resource Mgt. Resource Mgt. Multi Multi-

• Disciplinary

Disciplinary Care Care Plan Plan Health Health Plans Plans System wide Resource System wide Resource Optimization Optimization Multi Multi-

• Resource Mgt.

Resource Mgt. Dynamic System Dynamic System Configurator Configurator MAR MAR Flowsheet Flowsheet Medical Device Interface Medical Device Interface Ubiquitous Ubiquitous Scanned Text Scanned Text & OCR & OCR Text Text Templates Templates Knowledge Knowledge Templates Templates Windows Windows Pen Pen-

• Based

Based Computing Gesture Computing Gesture Voice Voice Recognition Recognition Natural Natural Language Language Processor Processor DRG DRG Retrospective Retrospective Case Case-

• Mix

Mix Mgt. Mgt. Managed Managed Care Care Capitation Capitation ‘At Risk’ ‘At Risk’ Capitation Capitation Actuarial Actuarial Pricing Pricing Activity Activity-

• Based

Based Costing Costing Proc. Proc. Appoint. Appoint. Diagnostic Test Diagnostic Test Dictate & Dictate & Translate Translate Telephone Telephone Govt Govt Insurance Insurance Bill Bill Patient Patient Acctg Acctg. .

• Clinician

Clinician Charge Charge General General Ledger Ledger

Assess Assess Plan Plan Order Order Sched Sched. . Perform Perform Account Account Identify Identify

CPM CPM

Document Document

Procedure Procedure Report Report Character Character Cell Cell Instrumentation Instrumentation Codifi Codifi-

• cation

cation Order Order Entry Entry

CERNER PROCESS MAP CERNER PROCESS MAP

Technology Technology Enrollment Enrollment CMPI CMPI MPI MPI ADT ADT Register Register

• Hospital

Hospital Rule Rule-

• Based Critiquing

Based Critiquing Focal AI Focal AI Bibliographic Bibliographic Case Case-

• Based Learning

Based Learning History & Physical History & Physical Heuristic Plan Redesign Heuristic Plan Redesign Managed Managed Protocols Protocols Task List Task List Standards Standards Protocols Protocols DRG/MDC DRG/MDC Reed Classification Syste Reed Classification Syste UNLS... UNLS... Gabrielli Gabrielli... ... Medical Entities Dictionary Medical Entities Dictionary Problem Problem-

• Oriented

Oriented SNOMED/ SNOMED/ ICD/CPT ICD/CPT Order Set Order Set Order Mgt. Order Mgt. Order Comm. Order Comm. Order Req. Order Req. Provider Cal. Provider Cal. Patient Appoint. Patient Appoint. Provider Provider Resource Mgt. Resource Mgt. Multi Multi-

• Disciplinary

Disciplinary Care Care Plan Plan Health Health Plans Plans System wide Resource System wide Resource Optimization Optimization Multi Multi-

• Resource Mgt.

Resource Mgt. Dynamic System Dynamic System Configurator Configurator MAR MAR Flowsheet Flowsheet Medical Device Interface Medical Device Interface Ubiquitous Ubiquitous Scanned Text Scanned Text & OCR & OCR Text Text Templates Templates Knowledge Knowledge Templates Templates Windows Windows Pen Pen-

• Based

Based Computing Gesture Computing Gesture Voice Voice Recognition Recognition Natural Natural Language Language Processor Processor DRG DRG Retrospective Retrospective Case Case-

• Mix

Mix Mgt. Mgt. Managed Managed Care Care Capitation Capitation ‘At Risk’ ‘At Risk’ Capitation Capitation Actuarial Actuarial Pricing Pricing Activity Activity-

• Based

Based Costing Costing Proc. Proc. Appoint. Appoint. Diagnostic Test Diagnostic Test Dictate & Dictate & Translate Translate Telephone Telephone Govt Govt Insurance Insurance Bill Bill Patient Patient Acctg Acctg. .

• Clinician

Clinician Charge Charge General General Ledger Ledger

Assess Assess Plan Plan Order Order Sched Sched. . Perform Perform Account Account Identify Identify

CPM CPM

Document Document

Procedure Procedure Report Report Character Character Cell Cell Instrumentation Instrumentation Codifi Codifi-

• cation

cation Order Order Entry Entry

CERNER PROCESS MAP CERNER PROCESS MAP

Technology Technology Enrollment Enrollment CMPI CMPI MPI MPI ADT ADT Register Register

• Hospital

Hospital Rule Rule-

• Based Critiquing

Based Critiquing Focal AI Focal AI Bibliographic Bibliographic Case Case-

• Based Learning

Based Learning History & Physical History & Physical Heuristic Plan Redesign Heuristic Plan Redesign Managed Managed Protocols Protocols Task List Task List Standards Standards Protocols Protocols DRG/MDC DRG/MDC Reed Classification Syste Reed Classification Syste UNLS... UNLS... Gabrielli Gabrielli... ... Medical Entities Dictionary Medical Entities Dictionary Problem Problem-

• Oriented

Oriented SNOMED/ SNOMED/ ICD/CPT ICD/CPT Order Set Order Set Order Mgt. Order Mgt. Order Comm. Order Comm. Order Req. Order Req. Provider Cal. Provider Cal. Patient Appoint. Patient Appoint. Provider Provider Resource Mgt. Resource Mgt. Multi Multi-

• Disciplinary

Disciplinary Care Care Plan Plan Health Health Plans Plans System wide Resource System wide Resource Optimization Optimization Multi Multi-

• Resource Mgt.

Resource Mgt. Dynamic System Dynamic System Configurator Configurator MAR MAR Flowsheet Flowsheet Medical Device Interface Medical Device Interface Ubiquitous Ubiquitous Scanned Text Scanned Text & OCR & OCR Text Text Templates Templates Knowledge Knowledge Templates Templates Windows Windows Pen Pen-

• Based

Based Computing Gesture Computing Gesture Voice Voice Recognition Recognition Natural Natural Language Language Processor Processor DRG DRG Retrospective Retrospective Case Case-

• Mix

Mix Mgt. Mgt. Managed Managed Care Care Capitation Capitation ‘At Risk’ ‘At Risk’ Capitation Capitation Actuarial Actuarial Pricing Pricing Activity Activity-

• Based

Based Costing Costing Proc. Proc. Appoint. Appoint. Diagnostic Test Diagnostic Test Dictate & Dictate & Translate Translate Telephone Telephone Govt Govt Insurance Insurance Bill Bill Patient Patient Acctg Acctg. .

• Clinician

Clinician Charge Charge General General Ledger Ledger

Assess Assess Plan Plan Order Order Sched Sched. . Perform Perform Account Account Identify Identify

CPM CPM

Document Document

Procedure Procedure Report Report Character Character Cell Cell Instrumentation Instrumentation Codifi Codifi-

• cation

cation Order Order Entry Entry

SLIDE 9

9 9

Summary...

Diverse organizational models Healthcare IT emphasis moving from enterprise to health system focus Increased emphasis on patient’s role and MD risk An open, net-based commerce model fits in all

• rganizational models

Definition...

• Definition:

– “Net-based clinical commerce” is the ability for patients, physicians, and other buyers of healthcare products and services to arrange, track, and pay for services, purchase healthcare commodity products from an electronic exchange, and manage health records on the Internet.

Context: Evolution of Commerce on the Internet...

• Commerce-enabled Web

– banking – retail

• Extensive use in healthcare

– research – communication

• Toward Clinical Commerce!!

Healthcare Commerce Entry Barriers

• Consumers purchase health processes
• Processes are ongoing with multiple points
• f contact with the provider
• Payment is by assignment of entitlement
• Payer exerts significant control over choice
• Payer exerts significant control over care
• Some goods and services require license

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Patient Identification Patient Identification

• Example: Partners Health Care EMPI

(Enterprise Master Patient Index)

– Lisa Adragna, J AHIMA 1998 Oct;69(9):46-8, 50, 52

• Probabilistic Models for Matching

Partners EMPI Goals

• (Context) Partners Healthcare is affiliation of

Brigham and Women’s, Mass. General, North- Shore Medical Center, Dana-Farber Cancer Institute, Spaulding Rehab, McLean, Partners Community Healthcare, …, formed in 1994.

• Eliminate need to renumber existing systems by

creating Partners-wide unique ID

• Foundation for Clinical Data Repository
• Minimally invasive to current operations
• Rapid installation

Partners EMPI Scope

• Medical record “crosswalk” across Partners

– Local medical record numbers linked to Partners-wide ID

• Back-end, real-time, one-way interface

– No modifications to existing systems

• Automated tools for identifying and

resolving duplicates

– No human intervention at “run time”

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Partners EMPI Matching

• Three methods of lookup:

– Last and First names – First name, Date of Birth and Gender – Social Security Number

• If no matches, create new EMPI number
• If exact match on all known features (above), then

link to existing EMPI entry

• If multiple possible matches, create new entry and

flag as potential duplicate; manual intervention

Partners EMPI Experience (1997)

• 1M records entered from BWH & MGH
• 170,000 pair of records identified as

potential duplicates

• 80% of new registrations match a unique

EMPI entry; ~1800/day

• Sites made 3308 “within-entity” merges
• EMPI Admin staff (3 FTE) resolved over

200,000 potential duplicates.

Models of Patient Matching

• Ad hoc methods are weak, and difficult to

improve

• Motivational observation:

– Two records that share the last name Kowalczyk are more likely to refer to the same individual than two that share the name Smith.

Computing posterior odds

• f a match
• O(match|obs)=O(match)L(obs|match)
• O(match)=1/N
• L(obs|match)=P(obs|match)/P(obs|~match)
• P(Smith,Smith|match) = P(Smith)
• P(Smith,Smith|~match) = P(Smith)^2
• L(Smith,Smith)=.01006/.01006^2=99.4
• L(Kowalczyk,K…)=1/.00001=100,000

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Multiple evidence accumulates

• Smith has same Soundex code as Smyth
• L partially matches Liz
• Same street address number, street name
• Ave. vs. Blvd.
• Different phone numbers
• …
• Assume conditional independence

Soundex

• Developed in 1800’s to represent phonetic

similarity of names

– E.g., Smith S-530; Smyth S-530

• Rules:

– 1 B, F, P, V – 2 C, G, J, K, Q, S, X, Z – 3 D, T – 4 L – 5 M, N – 6 R – Disregard the letters A, E, I, O, U, H, W, and Y. – Special rules for doubled consonants, prefixes, …

Soundex examples

K-422 Kowalczyk S-530 Smyth B-315 Beethoven S-413 Szolovits

Typing/Transcription Error Model

• Consider probabilities of

– Insertion – Deletion – Transposition – (Mutation) – varies with key layout

• Compute “distance” between mismatched

features

• Same idea in BLAST

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Frequency of U.S. Last Names

• -U.S. Census Bureau

Z*(n) Z*(n)∝ ∝ ∝ ∝ ∝ ∝ ∝ ∝1/(n+k) 1/(n+k)

Geographical Distribution of “Gonzales” vs. “Lewandowski”

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A Theory for Record Linkage

• Fellegi IP, Sunter AB. J. Am. Stat. Assn.

64(328):1183-1210. 1969

• Estimate L(obs|match) for all possible
• bservations

– Normally must make independence assumption to factor contributions of different aspects of obs

• Define decision policy

– P(A+|obs), P(A?|obs), P(A-|obs), sum=1 – Based on thresholds on L’s

• Yields errors

– P(A+|~match) or P(A-|match), minimize P(A?)

Blocking Sets

• Pair-by-pair comparison is expensive

– E.g., 1M records at Partners 10^12 comparisons

• Therefore, compare only smaller subgroups

– E.g., assume first letter of name is never misspelled, as Soundex does – E.g., assume Soundex pronunciation code is correct, even if spelling is not

• Increased chance of missing matches, much faster