Emergency Medicine Informatics Section Newsletter - September 2012
The Chair’s Letter – Emergency Medicine Informatics Section Newsletter, September 2012
Jeffrey A. Nielson, M.D., M.S.
Our specialty is maturing rapidly. In this issue, we present a list of fellows and their work and I am pleased to say that it reads like an AMIA (American Medical Informatics Association) poster session! It is amazing that we continue to grow and create applied specialty-specific cutting edge research during the downpour of government IT requirements. It shows me the types of improvements we will expect over the next decade.
Also in this issue, Dr. McClay briefly mentions the EDIS functional profile. Though I may steal some of his thunder, I want to emphasize how important this is. First an example: In emergency medicine, we have a very well specified model of clinical practice which guides our approach to EM. It puts a scope to disease and what our role is. Likewise, the functional profile is a map of the functions of the EDIS. Yes, this is a good document to show to the vendors. Yes, it is a good way to show them where they are deficient, but it is more so a reference point for innovation. It helps us answer the “so what?” question. It grounds us to a standard for growth. I see it as a dictionary, a book of scripture--a bill of rights.
The EHR is becoming ubiquitous, but has yet to be perfected. We see others recognizing the struggles we recognized years ago such as: horrible usability, slowing down the doctor, facilitation of medical errors, poorly designed alerts, out of date clinical rules, etc. I thought that I (or someone else) would have been able to fix some of these issues over the 10 years I have been working in Emergency Informatics. Talking about the issues hasn’t seemed to fix them. I thought the vendors would listen to us eventually. No magical medical iPad-like device fell from the sky to force other vendors to take notice. Each vendor has its strengths and weaknesses, but overall I don’t see the accelerated implementation coinciding with an acceleration of the quality. Perhaps I am too pessimistic. Perhaps medicine is different. Big advances sometimes take time.
When I started my master’s program 9 years ago, I was told that anything meaningful in medical informatics takes 10 years. Although I was innovative during my time as a fellow and graduate student, most of my time for the last five years has been spent implementing, not innovating. What should we be doing? I believe we should be innovating, but we need to figure out a way to do it broadly. Just as medical research is dealing with translational issues, so do we. I think we should consider “disruptive” ways to bring good work to light more quickly. We have seen shared decision rules between vendors (mostly failed). We have seen consolidation of the vendor space, which has been good and bad. Shortening the translation process is tough. If anyone can figure out a way to fast-track a process it is an emergency physician. I might not be able to accelerate the process, but it needs to be one of us.
HL7 Emergency Care Workgroup Update - Emergency Medicine Informatics Section Newsletter, September 2012
Jim McClay, MD, FACEP
Past Chair, Section of Emergency Medicine Informatics
Co-Chair, HL7 Emergency Care Workgroup
A patient in town for a convention who has a long complex history arrives at your emergency department in the middle of the night with vague symptoms. By now, everyone agrees that having access to this patient's electronic health record would be useful to reduce uncertainty, avoid errors, and increase efficiency. The patient tells you they have an online personal health record available through their home health system for you to review. Also, their medication prescriptions can be retrieved through the pharmacy exchange and automatically loaded into your local EHR. You can now review the patient's medical record and import their medication history into your EDIS no matter where they are seen. You determine that you can treat them symptomatically and let them go home feeling better. You didn't have to guess at medications, worry about abnormal labs or try to find someone in the medical records department at a hospital across the country to fax you the recent record.
How does this happen? Underlying all this cool technology are agreements on how patient information will be collected, shared and presented. These agreements represent a lot of careful work by groups called Standards Development Organizations (SDO's). These SDO's have developed all the standards that allow your computer to plug into the internet, retrieve information from another computer and display information on the monitor.
The SDO dedicated to administrative and clinical health care data collection and transmission is Health Level Seven (HL7). Created over 25 years ago by a group of clinicians who wanted to share laboratory data, HL7 is now an international organization recognized as the SDO for health care information. Over the years, almost all health information exchange systems have adopted the HL7 2.X specification.
HL7 is a voluntary group organized into workgroups dedicated to different areas of health care data. In 2004 the Electronic Health Record Work Group (EHR WG) created a standard specification for the functions of an electronic health record. The Electronic Health Record Functional Model (EHR-FM) was used to create certifying criteria for EHRs by the Office of the National Coordinator. The EHR WG worked with members of the Emergency Care Workgroup (EC WG) to specify standard methods for modifying the EHR -FM for specific areas of use. As co-chairs of the ECWG, Todd Rothenhaus, MD, FACEP, and James McClay, MD, FACEP, then facilitated an adaptation of the EHR-FM specific to use in the Emergency Department. This Emergency Department Information System Functional Profile (EDIS-FP) provides a great starting point for defining what an EDIS should do. While the EHR-FM version 1 was good, it wasn't enough. This past May, Dr. McClay, sponsored by ACEP, participated with HL7 EHR WG member and representatives of the US Navy and the Veterans Administration balloted a new, expanded version of the EHR FM. The EHR FM version 2 provides an extensive description of what an EHR system should do. The EDIS Functional Profile Version 2.0 will follow soon. Check the HL7 Website (www.hl7.org) for the Emergency Care Workgroup to see meeting schedules and documents.
While defining the functionality of the EHR is useful, it is just as important to agree on what information is included in the record, how it is represented, and how it is shared. Many of the HL7 workgroups work on this problem using a shared information model called the HL7 Version 3 Interoperability Standard (generally referred to as the HL7 V3 Reference Information Model or RIM). Recently, the EC WG took on the problem of defining the data elements that an EDIS should be able to share with other systems, third party agencies and registries. Using a 1996 CDC specification called Data Elements for Emergency Department Systems (DEEDS), the EC WG adopted and extended the DEEDS specification to create the HL7 Version 3.0 Data Elements for Emergency Department Systems. The HL7 DEEDS specification contains over 750 concepts related to emergency care along with unique identifiers and data types that match the HL7 Reference RIM.
The EC WG continues to represent the interests of ACEP members and the Emergency Care Enterprise in the ongoing development of Health Information Standards. The passage of the HITECH act in 2009 greatly accelerated the need for this work. Because standards development is traditionally a slow, careful process, The Office of the National Coordinator became impatient and set up Standards and Interoperability Framework (S&I Framework). The S&I Framework is an open, volunteer process that examines existing standards and how they may need to be extended. Where there isn't a standard, they create a non-standard specification. The intent is to use those specs to inform the standards development process. Everyone is invited to participate. You can sign up at http://wiki.siframework.org/. For those of you that want to start programming, a new initiative called the Fast Healthcare Interoperability Resources (FHIR, pronounced "Fire") http://wiki.hl7.org/index.php?title=FHIR started creating reusable software components out of the HL7 specifications.
What's in it for you? Well, when you see that unknown patient and experience the magic of health information exchange, you can thank the unseen genius that is HL7. But better than that, HL7 along with other SDOs are busy inventing the next version of health information software that will be modular, portable, interoperable, and easier to use. Come join us at the Emergency Informatics Association (www.emergencyinformatics.org) we can use your help.
Social Networking - Emergency Medicine Informatics Section Newsletter, September 2012
Nicholas Genes, MD
Social networking developments in the Informatics newsletter? Well, sure – both fields involve bringing information to influence point-of-care decision making (Twitter just does it in a more roundabout way).
Probably the most researched aspect of social networking in emergency medicine is biosurveillance and preparedness efforts. Several studies that documented the public’s awareness of H1N1 were reflected in the rise of Twitter discussions of the flu. One study suggested Twitter activity actually predicted regionalized H1N1 disease activity.
Similarly, in the wake of the earthquake in Japan and tornado in Joplin, MO last year, some called for a role for Twitter and Facebook in promoting situational awareness and resource management in times of disaster. For emergencies on a smaller scale, Penn’s MyHeartMap Challenge harnessed the power of GPS-equipped smartphones to locate and catalog Philadelphia’s AEDs, improving access and highlighting areas to improve distribution.
Of course, social media can be a powerful tool for communicating emergency medicine news, research, commentary and events – many EDs and emergency physicians have now set up Facebook and Twitter accounts for this purpose. And these platforms can be particularly useful during “old school” social networking like ACEP’s Scientific Assembly in Denver, CO. Follow the activity using Twitter hashtag #SA12 or on FB at http://www.facebook.com/ACEPFan.
Signorini A, Segre AM, Polgreen PM. The use of Twitter to track levels of disease activity and public concern in the U.S. during the influenza A H1N1 pandemic. PLoS One. 2011 May 4;6(5):e19467.
Tobias E. J Bus Contin Emer Plan. Using Twitter and other social media platforms to provide situational awareness during an incident. 2011 Oct;5(3):208-23.
The Penn MyHeartMap Challenge: http://www.med.upenn.edu/myheartmap/aboutus.html
Nomura JT, Genes N, Bollinger HR, Bollinger M, Reed JF. Twitter use during emergency medicine conferences. Am J Emerg Med. 2012 Jun;30(5):819-20.
Education and Fellowship Update - Emergency Medicine Informatics Section Newsletter, September 2012
Steven Horng, MD
Informatics Fellows Update
Anurag Gupta joins the Center for Evidence-Based Imaging at Brigham and Women’s Hospital as a first year NLM informatics fellow. His research focuses on appropriate medical imaging in the emergency department. His first project evaluates clinician order entry accuracy to assess appropriate use of clinical decision support.
James Foster continues on as a second year informatics fellow at Beth Israel Deaconess Medical Center. His research focuses on the use of mobile devices to improve patient care. His first project evaluates the effect of a decision support tool (NIH stroke scale) to improve documentation. His second project evaluates the effect of patient-facing computing to improve documentation of pain scores and analgesia administration.
Foster Goss graduates from the Division of Clinical Decision Making, Informatics, and Telemedicine at Tufts Medical Center. After fellowship, he will join the faculty in the Department of Emergency Medicine at Tufts Medical Center and continue his work with NLP of patient allergies from free text electronic medical records.
Steven Horng graduates from the informatics fellowship program at Beth Israel Deaconess Medical Center. After fellowship, he has joined as a faculty member in the Department of Emergency Medicine and as a faculty member in the Division of Clinical Informatics at Beth Israel Deaconess Medical Center and will continue his work in medical artificial intelligence and its use to drive automated information retrieval and targeted decision support.
Frederick Thum MD FACEP begins his medical informatics fellowship with the Division of Informatics in the Mount Sinai School of Medicine Department of Emergency Medicine. His research focuses on iterative usability testing of clinical decision support tools and on improving patient outcomes utilizing clinical decision support. He is also pursuing a master’s degree in the Department of Biomedical Informatics at Columbia University.
EM Residency Curriculum Update
The recently published 2011 model of the clinical practice of emergency medicine now includes several entries for clinical informatics under systems-based practice. The EM Model describes the core content of emergency medicine. It determines the curriculum taught at EM residencies, RRC accreditation of EM programs, and EM board certification. The addition of clinical informatics highlights the growing importance of clinical informatics within emergency medicine.
From the EM Model of Clinical Practice:
20.4 Systems-based Practice
20.4.1 Clinical Informatics
126.96.36.199 Computerized physician order entry
188.8.131.52 Clinical decision support
184.108.40.206 Electronic health record
220.127.116.11 Health information integration
Perina DG, Brunett P, Caro DA, Char DM, Chisholm CD, Counselman FL, Heidt J, Keim SM, Ma OJ; for the 2011 EM Model Review Task Force, The 2011 model of the clinical practice of emergency medicine, Acad Emerg Med. 2012; doi: 10.1111/j.1553-2712.2012.01385.x [Epub ahead of print]
EMI/QIPS whitepaper on EHR Safety - Emergency Medicine Informatics Section Newsletter, September 2012
Kevin M. Baumlin, MD
Over the past year members of the informatics section and quality committee have been working on writing a consensus document on EDIS safety. The paper is now complete and in the editing process and will be published in the near future.
The committee came up with 7 key recommendations to improve EDIS implantations and provide structure, oversight and guidance. One of the key recommendations is: EDIS-related patient safety concerns identified by the review process should be addressed in a timely manner by ED providers, the EDIS vendors, and hospital administration. Each of these processes should be performed in full transparency, specifically with openness, communication, and accountability.
Informatics Journal Club - Emergency Medicine Informatics Section Newsletter, September 2012
Steven Horng, MD1,2 Joshua W. Joseph, MD1,2 Jae Won Joh, BS3 Adam Landman, MD2,4
1 Department of Emergency Medicine, Beth Israel Deaconess Medical Center
2 Harvard Medical School
3 Baylor College of Medicine
4 Department of Emergency Medicine, Brigham and Women’s Hospital
The Beth Israel Deaconess Medical Center - Harvard Affiliated Emergency Medicine Residency Program reviewed several articles addressing applications of computers in clinical practice for our August 2012 Residency Journal Club. This journal club was attended by 42 medical students, residents, and attendings and introduced learners to difficulties in performing informatics research as well as critical literature appraisal skills.
Unexpected Increased Mortality After Implementation of a Commercially Sold Computerized Physician Order Entry System
Han, YY, JA Carcillo et al. Pediatrics 116.6 (2005): 1506-12.
This study investigated the impact of CPOE implementation in a pediatric ICU on mortality. This study was of particular interest as our ED transitioned to a computerized physician order entry (CPOE) system several months ago. The study was performed in the Children’s Hospital of Pittsburgh (CHP) ICU, which has ~3000 annual ICU admissions. During the 18 month study period, 1,942 children were admitted (1,394 admissions before implementation, 548 after). Only children who were admitted to CHP via interfacility transport for specialized, tertiary-level care were included. In the study, they discovered that the CPOE system led to an overall increase in mortality (OR 3.28, 95% CI 1.94-5.55). However, there were several limitations to the study that made the results difficult to interpret. First, the study was unable to separate the effects of transitioning to the CPOE system and several other dramatic system-wide changes in operations. For example, the new system prevented ordering medications and diagnostics on patients in advance of their arrival, removed satellite pharmacies from ICUs, and fundamentally changed how work processes and communication occurred in the ICU. These changes significantly confounded the study results. In addition, the authors identified some inherent difficulties with CPOE systems, such as decreased face-to-face time between physicians and nurses. The authors also provide several insights about their implementation that ultimately resulted in poor outcomes for their patients. It remains unclear if the observed increased mortality was from the CPOE implementation or from the other workflow changes. However, this study suggests that attention to change management principles, including testing, training, and communication, are critical to the success to CPOE implementations.
CURB-65 pneumonia severity assessment adapted for electronic decision support.
Jones BE, Jones J et al. Chest 140.1 (2011): 152-63.
Clinical decision rules help clinicians make diagnostic and treatment decisions; they are often simplified to aid calculation and recall. However, this simplification often diminishes the accuracy of the prediction. This study demonstrated that computers can automate risk stratification for patients with pneumonia, automatically retrieving CURB-65 score variables (the first 6 hours of vital signs, mental status, and the first 12 hours of laboratory results) from the electronic medical record and generating an individualized mortality risk estimate. Since this process is automated, the prediction model does not need to be simplified like traditional clinical prediction rules. The traditional, binary CURB-65 score predicted mortality in the U.S. cohort with an area under the curve (AUC) of 0.82. Jones’ electronic model generated from continuous, weighted CURB-65 elements was superior to the traditional CURB-65, with an AUC of 0.86 (P < .001). This finding was validated in the international database used to derive the original CURB-65 system, with an AUC of 0.85 for the electronic model compared with 0.80 for the traditional CURB-65 (P = .01). The results of the study have a number of implications. Automated risk stratification can be tightly integrated into the electronic medical record and provide decision support to providers on pneumonia severity. These tools can also be used as a method to risk-adjust patients when comparing hospital mortality and other performance measures. Fully automated, electronic decision rules are powerful tools that may become more commonplace as data standards are adopted and more clinical rules include standard data elements captured in EMRs.
The financial impact of health information exchange on emergency department care.
Frisse ME, Johnson KB et al. Journal of the American Medical Informatics Association 19.3 (2012): 328-33.
The final article examined the impact of emergency physicians’ access of a health information exchange on hospital admissions, diagnostic testing, and costs. The study population was drawn from a Tennessee Hospital Association hospital billing database consisting of all ED visit records from the 2-year period from January 2007 to December 2008 to 12 hospitals. An initial record set of 20,285 ED visits in which health information exchange (HIE) data access was documented. A matched cohort of ED patient encounters without HIE access was obtained by matching the above cases with a corresponding number of ED visits in which no HIE was accessed, matching for age (decile), gender, race, site of emergency care, presenting diagnosis, and primary payer source. This retrospective matched cohort study suggested that instituting HIE resulted in the savings of $1.95 million, which more than offset the $880,000 cost of using the HIE. Specifically, the cost savings were derived from 412 fewer admissions, 29 fewer head CTs, 196 fewer body CTs, and 258 fewer laboratory tests. The study’s key limitation is that there are differences between the study patients for whom HIE data were accessed and those for whom it was not, leading to a confounding by indication. Namely, providers tend to use HIE in patients presenting with chronic medical problems, whose current management may hinge upon additional information from other systems. This significant variation in intent between ED clinicians could not be adequately controlled for in this retrospective study. Despite these limitations, this paper presents compelling initial evidence of the cost-effectiveness of health information exchanges for emergency physicians and joins a growing body of literature supporting the value of HIE in general.
ED Physicians: Let Your Voice Be Heard - Emergency Medicine Informatics Section Newsletter, September 2012
KLAS is a healthcare IT research firm on a global mission to improve healthcare delivery by enabling providers to be heard and counted. KLAS gathers consumer satisfaction data from providers in order to deliver timely reports and statistical overviews on the performance of healthcare IT vendors and products.
For the past 9 years, KLAS has spoken with healthcare professionals and published reports that investigate EDIS vendor and product performance. Previously, KLAS collected data from and interviewed ED clinicians, IT Directors or the CIO, and everyone in-between.
This year, ACEP and KLAS are working together in order to amplify the voice of the ED physician. The KLAS 2012 EDIS report will be based exclusively on the voice of ED physicians.
In last year’s EDIS study, KLAS found that “The intent of the EDIS is to fully address patient needs, improve ED operations and maximize reimbursement. Some EDIS solutions are reportedly more effective in improving ED efficiency.”
KLAS wants to better understand, strictly through the eyes of the ED physician, what core aspects of an EDIS affect clinician efficiency, productivity, and patient safety the most. Let your voice be heard.
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