“Nursing Interventions and Outcomes in Three Older
Populations” Effectiveness Study
Project Consultant Meeting
University of Iowa College of Nursing
February 10-11, 2003
Advanced Controlled Medical Terminology
Wireless Palm-based Access to Health Information
James J. Cimino
Columbia University Department of Medical Informatics
Advanced Controled Medical Terminology:
The Medical Entities Dictionary (MED)
• Columbia Presbyterian Medical Center
• Health data repository since 1988
• Multiple uses of data
• Automated decision support
• Merger with New York Hospital
New York Presbyterian Hospital
Clinical Information Systems Architecture
Medical Logic
Modules
Clinical Database
Alerts & Reminders
Database Monitor
Results Review
Database
Interface
Medical Entities
Dictionary
Administrative
Research
Reformatter
...
Radiology
Reformatter
Discharge
Summaries
Reformatter
Laboratory
...
Central Controlled Terminology
MED Structure
Medical
Entity
Substance
Chemical
Laboratory
Specimen
Anatomic
Substance
Plasma
Carbohydrate
Bioactive
Substance
Glucose
Plasma
Specimen
Event
Diagnostic
Procedure
Laboratory
Test
Plasma
Glucose
Test
Laboratory
Procedure
CHEM-7
Part of
The MED Today
•
•
•
•
•
•
Concept-based (73,000)
Multiple hierarchy (90,000)
Synonyms (180,000)
Translations (125,000)
Semantic links (134,000)
Attributes (175,000)
Applications of the MED
•
•
•
•
•
•
Communicating terminology changes
Data modeling to support clinical applications
Terminology management
Conceptual mapping for decision support
Problem-based views of the EMR
Translation to link to information resources
Retrieving Results Individually
K#1 = 4.2
K#1 = 3.3
K#2 = 3.2
K#1 = 3.0
K#3 = 2.6
K#1
K#2 K#3
Retrieving Results by Class
K#1 = 4.2
K#1 = 3.3
K#2 = 3.2
K#1 = 3.0
K#3 = 2.6
K
K#1
K#2 K#3
Supporting Clinical Applications:
Example: Summary Reports
Lab Display
Lab Test
Intravascular Glucose Test
Fingerstick Glucose Test
Serum Glucose Test
Plasma Glucose Test
Chem20 Display
DOP Summary
WebCIS Summary
Maintenance: “Pushing” a Term
Medical
Entity
Laboratory
Test
Stat
Glucose
Test
Chemistry
Test
Plasma
Glucose
Test
Chem-7
Glucose
Test
Chem-20
Glucose
Test
Chemical
Carbohydrate
Bioactive
Substance
Glucose
Maintenance: “Pushing” a Term
Medical
Entity
Laboratory
Test
Stat
Glucose
Test
Stat
Glucose
Test
Chemistry
Test
Plasma
Glucose
Test
Chem-7
Glucose
Test
Chem-20
Glucose
Test
Chemical
Carbohydrate
Bioactive
Substance
Glucose
Maintenance: “Pushing” a Term
Medical
Entity
Laboratory
Test
Stat
Glucose
Test
Stat
Glucose
Test
Stat
Glucose
Test
Chemistry
Test
Plasma
Glucose
Test
Chem-7
Glucose
Test
Chem-20
Glucose
Test
Chemical
Carbohydrate
Bioactive
Substance
Glucose
Maintenance: Finding a New
Class
Medical
Entity
Laboratory
Test
Chemical
Chemistry
Test
Antigen
HBC
Core
Antigen
Hepatitis B
Core Antigen
Maintenance: Finding a New
Class
Medical
Entity
Medical
Entity
Laboratory
Test
Chemical
Laboratory
Test
Chemical
Chemistry
Test
Antigen
Chemistry
Test
Antigen
Hepatitis B
Core Antigen
Hepatitis B
Core Antigen
Test
Hepatitis B
Core Antigen
HBC
Core
Antigen
HBC
Core
Antigen
Maintenance: Automated
Classification
Medical
Entity
Chemical
Drug
Antibiotic
Pharmacologic
Substance
Sulfameth- Trimethoxizole
oprim
Allergy
Class
Sulfa Allergy
"S1"
Trimethoprim/
Sulfamethoxizole
Preparations
Septra
"S1"
Bactrim
"S1", "65"
Trimethoprim
Allergy
"65"
Terminology and
Automated Decision Support
• Data monitor checks for triggering conditions
• Medical Logic Modules decide if warning
conditions are present
• Message sent to appropriate channel
• Decision support concepts are more general
than clinical data
• MED provides mapping
• Example: Tuberculosis culture result
Automated Decision Support
Example: “Positive” TB Cultures
• Alert checks for late results of TB tests
• IF Result Not Equal “No Growth”…
• One day, an apparent epidemic of
positive results…
…but checking the lab shows
“No Growth to Date”
How the Lab Fooled the Alert
• Alert looked for results = “No Growth”
• Lab started reporting “No Growth to Date”
• “No Growth to Date”<> “No Growth”
• Solution: Use the controlled terminology
to map all No-Growth-like lab terms into a
single class, and have the alert logic refer
to the class.
How We Outsmarted the Lab
(Before)
Medical Logic
Module
No Growth
No Growth
to Date
How We Outsmarted the Lab
(After)
“No Growth”
Results
No Growth
No Growth
to Date
No Growth
after 48 Hours
Medical Logic
Module
No Growth
after 24 Hours
No Growth
after 72 Hours
No Growth
after ...
Problem-Oriented Views of the EMR
MED
Heart
Heart
Disease
Congestive
Heart Failure
Angina
Cardiac
Enzyme
Chest
Creatine
Kinase
Chest X ray
Intravascular
CK Test
Medical
Record
Admission :3/14/96
Stroke
Lab :12/28/96
Sickle Cell Test
Admission :2/14/98
Angina
Lab :1/1/99
Blood Type Test
Discharge :1/15/99
CHF
Lab :1/1/99
Cardiac Enzyme Test
Chest X ray
2 View
Radiology :2/28/96
Head CT
Radiology :2/1/97
Knee X Ray
Radiology :2/23/99
Chest X Ray
Translations with the MED
Intravascular
Gentamicin
Tests
Summary
Reports
Injectable
Gentamicin
Serum
Gentamicin
Level
Gentamicin
Gentamicn
Sensitivity
Test
Decision
Rule
Gentamicin
Toxicity
Drug
Information
Expert
System
Linking to Expert Systems
Linking to Expert Systems
Linking to Expert Systems
Wireless Palm-based Access to Health Information:
The Palm-Based Clinical Information System (PalmCIS)
• Lack of information contributes to errors
• Inadequate communication contributes to errors
• Multimodal studies of information and communication
• PalmCIS
• Virtual Whiteboard
• Infobuttons
Studies of Information and Communication
• Modalities
– questionnaires
– focus groups
– observational studeis
• Information needs:
– nurses: diagnoses, labs, policies, drug
information, educational materials
– physicians: diagnoses, labs, notes, disease
management, prescribing
• Communication needs:
– nurses: who’s the doctor?
– physicians: who’s the nurse?
PalmCIS
• Hand-held, wireless platform
– Kyocera SmartPhone
– Sprint PCS
– Eudora Web
• Security
– HTTPS
– Login/ID
– SecureID
– IP Address
– Device ID
• Clinical Data
– WebCIS Functions
– Shortcuts
PalmCIS
PalmCIS
PalmCIS
PalmCIS
Virtual Whiteboard
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•
•
•
•
•
Matches patients, teams, and roles
Notes added to team-member’s “to do” list
Answers “Who’s taking care of…?”
Asynchronous communication channel
Data capture/display interfaces
Scheduling systems
Virtual Whiteboard
Infobuttons
• Context-specific information needs
• Access to Internet resources
– PubMed
– Micromedex
• Access to Palm-based applications
– Epocrates
Infobuttons
Infobuttons
Infobuttons
Status Report
• Applications built
• Pilot testing with physicians and NPs
• Collecting scheduling info
• Clinical study planned