1. “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

2. 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

3. New York Presbyterian Hospital Clinical Information Systems Architecture Database Interface Research Administrative Alerts & Reminders Reformatter Database Monitor Clinical Database Medical Logic Modules Medical Entities Dictionary Results Review... Radiology Laboratory Discharge Summaries Reformatter

4. Central Controlled Terminology

5. MED Structure Medical Entity Plasma Glucose Test Laboratory Specimen Plasma Specimen Anatomic Substance Plasma Substance Sampled Part of Has Specimen Substance Measured Laboratory Procedure CHEM-7 Laboratory Test Event Diagnostic Procedure Substance Bioactive Substance Glucose Chemical Carbo- hydrate

9. The MED Today Concept-based (73,000) Multiple hierarchy (90,000) Synonyms (180,000) Translations (125,000) Semantic links (134,000) Attributes (175,000)

10. 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

11. K#1 = 4.2 K#1 = 3.3 K#2 = 3.2 K#1 = 3.0 Retrieving Results Individually K#1 K#2 K#3 = 2.6 K#3

12. K#1 = 4.2 K#1 = 3.3 K#2 = 3.2 K#1 = 3.0 Retrieving Results by Class K#1 K#2 K K#3 K#3 = 2.6

13. Supporting Clinical Applications: Example: Summary Reports Chem20 Display Lab Display Plasma Glucose Test Serum Glucose TestFingerstick Glucose Test Lab Test Intravascular Glucose Test

14. DOP Summary

15. WebCIS Summary

16. Maintenance: “Pushing” a Term Medical Entity Laboratory Test Plasma Glucose Test Bioactive Substance Glucose Carbo- hydrate Chemistry Test Chem-7 Glucose Test Chem-20 Glucose Test Stat Glucose Test Chemical

17. Maintenance: “Pushing” a Term Medical Entity Laboratory Test Plasma Glucose Test Bioactive Substance Glucose Carbo- hydrate Chemistry Test Chem-7 Glucose Test Chem-20 Glucose Test Stat Glucose Test Stat Glucose Test Chemical

18. Maintenance: “Pushing” a Term Medical Entity Laboratory Test Plasma Glucose Test Bioactive Substance Glucose Carbo- hydrate Chemistry Test Chem-7 Glucose Test Stat Glucose Test Chem-20 Glucose Test Stat Glucose Test Stat Glucose Test Chemical

19. Maintenance: Finding a New Class Medical Entity Laboratory Test Hepatitis B Core Antigen Chemical Chemistry Test Core Antigen HBC Antigen

20. Maintenance: Finding a New Class Medical Entity Laboratory Test Hepatitis B Core Antigen Chemical Chemistry Test Core Antigen Hepatitis B Core Antigen Test HBC Antigen Medical Entity Laboratory Test Hepatitis B Core Antigen Chemical Chemistry Test Core Antigen HBC Antigen

21. Maintenance: Automated Classification Medical Entity Drug Pharmacologic Substance Sulfameth- oxizole Chemical Antibiotic Bactrim "S1", "65" Trimethoprim/ Sulfamethoxizole Preparations Trimeth- oprim Septra "S1" Sulfa Allergy "S1" Allergy Class Trimethoprim Allergy "65"

22. 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

23. 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”

24. 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.

25. How We Outsmarted the Lab (Before) No Growth Medical Logic Module No Growth to Date

26. No Growth after... How We Outsmarted the Lab (After) No Growth No Growth after 48 Hours No Growth after 72 Hours “No Growth” Results No Growth after 24 Hours No Growth to Date Medical Logic Module

27. Lab :1/1/99 Cardiac Enzyme Test Radiology :2/23/99 Chest X Ray Radiology :2/28/96 Head CT Lab :12/28/96 Sickle Cell Test Admission :3/14/96 Stroke Admission :2/14/98 Angina Lab :1/1/99 Blood Type Test Radiology :2/1/97 Knee X Ray Discharge :1/15/99 CHF Medical Record Problem-Oriented Views of the EMR Chest X ray Intravascular CK Test Creatine Kinase Chest X ray 2 View Cardiac Enzyme Congestive Heart Failure Angina Heart Disease Chest Admission :2/14/98 Angina Lab :1/1/99 Cardiac Enzyme Test Radiology :2/23/99 Chest X Ray Discharge :1/15/99 CHF Heart MED

32. Translations with the MED Gentamicin Injectable Gentamicin Gentamicn Sensitivity Test Serum Gentamicin Level Gentamicin Toxicity Etiology Measures Sensitivity Substance Measured Has ingredient is-a Intravascular Gentamicin Tests Summary Reports Decision Rule Expert System Drug Information

36. Linking to Expert Systems

39. 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

40. 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?

41. 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

42. PalmCIS

46. 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

51. Context-specific information needs Access to Internet resources –PubMed –Micromedex Access to Palm-based applications –Epocrates Infobuttons

55. Status Report Applications built Pilot testing with physicians and NPs Collecting scheduling info Clinical study planned