1. Twenty Years of IAIMS: The Columbia University/ New York Presbyterian Hospital Clinical Data Repository James J. Cimino Department of Biomedical Informatics Columbia University College of Physicians and Surgeons IAIMS Consortium Annual Meeting Boston, MA April 10, 2005

2. History and evolution (or creation) Where we are today What we learned Overview History and evolution

3. History and Evolution (or Creation) 1983-1986: IAIMS Planning Grant –Rachel Anderson –Organizational 1986-1988: IAIMS Demonstration Grant –Paul Clayton and Rachel Anderson –Center for Medical Informatics –Vision

5. History and Evolution (or Creation) 1983-1986: IAIMS Planning Grant –Rachel Anderson –Organizational 1986-1988: IAIMS Demonstration Grant –Paul Clayton –Center for Medical Informatics –Vision –“$6M Demo” 1988-1993: IAIMS Implementation Grant –Funding from NLM, IBM, CU, Presbyterian Hospital –Network –Clinical data architecture

6. Clinical Data Architecture Central repository to collect data from myriad sources Myriad users of data - some not yet imagined

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

8. Clinical Data Architecture Central repository to collect data from myriad sources Myriad users of data - some not yet imagined Patient-oriented, not visit oriented, database Relational, not hierarchical, model Entity-attribute-value model

9. Entity-Attribute-Value Clinical Data Repository

10. Clinical Data Architecture Central repository to collect data from myriad sources Myriad users of data - some not yet imagined Patient-oriented, not visit oriented, database Relational, not hierarchical, model Entity-attribute-value model Coded data wherever possible Unify terminology

11. Medical Entities Dictionary: A Central Terminology Repository

12. Communicating Terminology Changes K#1 K#2 K#3 K#3 = 2.6 K#1 = 4.2 K#1 = 3.3 K#2 = 3.2 K#1 = 3.0

13. K#1 = 4.2 K#1 = 3.3 K#2 = 3.2 K#1 = 3.0 Solution: Hierarchical Integration K#1 K#2 K K#3 K#3 = 2.6

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

15. Where We Are Today - Repository Patients: 2.6 million Visits: >10 million since 1996 with archives going back to 1979 Visit diagnoses, locations, procedures, providers, insurance Lab procedures: 16 million with 130 million results (to 1989) Radiology procedures reports: 5.7 million Pathology: 1.4 million Cardiology procedures: 1.5 million Resident signout notes:760,000 Operative Notes: 426,000 Clinical Notes: 400,000 Discharge Summaries: 420000 Medication orders: >60 million ObGyn Procedure Reports: 241,000 GI Procedure Reports: 101,000 Neurology Procedure Reports: 54,000 Ideatel BP’s: 215,000 Ideatel Glucose: 650,000 Consult Events: 18000 HEENT Events:13000 Hospitalist Notes:30000 PFT: 25000 Provider profiles 11000 IDX 1.4 million East Campus

16. Where We Are Today - MED Domains: –HP lab terms –Misys lab terms –Cerner lab terms –Misys Radiology –Digimedix drugs –Cerner Drugs –ICD9-based problem list terms –Other applications –Knowledge terms Size: –Concept-based (95,641) –Multiple hierarchy (141,306) –Synonyms (239,581) –Translations (141,717) –Semantic links (225,698) –Attributes (210,456)

17. Where We Are Today - Outputs 7000 Users Clinical information systems

28. [LPRO]->(AE)->[ANTB]->(DS)->[PFUN]->(PO)->[ORGM]<-(PP)<-[OATT] A procedure assesses the effect of an antibiotic which disrupts a physiologic function which is a process of an organism which has an attribute (sensitive/resistant).

31. Where We Are Today - Outputs 7000 Users Clinical information systems MedLEE

32. HISTORY OF PRESENT ILLNESS: This 67 year old with a history of syncope in 1987 and 1989. She reported that she was evaluated both times and the work up was negative for any specific etiology. On the day of admission she reports having one episode of severe diarrhea and she was having increasing abdominal discomfort with flatulence and one episode of vomiting. When she returned to the bath room to move her bowels again she felt light headed and called for a family member. The family member reported that the patient was unconscious at that time and was placed in bed and recovered within 1-2 minutes. there was no history of any precipitating shortness of breath, chest pain or any seizure activity. At the time the patient was seen in the hospital she already felt fine. Problems present: diarrhea discomfort (abdomen )  vomiting lightheaded unconscious Problems absent: pain (chest ) seizure Findings present: demo ( 67 year ) History: syncope

33. Where We Are Today - Outputs 7000 Users Clinical information systems MedLEE Decision support systems –Vigilens: TB, Freq Admit, Lab Vals

35. Where We Are Today - Outputs 7000 Users Clinical information systems MedLEE Decision support systems –Vigilens: TB, Freq Admit, Lab Vals –Infobuttons

39. Where We Are Today - Outputs 7000 Users Clinical information systems MedLEE Decision support systems –Vigilens: TB, Freq Admit, Lab Vals –Infobuttons Clinical data warehouse

41. select patient_id, time = primary_time from visit2004_diagnosis where diagnosis_icd9_code like '410%' and b.primary_time between '01/01/2000' and '01/01/2005' and b.comp_code = 30366

42. Where We Are Today - Outputs 7000 Users Clinical information systems Decision support systems –Vigilens: TB, Freq Admit, Lab Vals –Infobuttons Clinical data warehouse Other clinical systems –Infection Control –CPOE –Marconi –IDEATel –Data Mining –Bioinformatics

43. Lessons Learned The repository architecture paid off Model the data, not the applications Write once, read many times Pay attention to your terminology You will reuse data You can’t predict how you will reuse it

44. Acknowledgements People: –Tom Morris –Henrik Bendixen –Rachel Anderson –Paul Clayton –Steve Johnson –George Hripcsak –Bob Sideli –Somitra (Sen) Sengupta New York Presbyterian Hospital Columbia University National Library of Medicine IBM