John D Amore Clinfometrics, Inc. 59 Washington St. Wellesley, MA December 1, To the Health Design Challenge:

Transcription

1 John D Amore Clinfometrics, Inc. 59 Washington St. Wellesley, MA December 1, 2012 To the Health Design Challenge: Thank you for the opportunity to participate in the Health Design Challenge. Clinfometrics is pleased to submit its design for how to present CCD data in a manner that improves and eases interpretation. Our submission relies on several design principles we believe critical for future CCD usage and health information exchange: When Data Are Limited, Design Tells the Story: CCDs are a finite extract of the medical record, but organizing its sections crafts the patient narrative. We start by chronologically listing observations to portray a patient over time. In the middle, we show therapeutic actions to maintain health, namely medications displayed in a patient-centric format. Finally, we outline upcoming care activities with future scheduled appointments. Organizing CCD sections this way provides an intuitive time axis that alphabetical layouts lack. Summarize First, Details Later: Good presentation demands an upfront summary. Since CCDs may hold a lot of historic data, a 1-2 page overview helps before diving into the detail. To enhance our summary, we manipulate CCD data in three ways. First, we intelligently order data (e.g. visits by date). Second, we provide section counts (e.g. 14 normal lab results). Finally, we select the most relevant data for presentation (e.g. current, but not past medications). In the detail sections, we display each and every CCD element, but a good summary demands consolidation. Not All Data Are Created Equal: For both patients and clinicians, not all CCD data are of equal importance. It s more important to review abnormal lab values than those with normal results. Medication allergies should be emphasized to minimize prescribing mistakes. For medications, using a pill chart format helps with low literacy and elderly populations. We ve selected and organized CCD data to facilitate understanding and care. Use Color, Fonts and Icons Sparingly: Colors and icons assist in cognitive interpretation, but it s easy to overload. We ve chosen three colors and a handful of public domain icons to assist in data presentation. Each color and icon should clearly print in grayscale as well as color. We ve also selected Arial, the popular font used in Google searches. Keeping the design simple and clear focuses attention on the message, not the carrier. Through our work and research, Clinfometrics has had the opportunity to examine thousands of CCDs. A better design will be essential for a meaningful adoption of the standard. We look forward to reviewing the results and have attached our sample design with accompanying explanations on the following pages. Best Regards, John D Amore

2 Conditions (4 Active) Allergies (1 Med, 1 Food) Onset Description Allergy Reaction (Severity) Dec 2009 Diabetes *Penicillin* Hives (Moderate) Mar 2010 COPD Shellfish Anaphylaxis (Severe) Mar 2012 Arthritis Nov 2012 Stroke Tests (14 Results)! Abnormal Tests (2 Results) Chemistry Chloride (2) HDL LDL Potassium Sodium (2) Hematology Hct (2) Hgb (2) MCHC MCV WBC Triglycerides *High* Chloride *Low* Target < /25/ mg/ dl Target meq/l 11/26/12 Medications (3 Current, 3 Past, 1 Immunization) Morning Noon Eve Bed Instructions Naproxen Swallow pills, twice a day (Ashby Medical Center) Albuterol Sulfate Inhale Insulin Glargine Inject 1 As Needed Use as needed (Ashby Medical Center) 1 shot in morning (Dr. John Knowles) Care Plan (3 Future Visits, 6 Past Visits, 2 Past Procedures) Date Activity (Instructions) 12/4/12 MRI (Ashby Medical Center) 3/7/13 Pap Smear (Ashby Medical Center) 3/14/13 PCP visit (1500 Gessner Rd, Houston TX)

3 Time Axis of Care Summary Flow of Time/Activity What was observed? What was measured? What meds to take? How to take them? Where to go next?

4 Design of Care Summary Header: Include identifying information of patient. Name, age and gender sufficient to minimize wrong patient errors. Other data provided on demographic page if printed Date: Clearly label date of CCD generation Allergies: List all entries, make medications bold Problems: List active entries Labs: Divide abnormal from normal results. List detail on abnormal but only names on normal. Use words and micrographic to show range and high/low abnormality Section: Count entries Current Meds: Use a pill card format to present data.¹ This eases interpretation of medication timing Care Plan: Provide count of all appointments and procedures. Provide additional detail on future care activity Icons for Route: ions can be categorized by route. Simple icons aid groupings: Oral Injection Inhaler Topical Eye Drops 1. How to Create a Pill Card. Agency for Health Quality and Research, 2008.

5 Source of Care Summary Data Header: First & Last Name, Gender, [CALCULATE Age = CCD Record Date Birthdate], Gender, Telephone CCD Record Date Allergies: Allergy Name, Reaction, Severity [FORMAT Bold for RxNorm] Conditions: Observation, Date, [SELECT Active ] Abnormal Labs: Component, Value, Unit, Reference [SELECT for outside Reference] Labs: Component, [SELECT for inside Reference] [COUNT for all section heads] Current Meds: Name, Dose Quantity, Rate Quantity, Instructions, Route, Prescriber Name, [SELECT Continued or no High Effective Date ] Care Plan: Date, Activity, Instructions, [SELECT for Date greater than CCD Record Date] Icons: [SELECT Icon by Route] OR [SELECT Icon by RxNorm Code] *Note that RxNorm codes, as required by Stage 2 Meaningful Use, are route specific.

6 Full CCD Table of Contents 1. Care Summary (shown previously) Complete Detail [XML Sections]¹ (Each section available for print/view) 2. Conditions & Allergies [Problem List & Allergies] 3. Lab Results [Results] 4. Medications [Medications & Immunizations] 5. Care Plan [Plan of Care, Encounters, Procedures] 6. Care Team [Healthcare Providers]² 7. Demographics [recordtarget]³ Notes: 1. XML sections based on Implementation Guide for CDA Release 2.0 Consolidated CDA Templates by Health Story, HL7 and IHE. 2. Healthcare Providers is not a section in CCDA Release 2.0, but this was a section based on HITSP C32 implementation. Providers were included in Health Design Challenge documentation and are included here. Author of CCD can also be used. 3. Demographics is not a CCD section but is generally captured in the recordtarget XML tag which precedes structuredbody portion of CCD.

7 Conditions (4 Active, 1 Resolved) Onset Description Status Age at Onset 12/12/09 Diabetes Active 56 3/19/10 COPD Active 57 7/6/11 Pneumonia Resolved 58 3/4/12 Arthritis Active 59 11/24/12 Stroke Active 59 Allergies (1 Medication, 1 Food) Allergy Type Reaction Severity *Penicillin* Medication Hives Moderate Shellfish Food Anaphylaxis Severe

8 Laboratory Results (14, 2 Abnormal) Name Date Value (Interpretation) CHEMISTRY TESTS Display Chloride 11/24/12 Chloride 11/25/12 Chloride 11/26/12 HDL 11/25/12 LDL 11/25/12 Potassium 11/26/12 Sodium 11/24/12 Sodium 11/26/12 Triglycerides 11/25/12 HEMATOLOGY TESTS Hct (Hematocrit) 11/24/12 Hct (Hematocrit) 11/25/12 Hgb (Hemoglobin) 11/24/12 Hgb (Hemoglobin) 11/25/12 MCHC 11/24/12 MCV 11/24/12 WBC (White Cell Count) 11/24/ meq/l meq/l 94.2 meq/l *LOW* 62 mg/dl 108 mg/dl 3.9 meq/l 141 meq/l 140 meq/l 242 mg/dl *HIGH* 42.1% 40.5% Hb/cell 92 fl 5.5k / mm³ Target Target Target Target > 40 Target < 120 Target Target Target Target < 150 Target Target Target Target Target Target Target 4k 12k

9 Current Medications (3 Current) Morning Noon Eve Bed Instructions Naproxen Swallow pills, twice a day (Ashby Medical Center) Albuterol Sulfate Inhale Insulin Glargine Inject 1 As Needed Use as needed (Ashby Medical Center) 1 shot in morning (Dr. John Knowles) Past Medications (3 Past, 1 Immunization) Date Name (Type) Status Rate Dose 12/12/09 Metformin 500 mg(tablet) Discontinued 2 / day 1 tablet Instructions: Route: Prescribed: Take 1 pill twice daily for management of glucose. Take with food. Oral John Knowles, MD 7/5/11 Influenza virus vaccine Completed Route: Prescribed: Injection (IM) Ashby Medical Center 7/5/11 Penicillin 500mg (tablet) Discontinued 4 / day 1 tablet Instructions: Route: Prescribed: Take 1 pill 4 times per day Oral Ashby Medical Center 7/7/11 Azithromycin 500mg (tablet) Completed 1 / day 1 tablet Instructions: Route: Prescribed: Take 1 pill 1 time per day Oral Ashby Medical Center

10 Future Appointments (3 Scheduled) Date Activity Instruction 12/4/12 MRI Ashby Medical Center 3/7/13 Pap Smear Ashby Medical Center 3/14/13 PCP visit 1500 Gessner Rd. Houston TX Past Care Activity (6 Visits, 2 Procedures) Date Activity Provider Location 12/12/09 PCP Visit John Knowles, MD 1500 Gessner Rd. Houston TX 12/23/09 Endocrinology Maureen Bo, MD 18 Redford Rd. Houston TX 1/14/10 Gastric Banding (Procedure) Les Pounds, MD Ashby Medical Center 7/7/11 Hospitalization John Knowles, MD Ashby Medical Center 7/18/11 PCP Visit John Knowles, MD 1500 Gessner Rd. Houston TX 9/12/11 Hemodialysis (Procedure) Not provided Ashby Medical Center 9/14/11 Consult Ashley Gnome, MD Ashby Medical Center 11/26/12 Hospitalization John Knowles, MD Ashby Medical Center

11 Care Team (3 Members) Name of Provider Telephone Address Ashby Imaging (345) Richmond St, Houston TX Ashby Medical Center (567) Fannin St., Houston TX John Knowles, MD (567) Gessner Rd, Houston TX CCD Source (Generated 11/26/12) Name of Provider Telephone Address Ashby Medical Center (567) Fannin St., Houston TX 77001

12 Patient Information Name: Jane Weigh Forrett Doe Gender: Female Date of Birth: 1/3/1953 Language: English Marital Status: Widow Religion: Baptist Ethnicity: Address(1): White Non-Hispanic 15 Indiana St, Unit #602 Houston, TX Address(2): Telephone(1): Telephone(2): (567) Home (567) Mobile Guardian Information (None Specified) Role: Name: Address: Telephone(1): Telephone(2):

13 References 1. CCD Sample Data i. Health Design Challenge sample data ii. NIST Sample CCD by Len Gallagher 2. Icons (available in public domain) i. Utah Government website (See inhalation icon) ii. Created in Microsoft PowerPoint 2010 (See No symbol for Allergies and Wingdings 2 for checkmark) iii. The Noun Project. All icons not otherwise specified 3. Design & Formatting Inspiration i. Donald Norman a. The Design of Everyday Things ii. Edward Tufte a. Envisioning Information, 1990 b. Visual Explanations, 1997 c. The Visual Display of Quantitative Information (2ed), 2001 d. Beautiful Evidence, Pillbox Formatting i. How to Create a Pill Card. Agency for Health Quality and Research. Publication No. 08-M016 ii. Note on Rate Quantity to Pill Card Mapping a. 1 time per day default to morning b. 2 times per day default to morning/eve c. 3 time per day default to morning/noon/eve d. 4 times per day default to morning/noon/eve/bed e. 5+ times or other display See Instructions f. As needed display As Needed