Electronic health records and the clinical narrative. Philip Resnik University of Maryland

Transcription

1 Electronic health records the clinical narrative Philip Resnik University of Maryl Electronic Health Record Informatics Workshop, 29th Human-Computer Interaction Lab Symposium, University of Maryl, Wednesday, May 23, 2012

2 With the widespread adoption of EHRs, what happens to natural clinical language, why should we care? 2

3 Providers Payers CHIEF COMPLAINT: Shortness of breath. HPI: This is a 68-yearold female who presents to the emergency department with shortness of breath going for several days codes $$

4 Providers Downstream data consumers Patients Researchers Clinicians Policy makers $$ Reimbursement Meaningful use 4

5 Source: This system is designed for physicians to point click their way through an entire exam quickly effortlessly. (EMR product review) 5

6 The clinical narrative In years past, a well-written history physical, or progress note, would unfold like a story, giving a vivid description of the patient s symptoms physical exam at the point of the encounter, as well as the synthesis of the data the plan of care." EMRs: Finding a balance between billing efficiency patient care", Henry F. Smith, Jr., MD, Commentary, The Times Leader, Wilkes-Barre, PA, June 12,

7 April 14, 2007 CHIEF COMPLAINT: Shortness of breath. HISTORY OF PRESENT ILLNESS: This 68-year-old female presents to the emergency department with shortness of breath that has gone on for 4-5 days, progressively getting worse. It comes on with any kind of activity whatsoever. She has had a nonproductive cough. She has not had any chest pain. She has had chills but no fever. EMERGENCY DEPARTMENT COURSE: The patient was admitted. She has had intermittent episodes of severe dyspnea. Lungs were clear. These would mildly respond to breathing treatments morphine. Her D-dimer was positive. We cannot scan her chest; therefore, a nuclear V/Q scan has been ordered. However, after consultation with Dr. C, it is felt that she is potentially too unstable to go for this. Given the positive D-dimer her severe dyspnea, we have waved the risks benefits of anticoagulation with her heme-positive stools. She states that she has been constipated lately doing a lot of straining. Given the possibility of a PE, it was felt like anticoagulation was very important at this time period; therefore, she was anticoagulated. The patient will be admitted to the hospital under Dr. C. 7

8 April 14, 2007 CHIEF COMPLAINT: Shortness of breath. HISTORY OF PRESENT ILLNESS: This 68-year-old female presents to the emergency department with shortness of breath that has gone on for 4-5 days, progressively getting worse. It comes on with any kind of activity whatsoever. She has had a nonproductive cough. She has not had any chest pain. She has had chills but no fever. EMERGENCY DEPARTMENT COURSE: The patient was admitted. She has had intermittent episodes of severe dyspnea. Lungs were clear. These would mildly respond to breathing treatments morphine. Her D-dimer was positive. We cannot scan her chest; therefore, a nuclear V/Q scan has been ordered. However, after consultation with Dr. C, it is felt that she is potentially too unstable to go for this. Given the positive D-dimer her severe dyspnea, we have waved the risks benefits of anticoagulation with her heme-positive stools. She states that she has been constipated lately doing a lot of straining. Given the possibility of a PE, it was felt like anticoagulation was very important at this time period; therefore, she was anticoagulated. The patient will be admitted to the hospital under Dr. C. 8

9 April 14, 2007 CHIEF COMPLAINT: Shortness of breath. HISTORY OF PRESENT ILLNESS: This 68-year-old female presents to the emergency department with shortness of breath that has gone on for 4-5 days, progressively getting worse. It comes on with any kind of activity whatsoever. She has had a nonproductive cough. She has not had any chest pain. She has had chills but no fever. EMERGENCY DEPARTMENT COURSE: The patient was admitted. She has had intermittent episodes of severe dyspnea. Lungs were clear. These would mildly respond to breathing treatments morphine. Her D-dimer was positive. We cannot scan her chest; therefore, a nuclear V/Q scan has been ordered. However, after consultation with Dr. C, it is felt that she is potentially too unstable to go for this. Given the positive D-dimer her severe dyspnea, we have waved the risks benefits of anticoagulation with her heme-positive stools. She states that she has been constipated lately doing a lot of straining. Given the possibility of a PE, it was felt like anticoagulation was very important at this time period; therefore, she was anticoagulated. The patient will be admitted to the hospital under Dr. C. 9

10 May 3, 2007 EMERGENCY DEPARTMENT COURSE: The patient was admitted nontoxic in appearance. Blood pressure was brought down aggressively. With this combined with BiPAP, she has reversed her respiratory distress promptly. She has improved significantly. She will not require intubation at this time period. Her family has elected to go back to M, Dr. W. I did discuss this case with Dr. G who is on call for L Cardiology. She has accepted him in transfer; however, there are no PCU or ICU beds at this time period. Will admit here for a brief period until a bed is available at M. I discussed this case with Dr. R who will admit. Clinicians were trying to determine whether the shortness of breath was due exclusively to her failing heart, or whether she has pneumonia. Prompt response indicates that pneumonia is not the issue. 10

11 I worry that EMRs as implemented can actually downgrade the quality of information passed between health care teams Henry F. Smith, Jr., MD, EMRs: Finding a balance between billing efficiency patient care", Commentary, The Times Leader, Wilkes- Barre, PA, June 12,

12 A head-to-head comparison Mr. John Roe was seen in our office today in follow up of his paroxysmal atrial fibrillation. As you know, he is a 57 year old gentleman who had electrical cardioversion in May 2002 had been maintained on Betapace since that time. His last visit in our office was July 23, He recently called our office in February stating he was back in atrial fibrillation which was documented on electrocardiogram. I elected to increase his Betapace to 160 mg twice a day he did convert back to normal sinus rhythm. We had recommended Coumadin to him at that time but he did not start any Coumadin. He has done well since with no recurrence of arrhythmia he is acutely aware of when he goes into the fibrillation. He denies any shortness of breath, chest discomfort of congestive heart failure symptoms has otherwise felt quite well. His only medication is the Lexa pro 10 mg a day as an antidepressant the Betapace. His review of systems is otherwise unchanged negative. Source: Resnik et al. Communication of Clinically Relevant Data in Electronic Health Records: A Comparison between Structured Data Unrestricted Physician Language, AHIMA,

13 Seriousness of omission Both experts Considered an omission only if both experts identified it as an omission 5 Percentage of documents 0% 50% 85% Average omissions per document

14 Some omissions seem straightforward to remediate with easy changes to the EMR specification, e.g. Negative patient reports ( denies SOB ) Degrees for symptoms ( mild/severe pain ) Reactions to allergies ( rash/hives ) 14

15 Results, disregarding remediable omissions Seriousness of omission Both experts Considered an omission only if both experts identified it as an omission 5 Percentage of documents 0% 25% 50% Average omissions per document

16 Difficult to remediate Nuanced/detailed elaborations able to walk on flat levels walk at a moderate pace for one hour without abnormal shortness of breath or chest pain Temporal/logical context ventricular tachycardia occurred during post myocardial infarction care far removed from the time of [patient s] infarction the dictating physician was hesitant to recommend [patient s] FAA certification renewal without a repeat of a previous catheterization Dictating physician s thought process recommends continuing Toprol because it seems to be controlling [the patient s] palpitations well considers discomfort to be suggestive of angina believes that results of stress testing would rule out significant major coronary artery disease, despite it being a somewhat incomplete study 16

17 Difficult to remediate: the things that make the clinical narrative a narrative As EMRs proliferate, increased Medicare scrutiny looms, medical documentation is evolving from its original goal of recording what actually was going on with a patient, what the provider was actually thinking, to sterile boilerplate documents designed to justify the highest billing codes. EMRs: Finding a balance between billing efficiency patient care", Henry F. Smith, Jr., MD, Commentary, The Times Leader, Wilkes-Barre, PA, June 12, If you lose the language, you lose the story. 17

18 A dilemma The future of healthcare depends on structured information we can aggregate analyze. EMRs are widely viewed as the way to get there. But typical EMRs threaten to eliminate or fragment crucial language in the record omit information that clinicians need in order to communicate effectively destroy the knowledge discovery cycle 18

19 Language the discovery cycle Structured input encodes the clinical concepts we already know are important. Language contains clinical content that we might only discover to be important later. First febrile seizure (Kimia et al. 2009) Head lag Swallowed magnet With structured input, that language never gets created. 19

20 A way forward: recognizing that structured datasets structured input Patients Researchers Clinicians Policy makers Transcription Informed by the best current knowledge Clinical history: data, language History Findings: of plasmacytoma (head) technology transforms clinical Mass Abnormality in right central in right skull central base Current medications: skull base language Mass subsequently into reduced stardized, in size Mass Melphalan smaller in size 9 mg/m 2 per day interoperable, Mild cerebral leukoaraiosis available Prednisone 100 mg/day information. Physicians focus on the care of the patient ORDER_EXAM: ORDER_EXAM: MRI Hd wo&w ORDER_IND: head - h/o plasmacytoma^ ORDER_EXAM: MRI Hd wo&w ORDER_IND: head - h/o plasmacytoma^ ORDER_EXAM: MR MRI head, Hd without wo&w ORDER_IND: with IV gadolinium. head - h/o Comparison plasmacytoma^ ORDER_EXAM: MR MRI head, Hd without wo&w ORDER_IND: with IV gadolinium. head - h/o Comparison plasmacytoma^ ORDER_EXAM: is made MR MRI is made with MR head, MRI Hd with previous head, without Hd wo&w previous without wo&w outside ORDER_IND: outside ORDER_IND: with MR head IV gadolinium. head with MR IV head gadolinium. head - h/o - h/o examinations Comparison plasmacytoma^ examinations Comparison plasmacytoma^ 5/3/04 is made MR 5/3/04 is made 11/16/04. with MR head, 11/16/04. with head, previous without previous On without the outside On the outside earliest with MR with IV earliest MR outside head IV gadolinium. outside head gadolinium. examination, examinations Comparison examination, there 5/3/04 is made there was was a mass 11/16/04. with previous a mass in in the the right On the outside right central earliest MR central skull outside head examinations skull base, base, extending examination, examinations Comparison 5/3/04 extending infratemporal there 5/3/04 is made was infratemporal fossa, a 11/16/04. with mass 11/16/04. previous On fossa, sphenoidsinus, in the right On the outside the earliest central earliest MR outside head sphenoidsinus, foramen skull outside examination, base, foramen ovale. extending examination, examinations there ovale. This This subsequently infratemporal there 5/3/04 was was a mass subsequently was fossa, a mass 11/16/04. in was demonstrated sphenoidsinus, in the the right On right the central central earliest skull demonstrated to to represent foramen skull outside base, extending examination, infratemporal there was fossa, a mass sphenoidsinus, in the right central represent foramen a skull base, base, a plasmacytoma. ovale. extending This subsequently plasmacytoma. ovale. extending infratemporal This This subsequently infratemporal This mass mass is is markedly was fossa, demonstrated markedly was fossa, sphenoidsinus, demonstrated reduced sphenoidsinus, reduced in to in size represent to size represent on foramen on the foramen a the subsequent plasmacytoma. ovale. a subsequent plasmacytoma. ovale. This outside This subsequently This outside MR. subsequently This mass MR. Our mass Our examination is markedly was examination is markedly was demonstrated demonstrated continues reduced in to continues reduced to in size to represent to show size represent on the a show on the a communicate abnormal subsequent plasmacytoma. abnormal subsequent plasmacytoma. signal outside This signal outside peripheral MR. This mass Our peripheral MR. mass Our enhancement, examination is continues enhancement, examination is markedly markedly reduced continues reduced in the the right to in size show right to size on show on the the central abnormal subsequent central abnormal skull subsequent skull base, signal outside base, signal outside involving peripheral MR. involving peripheral MR. Our right Our enhancement, examination continues right enhancement, clivus, examination clivus, right in right sphenoid, continues the right to show sphenoid, the right to show central abnormal base central abnormal base of skull of right skull base, signal right pterygoid. base, signal involving peripheral pterygoid. This involving peripheral This is is probably right enhancement, clivus, probably right enhancement, clivus, stable right in stable right when sphenoid, in the right central base of skull right base, pterygoid. involving This is probably right clivus, stable right when sphenoid, the right unimpeded, central base of skull right base, pterygoid. involving This is probably right full, clivus, stable right when sphenoid, base of right pterygoid. This is probably stable when sphenoid, base of right pterygoid. This is probably stable when when narrative clinical data. NLP Engine Both health drug information technology medical disease cancer steroid communities of practice plasmacytoma prednisone inform, are informed by, evolving medical knowledge. 20

21 Thanks! To follow up: 21