Guideline and Protocol Based Systems PDF

Guideline and protocol based systems HEALTH INFORMATICS, 2ND SEM 2019-2020 LILY ANN D. BAUTISTA, PT, DPT, PTRP, COMT, VCS SOURCE: GUIDE TO HEALTH INFORMATICS, 3E, COIERA, 2015  Clinical guidelines vs protocols ► Documents that provide best practice guidance...

Guideline and protocol based systems HEALTH INFORMATICS, 2ND SEM 2019-2020 LILY ANN D. BAUTISTA, PT, DPT, PTRP, COMT, VCS SOURCE: GUIDE TO HEALTH INFORMATICS, 3E, COIERA, 2015  Clinical guidelines vs protocols ► Documents that provide best practice guidance supported by research from experts recommendations ► Clinical Practice guidelines: contains recommendation or strategies to assist healthcare or strategies ↓ practitioners in making clinical decisions offer guidance ► Usually long -EMPHASIS ► Usually referred synonymously with protocol; emphasis is to offer guidance ► Advisory, the clinician still has to decide esp when instructions are not appropriate moreriptive ► Protocol: more prescriptive version of a guideline, contains specific instructions to follow. specificinstructions ► More precise  Other names of “protocol” set of instructions ↓ ► Algorithm: set of instructions to carry out some task programmatically programatically ► Usually small, specific and well defined steps ► Protocol: steps in management of a clinical condition with diagnosis, illness and treatment advisory ► Guideline: often used synonymously with protocol, guidance, advisory in nature no steps ► Care Pathway: does not show steps, but focuses on expected course of the patient’s management specificorder ► Checklist: when steps taken are executed in a specific order; once then, checklist are crossed off boundaries ► Practice parameter: emphasizes on the role of instructions to set boundaries or parameters in the course of patient’s silent case Protocol application ► Research ► Basis of comparison among studies ► Application of a particular treatment ► Delegation of responsibility ► Highly trained staff delegates routine problems to a more generally trained colleagues ► Patients can be given instructions to do at home ► Demarcation of responsibility ► To make clear what each member of the team does Protocol application ► Safety critical or complex situations: ► Checklists done to make sure that steps are taken ► Education ► minimum standard of training needed for delivery of care ► Uncommon conditions: ► Important for rare conditions, something that the person has not experienced before increased compliance - decreased variation ► Increased compliance with guideline should result in decreased variation in clinical practice, ► Review of 59 evaluations of clinical guidelines: all but 4 showed improvement in care ffg introduction of a guideline (Grimshaw and Russell, 1993) sa evals ↑ improvements Protocol characteristics / different presentations ► Always starts with an inclusion, eligibility or entry criteria – defines intended use ► Example: Rehab following ACL reconstruction ► Flow chart: simplest way to represent a protocol ► Graphical, with decision points and flow of logic, can be detailed or can be simple ► A decision tree: can be yes not OR, if-then statements. Protocol expressed in set of rules Protocol characteristics / different presentations standardized care ► Care Pathways ► Sets of stages; contributes to effective communication ► Structured multidisciplinary plan of care ► Translate guidance or evidence in local structures ► Detail the steps in a course of treatment ► Have timeframe or criteria that guide progression ► Standardized care for a particular clinical problem Criteria that will affect protocol ► Patient condition: pt may have concurrent illness; different fitness level, different body type, etc. ► Treatment variation: treatment may deviate from the standard due to one reason or another ► Resource constraints: sometimes even if the protocol gives you step 2 and the person doing step 2 is not available, you might need deviate from protocol Computer based protocol systems Computer based systems source ONLY -info ► Passive protocol: ► Acts as a source of information only, not integrated in the care process ► Makes it easier for clinicians to access protocol during routine care ► Can be integrated in the computer system through search button, info button, links Computer based systems ► Active protocol ► Guide the clinicians ► Must be integrated in the organization’s informational system – record keeping is important (automated or semi automated) ► Protocol driven record keeping: provides direct benefit only to those who use the system - ► Must have the ability to be shared among stakeholders Computer based systems ► Active protocol ► Can alert, provide reminders and task recommendations ► Alert: It can trigger someone to act accordingly ► Reminder: situational, providing guidance on what to do in certain scenarios Prerequisite for developing computer guideline systems ► Creation of computer-interpretable representations of the clinical knowledge contained in clinical guidelines Example of protocol representation systems ► Arden Syntax: ► Computer language ► widely recognized standard for representing clinical and scientific knowledge in executable format ► Can be used to code decision and actions within the clinical protocol system ► Protégé ► Structured around tasks ► Widely used open source tool that allows user to build a protocol ► Once constructed, protocol is translated into machine readable form ► Allows 3rd party plug ins to connect protocols with other information components that run under different standards Example of protocol representation systems ► PROforma ► Designed to emphasize on safe guidelines ► Simple and intuitive ► Guideline Interchange Format ► Supports sharing of guidelines among different institutions and software systems ► Build most useful features of other guidelines and incorporate standards used in healthcare DESIGNING, DISSEMINATIN G AND APPLYING PROTOCOLS Dissemination ► Every clinician has immediate and easy access to evidence based practice ► But even if better treatment, not all clinician will know about it Barriers on limiting use of evidence in clinical settings ► Clinicians lack of awareness of existing guideline ► Clinicians may lack familiarity with content of a guideline ► Clinicians may disagree with guideline, because they interpret research different and they believe that benefit is not worth to the comfort of the patient ► Clinician do not believe that guideline is applicable to their practice Barriers on limiting use of evidence in clinical settings ► They believe that guidelines are oversimplified or “cookbooks” or that guidelines reduce autonomy ► Clinicians may not feel able to execute the content of a guideline (also known as low self-efficacy) ► There may be a lack of belief that there will be any outcome benefit if guideline is used ► Clinicians feel constrained and unable to change from previous practice ► The guidelines may not be easy or convenient to use or may be confusing Factors that might affect likelihood of adaptation of a guideline ► Clinical inertia: failure of the healthcare providers to initiate or intensify therapy even when a treatment is indicated and clinician is aware of the need to do so ► Time ► Limited data ► Multiple problems ► Complexity (adoption of guideline inversely proportional to complexity) ► Clinical informatics skills: difficulty with use of online evidence resources, due to insufficient training in database searching and general technology skills Factors that might affect likelihood of adaptation of a guideline ► Organizational support: people who enthusiastically support innovation; accepts the uptake of new innovations ► Professional differences: ► Doctors emphasize on role of evidence from biomedical literature ► Nurses place greater valued on policies and procedures Measurement of efficacy and adoption rate of guidelines ► The effect on clinical outcome that a treatment produces ► The actual rate of adoption of a guideline that recommends the treatment ► Discoverability of information – that the community finds this information ► Utility of information – can the reader find something useful, they don’t already have Measurement of efficacy and adoption rate of guidelines ► ** IMPORTANT to consider both efficacy and adoption rate ► A treatment may be found effective with research but if with limited adoption rate due to one reason or another, success of guideline use is still not high Requirements to meet for guidelines and protocols to reflect best evidence ► Protocol utility: there must be an improvement in clinical processes compared to current ► Protocol designability: must be feasible to prescribe a course of action ahead of time ► Protocol usability: consider accessibility and applicability Protocol rigidity can be decreased by specific planning ► Treatment goals: should be able to guide, example nurse triage has to ascertain who are truly needing medical assistance ► The patient: protocol has to manage patient variation and likely to meet clinical needs ► Local resources: limited by available resources ► Users: skill level of the user affects different types of protocols ► Local process and workflow: a protocol has to be designed with understanding of how it be used within existing processes Design principles for protocols include ► Making assumptions about context of use ► Creating protocols that are no more specific than necessary to achieve a specific goal ► Reflecting the skill level and circumstances of those who will eventually use them  Activity will presented next visit (no more than 8 mins each presentation) – group of 8 FIND AN EXAMPLE OF A PROTOCOL OR GUIDELINE RELATED TO PHYSICAL THERAPY BRIEFLY DISCUSS ITS USABILITY, UTILITY AND DESIGNABILITY PATIENT RECORDS INITIAL EVALUATION TEMPLATE Free Microsoft office for students https://products.office.com/en-us/student/office-in-education?rtc=1 Creating a fillable template in Word https://support.office.com/en-us/article/create-a-fillable-form-39a58412-107e-426b-a10b-ac44937e3a9f E:\PHYSICAL THERAPY2\2018 Health Informatics\Lectures\Wk3 Lec\Create a fillable form - Word.pdf Creating a template using a different application GENERAL TEMPLATE USED IN PHYSICAL THERAPY ◼ E:\PHYSICAL THERAPY2\2018 Health Informatics\Lectures\Wk 3 Lec\Initial-Evaluation-Template-HealthInformatics.docx ◼ Let’s make a template for this evaluation form! ASSIGNMENT ◼ Evaluation template ◼ Start on your written reports ◼ Application in Physical Therapy (research -- presentation of new technology applicable to PT: ◼ multisensory environments, robotics, virtual reality, gaming system, music, computer guided mental practice, computer access, Telerehab, wearable technology, switches, power mobility, electronic aids to daily living. - look at Apps, computer websites, etc… ◼ Written report Due MARCH 2 2019 ◼ Ffg written report. You will present this technology in class, in the form of a short lecture but with focus on workshop (meaning, we want to see how the technology works!) ◼ GROUP 1 AND 2 WILL PRESENT ON MARCH ON MARCH 4, 2019 ◼ GRPS 3-8 WILL PRESENT ON MARCH 11, 2019 ◼ Rubic:..\..\Rubric\Rubric written Report output.docx SCHEDULING ◼ Use of Excel, Word, Schedule applications ◼ E:\PHYSICAL THERAPY2\2018 Health Informatics\Lectures\Wk 3 Lec\Sample schedule HI.xlsx COMMUNICATION Lily Ann D. Bautista, PT, DPT, (COIERA, 2015) PTRP, COMT, VCS COMMUNICATION SPACE Possibly the largest part of the health system’s information space Where most information is acquired and presented Contains the largest portion of information pathology Complex link amongst individuals COMMUNICATION COMPONENTS Agents: human or computation agents who or that takes part in the communication Agent relationships: interaction amongst agents, social networks (personal or professional) Communication channel: face to face, telephone, email, EHR Type of message: formal or informal; structured to achieve a specific task. Computer alerts, lab results, voice messages, etc COMMUNICATION COMPONENTS Communication services: mobile phones, voice and text messaging Communication device: computers, mobile devices, tables, smartphones, wearable devices Interaction mode: process to which message is conveyed; some demands immediate attention like a phone ringing, medical alerts; or some not interruptive like an email Communication policies: formal procedure, i.e., who can see the message, how to authenticate message, privacy act MODES OF COMMUNICATION – SYNCHRONOUS VS ASYNCHRONOUS Synchronous Asynchronous Same place Face to face meeting Local message Different place Remote conversation Remote message Same time Different time SAME TIME, SAME PLACE The participants able to hear and see each other. Live participation They can share materials at a specific point in time The opportunity for exchanging complex and subtle cues is high Technology devices commonly used to augment communication, i.e., computers, projectors, etc synchronous SAME TIME, DIFFERENT PLACE Distance conversation Example: broadcasting, telephone Synchronous DIFFERENT TIME, SAME PLACE Asynchronous No simultaneous discussions Conversations occur through delayed messages Not interruptive Example: notes to a colleague left on his or her desk DIFFERENT TIME, DIFFERENT PLACE Asynchronous Most challenging as time and location not shared by the communicating parties Example: radiology image, forwarded to a physician who looks at the image and interprets image at a much later time COMMUNICATION MEDIA Medium: “in the middle” of the communication; form of message between 2 agents Voice, video, newspapers, television, email, voice mail Voice Image Data Synchronous Telephony Video conference Share Electronic white boards, shared documents Asynchronous Voicemail Web access to Text messages, emails photographs and videos DISTRIBUTION MODE FOR COMMUNICATION Distribution mode Communication service Peer to peer Email, text messaging, video conferencing Narrowcast (specific transmission to specific target Email, cable TV, social media audience) Broadcast (wide population, non-specific) Radio and television ISOCHRONOUS Events that occur regularly in time. Regular interval Sending communication with a guaranteed regularity THE INTERNET HISTORY Cold War 1960s – military research project – designed to ensure communication after nuclear strikes – evolved until mid 1980s when it became a global network It was mainly used by academic institutions and few commercial companies, mainly used for electronic messaging and transfer of files HISTORY The third phase was the introduction of WWW (World Wide Web). It initially provided a simple and standard way to find and view documents on the internet, until it transformed into a tool that the public used widely, far and beyond The 4th phase was characterized by commercial and institutional exploitation of the internet and its technologies. A steady stream of innovation continues to emerge INTERNET AS A TECHNOLOGICAL PHENOMENON A network of networks Allows computers to communicate across the globe Computers communication was regulated via Internetworking Protocol (IP) Initially started as a text based program via email or computer files and later progressed to multimedia messaging (video, images, voice over texts) THE INTERNET AS A SOCIAL PHENOMENON The web permitted the public to navigate easily across global internet Information became a global resource, NET NEUTRALITY seeks to minimize imbalances in information access THE INTERNET AS COMMERCIAL PHENOMENON Big industries fought over control for many years, telecommunication carriers, cable TV companies, computer companies Internet business, online shopping, there is a continuous boom of “dot coms” Basic Businesses Transport (internet companies who built networks – transport of physical networks) Connection services (service providers, data storages, cloud services) Content (business utilizing internet online or offline) INFORMATION AND COMMUNICATION NETWORKS COMMUNICATION PROTOCOL -rules governing how a conversation should proceed -defines how 2 machines will communicate with one another, how to acknowledge receipt, how to improve errors or misunderstanding -a communication channel is usually measured in bits per second – a channel’s capacity to carry data is called bandwidth -type of data transfer protocol used over communications network contributes to bandwidth. -Integrated Service Digital Network (ISDN) and Asynchronous transfer mode (ATM) systems are the most important standard protocols for communicating multimedia such as video -governs communication channels, which may be Dedicated: old telephone system connected to local system; called circuit switched systems (connections via completed circuit between communicating parties) – separate lines Shared: packet switched systems (handles packets of data)-different packets of data passed down same wire over same period Circuit switched Packet switched HEALTH INFORMATION EXCHANGE Healthcare network designed to connect together information providers (local, regional, international) 4 types Centralized: info sent to a central clinical data repository (CDR) from feeder systems (i.e., data uploaded nightly and can be retrieved as needed from CDR) Federated or De-centralized: patient registry created centrally that lists name of all patients in all regions covered by registry HEALTH INFORMATION EXCHANGE 4 types Hybrid: combination of various elements (CDRs, EHR); allows some patient data to be easily accessed by institutions, i.e., emergency situations Research network: clinical data captured as part of the care process. Cannot directly access clinical records, but may request for approval if necessary ENCRYPTION -necessary for message exchanges that contain sensitive data -may have a public network key and also a private one to maintain confidentiality SOCIAL NETWORKS AND SOCIAL MEDIA INTERVENTIONS IMPACT OF SOCIAL NETWORKS ON HEALTH SYSTEMS (GRIFFITHS, ET.AL., 2015) Interaction through digital social networks to enable individuals to interact with others who have similar health risks or condition Area to seek health information SOCIAL NETWORKING SITES Personal profiles: individual page where one can display personal details, interests, photos, etc; customizable and information shared to the public is user defined Videos and multimedia: with embedded videos and multimedia which serves to inform or provide emotional support Ask an expert: people can directly contact professionals with health related questions through a network SOCIAL NETWORKING SITES Discussion forum: list of discussion threads, user generated in which other users can post comments or replies; discussion usually divided into subroups or categories (i.e. specific conditions); sometimes moderated by professionals Blog (expert): network hosts articles or blog posts written by medical professionals; can provide information and tips to users Blog / journal (participant-NON expert): users can post their own blog (journal) entries, which are visible to others; typically incl personal reflections, experiences, or advice for others SOCIAL NETWORKING SITES Posts /comments: similar to discussion forums but not structured or categorized by network owner; typically added to a stream of posts from other users (i.e, Microsoft support) Chat / private messaging: only visible to the two interacting parties DIFFERENT DIMENSIONS - PURPOSES Dissemination of information: share established information to users Collection, collation and correction of information: focuses on collection of information derived from network activity and user contributions to the network Emotional support: classifies networks, which embed elements that support exchanges of experiences, personal advice or other activity for emotional well being DIFFERENT DIMENSIONS - PURPOSES Campaigning: users are active in setting political goals or creating social movements around health issues Fundraising: clearly integrates options for participants to donate or raise money for health related FORMATION OF NETWORK COMPONENTS Medical profession: network founded by an experienced medical practitioner or health expert Managerial professional: network created by an individual with managerial, technical, commercial or other expertise not associated with expert health knowledge Lay: network formed by people who do not have professional skills; usually patients or other individuals who have gone through or live with a health condition NETWORK CHARACTER Visible network: social network of each user visible to other users Subnetwork: health networks embedded within a larger non health related social networks (e.g. FB dedicated to raising cancer awareness) Formation of connections: user defined, the user can choose how much information he wishes to disclose NETWORK CHARACTER Accessibility: divided into (1) restrictions which prevent individuals from viewing content on network (2) restrictions on whether an individual can participate within network Memory: refers to the length of time content is visible in the network. Those with “transient memories” rapidly updates with older content pushed further down. “Permanent memory” refers to information controlled by owner of the network; can be influenced by user activity NETWORK CHARACTER Moderation: filtering of user created content in the network; usually done by network owners or experienced users to ensure behavioral guidelines and etiquette to uphold and prevent the spread of information Expert research: refers to the use of information coming from activity within network by professionals for research purposes IMPACT OF SOCIAL NETWORKING Potential to link people who have something in common Allows interaction even with limited ability to interact socially (ie, people with disability, parents / caregiver of children with disability) MOST common interaction involve individuals seeking peer support as they struggle with their health condition SOCIAL MEDIA Term used to describe a diverse set of information and communication system elements, that when put together can facilitate group interaction Have the characteristic to make visible a group’s activity to its members and support group collaboration May allow users to narrow cast, share messages, image, video or music that supports collaboration CROWDSOURCING Practice of seeking advice or contributions from a group to solve a problem or get particular information Example: Wikipedia… maintained by the community Can be very useful but may also be inaccurate SOCIAL MEDIA APPLICATIONS IN HEALTHCARE Measuring the quality and safety of clinical services: crowdsourcing, conduit for reporting of patient safety events, incl drug interactions Emergency services: used as emergency broadcast channel, mechanism to track counts of citizens, may have video, audio, global positioning system (GPS); emergencies may be medical, personal or natural disasters SOCIAL MEDIA APPLICATIONS IN HEALTHCARE Public health messaging and health promotion: social media channel for broadcasting public messages – has the potential to reach a diverse audience as they provide mechanisms that foster engagement and partnerships among consumers around health promotion Disease management: social media can impact this component by creating online spaces wherein patients interact with clinician or share experiences with other patients ASSOCIATED HEALTH RISKS FROM SOCIAL MEDIA Marketing material prompting potentially harmful or risk products (tobacco, drugs) Public displays of unhealthy behavior (i.e., self injury behaviors, harming others, injecting or consuming drugs, pro anorexia videos Public health messages can be tainted: social media can give space to negative voices that disagree with public health messages ASSOCIATED HEALTH RISKS FROM SOCIAL MEDIA Individuals may suffer negative psychological impact ffg access to disturbing, inappropriate, offensive or biased content Social media info may be intentionally distorted to match policy or research funding agendas Thank you TELEHEALTH AND MOBILE HEALTH Source: Guide to Health Informatics, 3e, Coiera, 2015 Lily Ann D. Bautista, PT, DPT, PTRP, COMT, VCS Telehealth Any technologically mediated communication that facilitates clinical care, occurring across time and distance Information can be a voice, an image, elements of a medical record, etc Mobile health Or m-health Specificallyconcerned with using wireless communications, computer, sensing devices in / for service of care delivery Smartphones, wearable technology Falls under telehealth umbrella Benefits of telehealth Improved health outcomes Increased access to healthcare Reduced healthcare and other costs Supports clinical education programs Assistsin earlier delivery of care even if with shortages of healthcare providers Disadvantages May lead to abuse of system resulting to poorer quality of care Poor patient-healthcare specialist relationships due to lack of contact Some pts esp elderly may not do well with technology equipment Need for expensive equipment Regulatory barriers (laws unclear); lack of reimbursement in most cases Some issues reported Reimbursement and Need for technical support licensure issues Lack of available Referral and payment infrastructure Support personnel Accreditation and Liability regulatory requirements Lack of funding Confidentiality issue Quality service rendered Lack of standards Communication needs requiring telehealth applications Intra-organizational needs: exist within particular health services, i.e., hospitals, primary care centers Inter-organizational needs: exist between services; primary caregivers in the community; hospital based services  Communication in the community and primary care Teleconferencing: doctors can consult with distant patients Email exchange between patients and providers can improve patient satisfaction; inexpensive, quick communication with one another Telephone consultation services: can be used to provide simple communication if a formal visit is required; a means to triage pts on who would require urgent care Electronic records: Electronic exchange of critical documents: ie, electronic discharge summaries  Communication in the community and primary care Teleconsultation: video consults, remote access specialist advice Hometelecare/ telemonitoring: ie., home dialysis, delivery of chemotherapeutic agents for cancer pts, regular tele consultation for patients with diabetes, remote monitoring Text messaging: effective strategy for behavior change in disease prevention or management for weight loss, smoking cessation and diabetes management Research evidence User satisfaction seems to be high but the evidence base remains weak Limited research LANGUAGE, CODING AND CLASSIFICATION CLINICAL DECISION SUPPORT SYSTEM Clinical Decision Support System Computerprograms that may range from simple data to aid humans make a decision, generate prompts or alerts when a clinician’s decision appears problematic… to a system with capability to make decisions entirely on its own Benefits CDSS Improved patient safety Decreased medication errors, adverse events Improved quality of care Increased time of clinicians for direct patient care Improved efficiency in healthcare delivery Reduced costs of processing; decreased duplication of tests; changed patterns of prescribing less expensive but equally effective generic medicines Benefits CDSS Improved patient outcomes Lesser visits needed Improved clinical process measures Easier, more streamlined process Alerts have resulted to faster treatment by highlighting patients whose treatment needed review Improved compliance with clinical pathways and guidelines CDSS Applications Evidence retrieval Computerized provider order entry and electronic prescribing Diagnostic assistance Therapy planning and critiquing Risk assessment Process support systems Image recognition and interpretation Expert laboratory information systems Reasons for CDSS failure Dependence on electronic health record to supply data Poor human interface design Failure to fit naturally into the routine process of care Reluctance to change Computer illiteracy of some healthcare professionals  ARTIFICIAL INTELLIGENCE 3 basic components of an expert system A Knowledge base Contains rules needed to complete a task A working memory Where data and conclusions can be stored An inference engine Matches rules to data to arrive at conclusions Common types of computer programs utilized Neural networks Internal function based upon simple mode of neuron Layers of neurons (nodes) with interconnections between nodes of each layer Model based systems Designed to solve problem from first principles Constructed using different representations, i.e, physiological relationship, system dynamics Turing test To test if there is a difference between computer and humans Experiment: subject tested by having observer read exact same words from computer – if no distinguishable difference in responses then computer is considered intelligent  Factors that affect decision making on what technical approach to use On what task will the CDSS be used? (diagnosis, treatment, planning, monitoring will require different systems) What interaction mode will be used? (check human decisions, support humans, will it have partial or full responsibility to make decisions) In what circumstances will the task be executed? (resources, skills, needs of workers, patients, stakeholders; time available) What knowledge can the system have? Detailed systems can provide explanation on why something might occur (detailed ventilators) Can also be limited, access only to raw data and provide comparisons or historical outcomes Factors that affects decision making on what technical approach to use How will that knowledge be presented to the computer? Will it be a guideline or protocol? Set of equations? Will it require approximate or exact responses? What type of computational reasoning method will be used? Can it provide statistical inference APPLICATIONS FOR HEALTH INFORMATICS  I. HEALTH SURVEILLANCE Patient monitoring ECG,EEG, oxygen saturation, ventilators, drug delivery systems, blood test, blood pressure reading, cholesterol reading (monitor function) Alter or detect changes Hospital settings House / ambulatory settings (home telecare) Population Surveillance Detect population changes May occur at international level through national and state governments Essential precursor to epidemiological analysis and public health response Public health surveillance tasks include the following Biosurveillance:detection of new outbreaks of known diseases and those which has potential for outbreak (influenza, salmonella gastroenteritis) Prevention and screening – best way to decrease the burden of the illness is through vaccination earlyscreening for diseases assessing population risks Change in lifestyle also important such as decreasing smoking rates Public health surveillance tasks include the following Environmental health risks Measuring water and air quality, testing chemical traces that exceed standards, investigating geographical variation in measured levels Monitoring changing patterns in the burden of disease: We need to know variety of diseases, changing patterns of illness, allocation of existing services and resources Emergency event monitoring: Naturaldisasters, paramedic services, ER department, chemical spills, large scale hazards Post market surveillance Aimsto track performance of a new treatment after it has been cleared for use Check for efficacy or adverse events Health monitoring objectives Improve quality of care: Ability to track level of compliance with standards Improving safety of care: Determine type of risks, use of ICD codes to determine level of care at discharge Infection rates, surgical complication rates, length of stay, death rates Monitoring service effectiveness Calculation of metrics, i.e., length of time a lab order is performed after being ordered, then release of results Metrics such as time to create and receive a discharge summary  Contribution of Clinical Informatics Tools to Public Health Surveillance (1) Planning and system design: Informatics bring a set of principles, methods and tools to the task of information system design Definition of goal to be achieved Sources of data identified Workflow and information and communication architecture designed to capture or extract data (2) Data collection and management: Electronic data sources: major basis of signal used for population surveillance, case reports, lab reports, field data collected by public health officials, patient registries, EHR Personal smart phones allow members to take pictures, recordings, share rapidly, with GPS coordinators in identifying emergencies Contribution of Clinical Informatics Tools to Public Health Surveillance (3) Data modeling and analysis Pattern recognition, signal processing, detection, machine learning methods are invaluable in analysis of population surveillance data (4) Communication Eventscommunicated to individuals, organizations through proper communication channels (text, social media, print and broadcast media (5) Response Appropriate responses to emergencies or outbreaks, i.e., ambulance services, hospitals, police Population surveillance Central task is ensuring the health and well-being of human populations Mechanism to track burden of illness that changes over time Response mechanism to manage illnesses Ways of health services to monitor their performance to ensure safe delivery of care Informatics essential in the technical component of surveillance. Systems will not be able to function without modern technological support Public health surveillance focuses on Tracking infectious disease outbreaks (biosurveillance) Prevention and screening rates Environmental hazards, illness patterns and emergency preparedness Computational systems focuses on Improvement of quality Completeness of health surveillance Timeliness of health surveillance Health services surveillance focuses on Monitoring quality Monitoring safety Monitoring effectiveness of care delivery Post market surveillance tracks Performance of new devices, ie. Use of device registries New drugs (pharmacovigilance) Quality of research trials Scientific evidence II. BIOINFORMATICS (NOT DISCUSSED, INFORMATICS USE IN STUDY OF GENETICS) III. CONSUMER HEALTH INFORMATICS History Health consumers used to go to the doctor, asked advice and just takes the advice, simply accepts that good care is being delivered to us Now: Healthcare systems trying to find cost effective way to manage health Increasing aged population, therefore increasing levels of chronic illness- increased need for healthcare Patients also becoming more demanding of those who gives care, patients want more active involvement in their care (information accessible on the internet, allowing them to gather more information about their problem) CONSUMER HEALTH TASKS / RESPONSIBILITIES Maintain good health by measuring and managing lifestyle and setting life’s goals Deciding for self if health issue requires attention Select appropriate healthcare professionals who have expertise, interests and reputation based on rating, word of mouth or other data Schedule appts with healthcare services and order Rx refills Communicate with healthcare professionals about diagnosis, treatment options and management plans Provide high quality info on cause of disease and available treatment options  CONSUMER HEALTH TASKS / RESPONSIBILITIES Finding information on likely cause of disease from a patient’s point of view Understanding personal risk of disease (family, lifestyle, etc) Choosing the right treatment based on self understanding and information given by professionals Keeping track of one’s own health data; viewing personal data available in EHR Provide support to the community by sharing information for similar health conditions Provide online access to professionals in between visits; raise concerns that could trigger early visits CONSUMER HEALTH TASKS / RESPONSIBILITIES Participate in behavioral interventions to assist in management of mental health, ie health related diseases such as obesity Manage living wills and personal wishes on end of life or severe disability will be handled by family and professionals Manage personal preferences on who may or may not view personal data on EHR Assist with self medication decisions, ie, checking for known interactions Personal Health records: task specific support to consumers PHR: electronic application through which individuals can access, manage and share their health information (Tang et al, 2006) like EHR but mostly concerned about health info needs of consumers 3 main types of PHR Tethered PHR: connected to the EHR of health service provider. Allows consumers to do “limited” edits (passwords, users, demographics, etc.) and view Untethered PHR: no interface with provider record systems Personally controlled health management systems (PCHMS): provides additional tools to manage their health (appointments, vaccine reminders, social media links, support groups, communication with clinicians, decision aids, etc) Decision support systems (DSS): Decisionaids are standardized evidence based DSS designed to support the interaction between patient and clinician Should be high quality and updated information Must describe harms and benefits (to assist with clarification for different conditions) Must coach and guide on decision making Must assist with how to communicate values and preference to patients, families and clinicians Conflict Theory of Decision Making (CTM) Suggests that the responses to difficult decisions depends on whether one is aware of a serious risk if nothing is done; Or one has hope of finding solution or better alternative and there is enough time to choose a better alternative Factors that can contribute to decisional conflict Information deficits: lack of information, pros and cons Social deficits: not knowing what others decided or recommend, lack of support Cognitivedeficits: lack of skills and ability to make this type of decision Emotions involved in the decision making process  Tools that can help with decision making Decision aids Describe options and benefits and harms of each option, with clarification exercise and guide to decision making Decision or fact boxes Short summary of benefits and harms of intervention Option grids One page summary of possible options Addresses outcomes, concerns and questions frequently raised by patients Useful to highlight during patient consultation to know what is important for patient Tools that can help with decision making Question prompt lists Pre defined list of condition specific questions during consultation Evidence summaries Clinical practice guidelines and other summaries of evidence Risk calculator Derivesprobability of different outcomes based on pt’s history preferences and biomarker data Communication frameworks Genericset of questions / scripts that the clinician and patient can use during decision making Thank you!  TERMS CODES AND CLASSIFICATION  Coding Setof words with clinical concept translated into codes Tool used in coding Free code entry, with no support: use of set of manuals, up to the coder to interpret content of record, locate codes, then assign codes Free code entry with decision support: with some tools utilized to help, like computer tools, but still up to the coder to determine appropriate codes to be used Semi structured information entry: data entered in a structured way; coding occurs at time of information capture; when possible list of alternative also specified for each field Automatic coding: algorithms utilized to identify words in the record and then matched to terminology, phrases and sentence fragments ICD – International Classification of Diseases Published by WHO (World Health Organization) Currently on 11th edition Loading… Provides set of recommended terms and synonyms that correspond to the entries classified in the ICD 9 codes Reference point for many healthcare technologies Divided into multiple chapters The first character of the ICD code I a letter ASSOCIATED with particular chapter, example Chapter 1: infectious diseases  Chapter 2: neoplasms CPT – Current Procedural Terminology Medicalcode set that represents medical, surgical, diagnostic, procedures and services utilized by health care providers, health insurance companies and accreditation organizations Purpose of the codes Intended for clinical patient record Billing Coding Loading… Grouping of conditions with similar characteristics Common CPT codes 97161/62/63: PT evaluation 97124: massage (low/mod/high complexity) – flat rate 97140: manual tx 97164: RE, 1 unit, flat rate 97150: group tx TIME BASED 97530: functional activity 97010: HP/CP, non billable 97542: WC trng/mob/positioning 97018: Paraffin wax 97750: performance test measure 97035: US 97110: TheraEx 97112: balance/neuro/coordination Common ICD 11 codes for physical therapy – functional diagnoses R26.0: ataxic gait M62.81: generalized muscle weakness R26.89: other abnormalities gait and mobility M25.579: pain in unspecified ankle and joint of unspecified foot R26.1: Paralytic gait M25.569: pain in unspecified knee R26.9: Unspecified abnormalities of gait and mobility M25.559: pain in hip M54.2: cervicalgia M25.519: pain in unspecified shoulder R26.2: difficulty in walking M79.609: Pain in limb M54.5: lumbago, LBP Common ICD 10 codes for physical therapy – Medical diagnoses G30.9: Alzheimer’s Disease C71.9: malignant neoplasm of brain R47.01: Aphasia C72.0: malignant neoplasm of spinal cord I63.9: Cerebral Infarction, unspecified G12.21: Amyotropic lateral sclerosis G45.9: Transient Cerebral Ischemic Attack G10: Huntington’s disease G52.9: Cranial nerve disorder, G20: Parkinson’s Disease unspecified R27.0: Ataxia F84.0: Autistic disorder G71.0: Muscular dystrophy C71.6: malignant neoplasm of cerebellum G35: Multiple Sclerosis G80.0: Cerebral Palsy Common ICD 10 codes for physical therapy – Medical diagnoses G12.9: Spinal muscular atrophy M50.30 disc degeneration, cervical region G51.0: Bell’s Palsy M54.30: Sciatica, Unspecified side G61.0: Guillain Barre Syndrome M16.0: unilateral primary OA hip G70.00: Myasthenia Gravis M17.10: unilat primary OA knee G56.00: Carpal tunnel syndrome M54.10: Radiculopathy G58.9: mononeuropathy M75.00 :Adhesive capsulitis shoulder G63: Polynyeuropathies M75.100: RCTear M79.1: Myalgia M75.50 Bursitis of shoulder M79.2: neuralgia and neuritis Common ICD 10 codes for physical therapy – Medical diagnoses M48.06: spinal stenosis, lumbar region S83.509A: cruciate ligament, knee, 1st encounter M51.06: IV disc disorders with myelopathy, lumbar M51.15: IV disc disorders with radiculopathy M51.unspecified thoracic, thoracolumbar and lumbar IV disc disorder