Question

Read: Taylor, P. (2006). From Patient Data to Medical Knowledge: The Principles and Practice of Health Informatics. London: Blackwell Publishing. Chapter 2. This chapter discusses some of the earliest suggestions on electronic health record (EHR) charting. Reed’s paper is mentioned as a source from publication in 1966. How has electronic information changed the work environment for health care? Post a very brief discussion answering two of the following questions (remembering to cite the readings). Respond to at least two classmates’ postings about their chosen questions, again citing the reading. When the author says “it will be a theme of this book that health informatics is a field in which promises and expectations are renewed more often than they are fulfilled.” What are problem-oriented records? What does “Ontology” mean and how might you apply it to a concept in your profession or “Medical Ontology” in general? . Why are “controlled clinical terminologies” necessary? Why is there more than one type of controlled clinical terminologies? Can you name one terminological system with which you’ve worked? Do you think Van der Lei’s First Law of Health Informatics is a good rule of thumb? Why or why now? What is the question of granularity? (What does it mean?) Why does Taylor set the “three goals for an EHR” (page 30)?

Answer 1

How has electronic information changed the work environment for health care?

1. This electronic information changed the work environment for health care as it  is concerned with the effective use of patient data: the facts, findings, measurements, observations and assessments that doctors and nurses record about the patients in their care.
2. The creation, organisation, management and maintenance of patient records are the central preoccupations of health care systen and so as to health informatics.
3. This involves creation of an electronic integrated care record.
4. This, will help in retriving every relevant fact about a patient with an instant accessiblity to his or her GP in any department or place or clinics by different users.
5. Such creation of a system is allowing transferring information from paper records to computer files and also provides the solution to a host of other technical, intellectual and organisational problems.
6. There is a need to merge the information that is stored in very different forms on different systems and allowing Merging of information with communication between the applications running on those machines with each other.

What are problem-oriented records?

• These are ‘Medical records that guide and teach’ .
• The patient’s story is told as a simple linear narrative, events are described in highly abbreviated statements arranged in a chronological order and a short paragraph for each relevant date.
• The idea behind the problem-oriented record is simple but powerful: clinicians should structure their observations using a list of the patient’s current problems.
• Each time they need to make a decision about a problem, they can consult the record and find the information they require organised under headings that reflect their approach to the patient’s management.
• But it seems like For first few entries the information is set down in a way that might have seemed logical to the author but which gives no real assistance to the reader trying to make sense of the various observations.
• later on whenever the record is updated, the observations are organised according to a list of the problems involved in the management of that patient.
• This list of ‘currently active problems’ provides an organising structure for the record.
• The idea became associated with the acronym SOAP, so that for each problem the clinician was supposed to record observations under four headings: Subjective (what the patient says); Objective (what the doctor sees and hears); Assessment (what the doctor thinks); and Plan (what is to be done).

What does “Ontology” mean and how might you apply it to a concept in your profession or “Medical Ontology” in general?

• This is a software model concerned with consultations in general practice.
• The software designer might choose to represent such consultations as a set of activities performed by a GP in respect of a patient.
• The designer might say that each activity has a goal and that the goal is defined in terms of a clinical question and a patient problem.
• Each activity also generates observations, in the form of statements about the presence or absence of signs, and then about their severity, cause and location.
• The designer needs to have a model for the kinds of things recorded as observations and for the kinds of things required as contextual data for the interpretation of observations.
• So when the software is used to make a record of a consultation, it would ask the user to record one or more activities (e.g. physical examination). For each activity the system would ask first for the patient problem (breast cancer) and the clinical question (diagnosis) and then for a list of observations (one of which might be lymph node enlargement is absent).
• The finding would be recorded within a context that contains all the additional facts with which the finding will have to be associated.
• The important point is that it is a model of what is involved in recording a consultation; it does not embody any medical knowledge.
• This kind of model is often called an ontology. The term ‘ontology’ is borrowed from a branch of philosophy concerned with questions of what kinds of thing can be said to exist.
• In health informatics (and computerscience more generally) the word is used to refer to a specification of the concepts and relationships that can exist for a particular domain and application.
• Developing robust ontologies of medicine and clinical practice has been a major aim of many health informatics projects.

Why are “controlled clinical terminologies” necessary?

• The computer-based patient record systems needs to provide their users with more than just a set of templates mapping out the structure of the things that might need to be recorded.
• It also provides a complete standard terminology for recording clinical histories. That is to say, they would provide not only an ontology but also a list of concrete terms to fill the ontology’s abstract structures: "a controlled clinical terminology".
• The proposal is not to come up with a complete list of all known diseases, suitably qualified, but rather to come up with a complete list of everything that might need to be recorded about a patient: signs, symptoms, social circumstances and so on.
• The benefits are obvious. A standardised vocabulary would avoid confusion and ambiguity.
• Eradicating synonyms, slang and shorthand would simplify the compilation of statistics.
• If all the required terms are known to thesystem designer, he or she can design a simple menu-based interface allowing the user to enter terms without typing.

Why is there more than one type of controlled clinical terminologies?

• It were difficult for American hospitals and British family doctors in the 1920s to agree standard forms for recording patient encounters, so as it is difficult to get the profession to agree on a standard set of terms to describe those encounters.
• These difficulties are not just quibbles about terminology but reflect profound and genuine differences about the nature of diseases, the efficacy and appropriateness of interventions and the role of medical professionals.
• They stem from variations within and between nations and cultures, differences in training and experience as well as the priorities and prejudices of individuals.
• Controlled clinical terminologies have nevertheless been developed.
• The International Classification of Diseases (ICD 10) is sponsored by the World Health Organization (WHO) and is used mainly to standardise the recording of diagnoses in order to compile statistics about the prevalence of diseases in populations .
• Read Codes are a British attempt to develop a set of standard codes for use in primary care .
• The Systematised Nomenclature of Medicine (SNOMED) is a similar initiative on the part of the College of American Pathologists.
• A merger of the two has created SNOMED CT, the first release of which, at the time of writing, is somewhat overdue .
• Another project, Medical Subject Headings (MESH), created a standard set of terms for indexing biomedical research literature, and a related project,
• Unified Medical Language System (UMLS), attempts to provide a common structure within which MESH and the other systems can be used.

Can you name one terminological system with which you’ve worked?

• ICD 10