JMA Boards
Environmental scanning
'the study and interpretation of the political, economic, social and technological events and trends which influence a business, an industry or even a total market'
HL7
- A nonprofit standards development organization - domain is clinical and administrative data transmission, it is a prolific set of healthcare standards - the seventh level of the international organization for standardization (ISO) model for open system interconnection - meaning it lives in the application layer of the stack
MU Stage 1 core
- CPOE for medication orders, more than 30% of patients on medications or indicate their on no meds - implement drug drug and drug allergy interaction checking - maintain up-to-date problem lists, more than 80% have at least one entry or indicate no problems - generate and transmit electronic prescriptions, more than 40% are transmitted use using certified EHR - maintain active medication list, at least 80% of patients have at least one entry as structured data - maintain active medication allergy list, more than 80% - record demographic sex, race, ethnic city, date of birth, and preferred language on more than 50% as structured data - recorded chart height, weight, blood pressure, BMI, growth charts on more than 50% patients two years and older a structured data - record smoking status of patients 13 and older and more than 50% of patients as structured data - report quality measures to CMS or the state or six majors - implement one CDS pool and track compliance - provide clinical summaries for patients for more than 50% of visits within three business days - capability exchange electronically key clinical information (test) - implement systems to protect privacy and security, conduct or review a risk analysis
Barriers to negotiation include the following:
- Die hard bargainers - Lack of trust - Informational vacuums and negotiator's dilemma - Structural impediments - Spoilers - Cultural and gender differences - Communication problems The power of dialogue
HL7 v2.x
- HL7 v2.X separates messages into profitable chunks known the segments contains fields separated by pipes, fields can contain components separated by carets. - Segments are sewn together and to messages of a given type example ADT -messaging is performed over a minimal lower layer protocol (MLLP)
MU Stage 1 Menu
- Implement drug formulary checks for the reporting period - incorporate lab results in DHR a structured data for least 40% of lab results entered - generate patient list by specific conditions, one report with specific conditions - send reminders to patients further preference to at least 20% of patients 65 or older or five years or younger - provide patients with timely electronic access to their lab, problem was, medication list, allergy list within four days for at least 10% of patients - use EH R to identify and provide patient specific educational resources to at least 10% - perform medication reconciliation following transitions of care always 50% of the transitions of care - provide summary of care for any transitions of care for more than 50% of transitions of care capability to submit electronic data immunization Registry (test) - capability to submit electronic syndromic surveillance of public health (test)
HL7 v3
- Uses XML for packaging content - uses the clinical document architecture (CDA) - it's a content standard that makes documents human readable and machine profitable through the use of XML;
Data mining
- a blend of statistical methods, artificial intelligence techniques, and database design/retrieval approaches; knowledge discovery from databases
approaches to knowledge modeling and representation
- clincal algorithms - Bayesian statistics - Prodcution rules - scoring and heuristics
IOM's types of errors
- diagnostic: error or delay in dx, failure to act on test - treatement: medical error, delay, not indicated - preventive: inadequate monitoring or follow up or prophy treatment - other (communication or equipment failure)
Inernist 1 measures what for each finding
- evoking strength (likelihood of a disease given a finding) - frequency (the likelihood of a finding given a diease)
Clinical Algorithms
- flow chart with information and decision nodes - cds knowledge modeling and representation form - forerunner to clinical practice guidelines
Information Retrieval is composed of
- indexing: assing metadata to content (subjects, attributes, relationship to other info ex gene) to facilitate retrival (human indexing with controlled vocab vs automated of all words); MESH - retrival: queries, use NLP and/or Boolean expressions (pub med uses both)
Why is CDS not wide spread
- lack of a formalized infrastructure - the slow progress and development of standards for representing knowledge for decision support
automated indexing
- may use stop word list for common words (and) - may stem words - like cough from coughing
What are sensitivity and Specificity
- measures of test performance; they assume you know disease state; you are determining if the test performs as intended
methods of workflow analysis
- people: person oriented - artifacts: object oriented (staff colaboration using the paper supeerbill) - information: setting oriented - tasks: task oriented - ex medication admin
classification of knowledge based scientific info
- primary: studies, orginal reseach, meta-anlaysis - secondary: reviews and synopses (books)
what is workflow analysis
- reduce complex process into anlayzable parts, describe the complex clinical activity by identifyiing it components in a step wise fashion
CDS design considerations
- target audience - level of control: pre-emptive, supressive, hard stop, interruptive - delviery mode: suggestion, summarization, reminder, information, correct errors, recommend change in plan
relational database
- the relations is the table; - attribute is the column corresponding to a domain in the relation (table); tuple = row, elements = cell - can be a certain data type - varchar, date, etc
HIPAA Consumer Rights
--To see and get a copy of their health records, --have corrections added to their health information, -- receive a notice the discusses how the health information will be used and shared, --provide commission on whether health information can be used or shared for certain purposes such as marketing, --get reports on when and why health information was shared for certain purposes, --file a complaint with the provider/health insurer and/or the government of patient rights are being denied or health information is not being protected
HIPPA Minimum standard for protecting patient privacy
-Develop enablement written privacy policies and procedures - designated privacy official - work phrase training in management - mitigation strategy for privacy breaches - data safeguards (administrative, technical and physical) - designate a complaint official and procedure to file complaints - establish retaliation and waiver policies with restrictions, - documentation and record retention for six years - fully insured group health plan exception
Goals of public health surveillance
-Estimate the significance of the problem -determine the distribution of illness -outline the natural history of the disease -detect epidemics -identify epidemiological and laboratory,research needs -evaluate programs and control measures -detect changes in infectious disease -monitor changes in health practices and behaviors -assess the quality and safety of healthcare, drugs, devices, diagnostics and procedures -support planning
Usability evaluation
-Testing: coaching, think aloud, eye track -Inspection: cognitive (paper model walk through), heuristic design principle critique -Inquiry: obs, focus groups, surveys, usage logs
Evidence Pyramid
...
Incremental cost/effectiveness ratio (ICER)
...
Rollback analysis
...
Telehealth
...Relates to long-distance clinical care, education and administration
backward chaining production rules
...starts with a list of goals (or a hypothesis) and works backwards from the consequent to the antecedent to see if there is data available that will support any of these consequents.[2] An inference engine using backward chaining would search the inference rules until it finds one which has a consequent (Then clause) that matches a desired goal. If the antecedent (If clause) of that rule is not known to be true, then it is added to the list of goals (in order for one's goal to be confirmed one must also provide data that confirms this new rule).
Negative likelihood ratio (LR-) =
1-sensitivity /specificity = FNR/TNR
ONC Goals
1. Achieve adoption and information exchange through meaningful use of health IT - accelerate adoption of EHR's, facilitate information exchange 2. Improve care, improve population health and reduce healthcare costs through the use of health IT 3. Inspire confidence and trust in health IT 4. Empower individuals with health IT to improve their health and the health care system 5. Achieve rapid learning and technological advancement
The purpose of patient registries
1. Describe the natural history of disease 2. Determine the clinical impact our cost effectiveness of a program 3. Assessing the safety or Harvard treatment or approach 4. Measuring or improving the quality of care 5. Public health surveillance 6 disease control
how CDS can reduce errors and achieve quality
1. Detecting inappropriate practices before they can be carried out in order to suggest alternatives 2. monitoring and providing feedback on existing practices 3. carrying out studies aimed at EBM; determining optimal practices for situations where the optimal approach is not clearly defined and present
Sources of decision bias
1. Diagnostic inference is a problem of "revising opinion with imperfect information" 2. Blois' funnel: breadth of diagnostic considerations are refined, restricted over course of interaction between patient and practitioner 3. Making decisions based on opinion is subjective to predictable patterns of bias
Ways EHR can improve patient safety
1. Improve legibility of notes 2. Improved access 3. Reduce duplication 4. Reminders that tests are preventive service are overdue 5. Clinical decision support 6. Electronic summary lists
ARRA Goals
1. Improve medical quality, patient safety, health care efficiency and reduce health disparities 2. Engage patients and families 3. Improve care coordination 4. Ensure adequate privacy and security of personal health information 5. Improve population and public health
CDS lifecycle
1. Knowledge generation and validation 2. Knowledge management and dissemination - 3. implementation and evaluation
Levels of data
1. Nonelectronic data 2. Unstructured, viewable electronic data 3. Structured, viewable electronic data 4. Computable electronic data
Patient Protection and Affordable Care Act Goals
1. regulation and coverage - eliminating coverage restrictions 2. major expansion of coverage 3. bending the cost curve - higher quality
National Drug Code Delivery
11 digit, manufacturers, product name/strength/dose form, pkg
In outpatient EHR ROI to providers
11% return of investment - rest to labs and insurers
IOM Closing the quality Chasm
12 information technology applications that might narrow the quality chasm Web-based personal health records, patient access to hospital information systems to access their lab annex reports, access to general health information via the Internet, electronic medical records clinical decision support, pre-visit online histories, enter hospital data sharing and health information exchange, information to manage populations using patient registries and reminders, patient to physician electronic messaging, online data entry by patients for monitoring example glucose results, online scheduling, computer-assisted telephone triage and assistance for nurse call centers, online access to clinician our hospital performance data
How long does it typically take for evidence from research to become incorporated into practice by a majority of clinicians?
17 years
Strategic long-range planning is planning that is
3 to 5 years out, may be required to be revised during its lifespan; CIO, CMIO, executives
US healthcare expenditures is attributed to improper utilization of guidelines protocols and standards
30%
2 clinical questions for every 3 visits
30% answered during the visit
Requirements for success Paul Clayton
: institutional commitment, leadership, people, technical infrastructure, database, applications
False negative rate = 1-sensitivty
= 1-sensitivty
False positive rate
= 1-specificty
Sum of probabilities for options in a given scenario
=1 P (has it) + P (not have it) =1
Bit
A bit = zero (off) and one (on). Eight bits is a byte; Bits are aggregated into datatypes - integers, floating number points (decimal point) characters (A - Z), character strings
Ethnography
A branch of anthropology dealing with the scientific description of individual cultures
Centralized HIO
A central data repository that all entities must access Pros: simplicity, data uniform, faster access to data, easier to create cons: hire hardware and operating costs, more difficult with very large HIO's
An Internet
A collaboration between many disparate computer networks
National Center for healthcare leadership competency model
A comprehensive database for defining the competencies required for outstanding healthcare leadership
Leapfrog
A consortium of employers seeking to purchase the highest quality and safest healthcare, they have a hospital rewards program
Database versus knowledgebase
A database is a collection of individual observations without any summarizing analysis (EHR); a knowledge base is a collection of facts, heuristics, and models like used for problem solving and analysis of data
Ontology Definition
A description, like a formal specification of a program, of the concepts and relationships that can exist for an agent our community of agents; in biomedicine such ontology typically specify the meetings in hierarchical relationships among terms and concepts in the domain
Operating budget
A detailed projection of all estimated income and expenses based on forecasted revenue during a defined.; Includes projected profit and loss, cash flow and balance sheet
Vocabulary
A dictionary containing the terminology of the subject field
The internet
A global network of networks which used a telecommunications protocol/Internet protocol stack (TCP/IP) as their communication standard (it orders the packets and makes sure they get to the desination
Fundamental principles of EBM
A hierarchy of evidence exists (not all evidence is equal), evidence alone is insufficient for medical decision-making it should rather be complemented by patient's values preferences and circumstances
Written communication is an example of
A leading channel of communication, one way cheap
Representation
A level medical data encoding, the process by which as much detail as possible is coded
Abstraction
A level of medical data encoding that entails examining the recorded data in selecting an item for terminology with which to label the data
Assembly language
A low level language for writing computer programs using symbolic names and addresses of the computer memories, it is translated into machine language using an assembler
Decision tree
A method for representing and comparing the expected outcomes of each decision alternative and the threshold probability
Visual analog scale
A method for valuing health outcomes where a person simply raise quality of life with the health outcome on the scale from 0 to 100
NHIN or NwHIN
A network of networks that establishes standards, services and policies that define how HIOs will engage in the secure exchange of health information over the Internet
From a statistical perspective, the specificity of a test item describes the likelihood that
A patient without the disease has a negative test (not Given a negative test, the patient does not have the disease under consideration)
PHR
A personal health record is electronic, universally available, lifelong resource of health information needed by individuals to make health decisions. An individual's electronic record of health related information that conforms to nationally recognized interoperability standards and that can be drawn from multiple sources will being managed, shared, controlled by the individual
Decision-making is
A process and a skill (not now, it leads to an outcome)
MEDCIN
A proprietary medical vocabulary, contains concepts organized into categories: symptoms, history, physical exam, test, diagnosis and therapy.
The benefits of high operating leverage
A relatively small change in volume results in a large change in profit; you see this one a high proportion of the businesses total costs are fixed
Terminology
A set of terms representing the system of concepts of a particular subject field
Spiral model
A simple prototype is formed by performing all four phases rapidly, it's been reviewed on several cycles, the staff is expected remain intact remaining iterations of the essential knowledge is not lost because little time is spent on documentation
Disease management
A systematic population-based approach to defy persons at risk, intervene with a specific program care and major clinical mother outcomes
Delphi method for group decision-making
A systematic, interactive forecasting method which relies on a panel of experts, RAND corp; expert answer question into a more rounds, after each round facilitator provides anonymous summary of the forecasts and any reasons why they have via their judgments, everyone revises, it's an iterative process, the mean or median scores the final round determine the results, a pro-as it can be done without face-to-face meetings, minimizes the bandwagon effect, range of opinions are only as diverse as the experts in the group
A project is
A temporary endeavor with a defined beginning and end undertaken to meet unique goals and objectives to bring about beneficial change or added value, specific deliverables dates
Ruling in a diagnosis
A test with a high specificity or a high LR+
Gantt chart
A type of bar chart that represents a project schedule, display start and finish dates of milestones in points that comprise the project work breakdown structure; Henry Gantt 1910
Heuristic evaluation
A usability inspection method in which the system is evaluated on the basis of a small set of well tested design principles such as visibility of system status, user control and freedom, consistency and standards, flexibility and efficiency of use
Distributed cognition
A view of cognition that considers groups, material artifacts, and cultures that emphasizes the inherently social club or nature of cognition
Which organization certifies standards development in the United States
ANSI coordinates all standard development organizations (SDOs) and activities. ISO is an international organization. ANSI directs TAGs to work with ISO. NIST is a branch of the US Department of Commerce responsible for coordinating use of standards in US Government agencies
Absolute risk reduction
ARR is a difference between the experimental event rate and the control of that rate ARR= EER-CER
Five stages of medical technology acceptance Dr. Fredrick Knoll of Stanford University
Abject horror, swift denunciation, profound skepticism, clinical evaluation, acceptance as the standard of care
HIPPA Security Rule Technical Safeguards
Access control the restricts access to authorized personnel, audit controls for hardware, software, and transactions, integrity controls ensure data is not altered or destroyed, transmission security to protect against unauthorized access to data transmitted on networks in via e-mail
The primary focus of project management is to
Achieve all project goals and objectives while honoring preconceived constraints, the constraints normally our scope time quality and budget
Center for creative leadership six part model
Adapting and thriving during a time of transformative change
Gantt chart limitations
Address is primarily the time constraint of the project there are reality time scope and budget constraints as well; does not reveal the true implications of one activity being delayed schedule
AHRQ
Agency for healthcare research and quality - lead federal agency charge was improving the quality, safety, efficiency, and effectiveness of health care for all Americans, is one of 12 agencies within the Department of Health and Human Services; they maintain the national resource Center for HIT and the HIT knowledge library
McClelland's human motivation theory
Also known as three needs, motivational needs, learned needs: a person has one dominant motivator out of achievement, affiliation, power; dominance based on individual's culture and life experience, when knowing what motivates person you can communicate with them and leverage their talents more effectively
AMIA
American medical informatics Association, founded in 1990 by merger; they support translational bio informatics, clinical research informatics, health informatics, consumer health informatics and public health informatics
ARRA
American recovery and reinvestment act (ARRA) - 2009
Cognitive walk-through
An analytical method for characterizing the cognitive processes of users performing a task; seeks to defy potential usability problems that may impede the successful completion of a task work complexity that may frustrate a user
Data bus
An electrical pathway the transports encoded information between subsystems
Privacy
An individual's desire to limit the disclosure of personal information. Universal declaration of human rights article 12 - everyone has the right to protection of the law against such interference or attacks The Hippocratic oath- keep secrets of patients European convention of human rights 1950, article 8
Health information service provider (HISP)
An organization that offers national health information network participants with operational and technical exchange services necessary to fully qualify to connect to the NHIN
Health information organization (HIO)
An organization that oversees and governs the exchange of health related information among organizations according to nationally recognized standards
Ishikawa diagram
And advise multiple possible causes for an outcome, and effect or a problem;define the problem work back words to define causes or contributed factors; useful for failure analysis
Patient registry
And organize system that uses observational study methods to collect uniform data (clinical and other) to evaluate specified outcomes for population defined by a particular disease, condition, or exposure and that serves one or more predetermined scientific clinical or policy purposes
Consumer health informatics
Any electronic tool, technology or electronic application that is designed to interact directly with consumers, with or without the presence of a healthcare professional that provides or uses individualized information and provides the consumer with individualized assistance to help the patient better manage their health or healthcare
CDS
Any software designed to directly aid in clinical decision-making in which characteristics of the individual patient are matched to a computerized knowledgebase for the purpose of generating patient specific assessments or recommendations that are then presented to the clinician for consideration
API
Application programming interfaces
ASP
Application service provider - ehr software and patient data reside on a remote Web server
The posttest probability of a disease increases
As the pretest probability of the disease increases
Collaboration skills
Attempt to meet the need of all parties, based on a premise of cooperation to achieve effective outcome
REST
Basically how the internet works, it's architecture not a standard; can use any existing content standard for packaging of its messaging most, commonly will use XML or JavaScript object notation (JSON)Requires a uniform resource identifier (URI), and operation type, a multipurpose Internet Mail extension (MIME)
Creation of ONC and NHIN
Bush created ONC in 2004, ONC send out a request for information on how to govern finance and operate NHIN - recommended a quote decentralized architecture built using the Internet went white uniform communications and a software framework of open standards and policies (a network of networks) - in other words there would not be a a single centralized data repository of all patient health information. So NHIN - is not a network but a set of standards, services and policies the direct of us sure cure exchange of health information over the Internet will occur
CCD vs CCR
CCD can accept free text and is capable vocabulary specific semantic interoperability and is summarized in an XML format that can be shared by most computer applications and web browsers or printed as a PDF or shared as HTML he uses the CD32 specification for its modules, each module have additional data elements
CCDA
CCDA Starting December 2011, I am the new architecture in town, the Consolidated Clinical Document Architecture, and I will cleanup this mess that CCD/CCR created without discounting their feelings. I'm all about making CDA Templates, and guess what? CCD is one of my templates! I will be adopted by the United States through Meaningful Use efforts, and I will make it incrementally easy to achieve through attrition.
Center for Medicare and Medicaid Services (CMS)
CMS - the division of the department of health and human services that is responsible for developing healthcare policy in the united states and for administering the medicare program and the federal portion of medicaid program and maintaining the procedure portion o the international classifications of diseases
Types of public health surveillance
Case surveillance systems, syndrome X are railing systems, sentinel surveillance systems, behavioral surveillance systems, integrated disease surveillance and response, clinical outcome surveillance, laboratory-based surveillance
Issues of Clinical Competency
Challenges faced by clinicians: education (amount of information), diffusion of information, translational time from study to exam room, evolutionary (we can no longer teach classic medicine), retention
CDA
Clinical document architecture delineates the structure and semantics of clinical documents consisting of a header and the body; HL7 v3.0; the HL7 standard for naming and structuring clinical documents
Post coordination
Coding of data by using multiple terms, as needed, to express meaning that cannot be accurately captured by a single term
Negotiation skills
Collaborative style, prepare adequately with alternatives, agree what can become reminders, non-negotiables, try to be open to negotiation,build trust, effective communication strategies, transparency, be prepared to compromise, use innovation, go for win win
An environmental scan is designed to
Collect information and data about external and internal influences that affect your mission, vision, objectives and strategies; performSWOT analysis
Types of social influence
Compliance, identification, internalization, conformity, self-fulfilling prophecy, reactance, obedience, persuasion
Three pillars of information security
Confidentiality, availability, and integrity
Integration testing
Confirmation that information flow between the EHR and external systems occurs is expected
CCD
Continuity of care document standard (CCD) - marriage of the Continuity of care record (ASTM international) and the CDA (HL seven); The CCD specification is a constraint on the HL7 Clinical Document Architecture (CDA) standard. The CDA specifies that the content of the document consists of a mandatory textual part (which ensures human interpretation of the document contents) and optional structured parts (for software processing). The structured part is based on the HL7 Reference Information Model (RIM) and provides a framework for referring to concepts from coding systems, such as the SNOMED or the LOINC.
Effectively Communicating change
Create a compelling message of why change needs to occur, create and communicate a vision for that change, understand and address feedback, communicate success
The certification commission for healthcare information technology (CCHIT)
Created by HIMSS to decrease the risk of adopting HIT, 20 commissioners, CCHIT exceeds federal standards includes a usability's core, ONC -ATCB certification certifies for meaningful use using the standard from the NIST national institutes of standards and technology
Healthcare information technology standards panel (HITSP)
Created in 2005 by Health and Human Services, works with ONC, continuity of care document
Medical computers can provide the following basic functions
Data acquisition presentation, recordkeeping and access, communication integration of information, surveillance, information storage and retrieval, data analysis, decision support, education
CCD C32 Standards Components
Data modules - patient demographics advanced directives functional status payers vital signs social history purpose problems alerts results medical equipment procedures medications encounters family history immunizations plan of care
Van Der Lei's first law
Data shall only be used for the purpose for which they were collected. If no purpose defined prior to the collection of the data, the data should not be used.
IOM key to Health info infrastructure
Data standards are the key to the national health information infrastructure. Data standards make sure that information is understandable to all users
Information hierarchy
Data, information, knowledge, wisdom
Federated HIO
Decentralized approach were data stored locally on a server at each network node (hospital, pharmacy, lab - requires an import export schema. The pros are greater privacy, but examples exist, by in of organizations is easier if local. Cons: data is displayed might not be uniform, data retrieval delays from others, potential for node down time
The cons of the EHR as a communication tool
Decreases human situational awareness and interpersonal interaction, current design not ideal for hectic environments, may not support rapid transitions from one facility to another; can make or break patient communication, textual documentation EHR tends to be very lean
Project initiation steps
Defined problem, defy project formants, perform a feasibility study, identify product scope and project scope; aligns the project with the goals and work of the facility or organization the outcome is the project charter
Push/Pull
Defines how health information exchange through the Internet - push - clinicians push information to another provider by e-mail or other secure messaging - pull a clinician sends an electronic request for health information to a server (example HIE) the server searches for the data and then responds with the match
Integrity
Describes the trustworthiness and permanence of data, and assurance that the data is not modifiable by unauthorized entities were corrupted by a poorly designed process Methods to protect this include database best practices, data loss solutions and data backup and archival tools
Diffusion of innovations, Everett Rogers
Diffusion is the process by which an innovation (an idea, practice or object is perceived as new by an individual) is communicated through certain channels over time among members of a social system; Innovators 2.5%, early adopters 13.5% early majority 34%, late majority 34%, laggards 16%
DICOM
Digital imaging and communications in medicine the standard for imaging used in a HR and PACS was created by the national electrical Manufacturers Association and the American College of radiology
information retrival - text search
Direct text search is easy to do used in Web search engine such as Google; disadvantage one does not know how to potential items were not retrieved due to the wrong choice of term for free text search when there are multiple possible synonyms
ELINCS
EHR - lab interoperability and connectivity standards, lab interface for amb. EHR is to further constrain HL seven, is standardize the format and content of messages, standardizes model for transport, uses the standardize vocabulary LOINC, HL7 will maintain
Nominal group technique for group decision-making
Each member privately makes a list of solutions, each presents without analysis or tweak, group analysis, group ranking; works best for a single problem and not interrelated problems
E-Discovery Laws
Electronically stored data related to patient records can be considered discoverable for the purpose of malpractice so meta-data and audit trails the settlement EH R documentation can be used both to defend and impeach a physician and a malpractice case
XML Element
Elements are tags that can envelop data and be organized into a hierarchy, the headers and message is package by wrapping it in layers of tags. There are no predefined tags.
A reference terminology
Enables storage, analysis, retrieval
sirota' s three factor theory of human motivation
Equity/fairness, achievement, camaraderie; based on the premise that organizational goals are not in conflict with workers goals; organization should try to meet workers basic needs
Availability
Events that are more easily remembered are judged to be more probable; how easy remember it influences our assessment of the probability and this is misleading
EBM
Evidence-based medicine - the conscientious, explicit and judicious use of current best evidence in making decisions about the care of an individual patient
Elements of successful governance
Executive level commitment and vision for the organization as a whole, leadership presence throughout the lifecycle, availability of appropriate resources from the organization, continual reevaluation of how IT governance decisions will promote improve clinical processes and patient care, attention to workflow and process redesign
XML
Extensible markup language, and data packaging standard - serves as a structural component for domain specific languages for health information exchange helps to desparate health entities share messages and retrieve results by providing a data packaging standard - A predefined set of rules to structured data so it can be universally interpreted and understood; consists of elements and attributes
scope
Extent of the work involved to complete the project, definition of requirements
IT strategic planning: the component alignment model
External environment, emerging IT, organizational mission, organizational infrastructure and processes, IT infrastructures and processes, organizational business strategy, IT strategy
HIPPA Security Rule Physical Safeguards
Facility access and control limiting physical access to facilities, workstation and device security policies and procedures covering transfer, removal, disposal and reuse of electronic media
To form an HIO Must address
Financing, regulations concerning data, privacy and security standards, IT: who will create and maintain the actual network and is architecture, clinical process improvements - what processes will be improved are analyzed, incentives, PR, consumer participation, need social capital and trust to be sustained
Waterfall model
Flow study three phases of requirements analysis, design, implementation, testing, integration, maintenance Problems found in later phase require feedback hurler phase causing extensive rework Delays inherent in such a phase develop a process make the methodology and appropriate for innovative applications Maintenance cost average 25% per year which means they require greater financial commitment over time the original development phase
Complex adaptive systems or about relationships among members of the system
Fluidly changing collections of distributed interacting components the react to both their environment into one another for example electronic power grids telecommunication networks the Internet biologic systems
The Tuckman Model: for states of group development
Forming, storming, norming, performing
Health information exchange functionality
From the eHealth initiative survey: Results delivery, conductivity with the HR's, clinical documentation, large to clinicians, electronic prescribing, health summaries, electronic referral processing, consultation/referrals, credentialing, quality reporting, results distribution, EHR hosting, data loads into EHR's, EHR interfaces, drug drug alerts, drug allergy alerts, drug food allergy alerts, billing
Action centered leadership model
Functional leadership model: leadership is thought of a set of behaviors rather than an individual person who is a leader; these behaviors help a group of people perform their task or reach their goal; task team individual
IEEE 11073
Fundamental standard for medical device connectivity and data exchange, HL7 v2.X is used for data transfer but only supplies the syntax not the semantics, need more work for the semantics to allow interoperability
GOMS
Goals, operators, methods, selection rules; a method for describing a task in a very fine level of granularity such as a keystroke in the user's knowledge of how to perform the task; limited for cpoe
National eHealth Collaborative (NeHC)
Government - civilian - consumer collaborative, prioritization of HIT standards to promote interoperability
RIM
HL7 reference information model, it's HL7 version 3 started in 1997 approved in 2003
HITPC
Health IT policy committee - part of ONC created by ARRA, establishes priorities regarding what standards are needed for information exchange and the policy framework for the development and adoption of national health information exchange - Work groups include MU, HIE, certification, NwHIN, privacy and security
HITSC
Health IT standards committee - looks a standards, implementation specifications and certification criteria for the exchange of health information; they examine issues prioritized by the health IT policy committee; they use the standards from the national Institute of standards and technology (NIST) - Work groups include clinical quality, clinical operations, implementation and privacy/security
Categories of patient registries
Health service registries - track services such as hospitalization, visit, surgery Disease/condition registries: track chronic disease, rare diseases, transplants product registries: track patient safety related concerns such as tocsin, certain medications, adverse drug events, devices combination registries
XML Attributes
Help describe an element
AHRQ Unintended Consequences of EHR
Here are some examples of common unintended consequences: 1. More work for clinicians 2. Unfavorable workflow changes 3. Never-ending demands for system changes 4. Conflicts between electronic and paper-based systems 5. Unfavorable changes in communication patterns and practices 6. Negative user emotions 7. Generation of new kinds of errors - Busy physicians enter data in a miscellaneous section, rather than in the intended location. Improper placement can cause confusion, duplication, and even medical error. 8. Unexpected and unintended changes in institutional power structure 9. Overdependence on technology
Predictive models of hci:
Hicks-hyman law response time based on number of choices, response to hierarchal menus KLM (keystroke level model) - time to task completion is a sum of the keystrokes Buxton's three state model of graphical input - mouse is out of range, tracking, dragging
Security standards and the law
ISO 20,000/27,000, COBE IT, IT IAL (information technology infrastructure Library), NIST SP 800 - 53, socks, HIPPA, meaningful use, PCI - DSS (payment card industry data security standard), FISMA (Federal information security management act)
IT versus informatics
IT is concerned with data and information retrieval from data. Informatics is concerned that information (meaningful data) and knowledge. Overlaps with IT in the need for information retrieval. Information retrieval is different than searching for a string in the database.
IT strategic planning technology push model:
IT pushes the organization into new areas of business or service delivery, basic concept that evolving IT will enable the organization to expand its business scope significantly
non-repudiation
Impossibility of denying authenticity and identity
Goals of HIT
Improve, reduce, standardize, accelerate, protect Improve communication and continuity of care, quality of care, patient outcomes, clinician productivity, return on investment Reduce medical errors and litigation, duplication of tests Standardize medical care by individuals and organizations Accelerate access to care and administrative transactions Protect privacy and ensure security
Checklist effect
Improvements observed in decision-making due to more complete and better structured data collection one paper or computer forms are used to collect data
Referral bias
In the valuation studies, bias that is introduced when the patients entering a study or some way atypical the total population, generally because they have been referred to the study basing criteria the reflect some kind of bias by the referring physician
Barriers to health information technology adoption
Inadequate time to research and install, inadequate information (data rich information poor), inadequate expertise in workforce, cost, lack of interoperability, changes in workflow, privacy, legal (Stark and Antikickback changes), behavioral change
Critical elements of CHI applications
Individual tailoring, personalization, behavioral feedback. Tailoring refers to building and intervention in part on specific knowledge of actual characteristics of the individual receiving the intervention. Personalization involves designing the intervention to be delivered in a way that makes it specific for a given patient
The project management body of knowledge five stages of a project
Initiation, planning and design, executing, monitoring and controlling, closing; Each stage has different characteristics in terms of cost/staffing, level uncertainty, cost of change
IDN vs HIO for HIE
Integrated delivery networks can rapidly offer health information exchange to their networks without the long and difficult process of creating governance and trust between despair and competitive health organizations
What is the interoperability standard source for integrating two different types of radiology information systems (RIS)?
Integrating the Healthcare Enterprise published handbooks.
Terminology could be characterized as
Interface, processing, reference
IP Address
Internet protocol address; the domain naming system (DNS) maps the IP addresses to a domain name; IP addresses can be distributed among different tiers of layers or subnetworks
Confidentiality
Is a condition in which information is shared or released in a controlled manner. The HIPAA security rule defines confidentiality to mean ePHI is not available or disclosed to unauthorized persons.
Change management
Is an approach to transitioning individuals, teams, organizations from a current state to desired future street; it's an organizational process aimed at helping the stakeholders of change to initiate, facilitate, accept and embrace changes in their environment
Managerial accounting
Is concerned with providing information to managers in direct contrast to financial accounting which deserve providing information to stockholders and others outside of an organization; places more emphasis on the future, places more emphasis on nonmonetary data, emphasizes segments of an organization rather than the whole, It is not governed by generally accepted accounting principles
Object oriented database
It database of structured around individual objects or concepts that generally include relationships among those objects in some cases executable code that is relevant to the management and/or understanding of the object
Healthcare leadership alliance model
Leadership companies are central to a healthcare executive performance, the leadership domain is the center of all the domains business skill and knowledge, professionalism, communication relationship management, knowledge of the healthcare environment
Five attributes of usability
Learnability, efficiency, memorability, errors, satisfaction
LOINC
Logical observations indentifiers, names and codes; vocabulary standard for electronic exchange of lab results (HL7 is the content standard). - has lab, clinical and hit the portions - LOINC names for a test are: (component: property: timing: specimen: scale)
MU Medicare EP
MD, DO, DDS, DPM, OD, chiropractors;
MU Medicaid EP
MD, DO, NP, certified nurse midwives, DDS, and physician assistants who work any federally qualified health Center or rural health clinic that led by a physician assistant; MDs require at least 30% Medicaid volume (20% for pediatricians)
HIO Infrastructure Components
MPI, RLS, Provider Directory, data warehouses (document registry and repository pairs providing the storage and indexing of patient data accessible via the HIE)
Bridges transition theory, William Bridges PhD 1991
Managing a situational changes not as difficult as tending to the psychological transitions of people affected by the change; three phases Phase 1: ending/losing/letting go stage to the neutral zone confusion chaos attempt realignment, phase 3 new beginning with energy purpose and unity
MPI
Master patient index is a database containing all of the registered patients with in a HIO, there is a single unique location to the file, uses algorithms to locate the patient and existing records
Information
Meaningful data or facts and which conclusions can be drawn by humans or computers; organized data of knowledge that provide the basis for decision making
Security
Measures employed to maintain the confidentiality of information but also to ensure the integrity and availability of that information and information systems used to access
MeSH
Medical subject heading, the categorization of journal articles by NLM indexers in order to facilitate searching, articles are saved or two or more subject headings using a structured vocabulary called mesh
MESH
Medical subject headings; 16 hiearchical, 26000 terms, 83 subheadings
Cognitive heuristic
Mental process by which we learn, recall, or process information; we use these to make subjective assessments of probability
Strategic plan components
Mission statement which defines the purpose and primary objectives; a vision statement, objectives, strategies Three steps: assess current state including perform environmental scan; describe desired future state, devise a plan to get from one to two including financial planning
Effects if ARRA
Money to support ONC programs, established privacy officer, HIT standards HIT policy committees established, support for states for health information exchanges, NIST to develop HIT standards, HRSA to upgrade community health centers HIT, AHRQ and the NIH to develop comparative effective research programs, CMS to certify meaningful use, regional extension centers to promote HIT, HIT research Center, beacon community program, community college consortia to educate HIT professionals, health IT curriculum project, competency exam program, program of assistance of University based training, strategic HIT advanced research projects (SHARP), privacy and HIPPA changes, the national telecommunications and information administration's broadband technology opportunities program, the USDA's distance-learning program, telemedicine program, Indian health service HIT programs, Social Security administrative HIT programs, veteran affairs each HIT programs
Evidence appraisal
Must assess the validity, results and applicability
Famous production rule system
Mycin, difficult to maintain, shortliffe; used certainty factors to incorporate probablistic reasoning into otherwise deterministic, deciosn rule systeml used backward chaining; HELP another example
Number needed to treat
NNT - number patients who have to receive the intervention to prevent one adverse outcome NNT = 1/ARR
NCPDP
National Council for prescription drug programs - is the standard development organization for exchange of prescription related information, script version 10.10 is for communication between physician and pharmacists
NwHIN
Nationwide health information exchange, being coordinated by the ONC, with advice to the secretary of health and human services by the national committee on vital and health statistics.
Governance structures must have the authority and responsibility to affect positive change for the organization; skills necessary include
Negotiation, conflict management, collaboration, motivation, decision making
eHealth Initiative
Nonprofit organization promoting the use of information technology to improve quality and patient safety, provide an annual HIO survey
RCT vs Observational Studies
Observational studies make it more difficult to show cause and effect, most HIT studies are observational
Spectrum bias
Occurs when the study population included only individuals who have advanced disease and healthy volunteers; happens more when the test is first being developed
ONC Org Chart
Office of the chief scientist, office of economic analysis and modeling, office of the chief privacy officer, office of the Deputy national health coordinator for operations (office communications, office of oversight, office of mission support, office of great management), office of the Deputy national coordinator for programs and policy (office of policy and planning, office of standards and interoperability, office of provider adoption support, offices stay in community programs)
ONC
Office of the national coordinator for health information technology, reorganize 2009, goal is the creation of a universally interoperable electronic health record by 2014, they work to harmonize data standards to ensure interoperability and to facilitate health information exchange
ontology is distinguished from a terminology systems
Ontologies are distinguished by the use of relationships between terms
processing terminology
Optimizes natural language processing
Healthcare quality professional leadership development model 2008
Organizational awareness, fostering positive change, performance improvement, communication, self development and self-management, professionalism and professional values
Allocation bias
Overestimation of the effects of intervention Causeway systematic assignment of favorable subjects to the study group by investigators; randomization error
Assessment bias
Overestimation or underestimation of the effects of intervention caused by systemic a favorable or unfavorable evaluations of results what investigators; how the subject feels influences the performance
RR =
P (disease|exposure) / P (disease|no exposure) pg 5-20
EBM PCIO
P - patient or problem I - intervention, prognostic factor exposure C - comparison with other drug or placebo O - outcome when trying to measure otology, reduce heart attacks
formula for a systemic review of interventions
PICO - populaiton, intervension, comparator, operator
in Information retrieval what is precision equivalent to
PPV
PPV and NPV are used for
PPV and NPV are characteristics of test in context and are influenced by prevalence of the condition in that population. Assumes you know the test result and you are trying to determine the disease state
Social influence theory
People's behavior is intentionally unintentionally influenced by others;
PACS
Picture archiving and communication systems
four steps in the Deming (or Shewart) cycle for continuous quality improvement are
Plan - do - check - act
Capital budgeting
Planning process for expenditure of relatively large sums on long-term assets such as replacing worn-out assets with new ones in developing new business opportunities; would include licensing fees hardware consulting fees of a big project
elements of Managerial Accounting
Planning, Directing, Controlling Management accounting or managerial accounting is concerned with the provisions and use of accounting information to managers within organizations, to provide them with the basis to make informed business decisions that will allow them to be better equipped in their management and control functions. In contrast to financial accountancy information, management accounting information is: • primarily forward-looking, instead of historical; • model based with a degree of abstraction to support decision making generically, instead of case based; • designed and intended for use by managers within the organization, instead of being intended for use by shareholders, creditors, and public regulators; • usually confidential and used by management, instead of publicly reported; • computed by reference to the needs of managers, often using management information systems, instead of by reference to general financial accounting standards.
SDLC phases-
Planning, implementation (aka development), testing (verification - look for defects, validation (meet expectations), documentation, deployment, maintenance
PEST analysis
Political, economic, sociocultural, technological
Confidentiality
Prevention of data loss; the most common measures implemented to ensure confidentiality our usernames, passwords, encryption
Formal performance reviews should be based on
Prior stated performance expectations and include employee self-evaluation and can include peer evaluations, should align with organizational goals
IT strategic planning using the organizational pull model
Prioritizes the organization's business objectives as fully driving the IT requirements, first set organizational business objectives then have IT develop a plan to meet
IF <condition> THEN <action>
Production Rules
Knowledge as IF-THEN Rules
Production Rules; system combines evidence from different rules to arrive at a diagnosis
Scope statement contains
Project justification, project description, major deliverables, time and cost estimates, success criteria, assumptions, constraints
A project charter has the following elements
Project team requirements, stated project goals and objectives, makes the business case for the project, identified stakeholders
Work breakdown structure Components
Project title, project subsystems (subprojects), major deliverables, sub deliverables, work packages: used to estimate castration assign resources and perform cost and schedule estimates
HISP Role in Direct
Provide user authentication, message encryption and maintenance of system security for sending and receiving organizations or clinicians. The use of a HISP means health and disease to not need a contract with every person they exchange data with.
National committee on vital and health statistics (NCV HS)
Public advisory board to Health and Human Services, provide expertise on health statistics, electronic health information exchange, privacy, security, - they advise on the creation of the nationwide health information network; a public policy advisory board that recommends policy to the national center for health statistics and other health-related federal programs.
Which of the following best addresses the challenge of accurate and comprehensive data when creating and implementing a national disease surveillance database
Quality control and error checking
national disease surveillance database paramaters
Quality control and error checking are crucial for users to have faith in the accuracy and comprehensiveness of the data. Encryption of data refers to privacy and data protection before the transmission of the information. Standards for data transmission address the need for developers of electronic health records and clinical databases to adopt a single standard for communicating and transmitting the information. Standards for data definitions refer to the adoption of standards for clinical terminology and for schemas used to store clinical information in databases.
Relative risk
RR is a ratio of two risks - it is the ratio of the event rate of the outcome in the experimental group (EER - experimental event rate) to the event rate in the control group (CER - control event rate). RR=EER/CER In statistics and mathematical epidemiology, relative risk (RR) is the risk of an event (or of developing a disease) related to exposure. Relative risk is a ratio of the probability of the event occurring in the exposed group versus a non-exposed group.
Relative risk reduction
RRR is the difference between the experimental event rate (EDR) and the control of that rate (CER) expressed as a percentage of the control event rate RRR = (EER-CER)/CER
RLS
Record locator service - directs the Inquirer to the physical location of the patient's records once the MPI has identified multiple records
Benefits of CPOE
Reduce medication errors, reduce costs and reduced variation of care
Telemedicine
Refers to the remote delivery of medical care using technology
REC
Regional extension Center created under HITECH Purpose: provide technical assistance, best practice information, and education to support implementation and MU; also tasked to support and enable nationwide health information exchange
Business operations are
Repetitive, permanent, or semi permanent functional activities to produce products or services
Covered entities
Required to follow the hippa privacy rule: health plans, health care providers who conduct business electronically (includes clinics, hospitals, chiropractors, nursing homes, pharmacy, dentists), healthcare clearing houses. Those not required include life insurers, employers, work comp, school, CPA, law - revisions include business associates
Goals of healthcare
Safe, effective, patient centered, timely, efficient, equitable
Top three reasons informatics projects fail
Scope creep, managing expectations, managing competing priorities
NHIN Direct
Secure e-mail analog - and more simplistic HIE capability; represents a similar goal for health information exchange, scalability, geared towards stage one of MU. The purpose of direct us to supplement traditional fax and e-mail methods of exchanging health information between known and trusted resurgence with a faster, more secure, Internet pace method. Uses Push technology which is cheaper than pull. The secure messaging would be managed by a HISP
Accountability
Security function that ensures users are responsible for their access to, and use of information based on document needed and right to know
PPV/NPV vs Sensitivity/Specificity
Sensitivity = given the patient has disease what is the probability of a positive test = true positive rate Specificity = given the patient does not have disease what is the probability of a negative test = true negative rate PPV = given a positive test, what is the probability the patient has disease NPV = given a negative test, what is the probability the patient does not have disease
Hypotheticodeductive approach
Sequential, stage data collection, followed by date interpretation of the generation of hypothesis, leading to I hypothesis directed selection of the next most appropriate data to be collected; process is iterated until one hypothesis reaches the threshold of certainty then a management, disposition or therapy decision can be made
SOA
Services oriented architecture, most HIO's use Web services and SOA to exchange health related information
historic constraints of EHR adoption
Shortliffe - - The need for standardize clinical terminology - privacy confidentiality and security concerns - challenges to data entry by physicians - difficulties of integrating with other systems
SOAP
Simple object access protocol - A communication protocol standard for interacting with Web services, these services require a set of standards for content in a service oriented architecture (SOA) stack
IOM, Institute of medicine, 1970
Six aims: safe, effective, patient centered, timely, efficient and equitable medical care
Electronic disease Registry
Software application for capturing, managing and providing access to condition specific information for a list of patients to support organize clinical care; These are the tools the disease management programs used to track patients with chronic diseases or conditions
Rx Norm
Standard for medication vocabulary for clinical drugs and drug delivery devices developed by the NLM - Three drug elements: the active ingredient, the strength, the dose; encapsulates other coding systems such as NDC; only US drugs -standard for e prescribing/mu; RxNorm provides normalized names for clinical drugs and links its names to many of the drug vocabularies commonly used in pharmacy management and drug interaction software
Transport data standards
Standards that focus on communication between multiple systems
i2b2 data model
Store schema, facts - pieces of information that are queried; dimensions - these describe the facts
Strengths, Weaknesses, Opportunities and Threats (SWOT) Analysis
Strategic planning A SWOT Analysis examines "internal strategic factors, strengths and weaknesses attributed to the organization, and external factors beyond control of the organization such as opportunities and threats". The elements are described as follows: - Strengths: Internal business characteristics that are an advantage an organization has over others - Weaknesses: Internal characteristics that place the organization at a disadvantage compared to others - Opportunities: External factors that an organization can use to its advantage (e.g. provide EHR system access or partial funding for purchase and connection to your EHR system to community-based physicians who refer patients to your hospital) - Threats: External factors that may create negative impact on the organization (e.g. merger of two competing hospitals in your geographic area, thus creating a more efficient and larger single competitor to your hospital)
Factors of successful HIT governance
Strong leadership including clinical leadership, insight to leverage clinical provider input on the governance team, into space resistance adoption has tragedy overcome, aligned with organizational mission and other business drivers, resilience and agility
An interface terminology
Supports data entry
Syndromic surveillance
Surveillance using health related data that proceed diagnosis and signal a sufficient probability of a case or an outbreak to warrant further public health response
Switches and routers
Switches provide a point of connection among devices on a network. They vary in the degree of functionality by which they manage data traffic that passes through them (hub-->bridge-->repeater--> router. The hub is the simplest and least expensive device providing passive transmission or receipt of data from one computer at a time. A bridge performs the functions of a hub and in addition can limit the sending of data to specific known hosts thereby providing a level of security. A repeater is a device that receives a signal and retransmits it at a higher level, simply extending a network. A network router is the most technically sophisticated switch and is capable of examining the contents of data passing through it, identifying the sender and receiver, and providing a higher level of security using the Internet protocol (IP) address. AMIA content outline 3.1.3 Networks
Data
Symbols or observations reflecting differences in the world (singular datum); no meaning is associated with data
Interoperability relies on syntax and semantics
Syntax is related to the structure of the communication (HL7). Semantics denotes meaning of the communication (SNOMED)
Availability
System and network accessibility (loss of accessibility - can be natural or man-made) measures include backup generators continuity of operations planning and peripheral network security equipment to maintain availability
A clinical practice guideline with explicit encoded steps in an electronic health record falls into the
System hierarchy of evidence levels.
SNOMED
Systemized nomenclature of medicine: clinical terminology - medical vocabulary covering diseases, findings, procedures, drugs allowing a more convenient way to index and retrieve medical information although developed by the American College of pathologists it's maintained by the international health terminology standards development organization (IHTSDO) - 19 hierarchical categories; allows stating condition a is due to condition b - each concept has a description and a concept ID - items are related as they is a which connects concepts the same hierarchy or as an attribute which connects concepts in different hierarchies (example asthma is a lung disease, asthma is associated with inflammation
Specificity
TN/(FP+TN) D/(B+D)
NPV
TN/(TN+FN) D/(C+D)
PPV
TP / (TP+FP) A/(A+B)
Sensitivity
TP/(TP+FN) A/(A+C)
Web Services
Task specific applications which are deployed in a platform independent manner via a series of transactions to and from other web aware applications/services over a network. Web services can reduce the cost of converting data with external partners by allowing for a modular component of a larger system to be invoked with little upfront effort. Two categories: representational state transfer (Restful) - use www, internet as their backbone or simple object access protocol (soap)
NHIN delays
Technical issues about how much the standard support, procedural delays (agreed-upon vocabularies for semantic interoperability), political
System testing
Test all aspects of a given system or application, how well the software satisfies a stickler functionality, security, performance, load, reliability, availability, requirements
Regression testing
Test to make certain that with the exception of the change currently being requested, all components of the software's functionality and behavior unchanged
Application testing
Testing all modules and subunits of the application working in connection with each other
Unit testing
Testing directed at menus, templates, and other modules and subunits of the system without regard to the other system components internal or external to a given application
Performance testing
Testing with production loads end users, system functions within expected boundaries
MLM and Arden
The Arden Syntax for Medical Logic Systems encodes medical knowledge in knowledge base form as Medical Logic Modules (MLMs). An MLM is a hybrid between a production rule (i.e. an "if-then" rule) and a procedural formalism. Each MLM is invoked as if it were a single-step "if-then" rule, but then it executes serially as a sequence of instructions, including queries, calculations, logic statements and write statements. Arden was developed for embedding MLMs into proprietary clinical information systems. It was designed to support clinical decision making in particular: an individual MLM should contain sufficient logic to make a single medical decision.
Blue Button
The Blue Button is a symbol for patients to view online and download their own personal health records. Several Federal agencies, including the Departments of Defense, Health and Human Services, and Veterans Affairs, implemented this capability for their beneficiaries. Blue Button has pledges of support from numerous health plans and some vendors of personal health record vendors across the US. Data from Blue Button-enabled sites can be used to create portable medical histories that facilitate dialog among health care providers, caregivers, and other trusted individuals or entities. Currently widespread Blue Button usage supports downloading human-readable data in ASCII.[3] As a step towards enabling the exchange of parseable data, on 16 January 2013 the Office of the National Coordinator for Health IT recently announced [1], an implementation guide for data holders and developers to enable automated data exchange among Blue Button+ compliant applications using structured data formats. Blue Button+ is designed to enhance the ways consumers get and share their health information in human-readable and machine-readable formats; and to enable the use of this information in third-party applications.
Markle Foundation
The Markle connecting for health is a private public collaboration its primary mission is to promote interoperable HIT, they have best practices for health information exchange guides
commonly used by the Health Level (HL) 7 2.X messaging standard to separate fields in a message string.
The Pipe delimiter symbol (|) is
WWW
The World Wide Web began with the induction of web browsers and operates on top of the Internet, it's a software program that allows for connection to Web servers over the Internet using the (HTTP) hypertext transfer protocol. Webpages are written in hypertext markup language (HTML)
Opt in and Opt Out
The ability for content creators to determine whether or not the personal health record data they create can be shared as well as with whom
Interoperability
The ability for systems to exchange data and operate in a coordinated, seamless manner The transmission of information. It requires consistency of interpretation.
IEEE
The ability of two or more systems or components to exchange information and to use information that has been exchanged
Functional results oriented healthcare leadership model
The action oriented leadership model plus results, results emphasizes leadership responsibility for measurable outcomes in a healthcare setting including patient care outcomes; the individual the team in the task overlap to form results
Public Health
The art and science of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organizations, public and private, communities and individuals
Net present value
The difference between the present value of all cash inflows in the present value of all cash outflows used to determine whether or not a project is an acceptable investment; The value of future cash flows present in today's dollars
Project management is
The discipline of planning, organizing, motivating and controlling resources to achieve specific goals
HIPPA 2009
The expanded business associates, deed restrictions, disclosing and reporting requirements, and limited data sets, enforcement
Consensus mapping technique for group decision-making
The facilitator in a group reach consensus, it's based on an expectation of compromise; works best in a trained experience group
leadership principles considered a higher order motivator for people
The following are the eight leadership principles that are considered stronger, more long-term motivators than money: 1. Energize your team. 2. Exemplify that there's more to life than work 3. Put your people first 4. Act with integrity 5. Be a great communicator 6. Be a great listener 7. Be a problem solver 8. Lead through experience and competence, not through title or position
What is the principle difference between an ontology and a controlled vocabulary (terminology)?
The fundamental difference between an ontology and a controlled vocabulary is the level of abstraction and relationships among concepts. A formal ontology is a controlled vocabulary expressed in an ontology representation language. This language has a grammar for using vocabulary terms to express something meaningful within a specified domain of interest. The grammar contains formal constraints (e.g., specifies what it means to be a well-formed statement, assertion, query, etc.) on how terms in the ontology's controlled vocabulary can be used together. Controlled vocabulary used in making ontology not only to reduce the duplication of effort involved in building an ontology from scratch by using the existing vocabulary, but also to establish a mechanism for allowing differing vocabularies to be mapped onto the ontology.
Population health
The health outcomes of a group of individuals, including the distribution of such outcomes with and a group
Informed consent
The individual must be competent to consent, you must disclose information, the subject understanding of information being disclosed, violation or choice and consent and authorization of the consent; In health IT one way of obtaining informed consent for use in research is to obtain broad informed consent at the time the information was gathered
Healthcare IT governance
The infrastructure, strategies and approaches to support physicians in the definition of clinical content, refinement of care processes in the adoption of new technologies before, during and after implementation
Test sensitivity affects primarily
The interpretation of a negative test
Test specificity affects primarily
The interpretation of a positive test
A communication channel is
The medium through which a message is transmitted to its intended audience (print or broadcast)
Clinical information services must be strategically aligned with
The mission/vision/goals of the healthcare organization
Public health surveillance
The ongoing systematic collection, analysis, and interpretation of health related data essential to the planning, implementation and evaluation of public health practice, closely integrated with the timely dissemination of these data to those who need to know
Representativeness heuristic
The overestimates rare diseases by matching patients to the typical picture of that disease
Conceptual model
The parts the physical world that are relevant to the computation. The conceptual model is used to design and implement a computational model. The conceptual model to find what is relevant everything that is not in the conceptual model is therefore assumed to be not relevant.
Predictive value
The posttest probability that a disease is present based on the results of the tests
Bayes Theorem
The probability of a patient having a disease after the diagnostic test is completed (i.e. post-test probability) is related to the disease probability before the test (i.e. pre-test probability) and the probability that the test provides a true result (i.e. sensitivity and specificity)
Concept extraction
The problem of identifying concepts within unstructured data (As opposed to when concepts are mapped to a controlled vocabulary such as ICD-9 or snomed)
Security
The process of protecting information from destruction or misuse, including both physical and computer-based mechanisms
Risk
The rate of events during a specific period of time. Risk = number of pt suffering events/ the total number of patients at risk for events
Odds
The ratio of the number of patients with events to the number of patients without events. Odds = 1/(1+ risk)
RACs
The recovery audit pre-payment review allows Medicare recovery auditors (RACs) to review claims before they are paid to ensure provider complied with all Medicare payment rules
Working memory
The resources needed to maintain information during cognitive activity; 5 to 10 chunks; problems impose a varying cognitive load on the working memory
Content standards (data)
The rules that dictate the format of information as it is packaged for transport (the individual segments within a content package are governed by vocabulary
Public health informatics
The systematic application of information and computer science and technology to public health practice, research and learning
Hawthorne effect
The tendencies for humans to improve the performance of they know they're being studied
Communication model
The transfer of a message from the sender (encoder) sent to a receiver (decoder), the information source produces a message and the transmitter encodes the message and signals, the message is transmitted via channel, the receiver decodes or reconstruct the message from the signal, therefore the message has arrived at the destination
What is the time-trade-off utility in this situation
The utility of a health state is the quantitative measure from the patient's perspective of the desirability of the healthy state. Utilities are generally expressed from 0-1, with 0 representing death and 1 representing ideal health. The TTO utility (the indifference point) is the length of remaining life in perfect health divided by the length of remaining life with the evaluated health state.
A commonly employed method to assess a patient's utility preferences
The visual analog scale
HITECH Act
Title IV, XIII of ARRA, 2009 - devoted to funding of health information technology programs
The goal of healthcare IT governance
To establish a process that demonstrates value for all clinical providers and enhances provider satisfaction, consensusbuilding is enhanced and resistance is minimized; Focuses on performance and risk management, sure investments in health IT generate business value, mitigate risks
Basic system authentication
To factor multifactor authentication, factors are either something one knows, something one has something that one is
Depreciation
To lower the price or estimated value of a long-term asset that has diminishing value over time;
Patient communications should be targeted
To the fifth or eighth grade level
Covered entity permitted uses and disclosures of patient data
To the patient, for treatment or payment of healthcare operations, uses and disclosures opportunities to agree or object (facility directory), incidental use and disclosure, public interest and benefit activities (public health, required by law, domestic violence, workers comp, etc.), limited data set
Sensitivity
True Positive Rate
Specificity
True negative rate
HHS
US Department of Health and Human Services - consists of 12 agencies, for example the agency for healthcare research and quality, the CMS, CDC, HRS a (health resources and services administration), Indian health service, FDA, administration on aging, National Institutes of Health The ONC reports directly to the Sec. of HHS and is not an agency
Lewin's change theory
Unfreeze, change, phrase; during unfreeze you to create the right environment, then support change during the change; then reinforced anchor change during refreeze
URI
Uniform resource identifier - a set of characters defining a specific object, resource or location; it is used to provide for example the uniform resource locator or URL for an object on the World Wide Web
UDP
User datagram protocol - does not guarantee delivery of a packet its use for streaming video when you wouldn't want the transmission held up for one packet
Sarbanes-Oxley Act
What Sarbanes-Oxley covers: Enacted in 2002, the Sarbanes-Oxley Act is designed to protect investors and the public by increasing the accuracy and reliability of corporate disclosures. It was enacted after the high-profile Enron and WorldCom financial scandals of the early 2000s. It is administered by the Securities and Exchange Commission, which publishes SOX rules and requirements defining audit requirements and the records businesses should store and for how long. Who is affected: U.S. public company boards, management and public accounting firms. Key requirements/provisions: The Act is organized into 11 titles: 1.Public Company Accounting Oversight 2.Auditor Independence 3.Corporate Responsibility 4.Enhanced Financial Disclosures 5.Analyst Conflicts of Interest 6.Commission Resources and Authority 7.Studies and Reports 8.Corporate and Criminal Fraud Accountability 9.White-Collar Crime Penalty Enhancements 10.Corporate Tax Returns 11.Corporate Fraud Accountability
WiFi
Wireless fidelity
a class in object oriented programming
a blueprint for an object, describes the functions and common charactietics of objects in the class; obects can be comprosed (compositon) from smaller objects, also have inheritance
clinical data repository (CDR)
a central database that focuses on clinical information
heuristics
a commonsense rule (or set of rules) intended to increase the probability of solving some problem; They are mental shortcuts that usually involve focusing on one aspect of a complex problem and ignoring others
data elements for emergency department systems (DEEDS)
a data set designed to support the uniform collection of information in hospital-based emergency departments.
office of the national coordinator for health information technology (ONC)
a department of the U.S. Department of Health and Human Services established by executive order to advance the development, adoption, and implementation of healthcare information technology standards.
knowledge management in CDS
a knowledge management project transforms tacit knowledge into explicit knowledge so it can be effectively disseminated
master patient index (MPI)
a patient-identifying directory referencing all patients related to an organization and which also serves as a link to the patient record or information, facilitates patient identification, and assists in maintaining a longitudinal patient record from birth to death.
nation committee of vital and health statistics (NCVHS)
a public policy advisory board that recommends policy to the national center for health statistics and other health-related federal programs.
meta-analysis
a systematic review that use statistical methods to combine results across several studies to to address specific questions rather than a broad over view
evaluation of logical conditions
alert, reminders, constraints; decision tables, event/condition/action rules, production rules
Leadership is about behavior
alignment of people and visions; trust, inspiration, attitude, decision making
Fagan Nomogram
allows you to determine the post test probability given the pre test probability and the LR+
Statistical errors:
alpha - the difference represents a chance event - the p value measures the probability that the results are by chance p <0.5; beta - there is a difference but none is detected - can happen with small sample size
curly braces problem
any encoding of clinical knowledge (such as a MLM) must be adapted to the local institution in order to use the local clinical repository. This hinders knowledge sharing. Arden explicitly isolates references to the local data environment in curly braces ["{}"] in a MLM.
NIST 2013 recommendations for usability:
application analysis, user interface expert review (2 people), user interface validation test
Constraints on the services provided by an information system
are non-functional requirements.
Hierarchical database
are optimized for rapid transactions of hierarchical data; every attribute about one thing; can only traverse the tree in one direction
Resource Utilization Groups (RUG)
are part of this process (mDS), and provide the foundation upon which a resident's individual care plan is formulated
workflow analysis and process redesign steps
assess current --> envision future --> plan/act --> evaluate outcome
highly reliable database transaction will be
atomicity, consistency, isolation, durability
Clinical computing and the law:
authentication, authorization, non-repudiation
compelling reasons for CDS
avoid errors, optimize quality, and improve efficiency in healthcare; (early detection, follow up management)
Physical security Measures
badges, data center closet, rfid in nursery, cameras, locks,
Bayesian statistics
based on Bayes theory- the probability of disease can be calculated based on the prior probability of the disease and the probaility of findings occuring in the disease (new information)
Imperative/Procedural Computer Programing
basic, fortran, pascal, c++; tasks and subroutines, sequenced instructions
Contract negotiations:
basis for long term financial and professional relationship; contract controls project, functionality, payments
Experimental errors:
bias or chance
classificaiton of knowledge based content
bibliogrpahic (medline and rss), full text, annotated (visuial dx, emb, utd), aggregations (medline plus)
primary goal of health information technology (IT) governance
business value, and to mitigate the risks Health IT Governance focuses specifically on health information technology systems, their performance and risk management. It is a subset discipline of Corporate Governance. The primary goal of Health IT Governance is to assure that the investments in Health IT generate business value, and to mitigate the risks that are associated with these capabilities. This can be done by implementing an organizational structure with well-defined roles for the responsibility of information, business processes, applications and infrastructures.
how does CDS aid in decision making
by providing relevant knowledge which is knowledge that is directly pertinent to specific patient
Organizational strategies for EHR safety:
care process transformation, pt safety, human factors, software safety, project management, continuous improvement
Comparative research:
chose a question/population, select a sample by randomization, determine variable to measure (dependent or outcome: measure distance; independent or predictor: explains difference), apply an intervention, results show truth or error
CCOW
clinical context object workgroup, single sign on
Applying EBM
clinical question that is pertient and answerable; identify evidence to address the question, critical appraise the evidence to see if it applies to the patient
Structured data entry
codified data is easier for retrieval and analysis, reduces ambiguity if language used consistently; more time consuming, requires exhaustive vocab, requires dedication to use by MD
Go live set up:
command center, user support teams, communication methods and plan, issue management, review downtime procedures, back out/remediation plan
change theory - Social Influence Theory
compliance, identification, internalization, conformity, obedience, and persuasion
systematic review
comprehensive, rigorous and unbiased review and synthesis of UTD evidence, provides the most reliable information to inform health practice
HCI:
computer science, behavioral science, psychology, design, human factors analysis
database management system (DBMS)
computer software that enables the user to create, modify, delete, and view the data in a database.
Assumptions of Bayesian stats
conditional independce of findings (no relationship between differnt findings for a give disease); diseases are mutually exclusive (only one disease); these are the limits of this method
DUA Date use agreement
conditions for use and sharing of data between organizations
hippa security rule 1, 2 - security is
confidentiality, integrity, availability
Medical center bylaws
covers content of the medical record, who can add and view it, timely completion
Metadata
data about data; the fact that a number is a an icd9 code is meta data; the vocabulary used for encoding the fact
re-engierring workflow steps
define, assess, prioritize, choose a method, assemble, map, revise, implement, measure
Change - Motivation
defined as the process that initiates, guides and maintains goal-oriented behaviors. According to Maslow, people are motivated by unsatisfied needs. At lower levels of Maslow's hierarchy of needs, such as physiological needs, money is a motivator; however it tends to have a motivating effect on staff that lasts only for a short period (in accordance with Herzberg's two-factor model of motivation). At higher levels of the hierarchy, praise, respect, recognition, empowerment and a sense of belonging are far more powerful motivators than money, as both Abraham Maslow's theory of motivation and Douglas McGregor's theory X and theory Y (pertaining to the theory of leadership) demonstrate.
ITIL
defines the organizational structure and skill requirements of an IT area and documents a set of operational management procedures to foster more effective management of an it operation and infrastructure
Predictiors of provider satisfaction with CDS
degree to which is supportive, patient specific, relevant, and provided in a way that doesn't interfere with care or require extra effort or time
Information system needs and analysis and selection process:
determine requirements, request for proposal, selection process, contract negotiations
What is the purpose of Enrollment Standards?
develops interoperable and secure standards and protocols that facilitate enrollment of individuals in federal and state health and human services programs.
probabilistic and data-driven classification or prediction
diagnosis, treatment selection, classification and prediction, EBM; Bayes theorem, decision theory, rock, data mining, logistic regression, leaf analysis, meta-analysis
heuristic modeling expert systems
diagnostic and therapeutic reasoning, nuances of the human expertise; rules-based systems, frame-based reasoning
UNII - code
drugs components and ingredients
production vs prodcedural processing of rules
each IF THEN rule is independent of of every other one and can be executed without regard to the execution state of any other rule
High Reliability
each patient receives teh best quality care, every time; high reliability organizatons (nuclear power, airlines); quality improvement methodologies; best for an organ to adopt a single methodology and use it system wide
There are three provisions of the Affordable Care Act that target health information technology:
enrollment standards, information technology demonstration program, and Centers for Medicare and Medicaid Services (CMS) computer system modernization
cognitive biases
errors resulting from systematic deviations from logic, probability or rational choice theory; errors from using information processing shortcuts called heuristics;
Qualitative research (subjective) measurements:
ethnography (observed), focus groups, usability studies, protocol analysis (ask users the think aloud)
inference engine
evaluates the available data and statements and chooses which statement to execute next; rules may be applied agaist data uisng forward or backward chaining
ECA
event condiiton action rule, used to represent expert knowledge in databases and in WWW programming; an event is defined that specifies when conditions should be evaluated
calculations, algorithms and multistep processes
execution of computational processes, flowchart-based guidelines in consultations, biomedical images signal processing; process flow and workflow modeling, guideline formalisms and modeling languages
ETL
extract, transform, load
FEMA
failure mode and effects analysis
Anchoring Biases
failure to adjust probability of a disease or outcome based on new information, akin to " premature closure; at sign at they said x
information retrieval
finding information/answering questions, taxonomies/ontology
backward chaining
finds rules that conclude the goal state; then it tires to which if these conditions (LHS) if any can be satisified by data; ex critque sytems
Management is accounting practices
focus on control and problems solving to get things done effectively; planning, use of organizational systems, appropriate communication methods
EHR optimization:
focus on features and functions that have been incomplete or sub-optimally adopted; review of workflow and tailored education. goal is to use the EHR to assist in meeting organizational quality, safety, and financial goals;
type of clinical questions handled best by EBM
foreground questions - ask for knowldge about managing a patient wiht a disorder (background questions use text books)
Change control
formal process used to ensure that changes to a product or system or introduced in a controlled and coordinated manner
Information technology infrastructure library
framework for IT service management, UK CCTA, no Microsoft
white box testing
full view on each side, test cases, ex code coverage; like internal hl7 testing by a developer; unit testing, integration testing
Knowledge Lifecycle
generation, validation, refinement, representation, update
positive predictive value of a test
given a positive test, the patient has the disease under consideration
five key factors associated with successful clinical information system implementation
having organizational leadership, commitment and vision; improving clinical processes and patient care; involving clinicians in the design and modification of the product; maintaining or improving clinical productivity; and building momentum and support amongst clinicians.
ability of Computerized Provider Order Entry (CPOE) to improve patient care in an ambulatory setting?
help reduce the callbacks to providers for getting explanations for orders from ancillary staff in regards to illegible/indistinct orders.
De-identified data
hippa - 18 identifiers that must be removed Names, all geographic subdivision smaller than the state (can use first three digits of zip if more than 20,000 people in that zip code) all elements of dates, telephone numbers, fax numbers, e-mail address, Social Security numbers, MRN, health benefit numbers, account numbers, certificate numbers, VIN and serial numbers, device identifiers and serial numbers, URL, IP, biometric identifiers, full face photographic images and comparable images, unique identifying number/characteristic or code
Stages of creating a standard:
identification, conceptualization, discussion, specification, early implementation, conformance, certification
Request for information
implies not contract will be awarded at the end of the process
Microevaluation:
individual components of a system vs the macro - whole
EBM is the intersection of
indiviudal clinician expertise; best external evidence, patient values and expectations
Partial interoperability methods
interfaces, paper/scan; reciprocal access, embedded applications, CCOW, new application combining data
Experiment validity:
internal - methodology must be sound by avoiding bias and chance error; external: results generalizable to the real world and clinical significant
Admin security Measures
internet use policy, pw mgmt., protect ssn, business associate agreement
nationwide health information network (NHIN)
interoperable information infrastructure that links various healthcare information systems together, allowing patients physicians, healthcare institutions, and other entities nationwide to share clinical information privately and securely; network of networks
Leadership is
interpersonal influence, exercised in a situation and directed, through the communication process, toward the attainment of a specified goal or goals
foreground questions can be categorized as
intervention - benefit of treatment of prevention dx - test dx disease harm - etiology or cause of the disease prognosis question is formulated using PCIO
Health Level 7 version 3 Clinical Document Architecture
is a document markup standard that specifies the structure and semantics of clinical documents. The intent of the HL7 version 3 is to provide an on ramp for adoption of coded data and interoperability, but to preserve the original clinical meaning and to preserve clinical information in a way that is backwards compatible with legacy systems and makes information accessible to clinicians even when interoperability between systems is absent.
Expected utility
is a function of value and also risk aversion, personal preferences and circumstances
Arden syntax
is a language used for representing and sharing medical knowledge
Diagnostic inference
is a problem of revising opinion with imperfect information
Efficacy:
is evaluation in a controlled research testing
The Minimum Data Set for Long term care
is part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems
recall - in information retrieval
is the fraction of the true relevant documents that are actually retrieved (equal to sensitivity or true positive rate)
Model Decision
is the sum of the conditional probabilities Conditional Probabilities - probability of x given y P (x | Y)
object oriented programming
jave, objective-C, visual basic, .NET; collections if interacting objects
benefits of clinical algorithms
knowledge is explicit and easy to encode
scoring and heuristics knowledge representation
knowledge is represented as findings that occur in diseases; most scalbel, measures of improtance and frequence for each finding ex Internist 1/QMR, Dxplain; use Bayesian algorithm for diagnosis of the condition (DX plane, Isabel
high level programming languages are
less efficient than low level
system integration:
linking subsystems in software architecture - combination of software, hardware, interface skills; vertical/star/horizontal (enterprise server bus)
Precede - Proceed Model
look at the quality of life, health, lifestyle, environmental, predisposing, reinforcing, enabling - once you identify these factors; you then make the change; proceed with regulatory; evaluated
HIT governance strategies address specific needs:
managing change, clinician focused benefits, clinical knowledge base content, care processes by physicians/clinicians, communication, training and support, vendor system design
foward chaining inference
matches the left hand side or condition part of an in-then statement, executes matches until a goal state is achieved; clinical algorithgms, uses a precribed path
format for transmission of a clinical document from one healthcare provider organization to another is governed by what type of standard:
messaging standards.
provide data for decision analysis
meta-analysis is commly used for this
Interface engine
middleware application used to transform, route, clone, translate messages
Voice Recognition issues
missing terms, errors, suffix errors, added/deleted words,
forumlating the research question
most critical step in any systematic review or meta-analysis; iterative process, compromise to create a question that is answerable by avaliable evidence
Buxton's three state model of graphical input
mouse is out of range, tracking, dragging
NDF-RT
national drug file reference terminology, va , mechanism of action, physiological effect, structural class
regression
new feature breaks an old feature
limitations of clincal algorithms
no accounting for prior results, inability to puruse new treatmetns, causes, new knowledge difficult to generate
SWOT is a form
of needs assessment
data normalization uses techniques
of structuring tables to reduce redundancy and dependency between tables;
data extraction is a systematic review
often 2 people to reconcile discrepancies; need for subjective judgement in the data collection contributes to the bias
black box testing
only see one side, use testing; specification testing - only know if test script passed or failed; system testing -- testing against requirements; acceptance testing (user validation)
Quality Data Model
ontology for quality measurement in healthcare. The organization responsible for administering the information model is the: National Quality Forum (NQF)
Protocols are made of
order sets
RFP - request for proposal includes
organization description, functional/technical/business needs, timing and implementation requirements, vendor selection process, conform to organizational requirements, financial issues
Representativeness Biases
overestimating rare diseases by matching patients to "typical picture" of that disease; (no zebras); ? insensitive to pretest probabilities
Availability biases
overestimating the probability of unusual events because of recent of memorable instances
Availability heuristic is
overestimating the probability of unusual events because of recent or memorable instances; that ease at which one can recall similar events
Decision Making in health care
patient needs and values should drive variation in care, care based on continuous healing relationship, pt as a source of control, shared knowledge, anticipation of needs, evidence based decision making
Style of programming effects
performance, maintainability, memory requirements, length of code
A work breakdown structure is used in which phase of a project
planning - defined groups discrete work elements in a way that helps organize and define the total work scope of the project
System implementation plan:
pm, budget, external audit, testing, training, support, transition plan
CER Comparative effectiveness research -
practice-based research, attempts to link research with clinical practice using clinical data warehouses
Post-test odds
pre-test odds x likelihood ratio
database prediction: data mining and machine learning
probabilistic decision-making is critically depend on the nature of the data, well structured is better to allow precise retrieval - statistical techniques, fuzzy logic, prediction and artificial intelligence is used - example is golden jewel for evaluation of chest pain, CICU
Value induced bias
probability of an outcome based on value associated with that outcome (would be horrible to miss a brain tumor)
the probability of disease given a positive test
probability of positive test given disease x probability of disease / probability of a positive test = sensitivity x prior probability/ probability of true positive + probability of false positive P (A|B) = (P(B|A)* P(A))/P (B)
CDS decision rules representation
production rules and procedures pg 267
Loinc codes specify
property, time, specimen, method for a test
Subjectivist:
qualitative, interviews, interactions between people, general themes
data collection methods
qualitative, quantitative, interviews, focus groups
observational data collection for workflow analysis
quantitative - operational systems, observers - counting qualitative - ethnographic observation
objectisvt
quantitative research, measure, comparative; deaths, surveys
default anlaysis method for comibing studies in a meta-analysis
random effects model
Chance:
random error
Relative Risk (RR)
ratio of the probability of an event in an exposed group to the probability of an even in an unexposed group
Effectiveness:
real world, outcomes research
ROC Curve
receiver operating characteristic
CDS effectiveness
recommendations at the moment of decision are the most effective study: can decrease prescribing errors, unsure if can prevent ADE's
Benefits of order sets:
reduce entry time, reduce errors on ordering, increases completeness of orders and built ins evidence driven care, reduce variability in process/follow best practices
Post-Coordination of snomed refers to
refers to linking SNOMED Terminology with another terminology system.
Blois's funnel
refers to refining the diagnosis over the course of the interaction
likelihood ratio
reflects both the sensitivity and specificity in a single test; the LR + and - are published for signs, symptoms, and tests
Adv of production systems
representation of knowledge is independent of the control knowledge used needed to operate the CDS; can be aquired/maintained/shared
BAA Business associates agreement
required by hippa associate that have access to phi
Hicks-hyman law
response time based on number of choices, response to hierarchal menus
5 Rights of CDS (Osheroff)
right information, person (target), format, channel (mode), time (wf integration)
network topolgies
ring, mesh, star, flly connected, line, tree, bus
six health care quality demensions
safe, effective, efficient (avoid waste), equitable, pt centered, timely
attributes of high quality healthcare:
safety, effectiveness, patient centered emphasis, timeliness, efficiency, and equitable
agile:
scrum and extreme programming; highly flexible; scope --> define --> develop --> evaluate
HIPPA Security Rule Admin safeguards
security management process to reduce risk and vulnerabilities, security personnel response for developing a looming security policies, information access management minimum access necessary to perform duty, workforce training and management, evaluation of security policies and procedures
RXNorm
semantic structure for formulations and their components; clinical drugs
Snout
sensitive tests allow you rule out a condition; sensitive tests are good for screening, minimize false negatives, you can trust a negative test
Positive likelihood ratio (LR+) =
sensitivity /1-specificity = TPR/FPR
recall
sensitivity is eqivalent in information retrieval
modes of failure can be risk prioritized based on
severity, frequency of occurence, detectability
Spin
specific tests allow you to rule a condition in; good for confirmation, minimize false positives, you can trust the positive test
key lifecycle phases in the software development process
specification, implementation, iteration, and maintenance.
File formats
specify the way the data are organized within the file; common formats allows sharing, example JPEG wav
Limitations of disease registries
standardizing data elements among disparate disease registries, uniform method for patient education, systems and linking registries with the HR's, standardizing methodologies for statistical analysis, ensuring high clinician participation, guaranteeing registries sustainability, clinical and administrative claims data should be combined into the registry, the need to manually input data for some registries, the need for accurate coding, the need for frequent updating, the need for additional staff to maintain a registry
Errors of chance are minimized by
statistical analysis
associative groupings of elements
structured data entry, structured reports, order sets; report generators, document construction tools, document architectures, templates, markup language, ontology tools
Scripts:
structured simulations of workflow and system use that can reproducibly be used for testing versions of proposed production version
sources of medical evidence
studies --> syntheses (SR) --> synopses/summaries (text books, collections) --> systems (rules, orders sets) = actionable knowledge
Downtime:
system not available to a significant group, significant functions not available, performance degrade below usable
Bias
systematic error introduced by the experiment; selection, measurement, confounders; a systematic difference in outcome between groups that is caused by a factor other than the intervention in the study
used to describe a knowledge domain
taxonomy and ontology
driving forces for CDS adoption
technology imperative, knowledge explosion, new technologies for diagnosis and treatment, assimilating discovery and knowledge, the Internet society, empowerment of the patient and consumer, medical errors, variability in quality/access and adoption of best practices, EHRs, aging population and increase complexity of disease, doctors have less time/more pressure, fragmentation, defensive medicine, healthcare costs, pay-for-performance, demonstrated benefits, top-down initiatives from the government
health information exchanges (HIE's)
the "seamless exchange of health information across disparate organization"
Statistical power:
the ability to detect a statistically significant difference
department of health and human services (DHHS)
the cabinet-level federal agency that oversees all the health and human services-related activities of the federal government and administers federal regulations
Operations duties:
the day to day running, maintenance, enhancement and safeguarding of the system to meet the availability and reliability requirements
precision
the fraction of true relevant documents in the set of all possible documents retrieved, analogous to the positive predictive value
A communication is deemed successful when
the intended meaning is preserved from sender to receiver, communication is a process of transmitting information and information is the message, communication can have an effect on the message itself and on the message effectiveness
From a statistical perspective, the sensitivity of a test describes the likelihood that
the patient under consideration for having a disease has a positive test.
Computer based CDS
the use of the computer to bring relevant knowledge to bear on the healthcare and well-being of the patient, computer is information and communication technologies
What is a ROC Curve used for
the visual representation of the tradeoff between sensitivity and specificity; Graph of sensitive vs 1-specificty (TPR vs FPR)
Change control Planning
those making the change are expected to test changes, understand impacts, notify users, and minimize unexpected side effects
Database classes
tier I, II, III, IV
KLM (keystroke level model)
time to task completion is a sum of the keystrokes
IOM recommends workflow analysis
to improve healthcare quality, efficiency, effectiveness, safety
why do systematic reviews use a protocol for review
to minimize bias
Best Screening Test
try to minimize false negatives, high true positive rate - is highly Sensitivity; SNOUT
Best Confirmatory test
try to minimize false positives, high true negative rate - high specificy; SPIN
Pt identifiers
unique, non-disclosing phi, permanent, ubiquitous, canonical (each person has only one), invariable (no change over time)
taxonomy
use of a hierarchical classification of controlled terms to provide a conceptual framework for domain of interest, organization, analysis, or information retrieval; example mesh
deterministic reasoning
use of branching logic and deduction against the information of a particular situation to arrive at a plan of action
LEEDS abdominal pain system 1975
used Bayseian approach for diagnosis, was good but not transportable
ontology
uses a controlled vocabulary to formally represent concepts that describe objects and the relations among them; use richer semantic relationships then taxonomies, more formal rules and constraints about how terms are defined in relations are specified; allows synonyms
evidence based practice
using EMB to answer questions about intervention (treatment)
Downtime procedures:
workflow, data access, prep, back loading from paper Unexpected downtime - focus on getting up and not fixing the issue, involve vendor early, do a post mortem for root cause
Usability errors
wrong pt, wrong mode for action (wt vs non sig), inaccurate data display, incomplete data display, nonstandard terminology, reliance of user recall, inadequate feedback, corrupted data
ICD 9 format
xxx.xx - The first three digits represent the category, the next to represent the etiology, anatomic site, manifestation
ICD 10 format
xxx.xx xE - First portion represents the category, the second portion the etiology, and the last character the extension which represents the anatomic site or severity
types of cogntiive biases
• Availability • Representativeness • Anchoring • Value induced bias
components of clinical decision support:
• decision model - formula, Boolean conditional expression • knowledge base - logical and probabilistic • information model • results specification • application environment
principal methodologies for clinical decision support
• information retrieval - finding information/answering questions, taxonomies/ontology • evaluation of logical conditions - alert, reminders, constraints; decision tables, event/condition/action rules, production rules • probabilistic and data-driven classification or prediction - diagnosis, treatment selection, classification and prediction, EBM; Bayes theorem, decision theory, rock, data mining, logistic regression, leaf analysis, meta-analysis • heuristic modeling expert systems - diagnostic and therapeutic reasoning, nuances of the human expertise; rules-based systems, frame-based reasoning • calculations, algorithms and multistep processes - execution of computational processes, flowchart-based guidelines in consultations, biomedical images signal processing; process flow and workflow modeling, guideline formalisms and modeling languages • associative groupings of elements - structured data entry, structured reports, order sets; report generators, document construction tools, document architectures, templates, markup language, ontology tools
heuristic modeling and expert systems
• these simulate human expertise and reasoning processes • need these because in some settings you don't have enough data to use an probabilistic approach •these systems can explain their conclusions and be understandable to humans •examples -rule-based systems - individual logical statements in the form of production rules; rules determine if they should fire based on interference engine; 1975 MYCIN system (certainty factors); rules-based command executed and bottom-up (forword chaining) or backward chaining -frames or attributes; internist-1, QMR
probabilistic and data-driven classification or prediction
• updating probabilities based on evidence - Bayes theorem • decision analysis - formal methodology a statistical decision theory, Howard Raiffa; user decision tree circles equal chance squares equal decision nodes, used primarily for policy analysis and the formulation of guidelines and rules, allows you to lay out the sequence of decisions of possible outcomes eight steps of the decision-maker can focus on critical variables such as the probability of various branches the cost or risk of treatment; uses a fullback analysis • Bayesian belief networks
CDS methodology information retrieval
• used to find information, answer questions • can be user initiated such as searching MEDLINE or automated/semi automated such as infobutton • can be taxonomy/ontology based (controlled vocabulary, consisting of terms by which the concept has been pre-indexed) or text based --- more complicated expressions using term indexed resources can be done using Boolean expressions comprise the logical combinations of terms; hierarchical - so the higher levels room can be used to conotate the desire to explode the subtree into lower terms
CDW, Clinical data warehouses
- a shared database that collects, integrates, and stores clinical data from a variety of sources here the data is associated with metadata; they are designed to support queries about groups versus EHR's are designed for efficient real-time updating retrieval of individual data. Ex I2B2 at Harvard, Informatics for integrating biology at the bedside
five key factors associated with successful clinical information system implementation?
- organizational leadership, - commitment and vision; improving clinical processes and patient care; - involving clinicians in the design and modification of the product; - maintaining or improving clinical productivity; - building momentum and support amongst clinicians
1962 Everett Rogers diffusion of innovations
-- Innovators (2.5%) or so motivated they may need to be slowed down -- early adopters (13.5%) except the new changes and teach others -- early majority adopters (34%) will acquire some motivation and information from others in order to adopt -- late majority (34%) require encouragement to get them to eventually accept the innovation -- laggards (16%) require removal of all barriers and often require a direct order
Bridges to excellence
An organization consisting of employers, physicians, health plans and patients. Multiple care recognition programs incentivized by bonuses.
HIE
The electronic movement of health related information among organizations according to nationally recognized standards
Why is informatics hard
Because medicine does not contain strictly form (data)-based problems, it is difficult to reduce recognizing a sick patient into data so it's much more difficult capture computationally; Biomedical information is imperfect: incomplete information (potentially obtainable), uncertain information (can't objectively determine true or false), imprecise information, vague information, inconsistent information; a computer would have to be explicitly programmed to make judgments based on these variances
US Ethical Code
Code of fair information practice - no secret record-keeping, ability to prevent information to be used for another purpose, must use the data for the purpose for which it was gathered Belmont report 1979 - respect for persons, do no harm and maximize possible benefits, justice common rule - federal policy for the protection of human subjects 1991- informed consents, compliance, IRB's
Historical highlights
ENIAC first general-purpose computer 1946, 1980s IBM personal computer, computer from medical diagnosis hypotheses Ledley and lusted 1950s, MUMPS (programming language) from Massachusetts General Hospital 1970s - va, epic; 1960s France the term medical informatics, 1960s medline; artificial intelligence medical projects MYCIN (Stanford), INTERNIST-1 (University of Pittsburgh) 70-80's; Internet 1969 network of networks consisting of hardware and software that connects computers, 1968 as the result of a research activity funded by the Advanced Research Projects Agency (ARPA) - depart of defense, World Wide Web 1990 is a protocol supported by the Internet, first web browser Mosaic 1993; EHR 1970s and recommended by IOM 1991, PalmPilot 1996, 2003 human genome project completed, nationwide health information network concept developed in 2004
Barriers to EHR adoption
Financial barriers, physician resistance, loss of productivity, workflow changes, usability issues, integration with other systems, lack of standards, privacy concerns, legal aspects, inadequate proof of benefits
Why the government wants HIE
HIE is essential to improve: - the disability process - continuity of medical care issues - bio surveillance - research and natural disaster responses Electronic transmission of data is faster and less expensive than paper transactions
Informatics - why?
Health information technology provides the tools to generate information from data that humans can turn into knowledge and wisdom. Enabling and improving human decision-making with usable information is a central concern of informatics
Knowledge
Information that is justifiably considered to be true; Critical use of knowledge to make intelligent decisions is wisdom; relationships/fact/assumptions/ derived from formal or informal interpretation of data
Semantic gap
The difference between data and information is meaning (semantics) - the so-called semantic gap; There is a large semantic gap between health status and health information.
minimum data set for long term care (MDS LTC)
a federally mandated standard assessment form that medicare and/or medicaid certified nursing facilities must use to collect demographic and clinical data on nursing home resident includes screening, clinical, and functional status elements
essential medical data set (EMDS)
a recommended data set designed to create a health history for an individual patient treated n an emergency service
health plan employer data and information set (HEDIS)
a set of performance measures developed by the national commission for quality assurance that are designed to provide purchasers and consumers of healthcare with the information they need to compare the performance of managed care plans.
data definition language (DDL)
a special type of software used to create the tables within a relational database, that most common of which is structured query language
data manipulation language (DML)
a special type of software used to retrieve, update, and edit data in a relational database, of which the most common is structured query language
entity relationship diagram (ERD)
a specific type of data modeling used in conceptual data modeling and the logical level modeling of relational database.
database life cycle (DBLC)
a system consisting of several phases that represent the useful life of database including initial study, design, implementation, testing and evaluation, operation, and maintenance
objective oriented database (OODB)
a type of database that uses commands that act as small, self-contained instructional units that may be combined in various ways
national health information infrastructure (NHII)
an infrastructure proposed by the national committee on vital and health statistics in 2002 that would be a set of technologies, standards, applications, systems, values, and laws that support all facets of provider healthcare, individual health and public health.
enterprise content management (ECRM)
systems that enable scanning and indexing of paper documents and other content in digital form