ι 11

Progress towards interoperability Progress towards interoperability standards for anesthesiology standards for anesthesiology

HL7 UK 2007 Conference – Making Interoperability Work

November 22nd, 2007

Martin Hurrell, Terri Monk, Andrew Norton, Melvin ReynoldsMartin Hurrell, Terri Monk, Andrew Norton, Melvin Reynolds

APSF - DDTF / IOTA, HL7 SIGGAS, AMS ConsultingAPSF - DDTF / IOTA, HL7 SIGGAS, AMS Consulting

ι 22

Anesthesiology: Anesthesiology: what are the drivers ?what are the drivers ?

• The anesthetic recordThe anesthetic record— Medico-legalMedico-legal

— ‘‘On-line’ documentOn-line’ document

— Audit & researchAudit & research

• Data sharingData sharing— Common record structureCommon record structure : to identify clinical context: to identify clinical context

— Common terminologyCommon terminology : for aggregation and analysis: for aggregation and analysis

— Common modelCommon model : to enable AI applications, : to enable AI applications, reasoning and decision reasoning and decision

supportsupport

ι

Good news ….Good news ….

33

ι 44

APSF Commitment to AIMS SystemsAPSF Commitment to AIMS Systems

“ The APSF endorses and advocates the use

of automated record keeping in the

perioperative period and the subsequent

retrieval and analysis of that data to

improve patient safety ”

APSF Board of DirectorsOctober 2001

ι

… … and bad news ….and bad news ….

55

ι 66

Anaesthesia Information Management Anaesthesia Information Management Systems(AIMS)Systems(AIMS)

• Only installed in 3-5% of US hospitalsOnly installed in 3-5% of US hospitals

• Similar picture in the UKSimilar picture in the UK

• We expect universal implementations in the UK as We expect universal implementations in the UK as part of the National Clinical Records Service (NCRS) … part of the National Clinical Records Service (NCRS) … but the time scale is unclearbut the time scale is unclear

• Creating a data dictionary involves a long Creating a data dictionary involves a long implementation path and significant costimplementation path and significant cost

• Every implementation seems to have its own data Every implementation seems to have its own data dictionarydictionary

• The “not invented here” syndromeThe “not invented here” syndrome

ι

But more good news …But more good news …anesthesia records are anesthesia records are structuredstructured

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ι 88

Intra-operative recordIntra-operative record

• Device monitoringDevice monitoring— Fresh gas flow, concentration of inspired agent(s)Fresh gas flow, concentration of inspired agent(s)

• Physiological dataPhysiological data— BP, HR, SpOBP, HR, SpO2, 2, Temp, ventilation (and many others)Temp, ventilation (and many others)

• Drugs and fluidsDrugs and fluids— Bolus and infusion drugs, blood productsBolus and infusion drugs, blood products

— Anesthetic agents, resuscitation drugsAnesthetic agents, resuscitation drugs

ι 99

Demographics(highly structured)

Drugs and vital signs

(highly structured)

Case Events

(??unstructured)

ι 1010

ι 1111

Foundations for future AIMSFoundations for future AIMS

Ontology: domain model

Schema: record structure

Terminology

ι

TerminologyTerminology

1212

… … some issues …some issues …

ι 1313

Multicenter study of factors related to tourniquet injuries

9 0254 Tourniquet time (mins): 454

Hospital A

102 Tourniquet interval (mins): 102.5

Hospital C

T1 Tourniquet off-tourniquet on (mins): 01Ae2

Hospital B

ι 1414

Relevance of a Data DictionaryRelevance of a Data Dictionary

Used by APSFUsed by APSFCorporate partnersCorporate partners

SNOMED CT

DDTFReference

set

The terms are mapped/linked to an

existing wider body of work …

which is adopted by the medical community

AnesthesiaSubset

DDTFReference

set

ι 1515

The October 2007 termsetThe October 2007 termset

• General anaesthesiaGeneral anaesthesia

• Local anaesthesiaLocal anaesthesia

• Vascular access Vascular access proceduresprocedures

• Attributes and modifiers Attributes and modifiers for proceduresfor procedures

• Anaesthetic drugsAnaesthetic drugs

• Fluids and blood Fluids and blood productsproducts

• Monitoring termsMonitoring terms

• Anaesthesia equipmentAnaesthesia equipment

• Airway management Airway management

• Some administrative Some administrative terminologyterminology

• Scales and assessments Scales and assessments relevant to anaesthesiarelevant to anaesthesia

• Positioning and patient Positioning and patient protectionprotection

… around 3,500 terms

ι 1616

x73 Nomenclature & IOTA x73 Nomenclature & IOTA ontology / terminologyontology / terminology

• ““the Systematic Name is an <n>-tuple of a Base the Systematic Name is an <n>-tuple of a Base Concept and a series of Differentiating Criteria”Concept and a series of Differentiating Criteria”

• IOTA develops and maintains its ontology in OWL DLIOTA develops and maintains its ontology in OWL DL

• IOTA aims to use the x73 base concepts and IOTA aims to use the x73 base concepts and associated 1associated 1stst., 2., 2ndnd. And 3. And 3rdrd. level differentiators in its . level differentiators in its device and measurement ontologydevice and measurement ontology

• Concept names will use the x73 ‘Common Term’ and Concept names will use the x73 ‘Common Term’ and the associated description will be the x73 the associated description will be the x73 ‘Description / Definition’ – optionally, synonyms may ‘Description / Definition’ – optionally, synonyms may be definedbe defined

• x73 Differentiators will be properties of IOTA conceptsx73 Differentiators will be properties of IOTA concepts

ι 1717

The next stagesThe next stages

• Completion of pre operative assessment terminologyCompletion of pre operative assessment terminology

• Terms to support NSQIP (National Surgical Quality Terms to support NSQIP (National Surgical Quality Improvement Program)Improvement Program)

• Specialized terms necessary for anaesthesia Specialized terms necessary for anaesthesia subspecialties e.g.subspecialties e.g.

— Cardiothoracic, Obstetrics, Neurosurgery, etc.Cardiothoracic, Obstetrics, Neurosurgery, etc.

• CDA compliant schema for the anesthetic record CDA compliant schema for the anesthetic record

• Alignment of device terms with ISO 11073Alignment of device terms with ISO 11073

ι 1818

Current schema-related workCurrent schema-related work

• Development of use casesDevelopment of use cases

• Modelling of national business practices Modelling of national business practices

• Evaluation of current artefactsEvaluation of current artefacts

• Liaison with NSQIP on requirementsLiaison with NSQIP on requirements

ι 1919

Gardner M., Peachey T. A Standard XML Schema for computerised anaesthetic records. Anaesthesia, 2002, 57, pp1174-1182

ι 2020

CDA Anesthesia record

ImagePicture

ImageDICOM, JPEG

Waveforme.g. ECG

MFER

Monitoringmeasurement

X.73

LAB

With thanks to Masaaki Hirai, Nihon Kohden

ι

Outcomes research with AIMSOutcomes research with AIMS

2222

ι 2424

ObjectivesObjectives

• Why are we even bothering to do outcomes Why are we even bothering to do outcomes research?research?

• What are the opportunities?What are the opportunities?

• Why now do we want to look at anesthetic Why now do we want to look at anesthetic data?data?

• Why is it so hard and why have so few people Why is it so hard and why have so few people done meaningful research in this area? done meaningful research in this area?

ι 2525

National Surgical Quality National Surgical Quality Improvement DatabaseImprovement Database

• 2003 IOM report “2003 IOM report “Patient Safety, Achieving A New Standard of Care”— national health care infrastructure is needed to “capture

patient safety information as a by-product of care and use this information to design even safer delivery systems.”

• ACS NSQIP is already capturing information on preoperative patient risk factors, surgical factors, and adverse events following surgery

ι 2626

National Surgical Quality National Surgical Quality Improvement DatabaseImprovement Database

In November 2003, the Institute of Medicine (IOM) released a report entitled, Patient Safety, Achieving A New Standard of Care. In this report, the IOM stated that a national health care infrastructure is needed to “capture patient safety information as a by-product of care and use this information to design even safer delivery systems.” The American College of Surgery National Surgery Quality Improvement Program (ACS NSQIP) program is already meeting one of the IOM recommendations by capturing information on preoperative patient risk factors, surgical factors, and adverse events following surgery. However, the effects of anesthetic management on postoperative outcomes remains unclear largely because the nearly universal method for the documentation of anesthesia has been the paper anesthesia record completed in pen by the anesthesia provider. In recent years, Anesthesia Information Management Systems (AIMS) are being implemented in operating rooms so that accurate intra-operative hemodynamic and anesthetic management information can now be automatically collected. But, the lack of standards in both terminology and record structure prevents the transfer of intra-operative anesthesia data from AIMS into outcomes databases. The creation of a standard terminology and record structure is an essential requirement to support the movement of intra-operative data from AIMS into outcomes databases.

ι 2727

Which data from the anesthetic record Which data from the anesthetic record should we collect?should we collect?

• ““Half the money I spend on advertising is Half the money I spend on advertising is wasted: the trouble is I don’t know which half”wasted: the trouble is I don’t know which half”

John WanamakerJohn Wanamaker

• In 5 year’s time it is too late to say ‘we should In 5 year’s time it is too late to say ‘we should have collected X & Y, they’re beginning to look have collected X & Y, they’re beginning to look important’important’

• Measure twice, cut once – have a sound plan, Measure twice, cut once – have a sound plan, be standards-based and model future be standards-based and model future requirements not just those for the short-term requirements not just those for the short-term

ι

Outcomes research in anaesthesiaOutcomes research in anaesthesia

• Research based on AIMS Research based on AIMS — Is almost universally restricted to examination of Is almost universally restricted to examination of

physiological variablesphysiological variables

— Current lack of structure and standardisation of records Current lack of structure and standardisation of records and terminology does not support outcomes researchand terminology does not support outcomes research

TechniquesTechniques ProceduresProcedures Therapeutic regimens and drugs etc. etc.Therapeutic regimens and drugs etc. etc.

2828

ι 2929

Reports that say that something hasn't happened are always interesting to me, because as we know, there are known knowns; there are things we know we know. We also know there are known

unknowns; that is to say we know there are some things we do not know. But

there are also unknown unknowns - the ones we don't know we don't know

Which data from the anesthetic record Which data from the anesthetic record should we collect?should we collect?