Information Technology Reference
In-Depth Information
The exchange of these electronic documents shows the potential of information
technology to transform and expedite processes. Today, in most offices, the process
of sending clinical data for purposes of a patient referral would involve pulling a
paper chart, making a copy and either faxing that copy or mailing it to the office to
which the patient is being referred. The referring office would then reverse the pro-
cess. This involves costly and error prone manual processing at both ends. Moreover,
the information is in a form that is basically useful only for reading.
The digital process, at least using DIRECT, is essentially free and virtually error
proof. Moreover, the information, once received, can be combined with other digital
clinical information to help the receiving physician make correct, safe and appropriate
clinical decisions.
The applications of this technology aren't limited to provider referrals. Some
commercial systems already use a variation on this approach to support care coor-
dination across practices, the management of populations of chronic disease patients,
and the delivery of care against quality metrics across an entire health system. We
will see some examples of this in
Chapter 5
.
Beyond Data and Interoperability
Even the most sophisticated coding systems don't deal with the issue of the “clinical
logic” - relationships among data elements or linking those relationships to current
medical knowledge. For example, a chronic disease patient might have 6 problems
coded in ICD-9, they might be on 12 medications and they might have recently had
10 laboratory tests and 3 imaging studies done. No existing coding system provides
specific support to indicate what medications, laboratory tests and imaging studies
were done for each of the patient's problems and why they were done.
As we've said, Larry Weed's solution is that the provider should specifically
indicate these relationships as part of charting. His Problem Oriented Medical
Record (POMR) uses the acronym SOAP to indicate this. The provider should indi-
cate the
S
ubjective and
O
bjective data supporting each
A
ssessment (problem). They
should also indicate the
P
lan for dealing with that problem. In a computerized ver-
sion of a SOAP record these relationships might then be explicit. Realistically, how-
ever, that is not terribly common. An underlying informatics structure that can infer
these links is probably needed.
For the past few decades Dr. Weed has been working on his own approach to
linking medical knowledge to structured records which he calls Problem-Knowledge
Couplers. [
27
] Obviously this is greatly facilitated if the underlying medical data is
coded and if the clinical relationships are explicit. Achieving this, without reducing
physician productivity, is a long standing problem.
Another issue is standards of care. Ideally complex research that reveals best
medical practices should itself be described in some standard form so all EHRs
could more easily use it. Work supported by IBM over many years at Columbia
University developed such a framework, the Arden syntax. [
28
] It is an arti fi cial
