Guest Blog: Collective Clinical Wisdom by Heather Leslie

I'd like to invite and encourage all clinicians to register for the openEHR Foundation's new Clinical Knowledge Manager (CKM) - found online at www.openehr.org/knowledge.

CKM is an international repository for openEHR archetypes and has two primary purposes - that of archetype publication and archetype governance. It is a real opportunity for clinicians to collaborate and agree on clinical content definitions for publication and use in our electronic health records.

openEHR archetypes are open source, computable specifications that define clinical information about a single and discrete clinical concept. For example there are separate archetypes defining a 'symptom', 'diagnosis', 'blood pressure', 'medication order', and 'risk of disease based on family history'.

As structured and standardised definitions of clinical content, archetypes are increasingly being recognised as fundamental building blocks of electronic health records, especially when integrated with clinical terminologies such as SNOMED CT. If we all start to record information based on the same archetype, then we can meaningfully and unambiguously share health information between systems, and we start to query that information across systems.

A primary goal of CKM is to encourage a broad range of clinician input to make sure that the clinical content in each archetype is correct. Absolutely no openEHR experience is necessary to participate in CKM, although we anticipate you will learn about openEHR as part of the journey. All participation is purely on a volunteer basis, and you can opt out at any point.

Whilst CKM is still in its relatively early days, we are already seeing the benefits that contributions by grassroots clinicians are bringing to the archetypes currently undergoing team review. Technically oriented openEHR experts support the review process to provide guidance on design and implementation issues, so there are no unrealistic expectations of the clinicians. Contributions of clinical and technical nature are equally and gratefully received;-)
By design, each archetype contains all the relevant information about the specific clinical concept - a maximal dataset which can be used in all clinical scenarios. So, for each archetype we are seeking a range of views from a variety of:

- professions - including every type of clinicial expert;
- geographical locations - to make sure we can capture diverse clinical and cultural practice; and
- knowledge domains - from general healthcare to all specialist areas.

Please actively 'adopt' the archetypes that you would like to be involved in. This will ensure that you will be invited to participate in the review of archetypes that are of interest to you. At other times you may also be invited to participate in a review where we consider that your expertise might provide balance out the current team of reviewers.

While we will strive to achieve maximal datasets for each archetype, we are pragmatic and know that we won't get it 100% right - certainly not at first try. However, I suggest that a small group of 3-4 clinicians with complementary skills and appropriate expertise can create and develop a draft archetype to approximately 80-85% complete. Further review within CKM by a team of clinicians from a range of professions, countries, institutions, research, and health domains will contribute and refine the archetype further - maybe this still will only get it to 90% complete; but maybe much more. Our experience to date shows that maximal datasets are much easier to agree on than minimal datasets!!

Over time it will be interesting to see how the models evolve - no doubt a good research topic!

Obtaining agreement on clinical content within archetypes in this manner is a significant achievement, even if in retrospect we find they are not 100% complete at the start. The flow-on benefits that come from sharing a standardised set of clinical specifications for EHRs can potentially transform some eHealth initiatives and is a necessary foundation for the truly sharable electronic health record.

So, all clinicians are welcome to get involved in CKM - we will certainly set you to work very quickly! We expect that by contributing domain expertise and insights, clinicians will also benefit personally by gradually developing openEHR understanding and expertise as part of the experience.

And then of course, there is also the contribution to the good of mankind... ;-)


[Instructions for registering can be found at: www.openehr.org/wiki/display/healthmod/Registration+in+CKM]‎ Full story...

Guest Blog: The War Being Waged Against Hospital Acquired Infections by Thomas Cherry

Warning: You May Find The Statistics You Are about to Read Alarming

One in every 20 hospital patients contracts an infection unrelated to their primary condition during a hospital stay, adding up to approximately two million people each year.

According to estimates from the U.S. Centers for Disease Control (CDC), hospital acquired infections (HAIs) claim the lives of approximately 90,000 patients annually, a number greater than breast cancer and auto accident deaths combined.

While these statistics are certainly alarming, the good news is that hospitals across the globe are stepping up their infection prevention initiatives and the war against HAIs is heating up. Dirty hands, inadequately cleaned equipment and lax procedures are all contributing to the dilemma and have become the subject of the infection prevention initiatives. In the U.S., a variety of organizations, including the CDC and the Institute for Healthcare Improvement (IHI), have put forth guidelines and campaigns designed to assist hospitals and medical centers in reducing infection rates. To date, these initiatives have made a significant impact on national infection rates.

Compelled by this growing awareness of HAIs, healthcare facilities are now paying more attention to one of the most fundamental HAI prevention measures – the practice of proper hand hygiene.

Over time the emphasis placed on hand hygiene has emerged and progressed. Today the debate over cleansing hands with soap versus antiseptic agents has pursued, but the underlying stress on hand hygiene cannot be denied. Not only does the implementation and execution of accepted hand hygiene practices reduce the potential risks of transmitting infections from caregivers to patients, it also protects health care workers from obtaining infections caused by microorganisms acquired by the patient.

As infections are most often transmitted through the contaminated hands of health care workers, hospitals must ensure that their staff is fully educated on the importance of hand hygiene compliance and that barriers to achieving hand hygiene are adequately eliminated. Basic hand washing involves cleansing hands with soap and water. Antiseptic cleaning agents used in conjunction with diligent hand washing can also assist in combating bacteria. New guidelines developed by the CDC and infection control organizations recommend that health care workers use an alcohol-based antiseptic to routinely clean their hands. When water is not available waterless antiseptic agents can be applied to hands. However, if hands are visibly soiled soap, which could contain an antiseptic agent, and water are recommended.

In healthcare settings, patient needs are paramount and as a result, hand washing initiatives may fall behind in priority of care in an emergency situation. As one would also expect, caregivers are often pressed for time and in these busy healthcare facilities pressure situations tend to decrease compliance. This is especially true in facilities that are overcrowded or understaffed, as this environment could keep health care workers from taking the proper hand washing precautions.

Additionally, there are health care workers who forget the guidelines or who are not even aware of these recommendations. In this case, educational materials posted around facilities can inform, remind and inspire compliance through emphasizing the value of and support for adherence. Promotional and “watchdog” programs and incentives can also serve to establish expectations and encourage observation of best practices.

In addition to proper hand hygiene, other methods can be used to help improve infection rates. One method is the use of gloves during patient care. However it is important to note that gloves should never serve as a substitute for proper hand hygiene practices. Another essential practice is sterilizing medical devices before and after use, including stethoscopes, blood-pressure cuffs and chest tubes. Additionally, hospitals are adopting the use of devices, such as central venous catheters, that have been impregnated with antibiotics. Of course, antibiotic-impregnated medical devices should be used in conjunction with best placement practices to achieve the most effective outcome.

As illustrated above, there are several challenges to adherence to hand hygiene techniques and guidelines by health care workers but with the proper procedures in place they can be overcome. With approximately two million infections each year, HAIs result in approximately $4.5 billion in excess costs. These cost considerations coupled with increased national awareness require hospitals to seriously examine procedures and precautions necessary to combat HAIs and ultimately ensure the best quality of care for their patients. Infection prevention is a responsibility for all members of the hospital and with a solid commitment and adherence to infection control best practices hospitals worldwide will undoubtedly experience a significant reduction in HAI rates.

Thomas Cherry, Clinical Product Manager of the Critical Care division of Cook Inc.
http://www.cookmedical.com/home.do ‎ Full story...

Guest Blog: Open Source and Primary Care in the US by Timothy Cook

Tim Cook, a vocal proponent and leader of open source in the health care IT space and owner of possibly the most impressive list of achievements in the FOSS-meets-HIT space, managed to stumble across a post I made a while back about the National Health Information Network. Even though he was apparently having a much more interesting Christmas than I was, he took the time to drop me a note which led to the guest blog below. Thanks Tim!

Back in March 2007 Jaz-Michael King posted about open sourcing the National Health Information Network (NHIN). There are success stories regarding using open source as part of some trials being done with NHIN record locating such as the Mendocino HRE as well as others.

But, as Jaz pointed out in December 2007, Regional Health Information Organizations (RHIOs) are struggling more because of lack of "Information" as opposed to lack of funding. If they could get the information into the systems then the funding would take care of itself.

So the root problem lies in; why can't we collect the information? Virtually all primary care clinics have computerized billing systems. The problem is that billing information is not rich enough to really provide the content and context needed for longitudinal patient care.

The real solution is capturing information electronically at the point of care. That information can then be used for many purposes including driving the billing systems and decision support.

The reasons that US primary care clinics have not adopted electronic health/medical record applications is because of the economics of doing so. Just the licensing of these applications can run into the tens of thousands of dollars. There are several open source alternatives that carry no license fees. However, the real costs of implementation of these systems include so much more than just licensing. Books such as "Computerization and Going Paperless in Canadian Primary Care" (ISBN-13:978-1857756234) detail these processes and expenses. It can easily take up to 24 months to transition from paper to electronic medical records. This is expensive in terms of not only training but in temporary reduced efficiency.

But, even if a clinic forges ahead with an implementation and they are successfully converting from paper to electronic; who gains? In a 2004 View Point paper by the American College of Medical Informatics (J Am Med Inform Assoc. 2005;12:13–19. DOI 10.1197/jamia.M1669.) they identified some primary reasons for the failure of the health information technology market in the US. Two major ones are:

1) Misaligned incentives. Simply, the people being expected to pay for EHR systems are the ones gaining the smallest percentage of pay back. payors and employers have by far the most incentive to see EHRs implemented.

2) Lack of true interoperability standards. In order for payors and employers to gain their maximum benefits, the systems must be able to communicate semantically correct patient information using open standards. In order to be capable of communicating semantically correct information, they must first be able to STORE semantically correct information. I believe that this is a bigger problem than the health informatics community realizes.

Longitudinal patient information is arguably one of the most temporally and spatially complex information sets known. Certainly GIS and others are complex as well but the science of medicine and therefore healthcare is constantly changing creating a moving context. To understand how to treat a patient the healthcare provider needs to be able to understand what has worked as well as what hasn't worked in the context of what was known about the patient and the treatments available at any point in time. This creates an environment of very complex data relationships. If any one of those relationships are broken then the semantic context of the data is lost and now there is a loss of information. Data items need to be bundled and stored as a complete unit of understanding for them to constitute information. Once broken apart into separate data items they are much like Humpty Dumpty.

Open information exchange specifications have been proposed such as the Continuity of Care Document (CCD) but again it isn't really an electronic health record model.

The openEHR specifications ( http://www.openehr.org ) are an object-oriented information model based on over 15 years of research and implementation experience designed specifically as an electronic health record information model. The openEHR specifications provide an opportunity to avoid the Humpty Dumpty data fracture. Through the use of "two-level modeling", openEHR specs describe a solid reference model enhanced by archetypes that bundle data items into an contextual information packet. These information packets can be transported between systems without loss of semantic context. I believe that vendors, proprietary and open source, would do well to examine the openEHR information specifications for use as the basis of their systems.

Use of a common information model will open the door for payors and employers to see their benefits unfold as patient information can be exchanged maintaining its semantic context. I project that this will reduce healthcare costs, improve quality of care and improve patient
satisfaction in the processes of care.

Timothy Cook, MSc
Health Informatics Research & Development Services
LinkedIn Profile: http://www.linkedin.com/in/timothywaynecook
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