Addressing SNOMED CT Implementation Challenges Through Multi-disciplinary Collaboration

Unprincipled modeling decisions in large-domain ontologies, such as SNOMED CT, are problematic and might act as a barrier for their quality assurance and successful use in electronic health records. Most previous work has focused on clustering problematic concepts, which is helpful for quality control but faces difficulties in pinpointing the origin of those modeling problems. In this study, we examined the underlying structural patterns in SNOMED CT’s data model as such patterns directly reflect the modeling strategies of editors. Our results showed that 92% of all structural patterns found accumulated in the Procedure and Clinical finding sub-hierarchies, and pattern reuse was low; over 30% of patterns were only used once. A qualitative analysis of a sample of 50 such singleton patterns revealed modeling problems, including redundancy, omission, and inconsistency. The problems detected in the sample suggest that the analysis of structural patterns is a valuable technique for revealing problematic areas of SNOMED CT and modeling the styles of terminology editors. Furthermore, the patterns that describe the modeling of a large number of concepts could provide insights for template creation and refinement in SNOMED CT.

Exchange and sharing of clinical information through Interoperable Electronic Health Record (iEHR) can improve the healthcare organization's efficiency and enhance patient care quality. Following the footsteps of the US and many advanced European countries, Taiwan invested recently a big bundle in health information technology development. Systematic Nomenclature of Medicine-Clinical Term (SNOMED CT) has become one of the most valued clinical term standards of electronic health record and widely adopted by these countries interested. Aside from using literature review, by which we looked into the evolution and content of 7 existing versions of SNOMED CT, we also tried to find out the current situation of hospital development here in Taiwan through a case study, and to understand the preliminary needs of clinical physicians and information professionals in the establishment of operative matter system through interviews. SNOMED CT happens to be a powerful reference terminology system for clinical medicine, which contains more than 344,000 concepts, 913,000 descriptions, and 1,360,000 relationships. Clinical data are exchanged and interoperated by three, concept, description, and relationship, tab les. SNOMED CT clearly defines medical concepts, synonyms and semantic relationship, gives emphasis to the reciprocal manipulation of two meanings, and uses the like of relational database way to establish multi relations between concepts both in varied strata and channels, so that a patient's clinical data can be indexed, stored, retrieved, and aggregated by different participating clinicians at different locations of the caring, yet the reliability and coherence of it can be assured and the content variability be kept at minimum. 1n case of applying its information code system and reference terminology to clinical data, not only can healthcare workers use them to log patient's condition and do cancer registry, but also information personnel can develop electronic health record system with them, medical caring institutions can apply them as a versatile tool to support their decision making, cost analysis, and clinical research. Currently, more than 30 countries including the United States, Canada, and the UK have already adopted the system. In prospect, we believe that SNOMED CT terminology standard will be an important competition tool to run a healthcare institution, and an inevitable trend for hospital information construction. However, the formulation of this standard requires active collaboration of the government, the institution, and individual professionals in clinical medicine and information industry to establish a nationwide clinical terminology standard that meets internationally set criteria, and the goals include rendering healthcare institutions and the industry a standard to observe and facilitating information sharing and exchange, and thus vastly improving the quality of medical care.

The Effect of an Electronic Documentation System on the Trauma Patient’s Length of Stay in an Emergency Department

This study was conducted to determine the level of project management skills, people management skills and operational excellence of construction project managers in private construction services. The respondents were the project management team composed of 215 engineers, architects, technical staff and document controllers fairly distributed to the three business units. The study utilized the descriptive correlational research method. Analysis of data revealed the following findings: The construction project managers had a high level of project management skills in terms of scope management skills, schedule management skills, resources management skills, risks management skills, and quality management skills (=3.62). The construction project manager had a very high level of people management skills in terms of integrity, influence and persuasion, leadership, and planning (= 3.64). In terms of operational excellence, the construction project managers obtained a very high level on customer focus, flexibility, and systematic problem solving (= 3.62). A significant relationship was noted between construction project manager’s project management skills and people management skills; a significant relationship was perceived between project manager’s project management skills and operational excellence; and a significant relationship was noted on people management skills and operational excellence. Based on the summary of findings, the following conclusions were drawn, (1) The construction project managers had a very high level of project management skills in terms of scope management skills, schedule management skills, cost management skills, resources management skills, risks management skills, and quality management skills. (2) The construction project managers had a very high level of people management skills in terms of integrity, influence and persuasion, leadership, and planning. (3) The construction project managers had a very high level of operational excellence in terms of customer focus, flexibility, and systematic problem-solving. (4) The higher the level of construction project manager’s project management skills, the higher the level of their people management skills. (5) The higher the level of construction project manager’s project management skills, the higher the level of their operational excellence. (6) The higher the level of construction project manager’s people management skills, the higher the level of their operational excellence. (7) All the constructs of project management skills, only risks management skills and management skills are the significant predictors of the respondents’ level of operational excellence, implying that the higher the level of project management skills in terms of risks management and scope management skills, the higher the level of operational excellence of the respondents. To deliver the project successfully, the construction project managers should consistently demonstrate and balance the application of project management and people management since the area of focus of CPM in the project revolves in day to day managing of resources (material, manpower and equipment), solving problems, overcoming project challenges, dealing with changes in project requirements, communicating with stakeholders and satisfying the customer’s expectations. With these, the decision and approach of CPM would be solid and cohesive through collaboration with the project management team.

Introduction & Practice Change : The Health and Social Care professions (HSCPs) comprising of physiotherapy (PT), occupational therapy (OT), medical social work MSW), clinical nutrition (CN) and speech and language therapy (SLT) in St. James’s hospital together with the IT department, have designed and implemented an electronic clinical documentation system aimed at replacing paper-based documentation for these professions. This is in line with national and organizational strategic aims towards a complete electronic patient record. Aim : To examine the patient’s perspective on electronic documentation, to proactively address their concerns and expectations of the system. Targeted population : Patients from inpatient and outpatient settings across a variety of clinical areas were surveyed. The questionnaire included demographics, patients views on the security and efficiency of electronic vs paper based documentation, their preferred method of documentation and open questions for comments or suggestions they had regarding the use of electronic documentation. The inclusion criteria were; actively being treated by a therapist, the ability to understand questions and verbalise responses. The results were then entered into Microsoft Excel for analyses and performance of simple descriptive statistics. Timeline : August 2016 Highlights : 94 participants completed the survey (PT=20; OT=16; MSW=17; CN=21; SLT=20), comprising 44 inpatients and 50 outpatients. 32% (n=33) were over 65years of age. 41% (n=39) were male. 86% of participants (n=81) felt that electronic documentation was as secure or more secure than paper notes, while 95% (n=89) felt that electronic documentation was efficient or more efficient than paper notes. 45% (n=42) preferred electronic documentation, 25% (n=24) preferred paper while 30% (n=28) had no preference. Themes emerging from patients comments were mainly positive. Many remarked on efficiency and convenience. However patients expressed concerns over potential hacking and access to their documents. Sustainability & Transferability : The use of electronic documentation has been perceived positively by patients surveyed. 94% of patients identified efficiency as an advantage to this style of documentation. Their concerns regarding the security should be addressed by disclosing this information in an open manner. The information gained will be fed back through the hospital's information governance committee and a list of FAQs will be gvien to patients.

BackgroundThe volume and complexity of patient data – especially in personalised medicine – is steadily increasing, both regarding clinical data and genomic profiles: Typically more than 1,000 items (e.g., laboratory values, vital signs, diagnostic tests etc.) are collected per patient in clinical trials. In oncology hundreds of mutations can potentially be detected for each patient by genomic profiling. Therefore data integration from multiple sources constitutes a key challenge for medical research and healthcare.MethodsSemantic annotation of data elements can facilitate to identify matching data elements in different sources and thereby supports data integration. Millions of different annotations are required due to the semantic richness of patient data. These annotations should be uniform, i.e., two matching data elements shall contain the same annotations. However, large terminologies like SNOMED CT or UMLS don’t provide uniform coding. It is proposed to develop semantic annotations of medical data elements based on a large-scale public metadata repository. To achieve uniform codes, semantic annotations shall be re-used if a matching data element is available in the metadata repository.ResultsA web-based tool called ODMedit (https://odmeditor.uni-muenster.de/) was developed to create data models with uniform semantic annotations. It contains ~800,000 terms with semantic annotations which were derived from ~5,800 models from the portal of medical data models (MDM). The tool was successfully applied to manually annotate 22 forms with 292 data items from CDISC and to update 1,495 data models of the MDM portal.ConclusionUniform manual semantic annotation of data models is feasible in principle, but requires a large-scale collaborative effort due to the semantic richness of patient data. A web-based tool for these annotations is available, which is linked to a public metadata repository.

To implement the SNOMED CT electronic specifications for reporting quality measures and to identify critical issues that affect implementation. The Centers for Medicare and Medicaid (CMS) have issued the electronic specifications for reporting quality measures requiring vendors and hospital systems to use standardized data elements to provide financial incentives for eligible providers. The electronic specifications from CMS were downloaded and extracted. All SNOMED CT codes were examined individually as part of the creation of a mapping table for distribution by a vendor for incorporation into electronic health record systems. A qualitative and quantitative evaluation of the SNOMED CT codes was done as a follow up to the mapping project. A total of 10643 SNOMED codes were examined for the 44 measures. The approved SNOMED CT code sets contain aberrancies in content such as incomplete IDs, the use of description IDs instead of concept IDs, inactive codes, morphology and observable codes for clinical findings and the inclusion of non-human content. Implementers of these approved specifications must do additional rigorous review and make edits in order to avoid incorporating errors into their EHR products and systems.

OBJECTIVES/SPECIFIC AIMS: Dependence and abuse of prescription opioid pain medication has substantially increased over the last decade. The consistent rise in opioid dependence contributes to the rising prescription drug overdose deaths over the last decade. The study of the distribution and determinants of opioid dependence among patients who are treated with chronic pain medications prescribed by their healthcare providers would aid in answering some key questions about potential abuse and overdose on opioids. The descriptive epidemiology of opioid dependence would help in identifying the vulnerable age group, race, ethnicity, and type of opioid pain medications that more commonly result in dependence. METHODS/STUDY POPULATION: We implemented an Observational Medical Outcomes Partnership/Observational Health Data Sciences and Informatics (OMOP/OHDSI) database, to hold structured EHR data from our Allscripts patient records. We also created a high-throughput phenotyping, natural language processing system that can parse 7,000,000 clinical notes in 1.5 hours. This runs as a web service and provides a modular component based NLP system. After the full semantic parse, we match the content against any number of ontologies. For each match we tag it as either a positive, negative, or uncertain assertion. We then perform automated compositional expressions. The codes are stored in a Berkley database (BDB) NOSQL database and the compositional expressions are stored in Neo4J (a graph database) and Graph DB (a triple store). This flexibility allows rapid retrieval of complex questions in real time. The High-Throughput Phenotyping (HTP) Natural Language Processing (NLP) Subsystem (HTP-NLP) is software that produces, given biomedical text, semantic annotations of the text. The semantic annotations identify conceptual entities—their attributes, the relations they have with other entities and the events they participate in, as expressed in the input text. The conceptual entities, relations, attributes, and events identified are specified by various knowledge representations (KRs) as documented in Coding Sources. Examples of coding sources are medical terminologies [eg, SNOMED CT, RxNorm, LOINC and open biomedical ontologies (OBO) foundry ontologies, eg, gene ontology (GO), functional model of anatomy, OBI, and others]. The annotation results may be displayed or output in formats suitable for further processing. Entity identified is assigned a truth value from 0 to 1. Values from the text are assigned to entities from ontologies such as SNOMED CT. The retrospective analysis of EHR data from local clinic patients was performed using queries on the problem list, demographic data, and medication list of all the patients in the database. The OMOP/OHDSI database was collected from Allscripts EHRs from 2010 to 2015. This common data model helps in the systematic analysis of disparate observational databases of clinic records from the primary care and family medicine clinics in Western New York region. The database contained 212,343 patient records that were parsed and deidentified. Specific research IDs were assigned to each of the patient records and stored in a secure firewall device for data analytics. The entire 212,343 records were queried for opioid dependence from the ICD-9 and 10 diagnostic codes and SNOMED CT codes mapped to both the clinical notes and the problem list for each patient based on the mapped ICD and SNOMED CT codes. In total, 1356 patients were identified as to having opioid dependence. The records were stratified into 7 age groups from age 18 to 28 and ending with age 79–89 years. RESULTS/ANTICIPATED RESULTS: Of the 212,343 patients in the database 1356 patients revealed opioid dependence on the problem list, ICD9-10 codes and prescription opioid pain medication with or without Buprenorphine and Naloxone (Suboxone) in the medication list. The prevalence of opioid dependence in the clinic population was 0.64% (95% CI: 0.61%–0.67%) over a 5-year period. The 7,000,000 patient records generated 750,000,000 SNOMED CT codes (on average 107 codes per record). The highest numbers of opioid dependence were seen in the 29 to 38 years’ age group. That comprised 39.38% (95% CI: 36.78%–41.98%) of the total opioid dependent population but accounted for only 2.03% of whole clinic population in this age group (95% CI: 1.86% to 2.2%). The subjects were then stratified by race and ethnicity. There were 1005 patients with opioid dependence, in the non-Hispanic population (total number 108,402). Among the White non-Hispanic or Latino population with opioid dependence, 41.33% (95% CI: 38.27%–44.39%) were 29–38 years old. The next common age group among the White Non-Hispanic opioid dependent subjects was 19–28 years, comprising of 22.48% (95% CI: 19.88%–25.08%) of the total number of White non-Hispanic or Latino opioid dependent population. Among the total clinic population Hispanics comprise 51.24%, but they comprise only 2.58% (95% CI: 1.74%–3.42%) of the total opioid dependent population. The non-Hispanic population comprise 51.05% of total clinic population while the percent of people who are opioid dependent is 83.26% (95% CI: 83.04%–83.48%) of the total 1356 opioid dependent population. DISCUSSION/SIGNIFICANCE OF IMPACT: The trends of opioid dependence among the clinic population in the study indicate that the prevalence is more in a certain section of the population. The predominance is among the non-Hispanic White population in the 19–38 years of age. The prevalence in younger age implies that the complications related to opioid dependence would be there for a longer duration of time. The prevalence of dependence in this clinic population would be rising if this trend continues. Interventions at curbing prescription opioid dependence is necessary for the vulnerable population. The findings suggest that a broad based approach is necessary to address this problem. The distribution of opioid dependence in this patient population indicate the need for special attention to these specific age group and race ethnicities. The young age of many of the addicted patients demonstrate the risks of legitimate opioid prescriptions in leading this age group towards addiction and implies the need for routine screening for substance abuse. The evidence of complications of opioid overdose among long-term opioid users and risk of abuse with other agents including illicit agents makes the need for an approach that uses real-time interventions in addition to effect long-term improvement in addiction rates. A potentially cost-effective approach to implement monitoring programs and clinical decision support tools would be to develop inter operable linkage from the EHRs to the state Department of Healths’ prescription monitoring programs.

BackgroundNarrative medical reports do not use standardized terminology and often bring insufficient information for statistical processing and medical decision making. Objectives of the paper are to propose a method for measuring diversity in medical reports written in any language, to compare diversities in narrative and structured medical reports and to map attributes and terms to selected classification systems.MethodsA new method based on a general concept of f-diversity is proposed for measuring diversity of medical reports in any language. The method is based on categorized attributes recorded in narrative or structured medical reports and on international classification systems. Values of categories are expressed by terms. Using SNOMED CT and ICD 10 we are mapping attributes and terms to predefined codes. We use f-diversities of Gini-Simpson and Number of Categories types to compare diversities of narrative and structured medical reports. The comparison is based on attributes selected from the Minimal Data Model for Cardiology (MDMC).ResultsWe compared diversities of 110 Czech narrative medical reports and 1119 Czech structured medical reports. Selected categorized attributes of MDMC had mostly different numbers of categories and used different terms in narrative and structured reports. We found more than 60% of MDMC attributes in SNOMED CT. We showed that attributes in narrative medical reports had greater diversity than the same attributes in structured medical reports. Further, we replaced each value of category (term) used for attributes in narrative medical reports by the closest term and the category used in MDMC for structured medical reports. We found that relative Gini-Simpson diversities in structured medical reports were significantly smaller than those in narrative medical reports except the "Allergy" attribute.ConclusionsTerminology in narrative medical reports is not standardized. Therefore it is nearly impossible to map values of attributes (terms) to codes of known classification systems. A high diversity in narrative medical reports terminology leads to more difficult computer processing than in structured medical reports and some information may be lost during this process. Setting a standardized terminology would help healthcare providers to have complete and easily accessible information about patients that would result in better healthcare.

Background: Documentation of intravenous (IV) heparin infusion dose/hold by nurses is a vital component in heparin infusion management. The barcode electronic medication administration system is used when administering and documenting medications but precludes the documentation of continuous IV infusion doses such as heparin. Aim: To increase documentation of IV Heparin Administration Documentation in the electronic nursing documentation system. Methods: We reviewed multiple adverse patient events that involved heparin infusions. When discussing these events, we identified a common trend regarding the inability for nurses to document heparin IV doses/holds in the nursing electronic documentation. Although heparin volume infusion is charted every 4 hours, this does not reflect the exact heparin dose that the patient received when factoring heparin hold orders and boluses. With the involvement of clinical informatics, physicians, nurses, and a quality consultant (QC), we developed a method for nurses to document heparin IV doses and holds via the electronic documentation (Figure 1). On October 30 th 2012, two Cardiovascular Step-Down (CVSD) units championed the heparin process improvement documentation. The nurses on these units receive targeted education about the process improvement change. Audits were performed daily during the first month of implementation and periodically by the QC. Electronic communication was also sent out throughout VUH regarding the changes in heparin documentation. Results: Documentation of administered dose increased from 46% to 71% across VUH regardless of the type or level of education to the change. CVSD: Pre / Post n = 16/21 DOSE: 37.5% / 81% Both DOSE & VOLUME: 31.3% / 71.4% HOLD: 75% / 81% Drop Down: 43% use (68.8% annotation) Non ICU Control: Pre / Post n = 12 / 17 DOSE: 16.7% / 41.2% BOTH DOSE & VOLUME: 8.3% / 11.8% HOLD: 50% / 41.2% Drop Down: 11.1% use (88.9% annotation) ICU units were 100% in dose documentation post changes Conclusion: The heparin documentation change has increased the accuracy of the documentation of heparin dose, volume, and hold across VUH. Targeted education has the potential to increase compliance and adoption. The heparin dose documentation is now exported to an electronic heparin dashboard that physicians/providers can easily access.

BackgroundSince the introduction of electronic nursing documentation systems, its implementation in recent years has increased rapidly in Germany. The objectives of such systems are to save time, to improve information handling and to improve quality. To integrate IT in the daily working processes, the employee is the pivotal element. Therefore it is important to understand nurses’ experience with IT implementation. At present the literature shows a lack of understanding exploring staff experiences within the implementation process.MethodsA systematic review and meta-ethnographic synthesis of primary studies using qualitative methods was conducted in PubMed, CINAHL, and Cochrane. It adheres to the principles of the PRISMA statement. The studies were original, peer-reviewed articles from 2000 to 2013, focusing on computer-based nursing documentation in Residential Aged Care Facilities.ResultsThe use of IT requires a different form of information processing. Some experience this new form of information processing as a benefit while others do not. The latter find it more difficult to enter data and this result in poor clinical documentation. Improvement in the quality of residents’ records leads to an overall improvement in the quality of care. However, if the quality of those records is poor, some residents do not receive the necessary care. Furthermore, the length of time necessary to complete the documentation is a prominent theme within that process. Those who are more efficient with the electronic documentation demonstrate improved time management. For those who are less efficient with electronic documentation the information processing is perceived as time consuming. Normally, it is possible to experience benefits when using IT, but this depends on either promoting or hindering factors, e.g. ease of use and ability to use it, equipment availability and technical functionality, as well as attitude.ConclusionsIn summary, the findings showed that members of staff experience IT as a benefit when it simplifies their daily working routines and as a burden when it complicates their working processes. Whether IT complicates or simplifies their routines depends on influencing factors. The line between benefit and burden is semipermeable. The experiences differ according to duties and responsibilities.

ObjectiveTo evaluate the ability of an electronic system created at the University of Washington to accurately document prerecorded VF and pulseless electrical activity (PEA) cardiac arrest scenarios compared with the...

IntroductionThe ability to utilize the electronic health record (EHR) without compromising the doctor-patient relationship (DPR) is an essential skill of all physicians and trainees, yet little time is spent on educating or assessing learners on needed techniques. To address this gap, we developed a conventional OSCE station coupled with a simulated patient chart within the Epic program in order to assess our students' skills utilizing the EHR during a patient encounter.MethodsOf third-year medical students, 119 were given full access to the patient's simulated chart 24 hours in advance of their OSCE to review clinical data. During an in-person OSCE with a standardized patient (SP), students performed a focused history and physical, using the EHR to verify allergies and medications. Students completed an electronic patient note graded by faculty. SPs evaluated the students on communication and interpersonal skills with specific rubric elements. Faculty graded the students' notes to evaluate their expression of clinical reasoning in the assessment and plan.ResultsTraining SPs and faculty to assess students on EHR skills was feasible. After implementation of a comprehensive curriculum focused on EHR and DPR, there was a significant difference on EHR-related communication skills (M = 76.4, SD = 17.6) versus (M = 37, SD = 28.9) before curriculum enhancement t (117.9) = −12.4, p <.001.DiscussionThe EHR OSCE station provided a standardized method of assessing students' EHR skills during a patient encounter. Challenges still exist in the technological requirements to develop and deliver cases in today's EHR platform.

Clinical terms are noisy descriptions typed by healthcare professionals in Spanish language in the electronic health record system (EHR). Thus, an evaluation of terminology search engine that extends SNOMED CT and an approach that uses historical data of clinical terms is described. We show how to measure precision and recall using historical search data, and we show how the performance of the search engine can be improved significantly using the technology available in the search engine.

Intelligence in the form of skills that depend on tacit and explicit knowledge gained through formal and informal learning assists in informed decision-making, which is necessary for project execution. However, literature related to project failures attributes poor performance in construction to the level of skills of project stakeholders. The central issue here is the seemingly inadequate technical and management skills domiciled in public works departments of developing countries. In fact, anecdotal evidence suggests that this inadequacy marginalises the realisation of infrastructure development in sub-Saharan Africa. Therefore, using South Africa as an example, the paper reports on the consequences associated with skills inadequacies and future skills requirements. The report is therefore based on an extensive review of related literature, and an empirical study undertaken in South Africa. The research findings indicate that skills shortages in public sector departments may be responsible for a range of project failings such as unnecessary delays in contract award after tender submission, which in turn hamper project performance. Therefore, the study suggests that in order to deliver future infrastructure projects adequately, attention should be given to the development of management, project management and technical skills.