ι 1 Progress towards interoperability standards for anesthesiology HL7 UK 2007 Conference – Making Interoperability Work November 22 nd, 2007 Martin Hurrell, Terri Monk, Andrew Norton, Melvin Reynolds APSF - DDTF / IOTA, HL7 SIGGAS, AMS Consulting

ι 2 Anesthesiology: what are the drivers ? The anesthetic record The anesthetic record —Medico-legal —‘On-line’ document —Audit & research Data sharing Data sharing —Common record structure: to identify clinical context —Common terminology: for aggregation and analysis —Common model: to enable AI applications, reasoning and decision support

ι Good news …. 3

ι 4 APSF 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 Directors October 2001

ι … and bad news …. 5

ι 6 Anaesthesia Information Management Systems(AIMS) Only installed in 3-5% of US hospitals Only installed in 3-5% of US hospitals Similar picture in the UK Similar picture in the UK We expect universal implementations in the UK as part of the National Clinical Records Service (NCRS) … but the time scale is unclear We expect universal implementations in the UK as part of the National Clinical Records Service (NCRS) … but the time scale is unclear Creating a data dictionary involves a long implementation path and significant cost Creating a data dictionary involves a long implementation path and significant cost Every implementation seems to have its own data dictionary Every implementation seems to have its own data dictionary The “not invented here” syndrome The “not invented here” syndrome

ι But more good news … anesthesia records are structured 7

ι 8 Intra-operative record Device monitoring Device monitoring —Fresh gas flow, concentration of inspired agent(s) Physiological data Physiological data —BP, HR, SpO 2, Temp, ventilation (and many others) Drugs and fluids Drugs and fluids —Bolus and infusion drugs, blood products —Anesthetic agents, resuscitation drugs

ι 9 Demographics (highly structured) Drugs and vital signs (highly structured) Case Events (??unstructured)

ι 10

ι 11 Foundations for future AIMS Ontology: domain model Schema: record structure Terminology

ι Terminology 12 … some issues …

ι 13 Multicenter study of factors related to tourniquet injuries Hospital A Hospital C Hospital B

ι 14 Relevance of a Data Dictionary Used by APSF Corporate partners SNOMED CT DDTF Reference set The terms are mapped/linked to an existing wider body of work … which is adopted by the medical community Anesthesia Subset DDTF Reference set

ι 15 The October 2007 termset General anaesthesia General anaesthesia Local anaesthesia Local anaesthesia Vascular access procedures Vascular access procedures Attributes and modifiers for procedures Attributes and modifiers for procedures Anaesthetic drugs Anaesthetic drugs Fluids and blood products Fluids and blood products Monitoring terms Monitoring terms Anaesthesia equipment Anaesthesia equipment Airway management Airway management Some administrative terminology Some administrative terminology Scales and assessments relevant to anaesthesia Scales and assessments relevant to anaesthesia Positioning and patient protection Positioning and patient protection … around 3,500 terms

ι 16 x73 Nomenclature & IOTA ontology / terminology “the Systematic Name is an -tuple of a Base Concept and a series of Differentiating Criteria” “the Systematic Name is an -tuple of a Base Concept and a series of Differentiating Criteria” IOTA develops and maintains its ontology in OWL DL IOTA develops and maintains its ontology in OWL DL IOTA aims to use the x73 base concepts and associated 1 st., 2 nd. And 3 rd. level differentiators in its device and measurement ontology IOTA aims to use the x73 base concepts and associated 1 st., 2 nd. And 3 rd. level differentiators in its device and measurement ontology Concept names will use the x73 ‘Common Term’ and the associated description will be the x73 ‘Description / Definition’ – optionally, synonyms may be defined Concept names will use the x73 ‘Common Term’ and the associated description will be the x73 ‘Description / Definition’ – optionally, synonyms may be defined x73 Differentiators will be properties of IOTA concepts x73 Differentiators will be properties of IOTA concepts

ι 17 The next stages Completion of pre operative assessment terminology Completion of pre operative assessment terminology Terms to support NSQIP (National Surgical Quality Improvement Program) Terms to support NSQIP (National Surgical Quality Improvement Program) Specialized terms necessary for anaesthesia subspecialties e.g. Specialized terms necessary for anaesthesia subspecialties e.g. —Cardiothoracic, Obstetrics, Neurosurgery, etc. CDA compliant schema for the anesthetic record CDA compliant schema for the anesthetic record Alignment of device terms with ISO Alignment of device terms with ISO 11073

ι 18 Current schema-related work Development of use cases Development of use cases Modelling of national business practices Modelling of national business practices Evaluation of current artefacts Evaluation of current artefacts Liaison with NSQIP on requirements Liaison with NSQIP on requirements

ι 19 Gardner M., Peachey T. A Standard XML Schema for computerised anaesthetic records. Anaesthesia, 2002, 57, pp

ι 20 CDA Anesthesia record Image Picture Image DICOM, JPEG Waveform e.g. ECG MFER Monitoring measurement X.73 LAB With thanks to Masaaki Hirai, Nihon Kohden

ι 21 Data access to AIMS 1 AIMS 1 Data access to AIMS 2 AIMS 2 Data access to AIMS 3 AIMS 3 Data transformation from standard anesthesia data elements to NSQIP data elements Data transmission to NSQIP NSQIP data repository

ι Outcomes research with AIMS 22

ι 23 Why is it so hard and why have so few people done meaningful research in this area? Anesthesia-related reasons AIMS systems do not currently use a standard vocabulary / terminology and so the representation of information may be site specific or even specific to individuals AIMS systems do not currently use a standard vocabulary / terminology and so the representation of information may be site specific or even specific to individuals The representation of data even within a site may not be consistent especially where free text entries are allowed The representation of data even within a site may not be consistent especially where free text entries are allowed There are a number of issues surrounding the comparability of automatically recorded vital signs data e.g. differences in sampling rates, pre-processing etc. There are a number of issues surrounding the comparability of automatically recorded vital signs data e.g. differences in sampling rates, pre-processing etc. Data from different systems are not organised with reference to a consistent model of the anesthetic process Data from different systems are not organised with reference to a consistent model of the anesthetic process

ι 24 Objectives Why are we even bothering to do outcomes research? Why are we even bothering to do outcomes research? What are the opportunities? What are the opportunities? Why now do we want to look at anesthetic data? Why now do we want to look at anesthetic data? Why is it so hard and why have so few people done meaningful research in this area? Why is it so hard and why have so few people done meaningful research in this area?

ι 25 National Surgical Quality Improvement 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 26 National Surgical Quality Improvement 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 27 Which data from the anesthetic record should we collect? “Half the money I spend on advertising is wasted: the trouble is I don’t know which half” “Half the money I spend on advertising is wasted: the trouble is I don’t know which half” John Wanamaker John Wanamaker In 5 year’s time it is too late to say ‘we should have collected X & Y, they’re beginning to look important’ In 5 year’s time it is too late to say ‘we should have collected X & Y, they’re beginning to look important’ Measure twice, cut once – have a sound plan, be standards-based and model future requirements not just those for the short-term Measure twice, cut once – have a sound plan, be standards-based and model future requirements not just those for the short-term

ι Outcomes research in anaesthesia Research based on AIMS Research based on AIMS —Is almost universally restricted to examination of physiological variables —Current lack of structure and standardisation of records and terminology does not support outcomes research Techniques Techniques Procedures Procedures Therapeutic regimens and drugs etc. etc. Therapeutic regimens and drugs etc. etc. 28

ι 29 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 should we collect?