1. NHPRC Conference October 2006C. Arnott Smith © 2006 The ontology of the operating room Modeling medical records for the HIPAA-Aware EAD

2. The medical record: A capsule history Ancestors of the modern record  Case records (19 th c.)  Bedside chart  Physician order  Financial ledger Electronic? Not yet  10% penetrance in best studies  21% of systems capture >75% of information  75% of systems are hybrid International and federal standards enroute

3. What it contains Conglomeration of clinical documents  Voice dictation  Primarily qualitative, narrative text Typical cancer patient record (2001):  80% = 6 unique document types  Average of 68 documents/patient Structure little-studied Focus here: OR Notes

4. Definitions “Loosely structured document”  “documents that have much in common” (Essin, 1993)  Contain elements (document parts)

5. Example: Description element The patient was placed supine on the operating table. The left neck was prepped and then draped in sterile fashion. A transverse incision was made over a palpable lymph node in the left neck. Platysma was divided with cautery. The lymph node was dissected from its surrounding tissue by dividing its attachments between clamps and ligating them with silk ties. The specimen was sent directly to Hematopathology.

6. Example: Description label DESCRIPTION: The patient was placed supine on the operating table. The left neck was prepped and then draped in sterile fashion. A transverse incision was made over a palpable lymph node in the left neck. Platysma was divided with cautery. The lymph node was dissected from its surrounding tissue by dividing its attachments between clamps and ligating them with silk ties. The specimen was sent directly to Hematopathology.

7. Earliest standard American College of Surgeons (ACS) 1918: Minimum Standards for Hospitals Specified optimal content for operative reports Quality control initiative for certifying surgeons

8. Data 20 OR Notes, 3 time periods, various surgeons’ documentation Halsted, 1895-1926 Blalock, 1946-1951 EMR, 2001

9. Method Reviewed by 2 coders for  Total elements in 20 documents  Unique elements in 20 documents  Elements occurring across 3 collections  Elements with HIPAA-regulated content (18 categories for deidentification)  And without

10. Results 1895-1926 1946-1951 2001 354 238 304 Total elements

11. Results 1895-1926 1946-1951 2001 111 16 33 Total unique elements

12. Results 1895-1926 1946-1951 2001 18 12 15 Average elements per document R: 7-47R: 8-13 R: 12-19

13. Results Elements common to 3 collections, 1895- 2001  Anesthesia Type (Ether)  Identifier (10903)  Operation Description Operation Type (Anastomosis)  Patient Name (Mrs. Catherine A. Smith)

14. Results 1895-1926 1946-1951 2001 88 85 70 Elements with HIPAA content: “Name”

15. Results 1895-1926 1946-1951 2001 63 31 65 Elements with HIPAA content: “Date”

16. Results 1895-1926 1946-1951 2001 39 42 40 Elements with HIPAA content: “Any other unique.. Number..”

17. Results

18. Elements common to 3 collections, 1895- 2001  Anesthesia Type (Ether)  Identifier (10903)  Operation Description Operation Type (Anastomosis)  Patient Name (Mrs. Catherine A. Smith)

19. Results Elements common to 3 collections, 1895- 2001  Anesthesia Type (Ether)   Identifier (10903)   Operation Description Operation Type (Anastomosis)   Patient Name (Mrs. Catherine A. Smith) 

20. Implications for an EAD finding aid Attribute: “HIPAA”  Equals restricted (not viewable)  Allow (no problem)  Verify (may or may not be viewable)

21. Catherine Arnott Smith, PhD Assistant Professor School of Library and Information Studies University of Wisconsin-Madison casmith24@wisc.edu