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1 The helpful Patiet Record System: Problem Orieted Ad Kowledge Based Elisabeth Bayega, MS' ad Samso Tu, MS2 'Norwegia Uiversity of Sciece ad Techology, Departmet of Computer ad Iformatio Sciece ad Departmet of Commuity Medicie ad Geeral Practice, Trodheim, Norway 2Staford Medical Iformatics, Staford Uiversity School of Medicie, Staford, CA ABSTRACT I cotrast to existig computerized patiet record systems, which merely offer static fuctioality for storage ad presetatio, a helpful patiet record system is a problemorieted, kowledge-based system which provides the cliicia with situatio-specific iformatio from the patiet record, relevat to the activity withi the patiet care process. We suggest extedig the data model of curret patiet record systems with (1) kowledge for recogizig ad iterpretig care situatios, (2) kowledge of how cliicias work ad what iformatio they eed, ad (3) meas to rak iformatio accordig to its relevace i a give situatio. We preset a framework that eables represetatio of three prerequisite features for a future helpful patiet record system: the primary care workflow process, the problem-orieted iformatio model, ad meas to idetify relevat iformatio to the care process ad medical decisios. INTRODUCTION The likig of patiet-specific data with medical kowledge is crucial for efficiet ad high-quality patiet care. However, the task of extractig patiet-specific data that are both useful ad ecessary for medical decisios is ot a trivial task. Typically, today's patiet record iformatio model is time orieted; patiet data are related to a uique patiet ID ad date of etry. Such a rigid model prevets easy access to ad overview over iformatio i the record, for istace to view patiet data i relatio to a specific medical problem. Stiff ad Itle flexib last few days. ir---*----*--^--* *------*--*- _._:.... ga couple of days ago had dillcutes gettg out of bed, didl eve maage to put her clothes o. 1± Stiff ad paiful eck ad shoulder. X Detter ow. Dol have ay dtmcutes to get her blouse over her head ad to butto her clothes. Partfcularly teder i eck ad shoulder muscles, tese. Myosis alog scapula. Stiff also over her hips. <:dwll do tests vlth cosideratlo of polyralgla. But first of all, ecourage her to move more aroud. T BP : Coripulm NA. Puls 74, regular. MYALGA SHOULDER Lebtesgtetsto *hospltal MUJSCLE PAJNS Figure 1 A record etry from a time-orieted patiet record. Iformatio i the etry is ot easily reusable because of the ustructured text. The patiet record cotais a cosiderable amout of iformatio valuable i differet circumstaces, but as the situatio is today, most of the recorded cliical iformatio i patiet record systemsa is ustructured text. Record etries (Figure 1) are composed of descriptios of patiet's symptoms, sigs, complaits, reaso for ecouter, persoal, family, ad social history, examiatio fidigs, etc. I additio, patiets usually preset more tha oe problem; so idividual otes may cotai iformatio o may iterleavig problems. It is time-cosumig to extract iformatio from the record relevat to decisios that must be made durig patiet care. Cliicias work uder severe time costraits leavig little time left for them to search for iformatio. Although, cliicias beefit from efficiecy gais of computerized patiet record systems, efficiecy gais are ot eough: * Cliicias lose overview over record cotet after a few years of a log-term patiet-cliicia relatioship * The patiet record accumulates over time ad will cotai iformatio o may medical problems that, evetually, will have some relatioship to oe aother. The Problem-Orieted Patiet Record Lawrece L. Weed itroduced the Problem-Orieted Medical Record (POMR) i the late 1960s with itetios of improvig the structure of medical records l. Implemetatios of POMR such as the Problem-Orieted Medical Iformatio System (PROMISb) have yet to fid widespread acceptace. Of the most persistet complaits agaist PROMIS are costraits o iput data - the system was desiged to direct cliicias to become more complete, rigorous, ad systematic i documetig cliical iformatio. PROMIS required chage i all levels of health care delivery ad forced replacemet of existig practices, rather tha fuctio as a alterative or supplemet 2. The Helpful Patiet Record System POMR as a cocept offers a ituitive ad useful way to work with the patiet record by structurig iformatio amost refereces to patiet record system are based o experiece from Norwegia primary care patiet record systems. b Medical Ceter Hospital. AMIA 2002 Aual Symposium Proceedigs 36

2 related to a patiet's medical problem ito a uit, providig a cotext for dealig with medical problems, improvig efficiecy, ad supportig cotiuity of care. Despite less successful experiece with computerized POMR, we believe it is possible to overcome some of the kow deficiecies - such as eforcig strict ad thorough data etry - with a kowledge-based approach to implemetatio. We suggest extedig the curret patiet record data model with kowledge that eables the system to reuse iformatio that is already i the record, i situatios where it is useful ad eeded. Our framework icorporates three features: * Process kowledge of cliicias' work processes empowers the record system to recogize at what stage i the process they are ad to determie relevat iformatio eeded at that stage. Our objective is ot to take part i diagostics of health problems but to cotribute ad idicate potetially relevat iformatio for decisio-makig by takig advatage of iformatio that already exists i the patiet record. Addig process kowledge eables the system to adjust to the user ad ot vice versa. * A problem-orieted iformatio model, which structures related iformatio ito a problem uit. I cotrast to POMR, our sese of a problem-orieted patiet record (POPRC) has o madatory bidig to the classic SOAPd format. The model is flexible ad has o absolute restrictio that every etry i the record must relate to a problem; some etries have o atural relatio to a medical problem, while other etries are obvious problems ad will, as a cosequece, relate to a problem. Flexibility of the model lies i the fact that every record etry cosists of a set of iformatio uits each labeled with a cliical headig, istead of likig record uits to medical problems. The model hadles ucertaity i early stages of a patiet's medical problem ad groupig of problems as sub problems, by makig it possible to lik record etries at a later stage, if ad whe they appear as (sub) problems. * Relevace rakig of a set of iformatio sources. For each activity i the primary care process we idetify a set of iformatio sources as relevat to that activity. The rakig that is doe is based o: (1) problem orietatio which abstracts iformatio relevat to a medical problem ad 2) a set of cliical headigs that lik iformatio from the patiet record to activities i the process model. Both provide a robust tool for avigatig amog iformatio i the patiet record. c We use POPR istead of POMR to distiguish our coceptio of a problem-orieted record from the classic POMR ad SOAP format. d Subjective, Objective, Assessmet, ad Pla. Figure 2 Modelig of a geeric assessmet (sub) process to determie iteractio with the patiet record system. Diamod shapes represet activities, circles sub processes, squares decisio boxes, ad triagles iformatio sources. Iformatio sources cotai iformatio from the patiet record system relevat to the related activity. METHODS To develop our framework of process kowledge, a problemorieted iformatio model, ad meas to rak iformatio i the patiet record, we have used the Protege-2000 system. Protege-2000 is a set of kowledge-acquisitio tools for implemetig otologies ad kowledge bases. Besides beig a tool for defiig declarative domai otologies, Protege supports a graphical tool, has query abilities, ad produces machie-iterpretable data structures 3. We use Protege-2000 to make a otology ad to model the primary care process ad correspodig iteractio with the patiet record system. The otology comprises problem-orieted cocepts, cliical headigs, ad defiitios of iformatio sources. Modelig The Primary Care Process As our aim is to extract from the complete patiet record iformatio that is relevat to patiet-care situatios our system requires kowledge of how to recogize ad iterpret these care situatios ad kowledge of what iformatio is useful ad ecessary to each of them. We model the primary care process for the purpose of acquirig kowledge of each activity i the process ad correspodig iteractio with the patiet record system, which further provide us with isight o iformatio eeded by cliicias for each activity i the 37

3 care process. Moreover, a system that is able to recogize ad iterpret situatios ad provide with useful ad relevat iformatio to each situatio will miimize the traditioal gap betwee the way cliicias work ad how the system compels the user to work. The primary care process is modeled with a otology but also represeted graphically (Figure 2). Coceptually, we ca stratify otologies; lower levels defie geeric cocepts while higher-level strata have more specialized cocepts 4. Geeric cocepts for our process otology are based o the workflow model proposed by the Workflow Maagemet Coalitio 5 ad modified for our purpose. The geeric workflow model is applicable to all kids of processes, from busiess processes to differet processes i the medical domai 6; it defies geeric cocepts, such as processes, activities withi each process, ecessary tools ad data for each activity, participatig actors, ad trasitio requiremets from oe activity to aother. A graphic represetatio of the primary care process eables us to visualize a activity ad correspodig iteractio with the patiet record, so as to idetify a set of iformatio sources for each activity (see Figure 2). Iformatio sources are show as triagles i our graph; presetig a activity's set of relevat iformatio from the patiet record. Formalizig Patiet Data Part of the otology comprises a set of cliical headigs to formalize patiet data i the record. Oe of NHS Cliical Headig Project's objectives has bee to idetify a limited umber of headigs that will perform the jobs that are eeded for cliical commuicatio ad avigatio ad that ca be agreed upo by every participat ivolved i cliical commuicatio 7. The result is a well-established framework of cliical headigs compatible with both HL7 RIM subject areas 8 ad CEN TC251 stadardizatio work o electroic patiet record commuicatio. Cliical Headigs refer to a set of words ad phrases that cliicias use to ame sectios of their commuicatios (e.g. symptoms, examiatio fidigs, test results, diagosis, etc.). Cliical headigs have o formal sytax or defiitio, so our otology represets the formal data structure eeded to strictly defie cocepts i the patiet record. Most of the cotet i the patiet record is free text, despite this fact there is a iterestig feature that ca be used to our advatage whe structurig the cotet of the patiet record. Through our study of electroic patiet records, it was evidet that cliical headigs match our expectatios for ecodig patiet data; to match cliicias' iformatio eed i each activity with specific cotet i the patiet record. Seteces, or part of seteces, correlate easily to a cliical headig ad cliical headigs agai parallels directly with activities i the primary care process. As a result, we do ot eed to ecode every elemet of the patiet record it is sufficiet to ecode a set of seteces, which relate to a cliical headig. Thus, cliical headigs fuctio as a bridge betwee iformatio eeded ad the process activity it is required withi. The Problem-Orieted Iformatio Model Figure 3 illustrates the problem-orieted iformatio model ad show how cliical headigs act as a bridge betwee patiet record cotet (iformatio uits i the figure) ad activities - likig cocrete iformatio from the patiet record with specific activities i the primary care process. sessio Li, m problm1 uli m writ m 0 hifoiio diric ml L admtyf Figure 3 The problem-orieted iformatio model. The basic uit is the iformatio uit. Each iformatio uit is labeled with a cliical headig, which bridge patiet record cotet to activities i the process model. As see i figure 3, we have maitaied the classic etry i time-orieted patiet records (etry uit i our model) but have added two other cocepts such as sessio uit ad problem uit to the iformatio model. A etry (see figure 1) cotais a summary of problems, actios, cliical examiatios ad fidigs, laboratory tests ordered, etc. Eve though the uderlyig iformatio model is problem orieted the stregth of our model lies i the labelig of iformatio uits, each iformatio uit is labeled with a cliical headig, which i tur correlates to activities i the primary care process. The differece betwee classic record etries ad our etry uit is that a etry uit ow cosists of a set of iformatio uits that each are labeled with a cliical headig that specify its cotet ad purpose. The capturig of cotet i each iformatio uit eables us to reuse them i differet circumstaces. Iformatio uits are the basic buildig block of our iformatio model ad ca be a set of seteces, a setece or part of a setece. The cliical headig that labels the iformatio uit defies the cotet of it. Furthermore, a problem uit comprises a set of sessios or etries, or both. A etry uit cotais a set of iformatio uits that each belog to differet cliical headigs such as 38

4 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~. ;. L S.;...N symptoms, family history, cliical fidigs, test results, diagose, medical treatmet, etc. A set of related etry uits make up a sessio uit (i.e. a discharge etry has a correspodig referral etry for which the referral was specified). A iformatio uit, a etry uit, or a sessio uit, may belog to more tha oe etry uit, sessio uit, or problem uit, respectively. As a cosequece, the model is flexible, a etry may fuctio as a separate uit or it may be related to oe or several problems. Rakig Iformatio Sources For each activity i the primary care process a set of iformatio sources are idetified. Iformatio sources comprise relevat iformatio eeded by cliicias for a particular activity, preseted i levels accordig to their situatioal relevace. Curretly, we use topical relevace as criteria for determiig relevat iformatio sources for a activity (relevace criteria for cliical headigs will be discussed). The uderlyig problem-orieted iformatio model - combied with a set of cliical headigs - eables our framework to preset these iformatio sources. Rakig of iformatio as relevat is based o: helhcharactedstics oftgabrlella gra I 4> health charactestics '.:' Had surgery ad was treated with radia She also has a approimrate chroic dl May be related to radiato treatmet of <t> RP: APODORM Tabft5mg No:100 :. = =@ 4gs~~~~~RP:INCONTINENCE EQUIPMENT No, RP: CIMALTAL 400 mg No:60 Pck37 :: RP: TRIMETOPRIM Tabl. 160 mg No:20...L... Figure 4 A iformatio source for a specific activity. List of Problems ad Relevat Iformatio show two distict levels of relevat iformatio. Selectig a problem from the list will display problem-specific iformatio. 1. The problem-orieted iformatio model that structures iformatio from the patiet record related to a medical problem withi a uit. To orgaize iformatio ito problems is i itself a abstractio of relevat iformatio. 2. Cliical headigs that ecode the patiet record cotet. Labelig of iformatio uits ito headigs, combied with the problem orietatio, provide the record system with a robust tool for avigatig i patiet data. RESULTS To evaluate our framework, we have split the evaluatio i two: (1) evaluatio of cliical headigs ad the problemorieted iformatio model ad (2) evaluatio of the process model, activities, ad their attedat set of iformatio sources. Trasformatio of a Time-Orieted Patiet Record To evaluate the problem-orieted iformatio model, we were particularly iterested i discoverig how well our model would fit time-orieted etries ito problem uits ad if the set of cliical headigs was sufficiet to ecode the patiet record cotet. We trasformed a time-orieted patiet recorde to a problem-orieted patiet record - usig our problem-orieted iformatio model. Our problemorieted kowledge base cotais 267 iformatio uits, 112 record etries, 26 medical problems, ad 46 diagoses. The set of problems belog to three differet patiets. 13 cliicias - icludig physicias, urses, ad laboratory assistats - have bee treatig these three patiets over a period of 9 years, from primo 1991 to mid Results from the trasformatio demostrated that: * Cliicias do ot eter iformatio ito the record i a strict order; etries could be classified ito a set of fiite cliical headigs. * Cliical headigs were sufficiet labels of iformatio uits; they ecoded patiet data ad liked directly to activities i the process model * Some etries did ot aturally relate to a medical problem, while others had a obvious relatio to a medical problem. Our model was flexible ad permitted the optio of a etry to fuctio as a separate uit, or relate to oe or several problems. * The record cotaied redudat iformatio, which we iterpreted as: * A argumet for the problem-orieted patiet record. The problem-orieted patiet record provides a cotext i which cotiuity of care is supported, so as to prevet both redudat iformatio ad repeated actios * Emphasis o what type of iformatio cliicias eed; we will use this fact to develop rakig criteria for iformatio as relevat or ot to a situatio * A idicator that iformatio which cliicias eeded durig patiet care, was i the record but they did ot have the time to search for it. e The time-orieted patiet record system we used icludes more tha 1000 patiet records over a 9-year period ad aroud 30 cliicias operatig (readig/writig) o those records. 39

5 Simulatio of the Primary Care Process We coducted a simulatio of our process model to see how patiet-specific ecouters were captured ad what iformatio was determied as relevat to each activity withi the ecouter (i.e. iformatio sources). For a set of patiet ecouters, we simulated step-by-step activities i the care process ad evaluated the set of iformatio sources (i.e. a simulatio of the set of queries performed to abstract patiet data relevat for each activity). We performed 17 simulatios, which resulted i 31 iformatio sources, such as the oe illustrated i Figure 4. Figure 4 demostrates a iformatio source with iformatio relevat to "assessmet of myalgia shoulder". There are two levels of iformatio preseted i the iformatio source: List of Problems ad Relevat Iformatio. A third level is accessible by selectig a cocrete problem from the problem list. Each problem cotais a set of relevat iformatio to that specific problem. DISCUSSION AND FUTURE WORK The evaluatio of our work so far has bee formative with itets to validate ad esure that the three compoets i our framework are soud. Ultimately, we wat to evaluate our work i a cliical settig i terms of a system that is able to preset a problem-orieted patiet record capable of followig the work process of cliicias ad provide patietspecific iformatio from the record that is useful ad ecessary for medical decisios to be made. Before reachig this poit - a fully implemeted system - there are several itermediary steps that have to be addressed ad completed. Oe ext step is to cotiue our simulatio with a group of cliicias to clearly show our framework's potetial ad feasibility; as a first step we have to demostrate ad validate the set of iformatio sources as both relevat ad useful to cliicias. O the developmet side there is great potetial for extedig our kowledge model with kowledge ad rakig criteria that eable the system to do more specific rakig tha has bee expressed. However, the three levels of iformatio that our iformatio sources ow are able to preset represet a substatial improvemet from the chroological record provided i may patiet record systems today. The three levels of iformatio ca be further raked i degrees of relevace to a specific situatio. Right ow, there is o rakig amog cliical headigs, for istace there are o optios to rak amog family history, cliical fidigs, or prescribed medicatio. Whe a cliical headig - i.e. prescribed medicatio - is raked as relevat to a activity, the whole set of data for that cliical headig is show (e.g. both past ad preset medicatio). We will cotiue to work o heuristics that eable our system to rak amog cliical headigs accordig to problem ad situatio. A further challege is to decide what kowledge is sufficiet for the record system to be able to preset a list of relevat problems istead of presetig the whole problem list. CONCLUSION Although POPR as a cocept offers a ituitive structure ad orgaizatio of patiet records, implemetig a solutio that will gai widespread acceptace amog cliicias is aother matter. Most decisio-support systems up util ow ted to - iscribed - outlie who or what the relevat elemets are ad what their respective roles cosist of 9. Itroductio of a system ito a existig practice should be a process of cotiual egotiatio rather tha eforcig strict chage. As metioed i the itroductio, our kowledge-based approach to system implemetatio is suggested as a alterative to meet some ofthe challeges that exist i developig decisiosupport systems for health care. We argue i favor of a kowledge-based problem-orieted system as the key to a successful implemetatio of a patiet record. Problem orietatio is the foudatio for a well-structured record which supports the way cliicias work, removes redudat ad cofusig iformatio, ad eables easier access to ad overview over iformatio. A system that has kowledge of its cotet ad use is better able to itegrate with cotiual practice by beig o itrusive. REFERENCES 1. Weed LL. Medical records that guide ad teach. MD Computig, 10(2): , March/April Ludsgaarde HP, Fischer PJ, ad Steele DJ. Huma problems i computerized medicie. Uiversity of Kasas Publicatios i Athropology Number 13, Lawrece, Kasas, Muse MA. Medical iformatics: searchig for uderlyig compoets. Methods of Iformatio i Medicie. I press. 4. Beale T. Archetypes costrait-based domai models for future iformatio systems. Techical report, The Workflow Maagemet Coalitio Specificatio. Workflow maagemet coalitio iterface 1: process defiitio iterchage process model. Techical report, Quaglii S, Stefaelli M, Lazola G, Caporusso V, ad Pazarasa S. Flexible guidelie-based patiet care flow systems. Artificial Itelligece i Medicie, 22:65-80, Kay S et al. Headigs for commuicatig cliical iformatio. Techical report, Salford Research Group, NHS Research report, Sprig Beeler G et al. HL7 Referece Iformatio Model. Versio V (1/2/2002), ModelID: RIM_0112. HL7 Versio 3 Stadard. 9. Berg M. Ratioalizig medical work: decisio-support techiques ad medical practice. The MIT Press, Ackowledgemet Assoc. Prof. Mark A. Muse, Staford Medical Iformatics, Erik Naggum, Assoc. Prof. Aders Grimsmo, NTNU, Departmet of Commuity Medicie ad Geeral Practice ad Assoc. Prof. Oystei Nytro, NTNU, Departmet of Computer ad Iformatio Sciece. 40

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