Using SNOMED CT enabled EMRs to assess the quality of care for patients with head and neck tumors

Transcriptie

1 Using SNOMED CT enabled EMRs to assess the quality of care for patients with head and neck tumors Netherlands National Federation of University Medical Centers (NFU) Ø Jetty Hoeksema, PhD Ø Jozé Braspenning, PhD Ø Mariëlle Ouwens, PhD, MD IQ healthcare, Radboudumc, The Netherlands Ø Thijs Merkx, PhD, MD also the National Federation of Head and Neck Cancer Centers Ø Lydia van Overveld, MSc The Dutch National Institute for IT in Healthcare (Nictiz) Ø Patrick Lubbers Ø Michiel Sprenger SNOMED CT Implementation Showcase 2014 Amsterdam

2 Introduction of myself Ø Health Sciences University Maastricht The Netherlands Ø Advisor/policymaker on Quality and Safety in healthcare Ø PhD-Reseach on improving integrated care for patients with cancer in particular patients with head and neck cancer Ø Applied Researcher and Projectleader

3 Content 1) Patients with head and neck cancer 2) How do we assess the quality of care? 3) What is registred in EMRs? 4) To what extent is the information for QI available? 5) To what extent can we use existing building blocks? 6) Conclusions 7) Next steps

4 1. Patients with head and neck cancer Head and neck cancer

5 1. Patients with head and neck cancer

6 Alkmaar Enschede (MST) Tilburg (Elisabeth zkh)

7 2. How do we assess the quality of care? Indicators are explicitly defined and measurable items referring to the structures, processes, or outcomes of care input process outcome Improving the quality of health care Research methods used in developing and applying quality indicators in primary care S M Campbell, J Braspenning, A Hutchinson, M N Marshall BMJ, 2003

8 Andere zorgverlener Diagnosticeren 1 e 2 behandeling e behandeling Nazorg & follow-up Chirurgie Informeren pa:ënt & PA uitslag Opname & opera:e Bespreking HHWG/ MDO * Vervolg cura:ef of pallia:ef? Ontslag Verslag PA & paramedici betrekken Informeer pa:ënt & voorlopige diagnose Verwijzing huisarts/ tandarts * Verwijzing intern of extern specialist Informeren pa:ënt & voorlopige diagnose Poli bezoek preferred partner Poli bezoek HHOC * Intake incl. diagnos:ek Evt betrekken paramedici 18 Bezoek HHOC Diagnos: ek Pathologie rapport 4 Bespreking werkgroep of MDO * 5, 6, 7 8, 9 Vaststellen behandelplan Geïntegreerde dossiervoering 17 Informeren pa:ënt, PA uitslag & (voorlopige) diagnose Gesprek pa:ënt Evt. extra diag- nos:ek Evt betrekken paramedici * Cura%ef Radioth. 10 Chemoth. Informeren pa:ënt Opname & behandeling Masker & paramedici betrekken Informeren pa:ënt Planning & bestraling Bespreking HHWG / MDO Bespreking HHWG / MDO * Vervolg cura:ef of pallia:ef? * Vervolg cura:ef of pallia:ef? Ontslag Ontslag 11, 12 Informeren pa:ënt Follow- up Controle schild- klier Betrekken paramedici 1, 2, 3 Uitkomst Betrekken paramedici Informeren pa:ënt e bezoek tot aan afronden diagnostiek Afronden diagnostiek tot aan starten behandeling 1 e bezoek tot aan behandeling 15 Pallia%ef Pallia:eve zorg Betrekken paramedici 16 Wachttijd tussen 1 e en 2 e behandeling 1-18 = indicatoren * = Case mix factor Blauw = pa:ënt gericht Rood = ac:es / betrokken zorgverleners Groen = op:oneel

9 2. How do we assess the quality of care?

10 2. How do we assess the quality of care? Number of quality indicators Medical = 16 area Outcome indicators (n=3) Diagnostic indicators (n=6) Treatment indicators (n=1) Follow-up indicators (n=2) Coordination and organization (n=4) e.g. % cancer recurrence within 5 years % patients discussed in MDT % patients seen by a dental team % check thyroid function % start treatment within 28 days

11 2. How do we assess the quality of care? Number of quality indicators Paramedical = 21 area Outcome indicators (n=3) Nutritional care (n=3) Psychosocial care (n=3) Dental care (n=3) Physical functioning (n=3) Speech therapy (n=3) Coordination and organization (n=3) e.g. % cancer recurrence within 5 years % malnutrition screening % assessment psychosocial need % muscositis prevention % post surgical screening % oral revalidation % transmural transfer

12 2. How do we assess the quality of care? Number of quality indicators e.g. Structure indicators (n=3) Availability of a casemanager

13 3. What is registred in EMRs? By interviewing Head and Neck specialists, nurses and paramedics

14 3. What is registred in EMRs? Referral Intake Diagnos:cs Treatment Follow- up What information is being registred for patient care?

15 4. To what extent information for QI available? Number of indicators Medical = 16 Needed variables General (n= 28)* Surgical (n=7) Radiotherapy (n= 7) Chemotherapy (n= 7) Follow-up (n=8) Pathology report (n= 28) e.g. date of birth; smoker; social status type of surgery; date of surgery dosis; start dosis; start dismissal; readmissions tumor size; tumor classification * Including casemix and identification

16 4. To what extent information for QI available? Number of indicators Paramedical = 21 Needed variables Nutritional care (n=11) Psychosocial care (n=6) Dental care (n=6) Physical functioning (n= 9) Speech therapy (n=5) Follow-up (n=7) e.g. loss of weight; BMI assessment date assessment date date preoperative screening assessement swallowing problems aftercare, weight

17 4. To what extent information for QI available? Referral Intake Diagnos:cs Treatment Follow- up 1. Not registred 2. Registred in the EMR in any possible way (including free text) 3. Structured registred (means NOT free text) 4. Registred using terminology standards (SNOMED-CT, ICD-10)

18 4. To what extent information for QI available? Referral Intake Diagnos:cs Treatment Follow- up Overall conclusion: Analysis is still going on but general conclusion is that most variables are registred but not structured and standardized and not only from EMRs!

19 Sources for variables needed for Quality Indicators EMR s Primary care process Administrative data PROM s PREM s Quality registration Quality reports

20 5. To what extent can we use existing clinical building blocks? Care process Research Quality indicators

21 CCR/CCD Header Sec:e 1 Payers Sec:e 2 Advance Direc:ves Sec:e 3 Support Sec:e 4 Func:onal Status Sec:e 5 Problems Sec:e 6 Family History Sec:e 7 Social History Sec:e 8 Alerts Sec:e 9 Medica:ons Sec:e 10 Medical Equipement Sec:e 11 Immuniza:ons Sec:e 12 Vital Signs Sec:e 13 Results Sec:e 14 Procedures Sec:e 15 Encounters Sec:e 16 Plan of Care Sec:e 17 Healthcare Providers Klinische bouwsteen OverdrachtPa:ent OverdrachtZorgaanbieder OverdrachtZorgverlener OverdrachtBetaler OverdrachtBehandelAanwijzing OverdrachtContactpersoon OverdrachtFunc:oneleStatus OverdrachtBartheIndex OverdrachtProbleem OverdrachtFamilieanamnese OverdrachtBurgerlijkeStaat OverdrachtDrugsgebruik OverdrachtIntoxica:eAlcohol OverdrachtIntoxica:eTabak OverdrachtLevensovertuiging OverdrachtNa:onaliteit OverdrachtOpleiding OverdrachtWoonsitua:e OverdrachtAlert OverdrachtMedica:e OverdrachtMedischeHulpmiddel OverdrachtVaccina:e OverdrachtAdemfrequen:e OverdrachtBloeddruk OverdrachtGewicht OverdrachtGlasgowComaScale OverdrachtHarirequen:e OverdrachtLengte OverdrachtO2Satura:e OverdrachtPijnscore OverdrachtPolsfrequen:e OverdrachtTemperatuur OverdrachtLabUitslag OverdrachtTekstUitslag OverdrachtProcedure OverdrachtContact OverdrachtPlanOfCare OverdrachtZorgverlener

22 Standards used Standaard ICD- 10 ICD- O- 3 SNOMED- CT (C/P/R) TNM ACE- 27 VAS CTC/RTOG Karnofsky Registra%e Classifica:e medische diagnose Classifica:e oncologische diagnose Codering medische gegevens Stadiering tumor Specifieke oncologische comorbiditeit Classifica:e van pijnscores Classifica:e oncologische toxiciteiten Classifica:e func:onele toestand pa:ënt

23 Specific information elements and available building blocks Informa%e- element (mid- level) Voorgeschiedenis Anamnese algemeen Anamnese familie Anamnese sociaal Lichamelijk onderzoek algemeen Lichamelijk onderzoek gewicht Lichamelijk onderzoek eetgewoonte Intoxica:es alcohol Intoxica:es drugs Intoxica:es roken Allergieën Medica:e Comorbiditeit Tumor Metastasering Behandeling Complica:es Toxiciteit Pijnscore(VAS) Lab bepalingen MDO Klinische bouwsteen beschikbaar? Ja, OverdrachtProbleem Ja, OverdrachtProbleem Ja, OverdrachtFamilieanamnese Ja, OverdrachtWoonsitua:e Nee, maar in ontwikkeling Ja, OverdrachtGewicht Nee, maar in ontwikkeling Ja, OverdrachtIntoxica:eAlcohol Ja, OverdrachtDrugsgebruik Ja, OverdrachtIntoxica:eTabak Ja, OverdrachtAlert Ja, OverdrachtMedica:e Ja, OverdrachtProbleem Nee Nee Ja, OverdrachtProcedure Ja, OverdrachtProbleem Nee Ja, OverdrachtPijnscore Ja, OverdrachtLabUitslag Nee

24 5. To what extent can we use existing clinical building blocks? Results careproces patients with Head and Neck Cancer 1. Directly useful (e.g. CBB Weight) 2. Useful with modification (e.g. CBB Plan of care) 3. No CBB available (e.g. MDT and Tumor classification)

25 6. Conclusions en next steps Ø Quality indicators need far more information elements than minimal necessary for the care process. Ø Most information elements needed for Quality indicators that in EMRs is unstructured and not standardized (e.g. Snomed CT) Ø A discussion is needed about which elements must be registred in EMRs for both the care process as quality indicators. Ø Standardized registration needs to be improved

26 6. Conclusions and next steps Ø New Clinical Building Blocs will be developed for a.o MultiDisciplinary Team meetings and Tumor classification, Ø By specifications of existing blocs Ø By creating complete new blocs Ø Test in practice which information elements can directly be extracted form EMRs Ø Process evaluation of the usefulnes of the building blocs

27 7. Take home message Registration at the source implies that information elements needed for Quality indicators either Ø must be registred in the EMRs (structured and standardized) OR Ø the Quality indicator must be removed Clinical Building Blocks (DCM), including using SNOMED CT, can help to improve structured and standardized registration.

28 Quality Indicators HNC Information needed from Less indicators Administration Patients (QoL,Proms) EMRs structured and standardized (Snomed CT e.g ) If not in EMRs Register in EMRs

29 More information