OUR SPEAKER TODAY, DR. JAMES CIMINO, I READ HIS BIO. I HOPE YOU DID. I WILL NOT READ IT BACK TO YOU, RIGHT? HE'S A BOARD CERTIFY INTERNIST AND INFORMATITION AND CURRENTLY PROFESSOR OF MEDICINE AND INAUGURAL DIRECTOR OF INFORMATTICS INSTITUTE AT THE UNIVERSITY OF ALABAMA BIRMINGHAM SCHOOL OF MEDICINE. HE'S BEEN CARRYING OUT CLINICAL INFORMATTICS RESEARCH FOR AROUND 30 YEARS, HE DOESN'T LOOK THAT OLD BUT THAT'S WHAT HE SAYS, RIGHT? HE'S AN EARLY DEVELOPER OF METHODS FOR LINKING KNOWLEDGE INTO ELECTRONIC HEALTH RECORDS, AND HE'S HAD PREVIOUS APPOINTMENTS AT COLUMBIA UNIVERSITY SCHOOL OF MEDICINE AND ALSO AT THE NIH CLINICAL CENTER HERE FOR A NUMBER OF YEARS AND IS CO-EDITOR WITH TED SHORT LIFE WITH THE BIO-INFORMATICS. I WAS GOING TO BRING IT FOR YOU BUT I DON'T WANT TO HAVE TO CARRY IT. IT'S A WONDERFUL BOOK, IF YOU HAVEN'T LOOKED AT IT, YOU SHOULD. HISON ARES INCLUDE AMERICAN FELLOWSHIPS OF THE AMERICAN ACADEMY OF MEDICINE, DONALD LINDBERG AWARD FOR INFORMATION AND PRESIDENT'S AWARD FROM THE INFORMATTICS ASSOCIATION AND ELECTED TO THE NATIONAL ACADEMY OF MEDICINE. HE PUBLISHED MORE THAN AND NOVEL CLINICAL INFORMATION AND CLINICAL RESEARCH INFORMATTICS, HIS PAPER IS MEDICAL CONTROL VOCABULARIES IN THE 21st CENTURY HAS BEEN CITED MORE THAN 300 TIMES AND HAS A RELATIVE CITATION RATIO, YOU KNOW WHAT THAT IS, RIGHT? IT'S THE NIH WAY OF LOOKING AT SOMETHING OF 12 PBT .4, WHICH IS 12 MORE CITATIONS FROM THE AVERAGE COLLECTION OF ARTICLES OF SIMILARLY SUPPORTED WORK. HIS TOPIC TUESDAY IS TRANSFORMING ELECTRONIC HEALTH RECORDS FROM ANNOYANCES TO ASSISTANCE, A RESEARCH AGENDA FOR THE NEXT DECADE, SOMETHING THAT MATTERS TO ALL OF US A LOT. SO WELCOME JIM, WE'RE LOOKING FORWARD TO HEARING YOU. [ APPLAUSE ] >> THANKS ARE THE NICE INTRODUCTION. SO THE LAST TIME I SPOKE HERE WAS ABOUT 30 YEARS AGO AND I MUST HAVE DONE A GOOD JOB BECAUSE THEY INVITED ME BACK. SO I WAS HERE FOR ABOUT 7 YEARS BUILDING A REPOSITORY OF CLINICAL RESEARCH DATA MOSTLY FROM THE ELECTRONIC HEALTH RECORD DATA HERE AT NIH, BUT GOING BACK TO 1976, AND WHEN I STARLIGHTED TRYING TO RE--STARTED TRYING TO REUSE IT FOR RESEARCH, I REALIZED THERE WAS A LOT OF PROBLEMS WITH THE CONTENT OF THE RECORD TO MAKE IT HARD TO DO MY JOB AND I STARTED THINKING ABOUT WHAT THOSE THING HEAT SHOCK SYSTEM BE AND SPENT THE LAST COUPLE OF YEARS TRYING TO FIGURE OUT HOW TO ARTICULATE THAT SO I WILL GIVE YOU SOME OF MY IDEAS TODAY. I HOPE PATTY BREN AN IS LISTENING BECAUSE THIS IS REALLY A TALK FOR HER BECAUSE I WOULD LIKE TO SEE THE NIH PURSUE THE RESEARCH TOPICS THAT I AM GOING TO TALK ABOUT AND NIH CERTAINLY HAS BEEN THE LEADER OF INFORMATTICS RESEARCH THANKS TO DON LINDBERG'S LEADERSHIP HERE IN INCLINICAL INFORMATTICS RESEARCH, THE OTHER INSTITUTES COULD TAKE A LESSON FROM NIH AND I HOPE THEY WILL BE LISTENING IN, TOO. SO WHAT I WILL TALK ABOUT. I WILL TALK ABOUT MY VISION FOR ELECTRONIC HEALTH RECORDS, EVERYBODY HAS 1 OF THOSE. I WILL BABBLING MINE UP A BIT BUT I WILL START WITH A BRIEF HISTORY HOW WE GOT INTO THE MISS IN THE FIRST PLACE AND PROVIDE A PRACTICAL ROADMAP FOR GETTINGITOUS WHERE WE SHOULD BE AND IN THAT I WILL INCLUDE AN AGENDA FOR THE KINDS OF RESEARCH TOPICS, I THINK WE NEED TO EXPLORE IF WE'RE GOING TO GET THERE BECAUSE I DENT THINK WE WILL GET THERE BY THE CURRENT METHOD WHICH IS TO TAKE SMART PEOPLE AND TELL THEM THERE'S A PROBLEM WITH ELECTRONIC HEALTH RECORD AND TELL THEM TO FIX IT AND THEY DO GREAT STUFF BUT IT'S NOT GETTING US ANY CLESSER TO WHERE WE WANT TO BE. SO I WILL COVER THIS TIME SPAN IF YOU CAN SEE THAT--YOU CAN SEE THE TIMELINE AT THE BOTTOM THERE. OKAY, SO, IT WAS ANOTHER SLIDE. THAT'S GONE. SO I WILL HAVE TO TELL YOU A STORY. HERE IT IS. OKAY. SO PATIENT COMES IN TO THE HOSPITAL, HERE FOR CARDIO VERSION, CAME IN WITH PALPITATIONS, NOTED IN THE EMERGENCY ROOM TO HAVE ATRIOLE FIB ROUGH ATOMALATION, DOCTOR DOES A CARDIO GRAM, SEES IT AND SAYS OKAY, HOW LONG YOU HAVE BEEN HAVING SYMPTOMS PATIENT SAYS I'M FINE, HAVEN'T HAD PROBLEMS AND THEY DO CARDIO VISION AND IT SAYS YOU ORDERED CARDIO FIB ROUGH ATOMALATION, WE CONFIRMED SHE HAS ATRIOLE DURATION, NO EVIDENCE OF ANTICOAGULATION DURING THIS PRIOR MONTH AND THEN IT SAYS RECOMMENDATION IS THAT SHE SHOULD BE ANTICO AGULATED FOR A MONTH PRIOR TO CARDIO VERSION. SO THE SYSTEM STOPPED THE CARDIO VERSION WHICH IS GOOD BECAUSE IF SHE HAD PROLONGED ATRIOLE FIB ROUGH ATOM LIEWGZ SHE MIGHT HAVE A CLOT IN THE ATRIUM OF HER HEART AND WHEN THEY GET THE HEART GOING IN AND NORMAL RHYTHM AND IT WILL KICK THE CLOT OUT AND DO SOMETHING BAD TO YOUR BRAIN OR LUNG OR SOMETHING LIKE THAT. HOW DID THE SYSTEM KNOW THAT? IT HAD TO KNOW THAT THE SYMPTOMS WERE RELATED TO THE DIAGNOSIS, IT'S NOT SOMETHING WE TYPICALLY PUT IN OUR RECORDS. IT HAD AATISMERAL ASPECT, SAID HEY IF THE SYMPTOMS STARTED A MONTH AGO, MAYBE THE DIAGNOSIS STARTED A MONTH AGO AND THEN IT INCLUDED THIS GUIDELINE FOR CARDIO VERSION AND IT WAS ACTUALLY ABLE TO MAKE USE OF THAT INFORMATION. BUT HOW DID THE EHR KNOW THAT. SOMEBODY HAD TO TELL IT. SOMEBODY HAD TO PUT THAT INFORMATION EXPLICITLY INTO THE RECORD AND 1 FORM OR ANOTHER, SO THAT SYSTEM COULD THEN MAKE INFERENCES IT NEEDED. ALL RIGHT, SO, THIS IS A PHOTOGRAPH OF LARRY WEID WHO PASSED AWAY EARLIER THIS YEAR. THIS IS A VIDEO FROM A LECTURE HE DID AT--I'M BLANKING ON WHERE IT WAS. BUT GO LAWRENCE WEID AND PROBLEM ORIENTED MEDICAL RECORD ON YouTUBE AND YOU'LL FIND THIS VIDEO AND IT'S WORTH WATCHING. HE RIPS INTO THE RESIDENTS THAT ARE WRITING THE RECORDS IN THE NOTINGS, AND SO LARRY START THE OWED WITH THESE PAPERS IN THE NEW ENGLAND JOURNAL OF MEDICINE MEDICAL RECORDS THAT GUIDE AND TEACH AND IN THOSE RECORDS, IN THOSE PAPERS HE ANALYZED WHAT KIND OF INFORMATION IS IN ELECTRONIC OR PAPER RECORDS AT THE TIME AND WHAT HE THOUGHT SHOULD BE IN THERE. SO THIS IS AN EXAMPLE FROM THE PAPER AND IT SAYS, WELL THE PATIENT GOT INSULIN BECAUSE THE BLOOD SUGAR WAS THIS AND HE GOT AMGEN, FIB RILE, UP ALL NIGHT, ET CETERA, ET CETERA, VOMITED GREEN FLUID AND SO ON. SO KIND OF A DIARY TELLING WHAT WAS GOING ON WITH THE PATIENT. BUT LARRY SAID DON'T JUST RECORD WHAT'S HAPPENED TO THE PATIENT, YOU NEED TO RECORD WHAT YOU'RE THINKING OKAY SO THAT THE NEXT PERSON WHO PICKS UP THE RECORD KNOWS WHAT'S GOING ON AND KNOWS HOW YOU THINK ALL THOSE PIECES FIT TOGETHER AND THAT'S WHERE THE PROBLEM ORIENTED MEDICAL RECORD CAME FROM IS A WAY TO FORMALIZE REPRESENTATION, WHAT YOU THINK IS GOING ON WITH A PATIENT AND WHAT YOU WILL DO ABOUT THOSE PROBLEMS, NOT JUST WHAT YOU DID ABOUT THEM AFTER THE FACT. SO THAT REALLY STARTED TO CHANGE IN THE WAY WE RECORDED INFORMATION AND PAPER RECORDS, AND TO A CERTAIN EXTENT HAS CARRIED OVER INTO ELECTRONIC HEALTH RECORDS BUT NONAPOPTOTIC NOT IN A WAY THIS' USEFUL AS IT COULD BE. SO ELECTRONIC HEALTH RECORDS STARTED BECAUSE WE HAVE PAPER RECORDS AND SO WHAT WE DYOU KNOW WE SAID, WELL, NOW WE HAVE A COMPUTER AND LET'S TAKE THESE AND COMPUTERIZE THEM AND SO, WE DID WHAT WE TYPICALLY DO WHEN WE APPLY A NEW TECHNOLOGY TO DEVELOPMENT. THINK ABOUT THE HORSE DRAWN CARRIAGE AND THINK ABOUT AUTOMOBILES AND WE HAD HORSELESS CARRIAGES SO THEY BASICALLY WERE THE SAME TECHNOLOGY AS THE HORSE DRAWN CARRIAGE WE JUST REPLACED THE HORSE WITH THE MOTOR. AND SO THEN WE STARTED THINKING ABOUT HOW WE WERE GOING TO MAKE THESE THINGS BETTER, WHAT WE STARTED WITH THOUGH, WAS THIS ELECTRONIC DIARY, MOSTLY FOR BILLING PURPOSES AND SO WE HAVE THIS RECORD OF THIS PATIENT THAT SAYS OKAY, WE HAVE A HISTORY, WE DID A CARDIO GRAM, ATRIOLE FIB ROUGH ATOM LIEWGZ, THERE'S IMPRESSION AND PLAN HERE, AND ORDERS BUT WHAT'S NOT IN HERE IS FOR INSTANCE SAYING WHY DID I ORDER THE DIG OXIN, AM I GIVING IT FOR OR YOU KNOW WHY AM I DOING A THYROID FUNCTION TEST FOR HEART DISEASE. IT DOESN'T TIE IT ALL TOGETHER IN A FORMAL WAY. IT'S ALL IN THE TEXT IDEALLY. IN FACT IF YOU LOOK AT RECORDS TODAY, YOU WILL FIND A LOT OF THIS IS NOT IN THE TEXT. PEOPLE ARE SO BUSY MAKING SURE THEY HAVE ALL THE PIECES REQUIRED BY LAW TO HAVE THAT THEY DON'T PUT THEIR ACTUAL THINKING IN THE RECORD ANYMORE. SO WE HAVE THEN THESE LITTLE AREAS HERE. SO NOW WE HAVE OUR FIRST VERSION, HAD TO START SOME PLACE, SO WHAT DO WE DO? WHAT DID THE AUTOINDUSTRY DO? THEY STARTED WITH HORSELESS CARRIAGES AND THEY BUILT BETTER HORSELESS CARRIAGES SO THAT'S WHAT EHRs ARE TODAY TO A CERTAIN EXTENT. THEY'RE BETTER HORSELESS CARRIAGES. THERE WAS A REPORT TO THE PRESIDENT, BY THE SCIENCE ADVISOR COMMITTEE THAT SAID WE SHOULD HAVE A COMMITTEE TO ESTABLISH A NATIONAL HEALTH RECORD AND THAT WAS 1963 WHEN THAT WAS DONE. NO COMMITTEE WAS ESTABLISHED FOR 50 YEARS OR SO, NOW WE HAVE THE OFFICE OF NATIONAL COORDINATOR AND WE HAVE PROMULGATION OF HEALTH RECORDS AND TO A CERTAIN EXTENT FURTHER RECORDS INTO WHAT I CALL THE THIRD GENERATION ELECTRONIC HEALTH RECORD SO THE FIRST AND SECOND GENERATION WAS REALLY MORE THE FREE RADICALS TEXT STUFF, THE THIRD GENERATION NOW, WE'VE GOT THIS--SOME OF IT'S STRUCTURED AND SOME OF IT'S CODED. SO THE THINGS IN BOLD ARE THE CODED STRUCTURED THINGS AND THE THINGS ARE NOT IN BOLD ARE THE FREE TEXT SO WE HAVE FIELDS NOW IN THE RECORD. YOU SAY OKAY, YOU WANT TO SEE THE HISTORY, THAT'S WHERE YOU LOOK FOR AND THERE'S A BUNCH OF TEXT, SOME OF IT IS STRUCTURED AND CODED SO WE SAY, WE HAVE A HEART RATE AND IT'S GOT A VALUE, 125 AND THEN THERE'S IRREGULAR, MAYBE IT'S PRETEXT MODIFIER, MAYBE IT'S A CHOICE FROM A BULL DOWN MENU, WE HAVE A PROBLEM LIST AND MAYBE WE HAVE A CONTROL TERMINOLOGY AND THEN WE LOOK AT ORDERSERS AND THOSE ARE OFFENSE CONTROLLED BECAUSE YOU NEED TO COMMUNICATE THEM TO SOME OTHER SYSTEM. SO WE HAVE AN ECHO CARDIO GRAM, SO ON AND THOSE GO TO THE AN ILLEGALSARY SYSTEMS SO THERE WE HAVE A CHANCE OF CAPTURING THINGS AND USING CONTROLLED TERMINOLOGY SO WE CAN DO INTERESTING DLINGS WITH THAT BUT WHAT WE SEE, YOU KNOW FOR INSTANCE THE DIFFERENTIAL DIAGNOSIS IS STILL IN FREE DEMOCRACY BUT WHEN YOU DO, IT'S NEVER IN A STRUCTURED THING WHERE THEY SAY OKAY, PICK SOME SNOMED CODES TO PICK DIAGNOSIS AND WE DON'T DO THAT. SO THAT'S WHEN WE UNDERLYING ASSUMPTIONS UP WITH IS ONOTICANCE IT IS IN THE RECORD. SO 1 PROBLEM WE HAVE IS THAT DATA IS SCATTERED AROUND IN DIFFERENT PLACES BECAUSE WE'RE NOT MODELING THE PATIENT, WE'RE MODELING WHAT HAPPENED TO THE PATIENT SO SOME PATIENTS HAPPEN IN OUTPATIENT, SOME HAPPEN WITH IN-PATIENT. THIS IS AN EXAMPLE OF PATIENT MEDICATION INFORMATION, SOME WAS IT OUT PATIENT, SOME OF IT WAS NOTE, SOME WAS DISCHARGE SUMMARY WAS THE ADMISSION *. SOME OF IT WAS THE ORDER WHEN IS THE PATIENT WAS ADMITTED AND WE HAVE ALL THESE DIFFERENT MEDICATION LISTS AND WE NEED TO TRY TO FIGURE OUT HOW TO RECONCILE THOSE AND SO WE--WE PUT THAT ON THE PHYSICIAN AND SAY, OKAY, HERE'S--GO LOOK AT THE RECORD AND TELL US THE EXACT LIST OF MEDICATIONS THAT PATIENTS SHOULD BE ON AND BY THE WAY, TELL US WHY YOU'RE NOT CONTINUING ALL THE RECORDS AND MEDICATIONS THAT WERE ELSEWHERE IN THE RECORD. WE DON'T GIVE THEM TOOLS TO DO THAT. WE SAY HERE'S THE RECORD, MAKE A LIST. ANOTHER ANNOYANCE. SO THIS IS INSTRUCTIONS I SAW RECENTLY FOR HOW TO RUES ELECTRONIC RECORD SYSTEM FOR ORDERING THINGS IN BETWEEN CLINIC VISITS. SO THESE ARE INSTRUCTIONS. USE YOUR LAST CLINIC VISIT TO PLACE ORDERS, USE A LOCATION TO ASSOCIATE CLINIC, THIS SIN SURES THE TASK IS THE APPROPRIATE TASK IN YOUR CLINIC AND MAKE SURE YOU CHECK, RECHECK RETRIEVAL COUNTERS AND SEE, DISCHARGE COUNTERS IF THE PATIENT RETURNS, CAN YOU LAUNCH ORDERBS IN FROM THE MESSAGE AND THE ORDERS WILL BE PULLED IN THE MESSAGE, IF THE PATIENT HAS BEEN SEEN BEFORE, A MESSAGE CAN BE SENT TO THE SCHEDULE, INCLUDE ANY DETAILS NEEDED FOR PRECERTIFICATION. I GUESS WE NEED TO KNOW WHAT THOSE DETAILS ARE. SO THIS IS A FINE SET OF INSTRUCTION FIST YOUR JOB IS TO SIT IN FRONT OF A COMPUTER ALL DAY AND DO ORDER ENTRY AND THIS IS WHAT YOU WILL DO. MAYBE YOU CAN FIGURE THIS OUT BUT IF YOUR JOB IS TO TAKE CARE OF SICK PEOPLE, FIGURE OUT WHAT'S GOING ON WITH THEM, TELL THEM WHAT THEY NEED ON DO AND THEN PUT SOMETHING IN THE COMPUTER THAT CAN GET THE COMPUTE TORE HELP THEM, HAVING TO KNOW WHAT THIS EVEN MEANS LET ALONE HOW TO DO IT A LITTLE OVERWHELMING. SO LET'S HAVE MORE ANNOYANCES. SO WE HAVE A RECORD AND WHEN WE REORDER A DRUG WE HAVE AN ALERTING SYSTEM, ALERTS HAVE BEEN AROUND SINCE THE LATE 60S AND WE'RE STILL HAVING TROUBLE WITH THEM. SO THE ALERTS TEND TO GENERATE A LOT OF STUPID ALERTS THAT'S THE SPONGE BOB CHARACTER, 80% MAYBE MORE OF THE ALERTS ARE STUPID IN THE SENSE THAT THE COMPUTER SAYS YOU SHOULD DO THIS AND PHYSICIAN STIONZ I'M NOT GOING TO DO THAT. AND THEN 20% MAYBE IF QUIEWR LUCKY ARE THE 1S THAT WILL SAVE THE PATIENT'S LIFE. THAT'S THE SUPER MANKIND. SO WE HAVE TO OVERRIDE THE STUPID 1S AND MAKE SURE WE DON'T FOLLOW THEM BECAUSE WE KNOW SOMETHING THE COMPUTER DOESN'T KNOW SO WE OVERRIDE THEM AND ENUNFORTUNATELY WE OVERRIDE THE SMART 1S SOMETIMES BECAUSE WE'RE SO BUSY, CLICK, CLICK, CLICKING THROUGH THE ANNOYING ALERTS THAT WE END UP WITH ALERT FATIGUE AND WE DON'T PAY ATTENTION TO THEM. SO THAT'S A REAL PROBLEM, SO THEN WE ADDED MORE THINGS TO THE RECORD AND WE HAVE A BARNACLE THAT WE SLAP ON TO THE--YOU KNOW WE HAD THIS BILLING LABORATORY SYSTEM, THE PROGRESS NODE IS AN EXTRA PIECE AND THEN WE DO MEDICATION RECONCILIATION AND ADVERSE EVENT REPORTING AND DISCHARGE ORDERS AND WE ADDEDDA ALL THESE PIECES TO THE RECORD THAT AREN'T INTEGRATED WITH EACH OTHER AND THEY REQUIRE THE DATA TO BE ENTERED INTO THE SYSTEM AND WE END UP WITH SOMETHING THAT IS JUFULT COVERED WITH THE BARNACLES. YOU CAN'T SEE WHERE THIS IS GOING. THIS IS A SERIES OF STATUES OUTSIDE--OFF THE COAST OF THE ENGLAND THAT GET COVERED UP WITH HIGH TIDE. I THOUGHT THEY MADE A NICE DEPICTION OF HOW WE OFTEN FEEL WITH THESE SYSTEMS WHERE EVERYTHING IS JUST ANOTHER DISJOINTED PIECE THAT WE HAVE TO WORK WITH. ALL RIGHT. SO WHAT IF INSTEAD OF NATURAL EVOLUTION WE HAD INTELLIGENT DESIGN IN THE ELECTRONIC HEALTH RECORD AND LET'S IMAGINE A PLANET WHERE THERE'S NO TREES. SO NO PAPER RECORDS AND SO SOMEBODY SAYS, YOU KNOW WHAT? WE HAVE COMPUTER AND IT IS THIS HEALTHCARE PROBLEM, WHY DON'T WE FIGURE OUT HOW TO MAKE THE COMPUTER DO WHAT WE NEED TO TAKE CARE OF SICK PEOPLE? SO INSTEAD OF SAYING LET'S BUILD A DIARY, THAT'S A GOOD IDEA, NO WE WOULD BUILD SOMETHING THAT WOULD TAKE CARE OF PATIENTS. SO IN THE FUTURE HERE, MAYBE THERE'S HOPE FOR US TO ACHIEVE THAT. ALL RIGHT. SO BEFORE WE THROW THE BABY OUT WITH THE BATH WATER, LET'S LOOK AT SOME OF THE THINGS THE COMPUTERIZED PATIENT RECORDS REALLY WELL. THEY DO BILLING WELL AND IMPROVE LEGIBILITY NO QUESTION ABOUT IT, THEY CAN READ THESE MUCH MORE EASILY THAN THE PAPER RECORDS A LOT OF US HAD TO GROW UP WITH. THEY'RE AVAILABLE FOR THE MOST PART. OF COURSE THERE ARE PROBLEMS, ALWAYS PROBLEMS, YOU KNOW WITH THE COMPUTER SYSTEMS, BUT THE PROBLEMS WITH PAPER SYSTEMMINGS ARE EVEN WORSE SO IT'S HARD TO BACK UP PAPER RECORD SYSTEM, HARD TO FIND A PHYSICAL CHART SOMETIMES WHEN MULTIPLE PEOPLE WANT IT AND SOMEBODY'S HOLDING ON TO TO BECAUSE THEY PRESENT IN ROUNDS NEXT MORNING BUT MEAN WHILE THE PATIENT'S HAVING A PROBLEM AND SOMEBODY NEEDS TO SEE IT. SO THE ELECTRONIC 1 IS MUCH MORE UBIQUITOUS. REPORTING IS LTHEY'VE BEEN DOING THAT SINCE THE BEGINNING, GETTING DATA FROM IA LABORATORY OUT TO A PLACE WHERE THEY CAN SEE IT WITHOUT HAVING TO GO TO A LAB AND GET THE ANSWER. THEY ORDER ENTRY TO THE EXTENT THEY DO COMMUNICATE THINGS AUTOMATICALLY BETWEEN SYSTEMS SO THAT AT LEAST THINGS AREN'T FALLING THROUGH THE CRACKS. AND THEY DO THESE ALERTS AND REMINDERS, YOU KNOW THEY CAN BE REALLY GOOD AT THAT. WHAT DO THAT I DO WRONG, FIRST THING IS ALERTS AND REMINDERS AND THEY DON'T DO AS WELL AS THEY COULD AND WHEN THEY ARE OVERENTHUSIASTIC THEY GET THE ALERT FACAS TIGER DATABASE WHICH IS A TAINCH--FATIGUE WHICH IS A DANGEROUS PROBLEM. DATA ENTRY, SO FOR INSTANCE IN THE MEDICATION RECONCILIATION, TYPICALLY, YOU HAVE TO PUT IN THE MEDICINE, YOU WANT AND CAN'T GO I FOUND THIS HERE AND HERE AND LET ME DRAG THIS IN AND CREATE THE LIST FROM ALL THE OTHER DATA IN THE RECORD. THEY ARE AWNCH INCOMPLETE, THEY ARE INCOMPLETE BECAUSE WE HAVE GAPS IN THE PATIENT CARE OR PATIENT IS GETTING CARE IN MULTIPLE PLACES AND SO THE RECORD WE HAVE DOESN'T ALWAYS HAVE EVERYTHING WE NEED TO KNOW ABOUT THE PATIENT. DESPITE THAT WE END UP WITH NOTE BLOAT AND DATA OVERLOAD BECAUSE WE DO BRING IN A LOAT OF THINGS AND REPEAT THEM OVER AND OVER AGAIN AND IT GETS A LITTLE OVERWHELMING AND I DON'T KNOW IF YOU HAVE OCCASION TO LOOK AT MEDICAL RECORDS AND SEE THE NOTES THAT THE HOUSE STAFF WRITE, I'M GETTING USED IT TO. I'VE BEEN AT UAB FOR 2 YEARS AND I'M GETTING USED TO FIGURING OUT WHERE'S THE ACTUAL INFORMATION IN THE WHOLE NOTE. YOU CAN'T SEE THE NO BECAUSE YOU HAVE TO SCROLLOT SCREEN AND THERE'S A LOT OF STUFF THAT'S OTOLAIRIN COPIED FROM OTHER NOTES AND THE OTHER RECORD AND ALL THE LABS AND WHERE'S THE PART WHERE THE PERSON ACTUALLY [AUDIO CUTS OUT ] --SO I WANT TO SAY FIND ME ALL THE LABS AND IF I SAY SHOW ME THE LABS WITH THE MED KAIGDZ AND HOW THOSE FIT TOGETHER THERE'S NO HOPE OF DOING THAT. EVEN WORSE THE SYSTEMS TODAY ARE BASED ON BILLING SYSTEMS SO A LOT OF TIMES WHEN YOU GO INTO THE RECORD AND SAY, SHOW ME THE PEASHT'S INFORMATION THEY GO, WELL, WHICH IS IT YOU'RE INTERESTED IN? I'M INTERESTED IN THE PATIENT, I WANT ALL THE NEVERGDZ BUT THE DATA HAS BEEN PARTITIONED BY VISIT BECAUSE THAT'S HOW THE BILLING IS DONE. OKAY, WHAT COULD THEY BE DOING, THERE'S A LONG LIST OF THINGS AND ACTUALLY YOU GO TO THE SYMPOSIUM NEXT WEEK AND YOU WILL HEAR IDEAS WHERE THAT'S BEEN GOING ON FOR NOW, 30-SOME-ODD YEAS THAT COULD THEY DO THIS BUT A LOT DIEOT VINE BECAUSE WE CAN'T FIND WAYS TO BRING THEM INTO THE CLINICAL SETTING. PHYSICIANS ARE DROPPING OUT OF PRACTICE, TELLS THEIR KIDS NOT TO GO INTO MEDICINE BECAUSE THEY CAN'T STAND THE MEDICAL RECORDS, ELECTRONIC MEDICAL RECORDS. I HAVE TO FIND AN ADD FOR THIS, I NEED TO PUT IT IN MY TALK. IT'S AN ADDAD FOR A HOSPITAL THAT IS RECRUITING PHYSICIANS AND THEIR BIG ATRAGHTOR IS, WE DO NOT HAVE AN ELECTRONIC HEALTH RECORD. SO SERIOUSLY, I NEED TO LOCATE THAT BECAUSE IT'S PRETTY TELLING. OKAY, WE NEED A SYSTEM THAT WILL TELL US WHAT'S GOING ON WITH THE PATIENT, NOT JUST HERE'S EVERYTHING YOU NEED TO KNOW, BUT TELL US THE STORY, TELL US WHAT'S GOING ON. WE NEED TO EDUCATE THE USERS OF THE SYSTEMS SO THAT AS WE BUILD BETTER TOOLS IN THERE, THEY KNOW WHAT IS ACTUALLY GOING ON WITH THE TOOLS, SO THAT THEY ARE NOT CONSTANTLY GOING, WELL, WHY IS IT ASKING ME THIS QUESTION, I WILL ANSWER HOWEVER I CAN BECAUSE THEY DON'T KNOW WHAT IT'S SUPPOSED TO DO ONCE THEY ANSWER THE QUESTION. SO THOSE USERS ARE NOT ONLY PHYSICIANS AND NURSES BUT OTHER --USING THE KNOWLEDGE AND--[AUDIO CUTTING OUT ] --CAUSAL REASONING IS THE ABILITY TO SAY IF I KNOW X AND Y, I CAN UNDERSTAND WHY THE IN THE PATIENT'S CASE, PATIENT HAS THIS GENE AND THEY HAVE THIS LAB RESULT AND THIS EXPOSURE, I THINK THEY'RE GOING TO HAVE THIS DISEASE. SO CAUSAL REASONING GOES BACK QUITE A WAYS. THIS A PAPER BY CASNICK, AND IT GOES BACK BEFORE 1982 ASK AND THIS IS A DIAGRAM OF A CAUSAL NETWORK FOR A VERY SMALL PART OF THE BODY FOR 1 DISEASE. IT'S THE EYE. IT'S GLAUCOMA. THIS IS 1982 SO IT'S PROBABLY MORE COMPLICATED NOW, SO HOW DO WE USE THINGS THAT WILL BE USEABLE AND SCALE AND WHAT I LIKE ABOUT THIS DIAGRAM ESPECIALLY IS THE THAT THE WORD IS A SIMPLIFIED CAUSAL NETWORK, SO IT'S--IT'S A CHALLENGING PROBLEM TO FIGURE OUT HOW TO DO THAT. ANOTHER 1 IS THE FORMAL REPRESENTATION OF CLINICAL COGNITION. WHAT IS--WHAT ARE THE ACTORS THINKING, WHAT IS THE DOCTOR THINKING, WHAT IS THE PATIENT THINKING. WHAT DO THE PATIENT'S PRIORITIES, DOCTOR'S PRIORITIES, HOW DO THESE PIECES OF DATA IN THE DIARY FIT TOGETHER IN SOME CO HERENT WAY AND SO, BY THAT I WILL TALK ABOUT--I WILL TALK ABOUT REPRESENTATIONS, DIFFERENTIAL DIAGNOSIS AND MAYBE OTHER THINGS AS WELL AND HOW THEY RELATE TO EACH OTHER. SO THE EXAMPLE OF A SYMPTOM BEING TIED TO A PHYSICAL FINDING AND SO O. I HAVE A DIAGRAM OF THAT. AND THEN PREFERENCES, AND PRIORITY SO THAT THE SYSTEMS KNOWS IF THE PATIENT HAS 2 PROBLEMS GOING ON AND 1 IS MY O CARDIAL INFARCTION AND 1 IS POISON IVY, WHICH 1'S MOST IMPORTANT. WELL, IT DEPENDS IF THE MY O CARDIAL INFARCTION WAS 6 MONTHS AGO AND UNCOMPLICATED BUT THE POISON IVY WILL REQUIRE IV STEROIDS, WE WANT TO PAY ATTENTION TOLT INFORMATTICS IVY. RIGHT NOW THE PROBLEM LIST IS A FLAT LIST OF THINGS. WHAT CAN WE AFFORD NOT TO MISS AND WHAT'S OKAY TO IGNORE, SO WE CAN HAVE THOSE ALERTS SHUT UP ONCE IN A WHILE, SO YOU KNOW IN THE MIDDLE OF A CODE, IT DOESN'T SAY, YOU KNOW THIS PATIENT HAD A FLU SHOT YET, YOU MIGHT WANT TO DO THAT WHILE YOU'RE DOING THESE OTHER THINGS. SO, WE NEED TO BE ABLE TO REPRESENT THEM IN MORE FORMAL WAYS. SO WITH THAT I THINK ABOUT WHAT WOULD I WANT IF I WAS STARTING FROM SCRATCH, WHAT WOULD I WANT IN ELECTRONIC HEALTH RECORD FOR MY FOURTH GENERATION EHR. FIRST THE DAILY BASIS THE ARE ABOUT THE SAME, DATA ABOUT THE PATIENT'S DEMOGRAPHICS, SYMPTOMS THE PATIENT'S HAD, PALPATIONS, SHORTNESS OF BREATH, PHYSICAL EXAMINATION, THE HEART IS IRREGULAR, PULSE IS IRREGULAR AND I THINK ABOUT, OKAY, I HAVE THIS PATIENT WHO HAS THESE SYMPTOMS AND PATIENT HAS THIS PHYSICAL EXAM AND MY IMPRESSION NOW IS THAT THE PRAISHT WILL HAVE AN ARRHYTHMIAOT PHYSICAL EXAMINATION AND I MIGHT SAY, YOU KNOW, THIS ARRHYTHMIA MIGHT BE EXPLAINING THE SHORTNESS OF BREATH AND PALPITATIONS AND I CAN TIE THOSE TOGETHER EXPLICITLY. SO I SAY OKAY, I HAVE A DIFFERENTIAL DIAGNOSIS BUT THE FIRST THING I WILL THINK OF IS THE IRREGULARLY--IRREGULAR NATURE OF IT SO I WILL USE A CARDIO GRAM TO MAKE DIAGNOSIS AND WHEN I DO IT CONFIRMS THAT THEY HAVE ATRIOLE FIB ROUGH ATOMALATION, SO NOW I'M REPRESENTING THE RELATIONSHIP BETWEEN THE FINDINGS ON THE EKG AND ALL THE OTHER PIECES OFLET PATIENT'S RECORD AND I SAY, OKAY, NOT ONLY IS IT PLAINING THESE SYMPTOMS BUT EXPLAINING THESE FINDINGS. I WILL SAY OKAY, WE FOUND THE PROBLEMS AND I WILL ASSOCIATE THEM WITH THE ATRIOLE FIB ROUGH ATOMALATION AND ANY OF THESE ARE GOING ON, I HAVE TO RETHINK THAT EXPLANATION BUT MEAN WHILE I CAN KIND OF PARTIGDZ THAT TASK OWF AND FOCUS ON THE ATRIOLE FIB ROUGH ATOMALATION. SO I WILL TREAT ATRIOLE FIB ROUGH FIB ROUGH ATOMALATION, I WILL MONITOR THE VITAL SIGNS AND THE SYSTEM CAN DO ALL OF THAT BECAUSE IT KNOWS THAT I'M TREATING ATRIOLE FIBALATION HERE WHAT YOU DO. GIVE ME AN ORDER SET AND WE DO THOSE NOTICE WITH ORDER SETS BUT THEY'RE NOT TIED INTO THE WHOLE NETWORK OF COGNITIVE REASONING. AND THEN AGAIN, WE HAVE OUR VITAL SIGNS TIED BACK TO THOSE FINDINGS. NOW I HAVE A PATIENT WITH ATRIOLE FIBROALATION, AND CONTROLLING THEERATE AND MAYBE THE SYMPTOMS BUT NOW I HAVE TO FIGURE OUT WHY THEY HAVE IT AND POSSIBLE CAUSES. IT COULD BE HYPOTHYROIDISM, PULL MONITORARY EMBOLISM, MIRROR IMAGE TRIOLE VALVE THINGS SO I WILL ORDER TESTS, THYROID FUNCTION TESTS, ECHO CARDIO GRAMS, SO MY SYSTEM HAS A WARNING, SO IF I ORD ARED A THYROID TEST A COUPLE WEEKS AGO, HEY, YOU KNOW WHAT? DON'T DO THYROID FUNCTION TEST, YOU'VE DONE THEM RECENTLY, I DID THOSE BEFORE THE PATIENT HAD THE ATRIOLE FIB ROUGH ATOMALATION AND MAYBE THERE'S BEEN A CHANGE SO WE COULD SUPPRESS THE ALERT BECAUSE WE KNOW IT'S NOT RELEVANT IN THIS PARTICULAR SITUATION. OKAY, SO WE DO THE THYROID FUNCTION TEST AND FIND OUT THE PATIENT HAS HYPER THYROIDISM AND HERE'S HOW YOU WORK UP THE HYPOTHYROIDISM AND HERE'S HOW YOU TREAT WHATEVER WITH THE CAUSE, AND THERE'S A WHOLE PATH THAT GOES ALONG THERE AND WE HAVE THE ATRI OPEN FIB ROUGH ROUGH ATOMALATION AND WE GET THE PATIENT OUT OF THAT RHYTHM SO WE WILL TREATLET PATIENT WITH CARDIO VERSION, SO WE ORDER THE CARDIO VERSION AND THAT'S WHERE WE GET THAT ALERT AND I SHOWED AT THE BEGINNING BECAUSE THE SYSTEM SYSTEM WAIT A MINUTE, THIS PATIENT'S DISEASE MAYBE MORE THAN 2 WEEKS DURATION BECAUSE THE SYMPTOMS YOU TOLD ME YOU THINK ARE DUE TO DISEASE HAVE BEEN GOING ON THAT LONG. SO NOW WE CAN ISSUE AN ALERT THAT BLOCKS THAT POTENTIALLY LIFE THREATENING MEDICAL DECISION. OKAY. ASK THEN SO WHAT ELSE? WE WANT TO REPRESENT MORE THAN JUST THE TACTICS. THE TACTICS ARE THE THINGS THAT WE ORDER, THE STRATEGIC PLAN EDGE SEWHAT WE'RE TRYING TO DO, SO I USE THIS--THIS DIAGRAM TO KIND OF DISPLAY IT. THIS IS MY SON PLAYING WITH A GIANT CHESS GAME AND TACTICS ARE THE ACTION OR PLAN TO ACHIEVE AN IMMEDIATE PARTICULAR GOAL. SO YOU SEE MY SON MOVING THE PIECES AROUND AND YOU TRY TO GET A BETTER POSITION, TRYING TO THAT I CAN THAT PIECE BUT YOU DON'T KNOW WHAT HIS OVERALL STRATEGY, THE PLAN FOR ACHIEVING A GOAL OVER A LONG PERIOD OF TIME. YOU DON'T GET THAT FROM THE INDIVIDUAL MOVES AND WE DON'T PUT THAT IN THE RECORD. IN MY SON'S CASE IT WAS WORLD DOMINATION AND DIDN'T BECOME IMMEDIATELY APPARENT BUT WE DON'T PUT THIS EXPLICITLY IN OUR RECORD. OKAY, SO REPRESENTING THIS SITUATION, I WANT TO REPRESENT ASPECTS OF THIS, HOW DO I DO THIS IN SOME FORMAL WAY, FINDINGS, FINDINGS SUGGEST DIFFERENTIAL DIAGNOSIS, TESTS TO CONFIRM THE DIAGNOSIS, THE DIAGNOSIS EXPLAINS THE FINDING, THERAPY TREATS THE DIAGNOSIS, THERAPY PREVENTS DIAGNOSIS AND WE REPRESENT THE PATIENT'S STATE IN SOME FORMAL WAY. SO ACTUALLY THE CLASSES OF THINGS I'M TALKING ABOUT ARE RELATIVELY SMALL HERE. TESTS, DIAGNOSIS, THERAPY, AND THE RELATIONSHIPS ARE RELATIVELY SMALL, TOO, AND THIS VERY LIMITED ONTOLOGY IF YOU WILL MIGHT BE SUFFICIENT FOR DOING A LOT OF THINGS THAT WE WANT TO DO IN THE RECORD THAT WE CAN'T DO NOW. OKAY, SO IF WE DO THIS, THE SYSTEM CAN START THE WORK UP FOR THE HYPOTHYROIDISM, IT CAN BRING JUST IN TIME KNOWLEDGE WITH INFO BUTTONS AND IT KNOWS WHICH QUESTIONS ARE LIKELY TO BE ASKING, IT CAN IDENTIFY THE GOAL SO FOR INSTANCE WHEN WE WANT TO ANTICO AGULATE SOMEBODY, THE DEGREE WE CHOOSE DEPENDS ON THE REASON SO THE SYSTEM KNOWS THE REASON IT CAN BRING UP THE APPROPRIATE GUIDELINE AND MAYBE IT CAN ALSO SAY, YOU KNOW BEFORE YOU DO THIS ANTICO AGULATE, YOU BETTER DO A PREGNANCY TEST BECAUSE IF THIS IS ANTICO AGUE LANT IS CONTRA INDICATE INDEED PREGNANCY. IT CAN TELL US ABOUT THE ROLE OF GENETICS IN CHOOSING THE DRUG OR THE DOSE, BRING THAT TO BEAROT PROBLEM. SO WE CAN HAVE THIS PERSONALIZED GOAL BASED DRUG SELECTION INDUCED ALGORITHM. AND THEN ESTABLISHING THE PLAN FOR CARDIO VERSION WHICH INCLUDES WELL, IF YOU HAVE TO MONITOR THE ANTICOAGULATION, DO YOU THAT, YOU FOLLOW UP APPOINTMENT. GIVE THE PATIENT INSTRUCTIONS AND SEND AN E-MAIL BEFORE YOU TELL THEM NOT TO EAT, WHATEVER IT IS YOU HAVE TO DO, THE SYSTEM CAN DO ALL THAT BECAUSE NOW IT KNOWS WHAT YOU'RE TRYING TO ACCOMPLISH AND THE LAST THING, YOU YOU KNOW WE'RE GOING TO ASK CLINICIANS TO PUT MORE INFORMATION IN THE RECORD, THERE HAS TO BE SOME KIND OF PAY BACK TO REDUCE THE DATA ENTRY TO COMPENSATE FOR THAT EXTRA EFFORT WE'RE GOING TO REQUIRE OF THEM. AND I THINK THAT IF WE DO THIS RIGHT, THAT THE SYSTEM WILL BE ABLE TO WRITE THE NOTE AT THE END OF THE DAY. I DON'T MEAN WRITE A NOTE BUT WRITE THE NOTE. SO IF IT KNOWS EVERYTHING EVERYBODY'S DOING IT CAN WRITE A NOTE ABOUT THE PATIENT, WHAT'S GOING ON WITH THE PATIENT AND WOULDN'T THAT BE NICE IF AT THE END OF THE DAY, YOU HAD SOMEBODY READ THE RECORD AND WRITE THE SUMMARY SO THAT 1 DAY YOU COULD READ THE 1 NOTE. PULLS THE HISTORY IN, AND A LOT OF THAT'S FROM THE ORDERS BUT MY IMPRESSION COULD BE NOTED AS I ADD THE EXTRA INFORMATION ABOUT TYING DIFFERENT THINGS TOGETHER AND THEN MY PLAN TO TREAT THE ATRIOLE FIBROALATION TO IMPROVE THE PATIENT'S SYMPTOMS AND I WILL EVALUATE THE CAUSE OF THE HYPOTHYROIDISM AND PERFORM ELECTROCARDIO VERSION AND SO O. SO IT CAN ACTUALLY I THINK GENERATE THIS TEXT GENERATION IS EASY, TEXT UNDERSTANDING HARDER BUT TEXT GENERATION ACTUALLY IS PRETTY EASE TO DO IF WE HAVE ALL THESE PIECES IN PLACE. OKAY, SO, GREAT. WE COME UP WITH THESE IDEAS WHAT DO WE DO? WE ARE STUCK WITH THESE ELECTRONIC HEALTH RECORDS WE SPENT BILLIONS OF DOLLARS PUT INTO PLACE. DO WE RIP THEM OUT AND START OVER? MAYBE WE DON'T HAVE TO DO THAT. WE CAN START WITH A BLACK BOX THAT'S A DOCUMENT WE STORE IN THE ELECTRONIC HEALTH RECORD SO SOEHR AND IT'S CONTROLLING DATA, MAKE SURE IT BELONGS TO THE RIGHT PAICIALT, KEEPS TRACK OF WHO'S LOOKING AT IT, DOESN'T KNOW WHAT THE DOCUMENTS ARE, A LOT OF TIME. THE LETTERS FROM OUTSIDE, LABORATORY TESTS, WHATEVER IT STORES THEM AND GIVES THEM BACK TO YOU WHEN YOU NEED IT. SO LET'S FIGURE OUT WHAT THIS SHOULD BE AND THEN LET THE EHR STORE IT FOR US AND TAKE CARE OF IT, AND WE CAN USE FIRE THE FIRST INTEROPERABLE RESOURCES EXCHANGE TO DO THAT. IT'S IT DOES IT NOW. SIMPLE. WE CAN ULTIMATELY PULL DATA FROM THE TABLES POETIC POPULATE WHAT'S IN THE BLACK BOX AND WHAT'S IN THE BLACK BOX IS A KNOWLEDGE STRUCTURE, AN RDF OR XML DOCUMENT THAT CAPTURES THE NEVERTIONZ WE WANT TO REPRESENT, WE CAN ENHANCE OTHER INFORMATION FROM THE EHR AND THEN WE CAN BUILD APPS, INCLUDING SMART APPS AND SUBSTITUTABLE, REUSABLE TECHNOLOGIES THAT COULD MAKE USE OF THIS INFORMATION TO DO THINGS LIKE SAY, HEY, HERE'S THE RIGHT ANTICO AGULATE TO CHOOSE FOR THIS PATIENT BASED ON EVERYTHING WE KNOW AND THEN BE ABLE TO ADD THAT TO THIS KNOWLEDGE STRUCTURE. SO I'M SMART ON FIRE, KIND OF GLOSSED OARVE--OVER THAT BUT SMART ON FIRE IS THE POPULAR WAY OF COMBINING THOSE ACRONYMSMENT SO THIS IS 1 APPROACH AND THE METAPHOR I USE IS THE PARASITISM METAPHOR, SO IF YOU THINK ABOUT A FIG TREE. SO A FIG TREE STARTS OFF AS I VINE. IT'S INNOCUOUS, IT GROWS UP AROUND A TREE BUT EVENTUALLY IT GROWS AROUND THE TREE AND REPLACES THE TREE. KILLS IT. SO THIS IS 1 POSSIBILITY IS WE BUILD A LOT OF THESE SMART APPLICATIONSA APS AND WE GET RID OF THE EHR ITSELF. THIS IS NOT A POPULAR IDEA WITH THE EHR VENDORS OF COURSE. BUT IT'S SOMETHING--IT'S 1 WAY WE COULD MOVE FORWARD, BUT I THINK ABOUT IT A DIFFERENT WAY WHICH IS TO EMPOWER THE EHR TO GET AT WHAT'S IN THAT BLACK BOX, SO WE HAVE DECISION SUPPORT, THE DECISION SUPPORT COULD IF IT HAD ACCESS TO THAT INFORMATION, SOPHISTICATEDY WE PUT THAT IN A TABLE, AN EAV TABLE, THAT THE EHR IS THERE DECISION TRPT CAN GET ACCESS TO IT AND START TO USE THAT AS A--AS PARLIAMENT OF ITS OWN--IT'S OWN FUNCTION. NOW WE DON'T LET THE EHR CHANGE IT, NOT INITIALLY BECAUSE WE WANT TO CONTROL WHAT'S IN THERE, BUT EHR CAN USE IT IN THE PAST POINT. BUT THEN WE CAN MOVE ON TO MUTUALISM, WHERE WE HAVE THE EHR TAKING ON THESE FUNCTIONS AND THE METAPHOR, I LIKE TO USE IS THIS 1. SO THIS IS AN ELECTRONIC MICROGRAPH OF A CELL, IT'S INFECTED WITH BACTERIA. I HAD--DON'T REMEMBER WHAT THE BACTERIA ARE. IT ALSO HAS AGER ANLES AND MITOCHONDRIA, YOU MAY NOT KNOW, THESE ARE THE ORGANLES IN ALL OF OUR CELLS THAT WERE ORIGEINALLY FREE LIVING BACTERIA MANY, MANY BILLIONS OF YEARS AGO, THEY INFECTED SOME PROCARIOTIC CELL AND THEY SURVIVED INSIDE THE CELL AND PROVIDED A FUNCTION AND ENERGY IN THE FORM OF ATP. SO THE MITOCHONDRIA HAVE THEIR DNA AND DIVIDE LIKE OTHER BACTERIA. THEY CAN'T LIVE OUTSIDE THE CELL BUT THEY GO ON ABOUT THEIR BUSINESS AND THE GENETICS ARE FASCINATING BECAUSE THEY'VE BEEN PASSED DOWN FROM MOTHER TO CHILD THROUGH THE OVUM, FROM EVE ON DOWN. SO THEY CAN DO ALL KINDS OF INTERESTING THINGS WITH THEM AND SO THEIR GENETICS HAS BEEN STUDIED WELL. I WAS AT A LECTURE TALKING ABOUT THIS AND THEY SHOWED THIS GENOME AND I SAID OH IS THAT--IS THAT THE WHOLE GENOME OR JUST A SCHEMATIC AND THEY SAID NO, NO, THAT'S THE WHOLE GENOME. I SAID HOW CAN THAT BE THE GENOME FOR A THING THAT IS A BACTERIA THAT DIVIDES AND DOES ALL THESE OTHER WONDERFUL THINGS AND THEY SAID I DON'T KNOW I'M A MATHEMATICIAN IS SO I HAD TO GO AND LOOK THIS UP AND THE FIRST THING I FOUND OF COURSE IS THAT GENOMES OF BACTERIA ARE VERY COMPLICATED, VERY ELABORATE AS YOU WOULD EXPECT AND I'M THINKING WHAT HAPPENED IN HOW DID THIS HAPPEN? IT TURNS OUT THAT AS THE MITOCHONDRIA SURVIVED IN THE PRO CARIOTIC CELL IT WAS ABLE TO SHED FUNCTIONS, IT DIDN'T NEED TO MAKE A LOT OF PROTEINS IT WAS MAKING BEFORE AND THE HOST CELL STARTED DOING THAT. SO THE HOST CELL ACTUALLY EVOLVED TO PROVIDE FUNCTIONS FROM THE MITOCHONDRIA SO IT COULD BE MORE EFFICIENT AT WHAT IT WAS GOOD AT DOING SO IT'S AN EVOLUTIONARY PROCESS AND THAT'S THE KIENTD OF THING WE CAN SEE, OUR CURRENT EHRs EVOLVE TOWARDS AS WE FIGURE OUT HOW TO DEFINE SOME OF THIS CLINICAL COGNITION THAT WE NEED TO ADD TO THE RECORD. OKAY, AND SO THE THEN THE IDEA WOULD BE THAT THE EHR TABLES WOULD HAVE THIS INFORMATION IN NATIVE FORM THAT THE EHR COULD USE. SO RESEARCH AGENDA.& WHAT DO WE HAVE TO DO TO GET FROM THERE TO--FROM WHERE WE ARE NOW TO WHERE I'M PROJECTING? SO FIRST OF ALL WE NEED INFORMATTICS RESEARCH ON THESE DEEPER MODELS. WHAT DO WE DO? PEOPLE HAVE STARTED WORKING ON THIS. SO THIS IS--THIS A PAPER FROM RECENTLY 2015 BY CHEN AND COLLEAGUES WHERE THEY ARE LOOKING AT CASE BASE REASONING AND DEVELOPING A COGNITIVE MODEL FOR CASE BASE REASONING WHICH IS CLOSE TO THE KIND OF INFORMATION WE WOULD PUT IN HEALTH RECORD. SO YOU NOTICE SOME OF THE BIGGER NODES THERE ARE PER DIAGNOSIS, PROGNOSIS TREATMENT AND PATIENTS AND ADMINISTRATION SCHEME AND ALL THESE OTHER PIECES THAT ARE ALL INTERACTING. SO THE ONTOLOGY HERE MAY VERY WELL BE A GOOD FOUNDING FIRST STEP IN DEVELOPING THE KIND OF THING WE WANT TO REPRESENT IN THE ELECTRONIC HEALTH RECORDS THEMSELVES. ANOTHER 1 WAS A STUDY THAT I'VE DONE, SO FAR UNPUBLISHED BUT BASICALLY WHAT I WAS LOOKING AT WAS WHAT ARE THE COGNITIVE--WHATY AT COGNITIVE INFORMATION THAT'S IN TYPICAL RECORDS AND IF I CAN'T FIND TYPICAL RECORDS THAT CONTAIN IT I COULD USE NEW ENGLAND JOURNAL OF MEDICINE CASE REPORTS. BECAUSE IN THE CASE REPORTS THEY TALK ABOUT PATIENTS THAT YOU WOULD DO IN THE HEALTH RECORD BUT THEY EXPLAIN WHAT THEY'RE THINKING. SO HERE'S THIS 1, PRESENTATION OF SPONTANEOUS BRUISE SUGGEST MOST SUGGESTING OF A CASCADE DEFECT. SO THE AUTHOR MADE A STATEMENT RELATING TO SOMETHING THE PATIENT HAS WITH SOMETHING THE PATIENT MAY HAVE IN AN EXPLICIT WAY. SO THAT'S THAT DIFFERENTIAL DIAGNOSIS PIECE THAT COMES UP. SO I SENT A BUNCH OF THESE CASES DIVIDED UP INTO INDIVIDUAL SENTENCES TO ACME MEMBERS, AMERICAN MEDICAL COLLEGE MEDICAL STUDENTS AND ASK THEM WHAT WERE THE CONCEPTS IN THOSE SENTENCES AND WE CAME UP WITH A LIST OF ABOUT 10 THAT KIND OF COLLAPSED DOWN INTO ABOUT 10 OF RELATIONSHIPS BETWEEN THESE THINGS AND THIS MAYBE THIS PAPER WILL SEE THE LIGHT OF DAY SOMEBODY BUT YOU GET A FLAVOR OF WHAT'S IN THERE. THERE'S A FINDINGS EXPLICITLY STATED AS NOT PRESENT SO SOMETHING IS ABSENCE AND THAT'S SIGNIFICANT. RESULT OF A CLINICAL OBSERVATION, FINDING PRESIDENT SUPPORTS HYPOTHESIS FOR SOME CAUSE AND SO ON AND THERE ARE EXAMPLES THERE AND I DON'T KNOW IF WE CAN MAKE THESE SLIDES AVAILABLE BUT PEOPLE CAN CERTAINLY PAUSE THE VIDEO AND READ THESE AT THEIR LEISURE, THIS WAS 1 NETWORK THAT I CREATED FOR 1 PARTICULAR PART OF THE CASE, THAT USES ALL THOSE RELATIONSHIPS AND I'M NOT GOING TO TRY TO DECODE IT BUT HERE'S THE INTERPRETATION OF THE UPPER CASE LETTERS AND THE CONCEPTS AND THE LOWER CASE LETTERS ARE THE RELATIONSHIPS AND THE LITTLE CHARACTERS THAT ARE NOT--SO NO HISTORY OF DISEASE OR DISEASE NOT PRESENT. THAT'S A NOT SIGN. THAT'S HOW YOU INTERPRET THAT. SO CAN YOU GO THROUGH AGAIN AND READ THESE OR I'M HAPPY TO SHARE THE PAPER. AND THEN FINALLY, NOT FINALLY--ANOTHER STUDY BY [INDISCERNIBLE], THEY GAVE A TALK LAST WEEK AT CHILDREN'S HOSPITAL PHILADELPHIA, TALKING ABOUT HOW THEY WOULD REPRESENT THE PLAN IN THEIR--IN THEIR FORMAL WAY THAT TAKES INTO ACCOUNT ALL THE OTHER TASKS THAT HAVE TO HAPPEN AND INCLUDING THINGS WITH THE PROBLEM LISTING AND SYMPTOMS AND SO ON. SO I THINK A LOT OF THESE PIECES ARE STARTING TO FORM. PEOPLE ARE STARTING TO SAY THERE'S AN AREA, GAP HERE WE NEED TO FILL IN IF WE ARE GOING TO MAKE OUR SYSTEMS BETTER, I THINK WE'RE STARTING TO CONVERGE ON THAT. SO INFORMATTICS RESEARCH ON DEEPER MODELS, WE NEED TO IMPROVE DATA CAPTURE, NEW WAYS TO CAPTURE DATA AND FOR THAT I TURN TO MY BODY TOM P A YNE AND TOM HAD A PAPER THAT HE'S PRESENTED AT AHRQ AND HAS PAPERS IN THE WORKS NOW BUT HIS APPROACH IS TO US - A CELL PHONE THROUGHOUT THE DAY SO THAT CLINICIANS GET A MESSAGE, THEY GET A LAB RESULT, WHATEVER AND THEY CAN DICTATE THAT PIECE OF THE RECORD AND IT ALL GOES INTO THE RECORD AND CAN BE COMPILED INTO A SINGLE NOTE AT THE END OF THE DAY. SO USING NEW TECHNOLOGIES, NEW WAYS TO GATHER THIS, LESS INTRUSIVE AND LESS TIME CONSUMER BETTER CHANCE OF MORE COMPLETENESS. AND THENY HAVE TO CHANGE EDUCATION, TEACH PHYSICIANS, NURSES, PATIENTS WHAT THESE SYSTEMS ARE DOING. THIS CAME UP AND OCCURRED TO ME WHEN I WAS AT EPIC OUT IN WISCONSIN. THEY WERE SHOWING ME THIS FANCY THING THEY WERE DOING WITH NATURAL LANGUAGE PROCESSING AND THEY WERE PULLING THESE OUT FROM THE RECORD AND UTR PUT THEM IN A LIST AND PUT RADIO BUTTONS NEXT TO THEM AND THE IDEA WAS THE CLINICIAN WOULD GO TO THOSE AND SAY 1 COLUMN WAS FOR PROBLEM, 1 PROBLEM COLUMN WAS FOR DIAGNOSIS AND 1 COLUMN WAS FOR PAST MEDICAL HISTORY AND THE IDEA IS YOU WOULD PICK WHAT THOSE WERE AND THEN IT COULD--IT COULD STORE THEM IN THE RECORD APPROPRIATELY. WELL MY FIRST QUESTION WAS EXCUSE ME WHAT'S THE DIFFERENCE BETWEEN A PROBLEM AND A DIAGNOSIS? AND THEY SAID, WE DON'T KNOW, WE'RE JUST SALES PEOPLE AND THEY SAID WE WILL GET THE TECHNICAL PEOPLE TO TALK TO YOU. WE NEVER HAD THE CONVERSATION BUT IF YOU DON'T KNOW WHAT IT IS AND YOU DON'T KNOW WHAT IT IS AND I DON'T KNOW WHAT IT IS, WHAT'S AN INTERNIST OR PROGRESS PHYSICIAN GOING TO DO WHEN HE SEES THIS LIST. HE WILL GO WHAT THE HECK IS THIS, CLICK, CLICK, CLICK, GET THIS OUT OF MY FACE, I HAVE PATIENT TOTION SEE, I CAN'T BE BOTHERED WITH THIS. I STARTED DOING TRAINING ON THIS, THIS WAS THE EPIC SYSTEM IN WISCONSIN, WHEN I GOT TO UAB, WE HAVE THE CERNER SYSTEM, AND THEY STARTED SMOAING ME HOW TO MANAGE THE PATIENT LIST AND THERE WAS THIS THING, THE PROBLEM LISTING AND THENCH I COULD MOVE IT TO DIAGNOSIS OR I COULD MOVE IT TO PAST MEDICAL HISTORY AND I THOUGHT OH THIS LOOKS FAMILIAR, LET'S SEE WHAT THIS DOES SO WHEN I TRIED TO MOVE A PROBLEM TO PAST MEDICAL HISTORY IT WOULDN'T LET ME DO IT. I COULD ONLY MOVE A DIAGNOSIS TO GO, AHA, SO THE PAST MEDICAL HISTORY IS ABOUT CONFIRMED DIAGNOSIS. IF YOU HAVE A PROBLEM LIKE CHEST PAIN, YOU CAN'T SAY THERE WAS A PAST MEDICAL HISTORY OF CHEST MAIN. SO NOW I'M GETTING AN IDEA OF WHAT THE DEEPER MODEL OF THIS IS AND MAYBE WHAT THE SYSTEM COULD DO WITH IT BUT I HAVE THIS PROBLEM NOW THAT IF THE NGZ GOES OH, IN ORDER DOESN'T PASS MEDICAL HISTORY, I HAVE DIAGNOSIS, CHEST PAIN, UNSPECKIFIED AND MAYBE I WILL GO TO PAST MEDICAL HISTORY. WE DO WHATEVER WE NEED TO DO TO GET OUR JOBS DONE. WE DO END RUNS AROUND THESE SYSTEMS AND I THOUGHT THIS SYSTEM MIGHT BE DOING SOMETHING USEFUL BUT IF THE PHYSICIAN DOESN'T KNOW WHY IT'S DOING THIS, SHE'S NOT GOING TO DO THE RIGHT THING, SHE WILL CLICK THE WRONG THING AND THEN THE SYSTEM WILL FAIL AT WHAT IT'S GOING TO DO OR WORSE IT MIGHT DO SOMETHING WRONG. SO FOR INSTANCE IT MIGHT SAY THIS IS PAST MEDICAL HISTORY. FINE. I WON'T REMIND YOU WHEN IT'S CRITICAL TO KNOW THIS THING IS A CURRENT PROBLEM. SO WE NEED TO MAKE SURE WE EDUCATE ALL THE USERS OF THIS SYSTEM AND IT INCLUDES PATIENT WHO IS WILL CONTRIBUTE MORE AND MORE TO THE RECORD SO THAT WE--WHEN THEY PUT THE INFORMATION IS IN THEY PUT IN WHATEVER POPS IN THEIR HEAD, THEY PUT IT IN KNOW WHAG THE IMPLICATIONS ARE OF WHAT THEY'RE DOING. OKAY. SO NEXT GENERATION EHR, WE WANT BETTER DATA ENTRY, USER FACE FOR SEARCHING AND NOX FAMILY NOX FAMILY NAVIGA TION, REDUCING DATA ENTRY, INTEGRATING HEALTH INFORMATION EXCHANGES SO WE BRING MORE INFORMATION IN, BUT NOT OVERWHELM THE PHYSICIAN BUT WE BRING IT IN AND ORGANIZE IT, WE WANT SMART ALERTS AND REMINDERS THAT KNOW WHAT'S GOING ON WITH THE PATIENT AND JUST IN TIME, EDUCATION OR DECISION SUPPORT AND THEN, THEN WE CAN LOOK AT HOW DO WE HAVE A LEARNING HEALTH SYSTEM, SO THE LEARNING HEALTH SYSTEM OF COURSE IS THE IDEA THAT WE HAVE ALL THESE RECORDS, LOT OF DATA ABOUT PATIENTS WE CAN GO IN THERE AND DRAW INFERENCES FROM WHAT WE SEE IN THE RECORD. THAT WAS THE THING THAT WAS FRUSTRATING ME HERE AT NIH WITH THE RECORDS FROM THE CLINICAL CENTER IS THAT I COULDN'T FIGURE OUT WHAT WAS GOING ON WITH IA--A PATIENT. SAID SOMEBODY HEY JIM I CHECKED PIE B12 LEVEL AND IT'S HIGH WHAT DOES THAT MEAN? I SAID WHY DID YOU CHECK YOUR B12 LEVEL? SHE SAID I HAD ACCESS TO TESTING AND CHECKING MY VITAMINS WELL NOW HAVE YOU A PROBLEM BECAUSE AN ELEVATED B12 PROBLEM IS A SIGN OF SOME BAD DISEASES BUT I DON'T THINK YOU HAVE THOSE BAD DISEASES BECAUSE YOU SEEM PRETTY HEALTHY AND I SAID FIND ME ALL THE PATIENTS WITH ELEVATED B12 AND LET ME FIGURE OUT HOW IT RELATES TO THEIR DISEASE AND IN 2-SECONDS I HAD 5000 PATIENTS WITH ELEVATED B12. GET RID OF PATIENTS THAT ARE TAKING B12, THAT WAS ONLY A FEW HUNDRED, I STILL HAD THOUSANDS OF PATIENTS I SAID OKAY, LET ME SEE WHAT THE PROBLEMS WERE, HOW THEY RELATED TO THE B12 LEVELS AND THEN I COULD START TO LOOK AT, WHAT IS IT THAT IS MAYBE B12 ELEVATION IS GOING TO PREDICT THE EVOLUTION OF SOME DISEASE. IT WAS HOPELESS. MOST OF THE PEOPLE HAD THIS 1 SAME DISEASE LYMPHPROLIFERATIVE DISORDER NOT ELSEWHERE CLASSIFIED SO IF YOU ARE FAMILIAR WITH ICD9, THAT'S A GARBAGE CAN DIAGNOSIS, DOESN'T TELL ME WHAT THEY HAD. EXCEPT I KNEW THE THINGS IN THAT GARBAGE CAN RAISE IT AND SAID THIS B12 LEVEL IS ASSOCIATE WIDE THIS DISEASE. AND WHEN I LOOKED TEMPORAL--AT TEMPORAL RELATIONSHIPS SOMETIMES THE B12 LEVEL WOULD APPEAR BUT THE DIAGNOSIS WASN'T THERE, SO THE DIAGNOSIS PROCEEDED THE B12 BUT THEN DIAGNOSIS DISAPPEARED SO DID THEY STILL HAVE THE DISEASE I COULDN'T TELL BECAUSE THE RECORDS WERE TOO SPOTTY. SO OUR LEARNING HEALTH SYSTEM WHERE WE CAN ACCOMPLISH THIS WHERE WE GO IN AND SAY, WHEN WE GIVE THE PATIENT A DRUG DOES IT WORK, WHY DID THE PATIENT STOP THE DRUG IF THEY STOPPED THE DRUG? THAT PATIENT WILL BE MORE FORMALLY REPRESENTED IF WE HAVE ANY HOPE OF USING IT. OKAY, SO THE FUTURE. SO WE HAVE OUR PATIENTS IN THE EMERGENCY ROOM FOR PALPITATIONS A MONTH AGO. SO NOW WE'RE BACK TO MESSRS. SMITH AND SO IT WAS A MONTH AGO SHE CAME IN THE EMERGENCY ROOM, THE SYSTEM STOPPED THE CARDIO VERSION, RECOMMENDED ANTICOAGULATION, RECOMMENDED FOLLOW UP AND BUNCH OF OTHER STUFF SO SHE'S ON ANTICOAGULATION AND NOW SHE'S BACK FOR HER CARDIO VERSION. SHE STILL HAS ATRIOLE FIB ROUGH ATOMALATION SO NOW WE DO THE CARDIO VERSION AND WE GET A GOOD RESULT AND HERE'S ELECTRONIC HEALTH RECORD OF THE FUTURE AND THIS IS--SO THE CARDIO VERSION OF ATRIIOLE FIB ROUGH ATOMALATION AND EKG AND IT'S RECOMMENDING A BOOK ON WORFORIN AND YOU, AND A LITTLE PLAY - WHAT AMAZON WOULD DO IF WE WERE LETTING AMAZON BUILD OUR ELECTRONIC HEALTH RECORDS. OKAY, SO THAT IS PRETTY MUCH MY TALK. HOW DO WE SPEND THE NEXT 20 YEARS OF THAT RESEARCH AGENDA? THIS IS WHERE I HOPE PATTY BRENNAN IS LISTENING, WE WANT INFORMATTIC TO MODEL ALL THESE TODAY. WE CAN'T BUILD THEM TODAY. WE'RE BUILDING IDEAS BUT WE CAN'T GO OUT AND BUILD A PROGRAM THAT WILL DO THIS OR WE WILL DO IT WRONG. WE NEED TO LOOK AT MODEL THIS CAREFULLY LIKE WE'VE DONE OTHER THINGS IN INFORMATTICS SO CAUSAL REASONING, CLINICAL KOGZ NITION AND STRATEGY AND LOOK AT THOSE MODELS FANATIC OUT WHAT WOULD THE EHR LOOK LIKE IF WE STARTED FROM SCRATCH AND BUILD TOWARDS THAT VISION SO THAT WE BRING IN THINGS THAT ARE USEFUL FOR CARING FOR THE PATIENT, NOT USEFUL FOR BILLING OR FOR LEGAL DOCUMENTATION, AND WHAT HAVE YOU. WE NEED TO FIND A WAY TO MANAGE THE TECHNOLOGY TRANSITION, WE CAN'T JUST BUILD THIS STUFF AND EXPECT IT'S GOING TO GET AKOPTED. THOSE DAYS ARE LONG GONE IN CLINICAL INFORMATTICS AND WE HAVE TO REMEMBER TO EDUCATE STAKEHOLDERS SO WHEN WE BRING THESE TO BEAR, WE KNOW WHAT THE ROLE IS AND THEY USE THEM AND CONTRIBUTE TO IT RATHER THAN JUST FIGHT T. I TALKED TOO FAST. I THOUGHT BEING IN BAM BOTTOM FOR 2 AND HALF YEARS I WOULD TALK SLOWER BUT, MOVING NORTH FOR THE DAY AS SPED ME UP. SO THERE'S TIME FOR QUESTIONS. [ APPLAUSE ] YES? >> JIM, THANK YOU FOR THE WONDERFUL TALK. SEE YOU SUGGESTED THAT THE EHR SHOULD BE MORE AWARE OF THE SITUATION IN THE CONTEXT OF THE INFORMATION THAT'S BEING CAPTURED SO IN 1 EXAMPLE YOU GAVE IS TO LINK FOR EXAMPLE, SYMPTOMS TO DIAGNOSIS. SO HOW MUCH ON--DO YOU SAIPT THAT TO BE DONE IN A SMART WAY? MEANING THAT NO ADDITIONAL DATA ENTRY BY PHYSICIAN AND HOW MUCH DO YOU THINK IS LIMITATION OF THAT APPROACH? >> SO THAT'S A GOOD QUESTION. YOU KNOW, I THINK IT'S CLEARLY, WE CAN'T JUST HAVE THE COMPUTER GO, OKAY, YOU SAID HE HAS THIS, WHY DO YOU THINK--WE CAN'T HAVE THE COMPUTER QUIZ FOR EACH OF THOSE PIECES OF DATA. WE CAN PROBABLY DO SMART THINGS WITH SAYING OH USUALLY WHEN THIS IS FOUND ON PHYSICAL EXAM, IT'S RELATED TO 1 OF THESE PROBLEMS AND MAYBE ASK THE PHYSICIAN IF WE CAN'T FIGURE IT OUT AUTOMATICALLY, SAY DO YOU THINK THIS IS FROM THIS, THIS, OR THIS. MAYBE WE COULD ADD GRAPHICAL INTERFACES SO WE HAVE A WAY OF DEPICTING THESE GRAPHICALLY SO WE COULD DRAW A LINE TO QUICKLY LISTEN THINGS UP AND WE HAVE THE EHR DEVELOPERS AND BUILD THE USER INTERFACES FOR THEIR COMMERCIAL PRODUCTS FOR FUTURE DEVELOPMENT THAT WOULD TAKE ADVANTAGE OF THAT KIND OF THING. I THINK THAT'S A RESEARCH QUESTION WE NEED TO ANSWER. CLEARLY WE CAN'T JUST DEMAND THEY WRITE, YOU KNOW TWICE AS MUCH INFORMATION INTO THE RECORD. WE HAVE TO FIND SMART WAYS TO DO THAT AND I THINK THERE'S PONLTS. --POSSIBILITIES. >> YES? >> SO I LOVE THAT. I MEAN THAT'S THE WAY THE WORLD SHOULD BE. I THINK THAT'S HOW SOME OF US CLINICIANS THINK, YOU KNOW WHEN WE WRITE NOTES. BUT, THE CHALLENGE IS, I MEAN WE'RE HERE, WE WILL GET THERE, PATIENT CANS PUT IT IN. WE DID 1 STUDY WITH PATIENTS ENTERING A STANDARD QUESTIONNAIRE, WHOLE BUNCH OF SYMPTOMS AND FINDINGS AND IT WAS LIKE 5 TIMES THE DENSITY OF SYMPTOMS AS WHAT THE CLINICIAN WOULD HAVE PULLED BECAUSE YOU GET A DIFFERENT ANSWER WHEN YOU SAY, WHAT'S WRONG VERSUS YOU HAVE THIS, THIS, THIS OR THIS. SO YOU THINK WE NEED RESEARCH IN THAT SPACE TO FIGURE OUT WHAT THIS DATA MEANS WHEN IT'S COLLECTED DIFFERENT WAYS, ABSOLUTELY AND THAT'S THE PATIENT SCHOOL, IDEAS, YOU KNOW WHAT IF WE TAUGHT PATIENTS HOW TO GIVE A MEDICAL HISTORY? THOSE OF US WHO ARE PHYSICIANS PROBABLY HAD OCCASION TO ACCOMPANY A FAMILY MEMBER AND LISTEN TO THE FAMILY MEMBER GIVING A HISTORY TO THE CAREGIVER AND CRINGING, YOU USED THAT WORD OR NOW THE CAREGIVER, PHYSICIAN OR NURSE IS THINKING YOU'RE HAVING A HEART ATTACK WHEN YOU REALLY HAVE SOME OTHER THING AND YOU OFTEN JUMP IN AND TRY TO SAY ARE YOU SURE YOU MEANT THIS OR DID YOU MEAN TO SAY IT THAT WAY? IF WE TAUGHT PATIENTS HOW TO GIVE HISTORIES AND THINK ABOUT THEIR PROBLEMS IN TEMPORAL WAY AND THINK ABOUT CAUSATIVE OR EXACERBATING FACTORS OR WHATEVER IT IS WE WANT TO BRING IN, MAC THE PATIENTS WOULD DO A BETTER JOB. ONE THING I THINK WE COULD DO IS TRAVEL HISTORY. PATIENTS KNOW WHERE THEY WERE. AND NO AMOUNT OF QUESTIONING THE PATIENT WILL MAKE THEM KNOW MORE THAN WHAT THEY KNOW. SO IF WE GIVE THEM A WHERE IN THE WORLD IS CARMEN SAN DIEGO THING, MAYBE THERE ARE WAYS WE CAN CAPTURE THAT THAT'S MORE MEANINGFUL. IT'S A RESEARCH ISSUE, IT'S NOT SOMETHING WE CAN SAY DON'T FORGET HOW TO TEACH THE PATIENT HOW TO USE THE SYSTEM, OR TEACH THE PHYSICIAN OR GET SLIDES WITH INSTRUCTIONS LIKE A SHOWED EARLIER. SO I THINK THAT'S PART OF THE RESEARCH AGENDA IS TO FIGURE OUT HOW TO DO THAT BUT DIFNITRIC OXIDELY A HUGE QUESTION. YOU CAN'T LET THE PATIENTS GO, CHECK OFF EVERY SYMPTOM YOU EVER HAD, THEN IT WOULD BE A SOLID LINE OF SYMPTOMS AND WE WOULD NEVER GET THROUGH IT ALL. QUESTION? YEAH? >> SO TODAY IS EXQUISITELY PUSHING FOR A INTERACTION TECHNOLOGY MOVING BEYOND SCREENS AND CLICKS AND TEXTS. THEY CALL IT THE A. I. FIRST WORLD WHERE TECHNOLOGY SURROUNDS US AND ASHES DATA PROTECTIONS TO US, SO SOME TECHNOLOGIES ARE MATURING SUCH SPEECH RECOGNITION AND SPEECH GENERATION SO MY SPEECH IS IF YOU HAVE A VISION FOR HOW THE EHR THE FUTURE SHOULD INTERACT WITH THE COLLISION OR THE HEALTHCARE PROVIDER AS A WHOLE BEYOND DICTATING TEXT TO A COMPUTER OR CLICKING ON A SCREEN? >> WELL I'M JUST A COUNTRY DOCTOR FROM ALABAMA, BUT I THINK THAT THERE'S DEFINITELY WAYS TO BRING NEW TECHNOLOGY TO BEAR ON THIS AND YOU KNOW EVEN SOME OF THE THINGS LIKE THE SIMPLE AMAZON EXAMPLE OF SORT OF SMART SUGGESTIONS BASED ON OTHER INFORMATION BUT CERTAINLY OTHER TECHNOLOGIES ARE GOING TO BE--PLAY A BIG ROLE IN THIS AND I THINK IT WILL BE UP TO THOSE OF WHO YOU ARE FOLLOWING BEHIND ME IN THE RESEARCH WORLD TO START TO ADDRESS THOSE ISSUES. I THINK WHAT WE CAN DO NOW IS CREATE A FRAMEWORK WHERE THAT KIND OF INFORMATION CAN BE ADDED WITHOUT SIMPLY OVERWHELMING. SO FOR EXAMPLE, I HAVE A FIT BIT. ALL RIGHT? AND I'M PRETTY SURE THAT IF WE LOOKED AT FIT BIT DATA, MAYBE SOMEBODY'S DONE THIS BUT IF YOU LOOK AT THE FIT BIT DATA FOR PATIENTS WITH CONGESTIVE HEART FAILURE AND YOU FOLLOWED THEM PROSPECTIVELY THAT YOU WOULD FIND PATTERNS IN THOSE DATA THAT PREDICT DETERIORATION WHICH OCCUR OVER DAYS OR WEEKS CAN BE SUBTLE FOR THE PATIENT AND AROUND THE PATIENT BUT IF YOU LOOK AT HOW MUCH THEY'RE WORKING AND DECRETIONS AND SLOWLY THEY GO UP THE STAIRS OR WHATEVER IT WOULD TELL US WE COULD PREDICT THINGS. WE CANNOT BRING OUR FIT BIT RECORDS TO OUR PHYSICIANS AND GO HERE'S MY FIT BIT RECORD HOW AM I DOING. THAT WILL OVERWHELM THEM. WE HAVE TO FIGURE OUT HOW TO BRING INTO THE COGNITIVE MELUE IN A SENSIBLE WAY SO WE INTERPRET INTO A PATTERN AND THAT PATTERN BECOMES DATA THAT WE USE FOR REPRESENTATION. I THINK THERE'S A LOT OF RESEARCH TO BE DONE THERE AS WELL. BUT THERE'S THINGS LIKE VIRTUAL REALITY, HEADS UP DISPLAYS ARE THINGS WE CAN DO DATA ENTRY AND ALSO DATA DISPLAY TO PEOPLE THAT ARE TRYING TO--WHERE WE'RE TRYING TO PREVENT THEM FROM GETTING OVERWHELMED. IMAGINE A VR GLASSES WHERE YOU COULD SEE THE PATIENT'S RECORD AND LOOK AROUND AND YOU WEREN'T CONSTRAINED TO A LITTLE SCREEN AND JUST LOOK OVER AND GOH I WANT TO SEE WHAT HAPPENED 5 YEARS AND AND THEN I WANT TO SEE WHAT HAPPENED TODAY AND I WANT TO LOOK AT ANOTHER PART OF THE RECORD AND DO THAT WITH GESTURES OR WAYS OF SORT OF MOVING YOUR HEAD AROUND. I THINK THERE'S A LOT WE COULD BE DOING TO TAKE ADVANTAGE OF THAT AND THE PROBLEM IS THAT WE HAVE NOW IS THIS ELECTRONIC BILLING DIARY THAT DOESN'T HAVE A STRUCTURE FOR US TO BRING THOSE KINDS THINGS TO BEAR. ALL IT WOULD DO IS MAYBE EXPORT DATA AND SAY DO ALL THIS STUFF AND NOW YOU'RE STUCK WITH THIS THING OUTSIDE THAT DOESN'T--THEN HAS NO WAY TO GO BACK TO THE RECORD AND SAY, ALL RIGHT, THIS EXPERT SYSTEM I WAS USING TOLD ME TO DO THIS SO DO IT SO IT WILL SAY, WELL, YOU'RE THE DOCTOR, PUT THE ORDERS IN AND START OVER AGAIN. SO WE NEED TO FIND WAYS TO BRING THAT INTO THE MODEL, EXPH BRING THAT MODEL INTO THE EHR SO WE CAN TAKE ADVANTAGE OF THOSE TECHNOLOGIES. >> I WILL GO WITH DON AND THEN-- >> BEAUTIFUL PRESENTATION. THANK YOU VERY MUCH, [INDISCERNIBLE]. MY QUESTION, PARTICULARLY SINCE YOU JUST CHANGED LOCATIONS WHAT SORT OF HEALTH PROFESSIONALS [INDISCERNIBLE]? >> SO THE QUESTION IS WHAT SORT OF HEALTH PROFESSIONALS ARE PREPARED TO FOLLOW ME? >> [INDISCERNIBLE]. >> SO I THINK THAT--I THINK THAT IT'S BOTH, THE CHAIRMAN OF MEDICINE AT UAB, SETH LANDFILL, IS ASKING ME WHAT IS IT YOU DO AGAIN? TELL ME YOUR HYPOTHESIS INFORMATTICS HYPOTHESIS BUT HE ALSO SENDS ME ARTICLES THAT ARE SHOWING, YOU KNOW SAY HEY WHAT DO YOU THINK OF THIS OR THAT. NEW TECHNOLOGIES, SO WE'RE STARTING TO DEVELOP SOME NEW METHODS ARE BEING ABLE TO REVIEW DATA THAT'S IN THE RECORD AND WE'LL BE WORKING WITH THE MEDICAL CLINICS THERE AND WE HAVE INTEREST AT ALL LEVELS, YOU KNOW I'M ON A COMMIT O THAT'S SUPPOSED TO IMPROVE THE ELECTRONIC HELT RECORD FOR THE SYSTEM, IT'S NOT AN H. I.T. COMMITTEE BUT A PHYSICIAN COMMITTEE AND WE'RE SUPPOSED TO BE LOOKING AT HOW WE IMPROVE THE RECORD. SO PEOPLE ARE INTERESTED IN DOING THIS, THE HOUSE STAFF ARE UNDER SPECIAL PRESSURE NOW TO GET THEIR DOCUMENTATION DONE BEFORE THEY FINISH OUT THE NUMBER OF HOURS THEY'RE ALLOWED TO WORK EACH DAY OR EACH WEEK AND SO, NEW TECHNOLOGY THATION THEY CAN USE THAT WON'T BE WRITING BIG LONG NOTES BECAUSE I WAS IN CLINIC YESTERDAY AND I--THE HOUSE STAFF NOTES WRITING THEM NOW, HOPEFULLY THEY WILL BE DONE BY THE TIME I CAN GET BACK TO MY COMPUTER AND REVIEW THEM AND SIGN THEM, BUT SOMETIMES IT TAKES THEM A COUPLE OF DAYS TO WRITE THOSE NOTES. AND THEY WILL BE VERY HAPPY TO HAVE SOMETHING THAT WILL SPEED THAT PROCESS UP AND OF COURSE THE QUALITY OF THE NOTES WILL BE BELTER IF YOU'RE NOT WAITING 2 DAYS TO REMEMBER WHAT IT IS SAID. >> [INDISCERNIBLE]. >> YEAH, WE'RE GOING TO--DON'S NOT ON MICROPHONE FOR THE FOLKSA THE HOME, DON LINBERG SAID WE WILL INFILTRATE THE CURRENT SYSTEM. >> YEAH, WE HAVE TO SNEAK UP ON THEM. CAN'T COME IN AND SAY HERE'S A WHOLE NEW SYSTEM WE WANT YOU TO WHAT WE HAVE TO DO ARE THE KINDS OF THINGS WE DID AT COLUMBIA AND WE ADDED A BUTTON AND PEOPLE WOULD SEE I HAD ALL MY PRESCRIPTIONS PRINTED OUT AND --I HAVE A BUTTON. I WANT THAT BUTTON BUT HERE THE PROBLEM IS YOU HAVE TO PUT YOUR MEDICATIONS IN THIS A STRUCTURED CONTROL WAY, THEY GO GREAT, SHOW ME HOW TO DO THAT AND WE WENT FROM HAVING NO MEDICATION LIST TO HAVING MEDICATION LISTS OVERNIGHT BECAUSE WE DIDN'T FORCE IT ON THEM WE GAVE THEM AN EXTRA LITTLE THING. HEY, READ THIS GIED LYNN AT KIEWMA DIN, HOW CAN I DO IT? WE WILL GIVE YOU A BUTTON AND WILL ANTICIPATE THAT INFORMATION. WE PROVIDE THESE SORT OF PUSH TECHNOLOGIES OR PULL TECHNOLOGIES RATHER THAN PUSH TECHNOLOGIES THAT SHOVE THINGS IN PEOPLE'S FACES SO WE HAVE TO BE SMART IT'S A EVERYONE ISSUE AND WE CAN'T PUT IT OUT THERE AND EXPECT THEY WILL USE IT. WE HAVE TO FIGURE OUT HOW WILL THIS FIT IN THE WORK FLOW. WHAT ARE THE WAYS THEY'RE THINKING, THEY SAID, YEAH, WE CLINICIANS THINK ABOUT PATIENTS IN THIS WAY AND HOPEFULLY WE WRITE IN OUR NOTES IF WE HAVE TIME TO DO IT. BUT WHEN WE DON'T HAVE TIME TO DO IT AND WE HAVE A CHOICE BETWEEN DOCUMENTATION AND PATIENT CARE, WE'RE GOING TO CHOOSE THE PATIENT CARE TIME AND DOCUMENTATION WILL SUFFER. SO, BUT YOU'RE RIGHT. WE HAVE FIND WAYS TO GET THIS INTEGRATE INDEED A WAY THAT'S AS POINTLESS AS POSSIBLE. >> I WANT TO FOLLOW UP ON THAT POINT. MY IMPRESSION IS THAT VENDORS NOW HAVE MUCH LARGER CONTROL OVER SYSTEMS AND OF THE KIND YOU'RE TALKING ABOUT, IS THERE ROOM FOR PARTNERSHIP DEVELOP DEVELOPMENT? OR ARE YOU SUGGESTING BETTER APPROACH IS TO BUILD AND FIND A WAY TO WORK WITHIN THAT? >> SO THE QUESTION WAS IS THERE STILL A WAY TO PARTNER WITH VENDORS AND I THINK ABSOLUTELY THERE IS. I KNOW COLLEAGUES WHO ARE TALKING TO FOLKS AT EPIC AND I'M TALKING TO FOLKS AT WAYS WE CAN DO THIS AND IMPROVING YOUR SYSTEMS, BUT DOING IT IN AN EXPEDEIENT WAY AND WHAT'S THE CHECK LIVES REGULATIONS I HAVE ON MEET WITH NIGH NEXT VERSION AND THAT'S WHAT TAKES PRIORITY, WE NEED TO DO THE INFORMATTICS RESEARCH TO FIGURE OUT HOW TO DO WELL, THEY WILL NOT TAKE THE TIME OR EXPEND THE RESOURCES ON THAT BASIC RESEARCH BUT WHEN WE HAVE FINDINGS FROM IT, I THINK THEY WILL IMPLEMENT IT, IT TOOK A WHILE TO GET THE ORDERS ANDANCE SYNTAX OUT BUT NOW WE HAVE THE ORANCE SYNTAX AND MODULES BY THE HEALTH RECORD SYSTEMS, THEY ARE FINE WITH THAT ONCE WE TELL THEM HOW TO DO THAT AND WHAT IT IS WE NEED TO DO WE CAN IMPLEMENT IT SO THERE'S DEFINITELY LOTS OF OPPORTUNITY FOR COLLABORATION. SO-- >> QUESTION? >> I HAD A SIMILAR QUESTION THAN VALORY. I SEE THE ABILITY TO MODIFY EHR DIMINISHED OVER THE NUMBER OF TIME, INSTITUTION WHO IS HAD HOME GROWN RECORD ARE NOW CONVERTED TO A NUMBER OF QUESTIONS THAT SAYS, WHAT'S YOUR RELATIONSHIP WITH THE IAS GROUP AND THESE RELATIONSHIPS TAKE A LONG TIME TO BUILD. SO IF SOMEONE IS SKEPTICAL ABOUT ABILITY TO DO RESEARCH--LET'S SAY EACH WE PUT OPEN SOURCE EHR AND DO ALL OUR EXPERIMENTS IN THE LAB, AND WE HAVE TO TRAIN THEM AND I DOABILITY THINK WE EVEN HAVE A GOOD OPEN SOURCE EHR, SO, I'M SKEPTICAL THAT WE WILL BE ABLE TO DO THAT BASIC RESEARCH BECAUSE WE'RE NOT ABLE TO MODIFY THE SYSTEMS THAT EASILY. >> SO IT'S A CONCERN FOR SURE THAT A LOT OF THE CLASSIC GREAT DEVELOPMENT SHOPS, YOU KNOW KIND OF GONE TO THE DARK SIDE TO A CERTAIN EXTENT BUT I CAN TELL YOU AT COLUMBIA, WHEN I LEFT COLUMBI ATHAT WAS THE TROUGH OF DESPAIR. WE WERE HAVING VERY LITTLE IMPACT ON OUR ABILITY TO CHANGE ELECTRONIC HEALTH RECORDS. BUT COLUMBIA PRESBYTERIAN MEDICAL CENTER REALIZE THAD HAVING A TOP NOTCH INFORMATTICS GROUP WAS IN THEIR FAIEVER AND WERE ABLE TO INCORP RAYERATE THEM AND THEIR MODULES, ADD MODULES TO THE EXISTING SYSTEM. YOU KNOW THE SMART ON FIRE APPROACH IS 1 WAY WE CAN BUILD THINGS THAT WE CANAT LEAST GET DATA OUT AND KIND OF SHOW THE POWER OF WHAT WE CAN DO WITH THESE IF WE HAVE MORE INFORMATION. PUTTING THE DATA BACK IN IS STILL, YOU KNOW STILL A CHALLENGE AND SO, WE NEED TO OVERCOME THAT BUT I THINK WE WILL GET THERE. WE WILL GET--YOU KNOW WE'RE MAKING HEAD WAY ON BEING ABLE TO WRITE INTO THE RECORD FROM OUTSIDE APPLICATION. SO I THINK THE WAY TO DO THAT IS TO BUILD THE OUTSIDE APPLICATIONS THAT THEN THE EHR VENDORS WILL GO, OH, THAT'S WHAT WE NEED TO PUT IN OUR SYSTEM. INSTEAD OF HAVING AN OUTSIDE THING LET'S BUILD A TAB OR WHATEVER WITHIN OUR SYSTEM THAT INCORPORATE ITS DIRECTLY INTO THE USER INTERNAIS. SO I THINK IT WILL BE AN EVOLUTION. >> [INDISCERNIBLE]. --VERY SIMPLE THAT THE LIBRARY HAS A ROLE IS BEYOND [INDISCERNIBLE]--WHAT ARE SOME SWEET SPOTS FOR US THAT WOULD BE USEFUL IN PARTICULARLY IN THIS AREA OF TRYING SHOW WHAT'S KNOW OR KNOWABLE IN TERMS OF THE [INDISCERNIBLE]? >> OKAY, I THINK THAT THE THINGS THAT SOME OF THE THINGS THE LIBRARY IS INTERESTED IN WILL ALIGN WITH WITH THIS VERY WELL. SO FOR INSTANCE HAVING REPOSITORIES OF KNOWLEDGE AND DATA THAT CAN BE BROUGHT IT BEAR ON PATIENT CARE WILL BE CRITICAL AND LIBRARIES IN THAT SPACE ALREADY AND WITH THE EXPANSION AND DATA SCIENCE WILL BE A BIGGER PLAYER IN THAT. SO TRYING TO FIGURE OUT, I DIDN'T GO INTO THE WHOLE PERSONALIZED MEDICINE ASPECT BUT NOW A SYSTEM SAYS, OH YOU'RE TRYING TO DO ATRIOLE FIB ROUGH ATOM LIEWLINGS AND LOOK AT GENETICS AND SOMETIMES WE DON'T KNOW THE ANSWERS BECAUSE NOBODY'S WRITTEN A PAPER ABOUT IT AND IT'S NOT IN A KNOWLEDGE BASE BUT IN A DAT BASE OF PATIENT DATA OR REPOSITORIES OF GENOMIC AND PHENOMMIC DATA SO THERE'S CERTAINLY PLACES WHERE WE WILL BE ABLE TO TAP INTO THAT. BUT I THINK THE LIBRARY COULD ALSO BE TRYING TO HELP US CONVINCE OTHER INSTITUTES THAT SOME OF THIS RESEARCH IS GOING TO BE NEEDED TO IMPROVE CANCER CARE AND IMPROVE KIDNEY CARE AND HEART CARE THAT OTHER INSTITUTION HEAT SHOCK SYSTEM BE PICKING UP SOME OF THE SLACK HERE AND HELPING US FIGURE OUT HOW TO SOLVE THOSE PROBLEMS ACROSS THE EXPECT RUM. >> I THINK WE WILL THANK YOU FOR A TERRIFIC TALK. IF YOU ARE GOING TO SAY, AND PEOPLE WISH TO COME QUESTION YOU MORE, THAT'S UP TO YOU. >> THANK YOU. [APPLAUSE ]