Ethical use of data for Clinical Decision Support

Noticed this ethics-related question on LOINC website http://loinc.org/articles/Bonney2009

“Is it appropriate, or ethical , to use health data collected for the purpose of direct patient care to develop computerized predictive decision support tools?”

I do not have access to the complete article, but the question itself triggered some thoughts in my mind. I guess the first question to ask is – does the end justify the means? Since use of CDSS (Clinical Decision Support Systems) has been shown on average to lead to better clinical decision-making for providers and hence impact patient care, is it okay to use patient care data for development of such tools?

I will attempt to answer this question using the ethical framework governing the research on human subjects to see if it may apply to this situation (source of framework: Emanuel EJ, Wendler D, Grady C. What makes clinical research ethical? JAMA. 2000;283:2701-11. [PMID: 10819955]).

Here is the list of 7 framework requirements and their applicability to CDSS development as assessed by me –

1. Social or scientific value: Benefits from CDSS should justify the resources spent and risks imposed on patients whose data has been used
2. Scientific validity: Predictive decision-making methodology used by CDSS should be properly structured to meet its objectives
3. Fair participant selection: Participant data should be selected to achieve a fair distribution of the burdens and benefits of CDSS.
4. Favorable risk-benefit ratio: CDSS should be designed to ensure that the risks to an individual human participant are balanced by expected benefits to the same participant
5. Respect for participants: Privacy of participant should be protected and confidentiality of their data should be maintained. This can be achieved by using de-identified data and obtaining patient consent for collection, use, and sharing of data
6. Informed consent: Participant consent to include data in development of CDSS must be obtained. The risk to participant should be measured relative to risk associated with receiving care without use of CDSS. This risk should be communicated to the participant when obtaining informed consent.
7. Independent review: CDSS development should receive independent ethical review that is appropriate to the level of potential risk it poses to participants.

Medical vs. Nursing Informatics - Part 3 (final)

Here is the final part of the comparison between medical and nursing informatics. Part 1 and Part 2 can be found here.

Medical and Nursing Vocabularies:

Number of medical vocabularies such as MeSH, SNOMED, LOINC have been developed over the years. 100+ separate controlled vocabularies were conceptually linked in 1986 to form a meta-thesaurus called the UMLS (Unified Medical Language System).

Some nursing products such as CINAHL (Cumulative Index of Nursing and Allied Health Literature) use a medical vocabulary MeSH as an underlying vocabulary for diseases, drugs, anatomy, and physiology, and have expanded the vocabulary to include unique nursing terms in the vocabulary http://www.universityhealthsystem.com/Research/docs/Searching%20sEBSCO%20CINAHL.pdf

Growth opportunities: Lastly, both medical and nursing informatics domains are ripe for innovation and improvement. Consider the emerging health care models such as Patient Centered Medical Home that are likely to impact the physicians and nursing professions, in addition to impacting the related informatics domains as well.

Medical vs. Nursing Informatics - Part 2

Here is the second part of the comparison between medical and nursing informatics that highlights the similarities and differences between their information needs. First part can be found here.

Physician vs. Nursing Information needs:

It is important to compare and contrast physicians’ and nurses’ information needs to appreciate why we need to two separate informatics disciplines.

There is significant overlap between nurses’ and physicians’ needs for information – drug-drug interaction, pill identification, etc. However, there are certain information needs that are very specific to nurses’ needs – nursing procedures, nursing care plans, etc. Arguably, a nurse may need access to both information sources created for physicians (such as MD Consult, UpToDate, VisualDx, MediSpan, Micromedex, EMBASE, etc.) as well as those created specifically for nurses (CINAHL, NursingConsult, etc.) in order to do his/her job. For instance, a nurse administrator creating or updating a training program for practicing nurses may need current educational materials. Or, when a patient is being discharged and nurse wants to provide educational or instructional material for patient’s care at home.

Similary, there is an overlap on evidence-based information needs but some of the needs for evidence are unique to nursing. For instance, each Evidence-Based Nursing monograph available on Mosby’s Nursing Consult (www.nursingconsult.com) contains a concise review of the current evidence available on a clinical problem and presents specific recommendations for nursing care. Another such example is Nursing Reference Center by EBSCO. See the related press release http://www.ebscohost.com/uploads/thisTopic-dbTopic-871.pdf

In clinical settings, physician and nursing workflows are quite different, so their information needs at the point-of-care differ. For instance, a nurse may enter patient symptoms and signs in a nursing information product that returns what other observations should be made, not for diagnosis, but to know what to report to physician. In research settings, information needs of nurses and physicians may differ as well. These differences impact the human-computer interaction (HCI) concepts that are used to design and implement systems built for physicians and nurses within these settings.

From administrative perspective, information needs of CNIO and CMIO would be different. For instance, in a hospital different policies may be created by CNIO and CMIO for nurses and physicians respectively to impact their productivity.

Lastly, education needs of a nurse and a physician would differ based on certifications they would like to pursue, specialty-specific training required for a floor nurse, etc. For instance, a nurse administrator creating or updating training program for practicing nurses may retrieve information related to procedures, processes, general discussion information that is usable for nurse education.

In the third and final part, I will discuss medical and nursing vocabularies as well as growth opportunities.

Medical vs. Nursing Informatics - Part 1

Here are a series of articles contrasting Medical informatics with Nursing informatics. I present the first part below -

Medical Informatics deals with the storage, retrieval, and optimal use of biomedical information, data, and knowledge for problem solving and decision making (as defined by Dr. Shortliffe). Nursing Informatics is defined as a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge into nursing practice. (source: American Nurses Association)

Both definitions sound very similar. In fact, both medical and nursing informatics fields are similar in many respects:

Ø Support for improvement in quality of care and patient outcomes

Ø Availability of contextual information – right information to right person at right time

Ø Support for security and privacy of data

Ø Inter-relation to other health informatics specialties – public health informatics, bioinformatics, pharmacy informatics

Ø Inclusion of both clinical and non-clinical areas (such as medical research, nursing research)

History:

Medical Informatics has a rich and long history. Some of the significant milestones in development of this practice include the following:

Ø Establishment of NLM and Index Medicus by John Shaw Billings (1890)

Ø Development of MEDLINE (1966)

Ø Development of Mycin, first CDSS by Dr. Shortliffe (1970)

Ø Development of MUMPS, the first programming language designed specifically to deal with medical data (1986)

In contrast, as a formal specialty practice, Nursing Informatics is fairly recent. In fact, for many years before a dedicated and concerted effort to Nursing Informatics was established, nurses relied on retrieval of information using same systems that were developed primarily for physician users. However, nurses have significant unique information needs that are not met by physician-focused information systems. Consider the number of print journals that have been developed uniquely for nurses – Nurse Leader, Journal of the Association of Nurses in AIDS Care, Newborn & Infant Nursing Reviews, Journal of Radiology Nursing, Journal of Pediatric Nursing, Applied Nursing Research, etc. Large subscriber base and high usage of these journals amongst nurses suggests the uniqueness of nurses’ needs. Over the past few years, the number of nursing-focused CDSS (Clinical Decision Support Systems) such as Nursing Consult (http://www.NursingConsult.com) with support for nursing point-of-care and research needs has been steadily increasing over the years.

In part 2, I will discuss physician vs. nursing information needs. Stay tuned.

PowerPoint 2010 - sneak preview

According to Microsoft PowerPoint team's blog, new features include:

• Completely revamped their media playback technology
• Improved the media workflow: insertion, editing, presenting and distribution
• Added features to help trim media, integrate with the animation timeline, and export PowerPoint presentation to video

Here is a sneak peek at PowerPoint 2010. Looks good!