Workflow-based Data Reconciliation for Clinical Decision Support: Case of Colorectal Cancer Screening and Surveillance

Kavishwar Wagholikar, MBBS PhD1, Sunghwan Sohn, PhD1, Stephen Wu, PhD1,Vinod Kaggal1, Sheila Buehler, RN CNP2, Robert A. Greenes, MD PhD3,8, Tsung-Teh Wu, MD4, David Larson, MD MBA5, Hongfang Liu, PhD1, Rajeev Chaudhry, MBBS MPH6, Lisa Boardman, MD7

AMIA-CRI 2013, San Francisco CA, 21 March 2013

Statistics and Informatics, 2Internal Medicine, 4Anatomic Pathology, 5Colon and Rectal Surgery, 6Primary Care Internal Medicine, 7Gastroenterology and Hepatology, Mayo Clinic Rochester, MN 3Biomedical Informatics, Arizona State University, Scottsdale, AZ; 8Health Science Research, Mayo Clinic, Scottsdale, AZ

1Biomedical

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CDSS Data quality Workflow analysis Data reconciliation Formative evaluation

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Data Quality and CDS

Deficient data quality can impact the clinical decisions and consequently health outcomes

Data quality: completeness, accuracy,

Stetson et al. Assessing Electronic Note Quality Using the Physician Documentation Quality Instrument (PDQI-9). Appl Clin Inform. 2012;3(2):164-74. Weiskopf et al. Methods and dimensions of electronic health record data quality assessment: enabling reuse for clinical research. J Am Med Inform Assoc. 2012 Jun 25.
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Data quality and data use

Factors influencing data quality: motivation or purpose for the document time available for documentation use of schemas expertise and qualifications of the documenter documentation tools Deeper understanding of the document is critical to determine if the data is suitable for a particular task. e.g. diagnostic coding by abstractors for insurance reimbursement lack sufficient accuracy and completeness for clinical decision making.
Reiser SJ. The clinical record in medicine. Part 2: Reforming content and purpose. Ann Intern Med. 1991 Jun 1;114(11):980-5. Rosenbloom ST, et al. Data from clinical notes: a perspective on the tension between structure and flexible documentation. JAMIA. 2011 Mar-Apr;18(2):181-6.
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Workflow study to determine data quality

use workflow analysis :

i) to identify data sources

ii) and to design data reconciliation processes in a CDSS for colorectal cancer prevention

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Challenges for the CRC CDSS

i) several parameters and logical decision steps are involved

ii) the documentation is of inadequate quality or iii) is in free-text form

iv) high degree of decision accuracy

Wagholikar K, et al. Clinical Decision Support for Colonoscopy Surveillance Using Natural Language Processing. IEEE Healthcare Informatics, Imaging, and Systems Biology Conference. University of California, San Diego, CA; 2012.

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h/o CRCsyndrome
no

yes

GI-consult if no addendum

Age
yes

>=50y

Colonoscopy now

h/o IBD
no

IBD-consult if no addendum

no

Risk
reportAbsent

no
yes

Age
yes

>=40y

Colonoscopy now

h/o CRCancer

Recent Colonoscopy. Time

>0 years

Colonoscopy at 3yrs after the time CRcancer was detected

10y
yes

3y

5y
>=40y

CRCancer
no

GI consult 1 year
<1yr

>=50y && <76y

Age at
Recent cololoscopy +10y

yes no

Age at Recent
colonoscopy +5y

Colonoscopy. Preparation
adequate, good, excellent

h/o CRCancer
no >=1yr yes

h/o CRC since

yes >=10 months

CRrisk 8
no

Hyperplastic polyp
hyperplastic yes

poor, inadequate

TimeSincePrevious Colonoscopy (with

adequate prep)

h/o CRC

no

Recent.Poylp

PolypType

<10 mths

Repeat in 1 or 2 days

RecentCRPath is recent Colorectal Endoscopy Pathology

Adenomatous: tubular, serrated adenoma

Adenomatous: tubulovillous, villous, SSA

Recurrent loop

Recommendation for colonoscopy are indicated in years from Recent CRPath

group1

group2

Methods
Studied workflow analysis Designed several processes for data reconciliation To determine the utility of these processes, quantitative analysis after selectively adding/removing each of reconciliation processes. Two parameters: i. accuracy gain of the patient parameter reconciled by the process, and ii. accuracy gain of the recommendations computed by the CDSS. 106 cases
Unertl KM,et al. Traversing the many paths of workflow research: developing a conceptual framework of workflow terminology through a systematic literature review. JAMIA. 2010 May-Jun;17(3):265-73.
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Workflow
Coded Patient response Questionnaire System Annual Questionnaire Registration Demographics Coded Problem List Free text Problem section in Clinical notes Endoscopists dictated free-text procedure note Pathology report templatized free-text Pathology dept. system
RFID tag on biopsy

Referring Care provider

Recommendation Guideline rules Data reconciliation Structured Data Natural Language Processing

EHR

Patient

Care providers

Previous Hospital Visits Colonoscopy visit

Endoscopist

Biopsy specimen

Pathologist
during procedure

CDSS
findings

GI Dept. system

R.Nurse
before procedure

indications

Colonoscopy TV

TV

Clipart from Microsoft Office

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Colonoscopy 20-30 mins TV

TV

Structured event information Specimen label

Clipart from Microsoft Office
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Colonoscopy TV

Endoscopy dictation

TV

Clipart from Microsoft Office

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Results

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 Conventionally, software engineering practices involve workflow studies, when the software is primarily for workflow support. Our study demonstrates that when there is lack of adequate data quality, workflow studies of the documentation phase can help discover data reconciliation strategies that can resolve the data deficiencies

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 Lack of NLP sensitivity can be overcome with multi-source data reconciliation. e.g. NLP on the endoscopy note for polyp size was effective when supplemented with structured GI findings. Findings of the workflow analysis obviated the laborious effort to develop NLP for some information. e.g. the RNs structured recording obviated NLP for detecting number of polyps from endoscopy note.

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Conclusion
Workflow analysis was useful to identify data reconciliation strategies to address documentation gaps, which improved CDSS performance. Workflow-based data reconciliation can play an important role in designing new-generation CDSS based on complex guideline models and NLP.

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Questions
Contact and related resources: waghskATgmail.com

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References
Stetson et al. Assessing Electronic Note Quality Using the Physician Documentation Quality Instrument (PDQI-9). Appl Clin Inform. 2012;3(2):164-74. Weiskopf et al. Methods and dimensions of electronic health record data quality assessment: enabling reuse for clinical research. J Am Med Inform Assoc. 2012 Jun 25 Reiser SJ. The clinical record in medicine. Part 2: Reforming content and purpose. Ann Intern Med. 1991 Jun 1;114(11):980-5. Rosenbloom ST, et al. Data from clinical notes: a perspective on the tension between structure and flexible documentation. J Am Med Inform Assoc. 2011 Mar-Apr;18(2):181-6. Unertl KM,et al. Traversing the many paths of workflow research: developing a conceptual framework of workflow terminology through a systematic literature review. J Am Med Inform Assoc. 2010 May-Jun;17(3):265-73. Wagholikar K, et al. Clinical Decision Support for Colonoscopy Surveillance Using Natural Language Processing. IEEE Healthcare Informatics, Imaging, and Systems Biology Conference. University of California, San Diego, CA; 2012. Wagholikar K, et al. Clinical decision support with automated text processing for cervical cancer screening. J Am Med Inform Assoc. 2012; 19 (5), 833-839, Wagholikar K ,et al. Formative evaluation of the accuracy of a clinical decision support system for cervical cancer screening. J Am Med Inform Assoc. 2013. (in press)

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