fiedler_john hopkins ppt medsim

U.S. Army Research, Development and Engineering Command

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Presentation Date: May 11, 2011

Developing Data Exchange Protocol Standards for

Healthcare Simulators

Beth Ann Fiedler, Brian Goldiez, Teresita Sotomayor, Joshua Estes, Donald A. Washburn

SFC Paul Ray Smith Simulation & Training Technology Center

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Outline

• Introduction

• Purpose

• IEEE1278 Standard

• Facilitating Interoperability and Standards for Simulators in

Healthcare

• Key Elements of Patient Information and Medical Systems

• The Role of the Injury Severity Score

• Missing Parameters and Source for Medical Simulator

Information

– Medical Coding Systems

– Data Set Coding Structures

– DICOM

• Conclusion

• References


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Introduction

• MedBiquitous, a nonprofit organization founded by Johns Hopkins Medicine, has

developed a Virtual Patient (VP), ANSI VP.10.1-2010

• The US Army is interested in prototyping a structure to exchange physiological

information between simulators

– Leveraging existing standards and programs

– Consistent and growth with existing simulators

– Useful by non-DoD entities

– This structure is currently being considered by the SISO for IEEE balloting

• Creation of system architecture for translation of clinical conditions to Virtual Patient

– IEEE1278 Protocol Data Units

– DICOM Hierarchical Client-Server System Architecture

– Current medical coding system (e.g., ICD-9, ICD-10, SNOMED-CT, DRG, and

CPT)

• Medical history

• Integrated and human readable virtual patient chart

• In situ simulation → point of injury data access


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Purpose

• Goal: Create an interoperability standard amongst

computer based medical simulators and between medical &

other simulated entities

• Benefit: Potential to increase the functionality, utility,

training effectiveness, and realism needed to properly train

and maintain proficiency among medical professionals in

both the private and government sectors

• Opportunity: Create standard interchange protocols.


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IEEE 1278 Distributed

Interoperable Simulation (DIS)

• IEEE 1278 Distributed Interactive Simulation (DIS)

– Interchange between virtual simulators communities since 1995

• Utilizes Protocol Data Units (PDUs)

• Multiple connection strategies, real time, no central clock, uses a heart beat, dead

reckoning, etc.

• Built from DARPA SIMNET Program

– Contains Entity State PDU (which includes life forms)

• Opportunity for Enhanced Medical Relevance

• DICOM PDUs

• Medical Code PDUs

– Simulation Interoperability Standards Organization (SISO) manages and

ballots changes for the IEEE

• Compatible with Army’s Program Executive Officer – Simulation, Training and

Instrumentation (PEO-STRI)

– Leverages Synthetic Environment Core (SE CORE)


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Facilitating Interoperability and

Standards for Simulators in Healthcare

• Protocol Data Units (PDUs)

– Data messages passed between network simulation applications

– IEEE Standard 1278.1, Draft 15 contains 60 PDU instances

– Proposed Virtual Patient information and data

• Leverages Medbiquitous Virtual Patient

• Entity State PDU: low fidelity data about VP using Variable Parameter

• Attribute PDU: higher fidelity info about VP via its Attribute Records

• Entity State PDU

– Defines all entities in the simulated environment (e.g., Life Form PDU)

– Basic Patient Data

– Physiological Data

• Current design use cases

– Transfer ownership

– Supply consumables

– Partial control of parameters


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• Variable Parameter

– Used by Entity State PDU to store basic information

– 128 bits in length, holds pertinent virtual patient information

– Lower-fidelity information

• Attribute Record

– Similar to Variable Parameter records with exceptions

• Attribute Records are not part of an Entity State PDU

• Attribute Records have no bit limitations (infinite storage capacity)

• Attribute Records are useful for high fidelity patient data


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Figure 1: The 11

physiological systems

as represented by

Attribute Records (IEEE

1278). These records

hold higher-fidelity

virtual patient data.

Figure 2: A closer look at the Cardiovascular

System Attribute Record. Note that the

parameters are separated into 64-bit blocks.

Figure 3: The Extended Lifeform Basic Attributes Variable Parameter record. This data

structure is used to hold lower-fidelity virtual patient data inside of an Entity State PDU.

Figure 4: A diagram outlining one possible method for “sharing ownership”

of a virtual patient. The main steps include: 1)Creating and copying a

patient (so that one exists in each application) and 2) Querying and setting

patient information so that both patients’ statuses are the same.


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Our Focus: Conveying Additional

Relevant Information

• Significant gap in translating clinical conditions to the Virtual Patient (VP)

• Existing healthcare medical coding systems may provide the basis to

demonstrate dynamic patient episodes of care through the expression of

physiological conditions supporting the current state of the VP

– Clinical conditions and other patient data from actual/simulated from medical

service encounters incorporated into medical simulation training

• Triage

• Physician office visits

• Hospital emergency

• Surgical procedures

• Current Proposition

– Medical codes can be reverse engineered to create a virtual chart

• Specific patient

• A class of patients

– Access to images can augment codes

– Data can be packaged into PDUs.


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Medical Coding Systems

• International Classification of Diseases, Clinical Modification,9th Revision (ICD-9-CM)

– US payer system developed by AHA, AHIMA, NCHS

– Three to five digit field length with variations

• External Cause of Injury (E)

• Reason for Encounter (V)

• Morphology (M)

– 13,000 codes in ICD-9-CM Diagnosis Volumes 1 and 2

– 3,000 codes in ICD-9-CM Procedure Coding System Volume 3

– Classification expansion prohibited due to data structure


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• International Classification of Diseases, Clinical Modifications, 10th Revision

(ICD-10-CM/PCS)

– Consists of Clinical Modification (CM) and Procedures Coding System (PCS)

– Dominant payer system outside US, expandable

– Three to seven alphanumeric digits

• External Cause of Injury (ICD-9 E Codes) embedded in new structure

• Reason for Encounter (Z) from ICD-9 V Codes

• Morphologies (C, D)

– CMS projected change October 2013 developed in US by AHA, AHIMA,

CDC, CMS

– 68,000 codes ICD-10-CM consolidates ICD-9 V1 and V2

– 72,000 codes ICD-10-PCS replaces ICD-9 V3


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• Systemized Nomenclature of Medicine, Clinical Terms (SNOMED-CT)

– Provider system developed by CAP to capture primary diagnosis

– Four to nine digit numeric codes, first character alphanumeric

– 366,170 Terminologies

– One million English language descriptions

– 1.46 million semantic relationships

• Current Procedural Terminology (CPT)

– Payer system for non-hospital physician services developed by AMA

– Five digit standard, first character alphanumeric

– Symbol and numeric modifiers to reduce payment time

– 7800 codes

• Diagnostic Related Groups (DRG)

– Internal facility system determines resource utilization developed by CMS

– 500 Medical/Surgical Groups, 1,200 Subclasses

– Medicaid Severity MS DRG common three to five digit codes*


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Data Set Coding Structures

Medical Code System General Coding Alphanumeric Options

ICD-9-CM

-Diagnosis

-Procedure

-Sub classifications

Character 1 (E, M, U, or V) or null;

Characters 2-4 (numeric); Character 5

(numeric or alpha-x); Character 6 (numeric);

Character 7 (forward slash /); and Character 8

(numeric).

ICD-10-CM/PCS

-Diagnosis

-Procedure

Character 1-7 (alphanumeric).

SNOMED-CT Character 1 (alphanumeric), Characters 2-9

(numeric).

CPT Character 1 (alphanumeric); Characters 2-5

(numeric); Character 6 (symbol); Characters

7-8 (numeric)

MS DRG, All Patient AP

DRG.

All Patient Refined

APR DRG

Characters 1-5 (numeric).

Characters 1-3 (numeric), Character 4(alpha);

Characters 5-6 (numeric).


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Enhanced Medical PDU

Designed to support conveyance of data between disparate systems

Not the manipulation at either end point


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Data Set Coding Structures

Proposed MEDICAL CODING SET PDU (Partial) Figure 1: Medical Codes Attribute PDU

Group Field Range Number of Bits Precision

International Classification of

Diseases (ICD)-9 & 10 Record

Record Type

N/A 32-bit enumeration N/A

Record Length

N/A 16-bit unsigned integer N/A

Padding N/A 8-bit unused N/A

Number of ICD

Codes (N) 0-255 8-bit unsigned integer 1 Code

ICD Code Record (N Records)

ICD Code Record Type

Not specified, Primary ICD-9-CM, ICD-9-E, ICD-9-M, ICD-9-PCS, ICD-9-U, ICD-9-V, Primary ICD-10-CM, ICD-10-PCS, ICD-10-C, ICD-10-D, or ICD-10-Z

8-bit enumeration N/A


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Digital Images and Communication in

Medicine (DICOM)

• ISO-OSI model of communication

• Established by ACR and NEMA in 1982

– Initial use: transfer of radiology data, data storage

– Current use: Network Protocol Digital Archive and Communication System

• Non radiology expansion

• 20 Working Groups (e.g., nuclear medicine, cardiology)

• International Acceptance

• Opportunity to optimize DICOM protocols

– Establish workflow

– Create unique VP data exchange identifiers

• Permit computer-based mannequins or simulator communication

• Permit communication between clinical equipment modalities and VP

– Magnetic Resonance Imaging (MRI)

– Computed Topography (CT)

– Ultrasounds (US)


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Medicine (DICOM)

Proposed DICOM PDU Figure 1: DICOM Image Record for Attribute PDU

Group Field Range Number of Bits Precision

DICOM Image Record (1664 bits)

Record Type

N/A 32-bit enumeration N/A

Record Length

N/A 16-bit unsigned integer N/A

Padding N/A 16-bit unused N/A

Note: The DIS Entity ID included in the header will be converted into the DICOM Patient ID before accessing the images

Study Instance UID (Optional, null-

terminated)

DICOM Study

Instance UID

0 – 9, or

Period

64 character ASCII string (512 bits, null-terminated)

N/A

Series Instance UID (Optional, only if Study Instance UID is valid,

null-terminated)

DICOM Series

Instance UID

0 – 9, or

Period


N/A

SOP Instance UID (Optional, only if Series Instance UID is valid,

null-terminated)

DICOM SOP

Instance UID

0 – 9, or

Period


N/A


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Medicine (DICOM)

Figure 5. Proposed Protocol Data Units for Digital Images and Communication in

Medicine (DICOM) Element Indicating Image Hierarchy


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Status and Plans

• Feedback being sought

– Healthcare user community

– Manufacturers

– Regulators/Decision Makers

• Basic Life Form PDU being prepared for IEEE review & balloting

– Presented at IMSH (Jan ‘11)

– Presented at SIW (Apr ‘11)

• Attribute PDU for physiology being prepared for IEEE review & balloting

– Presented at IMSH (Jan ‘11)

– Presented at SIW (Apr ‘11)

• Prototyping underway with data converters

– General physiology model

– Simulator manufacturer’s model

• Coding and DICOM being prepared for IEEE review & balloting

• Tutorial for I/ITSEC being prepared for review


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Conclusions

• Short Term Benefits

– Increased VP Capabilities

• Transmit entity information

• Transfer an entity between multiple simulation applications

• Approximate impact on entity’s in proximity to a simulated explosion

– Flexible roadmap to incorporate medical coding systems that expand the

interoperability standards in healthcare simulation

– Restores capture of most condition information

• Potential to overcome inability to capture all written, verbal, and

interpretive information not presently translated in billing/payment driven

medical coding systems

• Long Term Benefits

– Overcomes present inability to view dynamic body changes in patient injured

condition

– Growth as simulators grow

– Recognized standard body for developers, users, managers


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References

Advanced Technology Applications for Combat Casualty Care (ATACCC). Proceedings of the ATACCC

Conference August 16-19, 2010. St. Pete Beach, FL.

Alexander, S., Conner, T., & Slaughter, T. (2003). Overview of inpatient coding. American Journal of

Health-System Pharmacy, 60(21 Suppl 6): S11-4.

Cardillo, E., Eccher, C., Serafini, L. & Tamilin, A. (2008). Proceeding AIMSA '08 Proceedings of the 13th

international conference on Artificial Intelligence: Methodology, Systems, and Applications Springer-Verlag

Berlin, Heidelberg. doi>10.1007/978-3-540-85776-1_26 .

Centers for Medicare & Medicaid Services, Department of Health and Human Services. Medicare program;

hospital inpatient prospective payment systems and FY 2005 rates. Final rule. Federal Register 69, no. 154

2004a (August 11); 48916–49781.

Institute of Electrical and Electronics Engineers, Inc. IEEE Standard P1278.1/D15. (2010, April). IEEE Draft

Standard for Distributed Interactive Simulation—Application Protocols.

Pianykh, O. S. (2008). Digital Imaging and Communications in Medicine (DICOM): a Practical Introduction

and Survival Guide. Berlin: Springer.


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Back up Charts


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The Role of the Injury Severity Score

(ISS)

• ISS Primary role Pre-Treatment

– Triage

– Chief Complaint

– Review of Systems

• Comparable Acute Care Case Mix Complexity

– Assessment Post Treatment Historical Analysis

• Resource utilization


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Key Elements of Patient Information and

Medical Service

• Creation of a virtual chart

• PDU Data Source: 4 patient data elements

1. Chief Complaint

2. Review of Systems (body)

3. History of Present Illness

4. Medical History

• 1 & 2 focus of current efforts

• 3 & 4 verbal or scripted (technological gap in IEEE 1278)


* Classification *


Medicine (DICOM)

http://www.mfdigital.com/images/dicom.jpg




fiedler_john hopkins ppt medsim

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