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A Personal History of Medical Informatics W. Ed Hammond. Ph.D., FACMI, FAIMBE, FIMIA, FHL7 Director, Duke Center for Health Informatics Director, Applied Informatics Research, DHTS Associate Director, Biomedical Informatics Core, DTMI Professor, Department of Community and Family Medicine Professor Emeritus, Department of Biomedical Engineering Adjunct Professor, Fuqua School of Business Duke University Chair Emeritus and Secretary, HL7

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11/8/00 e-hammond 2 The Medical Record - TMR Over 40 different implementations 14 different medical specialties support from 1 to 350 providers maximum of 750,000 patients in one system operational in 28 different sites

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11/8/00 e-hammond 3 Early Years Automated 19 page screening medical history

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11/8/00 e-hammond 4 Early Systems Interactive Neurology Questionnaires OB Computer-based Patient Record Automation of manual process Output duplication of paper system Data overflow Replacing required manual task External to program storage of display and flow control characteristics

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11/8/00 e-hammond 5 PDP 12 4Kbytes 12 bit word 300K mass storage Programming Languages -Assembly -Basic -GEMISCH

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11/8/00 e-hammond 6 Programming Language GEMISCH Input Frames Massage Print Retrieve Store Assembly Language - Focused set of tools to do specific tasks

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11/8/00 e-hammond 7 GEMISCH Powerful text manipulating functionality Smart print generating capability Variable and flexible file types Programmable display functionality within constraints of character-based terminals Total control of interface capability

Slide 8 " R (F:-1) D WT -1 M LINE^WT+SAPPTR-1 P "[X$,LINE,14,BMI]" P "[M1,2]ENTER CODE FOR HEIGHT => " R (F:-1) D HT -1 P "[M1,3]CODE FOR BMI IS [VBMI]" M LINE^BMI+SAPPTR-1 D %-300 S "[X$,LINE,5,BMIDO][X$,LINE,8]";CAL SET F FILE=1,NFILE D %-193 S "[X$,37,6]:[A91][K],11[A93]TMR.[~FILE,3,0]" L0:NEXTRECORD DONE =-193 D %-3 S "[H#,-176,1]" D AN -3 O "$" I AN,A2X2A D %-2 S "[H#,13,1]";BF PAT ADJUSTMENT NODE F AI=1,AN D %-1 S "[H$,-3,AI]" D %-2 S "[B-2=F[N-2]$][N-1]" P "[H,,-1,1,AK][H,,-1,3,AM]" M AL^AK+ACCPTR-1 P "[X$,AL,4,AK]" M AM^((AK=1)-(AK=2))*AM M AO^AO+AM M AB^AB+AM E D %-1 S "[VAO]" D %1 R -1 1 # D %13 R -2 1 #">

Example of Gemisch coding D %-194 S "ZA:[A91][K],12[A93]TMR.DBD" O D =-194 P "[X$,1,1,TMP]" Z TMP D %-1 S "[D2]" D JDATE -1 S SS8 ?1=MDATE,'1=0 M BUFF^-4 P "[X$,5,1,ENCOFF][X$,9,1,SAPOFF][X$,9,3,ASAPOFF]\ [X$,23,1,SAPPTR][X$,37,2,NFILE][X$,37,14,NEFILE]\ [X$,37,15,NSFILE]" P "[S][U11]ENTER CODE FOR WEIGHT => " R (F:-1) D WT -1 M LINE^WT+SAPPTR-1 P "[X$,LINE,14,BMI]" P "[M1,2]ENTER CODE FOR HEIGHT => " R (F:-1) D HT -1 P "[M1,3]CODE FOR BMI IS [VBMI]" M LINE^BMI+SAPPTR-1 D %-300 S "[X$,LINE,5,BMIDO][X$,LINE,8]";CAL SET F FILE=1,NFILE D %-193 S "[X$,37,6]:[A91][K],11[A93]TMR.[~FILE,3,0]" L0:NEXTRECORD DONE =-193 D %-3 S "[H#,-176,1]" D AN -3 O "$" I AN,A2X2A D %-2 S "[H#,13,1]";BF PAT ADJUSTMENT NODE F AI=1,AN D %-1 S "[H$,-3,AI]" D %-2 S "[B-2=F[N-2]$][N-1]" P "[H,,-1,1,AK][H,,-1,3,AM]" M AL^AK+ACCPTR-1 P "[X$,AL,4,AK]" M AM^((AK=1)-(AK=2))*AM M AO^AO+AM M AB^AB+AM E D %-1 S "[VAO]" D %1 R -1 1 # D %13 R -2 1 #

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11/8/00 e-hammond 9 Continued Development University Health Services Clinic Transaction-oriented architecture Added practice management functionality Scheduling Accounting Family Medical Center Quickly evolved into different system Four sites - required programming staff of 25 persons

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11/8/00 e-hammond 10 Clinical Focus

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11/8/00 e-hammond 11 Practice Management

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11/8/00 e-hammond 12 The Medical Record Modular construction - simplifies programming, documentation, evolution and maintenance Independence of data capture, data storage and data use Combination of problem-oriented, encounter-oriented and time oriented formats

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11/8/00 e-hammond 13 The Medical Record Multiple input modes parameter-oriented direct input mode for source data entry use of paper or dictation to capture physician input for subsequent input by 3rd party automated input from machine data message input - MAPS then HL7

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11/8/00 e-hammond 14 Renal Direct Entry

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11/8/00 e-hammond 15 Renal Encounter Entry Form

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11/8/00 e-hammond 16 The Medical Record Direct coupling of protocols to data entry and data display Knowledge required for system behavior defined in a dictionary of metadata

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11/8/00 e-hammond 17 Quality Assurance Protocol

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11/8/00 e-hammond 18 Continued Growth Cardiology Clinical database for research purposes New data types New displays and presentations Crude graphics Cross patient retrievals

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11/8/00 e-hammond 19 Cardiology

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11/8/00 e-hammond 20 Continued Growth Inpatient system New program navigation required Multiple day encounters Preorders for tests and treatments Increase in volume of data Late charges Increased importance of time stamp on data Patient tracking within institution

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11/8/00 e-hammond 21 Continued Growth Surgical Intensive Care Unit Increased volume Increased interfaces Bedside interfaces Nurse Charting Additional linkages

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11/8/00e-hammond 22 Generalizable lessons about clinical systems and databases

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11/8/00 e-hammond 23 Dictionary of Metadata data element definitions vocabulary and external code sets physical resources data capture protocols billing algorithms decision support rules work flow rules information flow linkages report generation drug-drug interactions people and places security

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11/8/00 e-hammond 24 Dictionary, Problems Code Set (ICD,ICPC,SNOMED,Read,) Name Type Classification Category Linkage to causal diagnosis Linkage to manifestations

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11/8/00 e-hammond 25 Dictionary, Problems Code Set (ICD,ICPC,SNOMED,Read,) Name Type Classification Category Linkage to causal diagnosis Linkage to manifestations

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11/8/00 e-hammond 26 Dictionary, Problems Linkage to S&P Linkage to Related Studies Linkage to Medications Linkage to Management Plan Problem-oriented display specification Protocol linkage Parent diagnoses

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11/8/00 e-hammond 27 Dictionary, Problems Coded modifiers Intervention linkage set Outcome linkage set Evaluation Linkage set

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11/8/00 e-hammond 28 GEMISCH Record Structure

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11/8/00 e-hammond 29 TMR Data Storage Time-oriented data 54!2!5$87023!2@1230|3@1015$87022!1@1015

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11/8/00 e-hammond 30 Database structure for studies Codes in display order DateTime Data 10|15|25|21|22|67|32|45|148|53 990600800|9823510156|981501500|971891215 150||155|165 |||20 3|3|3|3

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11/8/00 e-hammond 31 TMR Record Structure Demographics Payors Providers Summary Problems Therapies Studies History and Physical Findings Appointments Encounters Accounting

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11/8/00e-hammond 32 Primary TMR Patient Record Demographic Clinical Management Lab Pages Narrative Reports H&P Pages Encounter PagesAccounting Pages Composite Tests Past Medications Narrative Reports

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11/8/00 e-hammond 33 TMR Files TMR Patient Record Daily Record Backup Total Event Log Audit Summary Protocol Tracking Access Log

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11/8/00 e-hammond 34 Implications for MI Critical mass of functionality Visible benefit Partnership within development teams Ability to maintain and evolve Ability to prototype and later incorporate Ability to accommodate preferences Open interfaces Scalability

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11/8/00 e-hammond 35 Changing Technology

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11/8/00 e-hammond 36 Input/Output Devices

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11/8/00 e-hammond 37 Hostile (?) Environments

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11/8/00e-hammond 38 Technological progress will continue. It merely changes the challenges, but never eliminates them.