Medical Informatics Introduction and Overview
James J. Cimino, M.D.
Departments of Medicine
and Medical Informatics
Medical Informatics
Medical
Information
Science
We Are All Medical Informaticians
Medical Education
Patient Data Collection and Recording
Clinical Information Retrieval
Medical Knowledge Retrieval
Medical Decision Making
Some Definitions
Medical Informatics: the science of medical information collection and management
Medical Decision Making: quantitative methods for reasoning under uncertainty
Medical Computing: computer applications for information management
Medical Decision Support: computer-based information processing to help human decision makers
A Brief History - Past to Future
Ledley and Lusted - Reasoning foundations of medical diagnosis; Science 1959
El Camino Hospital - 1965 Help System - 1970 Financial systems - driven by billing and reporting
requirements Clinical Systems Information Resources Expert Systems
Medical Computing
Patient-Oriented Systems
Medical Information Resources
Medical Knowledge Systems
Patient Oriented Systems
Definition: systems which collect, store and retrieve data about individual patients
Financial systems
Electronic medical records
Research databases
Medical Information Resources
Definition: systems which contain general medical knowledge
Medline
Electronic textbooks
Computer-assisted instruction
Medical Knowledge Systems
Definition: systems which apply general medical knowledge, whether through pattern matching or application of clinical algorithms, to specific patients
Stand-alone: Mycin, Internist-I/QMR, DXplain
Integrated: Help, Columbia CIS
Case PresentationCase Description: 74 y.o. female with history of right CVA in 1989 (LLE weakness), one week of productive cough and increased debility. Exam consistent with bronchitis, oral antibiotic prescribed, but patient had a tonic grand mal seizure in clinic. Became flaccid, unconscious, pulseless, apneic, but upon positioning for CPR, developed pulse and spontaneous respirations and awoke about 2 minutes after start of episode, complaining of lower sternal chest pain.
Actions:» Transfer to Emergency Room» Examination» Bloodwork» Chest Xray» Cardiogram» Admission and therapy
CIS Demo - Part I
Lab Data: ABG and CPK/Isoenzymes
Radiology: CXR, VQ, Doppler
Cardiology: ECG, Cardiac Cath
Medications
Alerts
Discharge Summary
Case Summary
Case Description: bronchitis, bed-bound, venous thrombosis, pulmonary embolism, myocardial infarction, ventricular arrhythmia, hypotension, seizure, adult respiratory distress syndrome, methicillin-resistant Staph aureus
Discharge Plan» Where?» What happened?
Outpatient Follow-up» Medications» Laboratory» Health Maintenance
CIS Demo - Part II
Demographic Information
Additional Hospitalizations?
More Discharge Summaries?
Recent Lab Results
Outpatient Notes
How Did We Do It?
Information Science
Standards
Integration
Medical Informatics - Lecture II
Information Science
Standards
Integration
Information Science
Expert Systems
Decision Support Systems
Research Databases
Computer Assisted-Instruction
<Show 4 CAI Slides>
Standards
Messaging
Vocabulary
Logic
Databases
Standards for Messaging
Structured Query Language
Z39.50
Health Level 7 (HL7)
HL7 Example
MSH!^~\&!resquery!cicsu9!socratesqry!wash!19950314151110307!!ORF!199503141!!
MSA!AA!19941125165590!RESULT LIST COMPLETED.!!
QRD!19941125165542!R!I!0113142726!!!99!1644144!res!32309!!
QRF!*!19901101000000!19941230170100!PDQRES2~*~OPSTA!95~95~95~PF~~
OBR!!!M136903542294808^0001!35422^^L!!!1994080807190000000!!!!!!!!!!!!!!!!!F!!!!!!!!!
OBX!!TX!35456^^L!1^0!138$135-146]mM/l!!!!!!!
OBR!!!M140333542394808^0001!35423^^L!!!1994080807100000000!!!!!!!!!!!!!!!!!F!!!!!!!!!
OBX!!TX!35456^^L!1^0!136$135-146]mM/l!!!!!!!
OBR!!!X263 3542294807^0001!35422^^L!!!1994080706520000000!!!!!!!!!!!!!!!!!F!!!!!!!!!
OBX!!TX!35456^^L!1^0!140$135-146]mM/l!!!!!!!
Standards for Vocabulary
International Classification of Diseases, 9th Edition, with Clinical Modifications (ICD9-CM)
Diagnosis-Related Groups (DRGs)
Medical Subject Headings (MeSH)
Unified Medical language System (UMLS)
Systematized Nomenclature of Medicine (SNOMED)
Read Codes
Knowledge-Based Vocabularies
ICD9- CM Example003 Other Salmonella Infections
003.0 Salmonella Gastroenteritis
003.1 Salmonella Septicemia
003.2 Localized Salmonella Infections
003.20 Localized Salmonella Infection, Unspecified
003.21 Salmonella Meningitis
003.22 Salmonella Pneumonia
003.23 Salmonella Arthritis
003.24 Salmonella Osteomyelitis
003.29 Other Localized Salmonella Infection
003.8 Other specified salmonella infections
003.9 Salmonella infection, unspecified
DRG Example
75 - Respiratory disease with major chest operating room procedure, no major complication or comorbidity
76 - Respiratory disease with major chest operating room procedure, minor complication or comorbidity
77 - Respiratory disease with other respiratory system operating procedure, no complication or comorbidity
79 - Respiratory infection with minor complication, age greater than 17
80 - Respiratory infection with no minor complication, age greater than 17
89 - Simple Pneumonia with minor complication, age greater than 17
90 - Simple Pneumonia with no minor complication, age greater than 17
475- Respiratory disease with ventilator support
538 - Respiratory disease with major chest operating room procedure and major complication or comorbidity
MeSH Example
Respiratory Tract DiseasesLung Diseases
PneumoniaBronchopneumoniaPneumonia, AspirationPneumonia, LipidPneumonia, LobarPneumonia, MycoplasmaPneumonia, Pneumocystis CariniiPneumonia, RickettsialPneumonia, StaphylococcalPneumonia, Viral
Lung Diseases, FungalPneumonia, Pneumocystis Carinii
SNOMED ExampleD2-50000 SECTIONS 2-5-6 DISEASES OF THE LUNG
D2-50100 2-501 NON-INFECTIOUS PNEUMONIASD2-50100 Bronchopneumonia, NOS (T-26000) (M-40000)D2-50100 Lobular pneumonia (T-28040) (M-40000)D2-50100 Segmental pneumonia (T-280D0) (M-40000)D2-50100 Bronchial pneumonia (T-280D0) (M-40000)D2-50104 Peribronchial pneumonia (T-26090) (M-40000)D2-50110 Hemorrhagic bronchopneumonia (T-26000) (M-40790)D2-50120 Terminal bronchopneumonia (T-26000) (M-40000)D2-50130 Pleurobronchopneumonia (T-26000) (M-40000)D2-50130 Pleuropneumonia (T-26000) (M-40000)D2-50140 Pneumonia, NOS (T-28000) (M-40000)D2-50140 Pneumonitis, NOS (T-28000) (M-40000)D2-50142 Catarrhal pneumonia (T-28000) (M-40000)D2-50150 Unresolved pneumonia (T-28000) (M-40000)D2-50152 Unresolved lobar pneumonia (T-28770) (M-40000)D2-50160 Granulomatous pneumonia, NOS (T-28000) (M-44000)D2-50170 Airsacculitis, NOS (T-28850) (M-40000)
Standards for Logic
HELP Sectors
CARE System
Arden Syntax for Medical Logic Modules
MLM Examplemaintenance: title: Creatinine clearance;; version: 1.09;;
author: George Hripcsak, M.D. ([email protected]);; ;;
library: purpose: To calculate the creatinine clearance for every timed urine collection;;
explanation: When a timed urine collection is stored, the MLM checks for..... ;;
knowledge:
data:
let urine_creat_storage be event {'32506','1762'};
let (urine_creat, collect_time) be read last {'evoking', 'dam'="PDQRES1";'1762'; '1537'};;;
evoke: starting time of urine_creat_storage;;
logic:
let serum_creat be nearest (time of urine_creat) from (serum_creat_list where it is number);
let creat_clear be 0.07 * (24 / collect_time) * (urine_creat / serum_creat);
conclude true; ;;
action: write "The creatinine clearance is " ||int(0.5+creat_clear)|| " ml/min based
upon a " ||collect_time|| " hour urine creatinine of " ||urine_creat||.....; ;;
end:
Standards for Databases
Definitions for Computer-Based Patient Records
Data Model Standards
Integration
IAIMS: Integrated Advanced (Academic) Information Management Systems
Five Levels of Integration
World Wide Web (WWW)
<5 Levels of Integration>
Architecture at CPMC
Workstations
Local Area Network
Internet
ClinicalDepartments Web Browser
Web Server
VocabularyServer
Additional InformationSources
Clinical DataServer
ClinicalInformation
System
Resident Signout Editor(RSE)
World Wide Web Demo Visual Bed Browser JMW’s CIS Menu JMW’s Labs Lab Trend Medline Button Q's Medline Button Results Medline button Abstract DXplain Button Extract DXplain Button Results DXplain Button Disease Cholesterol Guideline Input Cholesterol Guideline Result
ECG Xray Xray Medline Q's Xray Medline Abstract Medications Single Drug Order Drug/Diet Information PDR JMW’s Discharge Summary
Summary
Classification of Systems
Development of Standards
Intelligent Integration
Challenges
Security and Confidentiality
Vocabulary
Data Entry
Changing Behavior» Outcomes assessment» Managed care» New paradigms for information use