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. (hripcsak@cucis.cis.columbia.edu);; ;;

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