module 3: clinical informatics

CAHIMS Review Course

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Clinical Informatics


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Learning ObjectivesIdentify basic clinical vocabulary/terms frequently represented in healthcare informatics (e.g., dosage frequency, dosage routes, body systems)Identify basic healthcare IT vocabulary/terms frequently represented in healthcare informatics (e.g., LAN, SMS, VPN)Identify basic clinical metrics frequently represented in informatics (e.g., average daily census, turnaround time, adherence, barcode medication administration)Identify and support opportunities to optimize clinical effectiveness and efficiencies

Understand various data visualization techniques (e.g., tables, graphs, charts)

Maintain clinical content and decision-support tools


What is Clinical Informatics?

HIMSS definition:

“activities that promote the understanding, integration and application of information technology in healthcare settings.”

AMIA differentiates:

by explicitly noting that it is the use of information by clinicians

ANIA definition:

“explicitly addressing improvements for the health of populations, communities, families and individuals by optimizing information management and communication.”

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Who are Clinical Informaticists?

Translators in the interprofessional team, as a professional that speaks both informatics and healthcare

To be able to speak the same language,

and understand each other,

common ground must be found.

Need to understand the basic

underpinnings of computers and how

they work to manage healthcare

information

Practice the expansive scope of clinical informatics, subset of informatics within the healthcare domain

Clinical informatics increasingly impactful to healthcare world

Clinical Decision Support (CDS) provides guidance clinicians

Artificial intelligence (AI) and machine learning on the rise

Social determinants of health, patient-driven care

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Basic Vocabulary• At the root of clinical language is the use of prefixes, suffixes, letters, words or

numbers which may form medical terms

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Prefix Meaning Prefix Meaning

Brachi/o Arm Lapar/o Abdomen, loin, or flank

Cardi/o Heart My/o Muscle

Cyt/o Cell Neur/o Nerve

Derm/a, derm/o, dermat/o Skin Ocul/o Eye

Encephal/o Brain Ophthalm/o Eyes

Gastr/o Stomach Or/o Mouth

Hemat/o Blood Ot/o Ear

Intestin/o Intestine Pulmon/o Lungs


Basic Clinical Abbreviations

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Abbreviation Definition Abbreviation Definition

AM Morning BP Blood pressure

AC Before meals BS Blood sugar

AD Right ear CC Chief complaint

Ad lib Freely Cap Capsule

Amp Ampule CM Centimeter

Ante Before CXR Chest x-ray

AS Left ear DC Discontinue

ASA Aspirin Disp Dispense

AU Both ears ER/EC/ED Emergency Room

BID Twice a day G Gram

BMI Body mass index Gr Grain

*Accepted form of abbreviations may be institution-specific

Caution:Duplicatedefinition?


Basic Clinical Abbreviations (Continued)

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HR Hour MCG microgram

H/O History of mEq/L Milliequivalent per liter

HR Heart rate mL Milliliter

HS At bedtime mm Millimeter

Hx History N/V Nausea and vomiting

ID Intradermal NKDA No known drug allergies

IM Intramuscular NPO Nothing by mouth

IN Intranasal OD Right eye

INJ Injection OS Left eye

L Liter OU Both eyes

LMP Last menstrual period oz Ounce


Basic Clinical Abbreviations (Continued)

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PM Evening Rx Prescription

PMH Past medical history SL Sublingual

Q Every SQ Subcutaneous

Q2h Every two hours STAT Immediately

Q6h Every six hours Supp Suppository

Qam Every morning T Temperature

Qpm Every night TID Three times a day

QID Four times a day w/o Without

QOD Every other day WNL Within normal limits

*Abbreviations may hold multiple meanings• ”D/C” – discharge or discontinue• “SSRI” – sliding scale regular insulin or selective-serotonin reuptake inhibitor• “MS” – morphine sulphate or multiple sclerosis


National Standards for Health Information Technology

Developed and maintained by a number of global organizations.

Critical to capturing and transmitting data effectively across institutions,

states, nationally and internationally.

Have evolved over time and continue to evolve.

Standards support certification of

electronic health records and the ability to capture and report data with consistency.

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Technology Standards for Healthcare

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Messaging Standards Used for

HL7 Clinical data (Health Level Seven)

X12N Financial data, HIPAA-mandated transactions, transport of data

DICOM Images (Digital Imaging and Communications in Medicine)

NCPDP Standards for pharmacy business functions, HIPAA-mandated transactions(National Council for Prescription Drug Programs)

IEEE Bedside instruments, medical information (Institute of Electrical and Electronics Engineers)

Terminology Standards Used for

LOINC Lab interoperability/data exchange (Logical Observation Identifiers Names and Codes)

Drugs NLM/FDA/VA collaboration on RxNorm, NDF-RT (National Drug File - Reference Terminology)

Billing CPT (Current Procedural Terminology), ICD-10-CM

(International Statistical Classification of Diseases and Related Health Problems)

Clinical UMLS (Unified Medical Language), SNOMED, and others


Computers in Healthcare

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Not a new phenomenon

• Decades of legacy systems (billing, lab, pharmacy, supplies)

Widespread adoption in the U.S. since the American Recovery and Reinvestment Act (ARRA) of 2009

• Health Information for Economic and Clinical Health Act (HITECH)• Created to motivate the implementation of electronic health records (EHRs) and supporting

technology• Created an economic stimulus effect• New jobs/roles created to support the expansion of EHRs, the clinicians who use these systems,

and far beyond


Computer Technology Basics

Fundamental building blocks

Bits

Bytes (kb, mb, gb, tb)

Hardware

Software

Connectivity considerations

Clinical informatics

professionals

Understand these foundational concepts

Often fill a role to manage these

components for the clinical teams alongside

IT colleagues

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Computer Technology Basics – Internal Components

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Component Definition Function

Motherboard The backbone of the computer Connects the computer parts

Central processing unit (CPU)

Often thought of as “the brains” of the computer

Responsible for interpreting and executing most of the commands from the computer’s hardware and software

Random-access memory (RAM)

The working memory of the computer Allows a computer to work with more information at the same time in active memory processing

Power supply A converter that supplies the power to the machine

Used to convert the power provided from the outlet into usable power for the many parts inside the computer case

Video card Graphics adapter or expansion card Allows the computer to send graphical information to a video display device such as a monitor, TV, or projector

Hard disc drive (HDD) Data storage device and an electromechanical magnetic disk drive

The HDD is the main, and usually largest, data storage hardware device in a computer where the operating system, software, and most files are stored

Solid-state drive (SSD) Data storage device; no moving (mechanical) components

Storage device that is typically more resistant to physical shock, runs silently, and has lower access time and less latency, but more expensive than HDD

Optical drive (Disc) Optical storage devices Optical drives retrieve and/or store data on optical discs like CDs, DVDs, and Blu-ray discs (BDs)


Hardware Specifications

Processing Speeds

Memory Requirements

Interface Requirements

Operating Systems

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Sample Recommended Specification for a Clinical Information Server

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Processor 2 × Six Core Intel Xeon Platinum Series

Memory 128 GB RAM

Network interface card 1 Gbit

Primary hard drive(s) 2 × 300 GB SAS in RAID 1

Repository hard drives 6 × 300 GB SAS or more in RAID 5 (SAN Preferred)

Operating system Microsoft Windows Server 2019

Database software Microsoft SQL Server 2019

See vendor for recommendations

Recommendations subject to change over time


Software Considerations

System software•Used to start and run the computer•Related to what the software does within the computer system to support the use of the computer

•e.g. device-driver software operates and manages all devices attached to the computer

Application software•Generally has a function or purpose specific to its use

•e.g. accounting/financial applications

Programming tools•Used to compile programs and link, or translate, computer program source code and libraries that

belong to either the system software of the application

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Types of Internal Components of Computer Software

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Type Description

Operating System The software that is responsible for the direct control and management of the hardware and running application software

Open-source software Free source code access licensed for use by an open community of developers and end-users; proprietary software is owned and distributed for commercial use

Boot loader or bootstrap The small program that loads and executes the command to “boot up” the computer; the program is stored in the RAM

Device drivers A program that operates the various devices on the computer, such as printers and peripherals; the driver provides software interface to the hardware device

Firmware Controls the devices typically seen in items such as mobile phones and digital cameras

GUI A graphics display with user-friendly point-and-click capability that allows the end-user to interact with the computer through the mouse and touchpad

Middleware Software that resides as an interface between the operating system and the applications that allows developers to control input/output devices, also referred to as “software glue”

Utility software Software that helps analyze, configure, optimize, or maintain the computer


Connectivity Considerations and Terminology

Short Messaging Services (SMS)

Virtual Private Network (VPN)

Local Area Network (LAN)

Mobile Technologies

Cloud Computing

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Connectivity

Consider ↑home automation with IoT

Smart television systems

Voice assistants

Alarm systems

Also ↑Healthcare mobile technologies

Notification to patients (follow up, labs)

Barcode medication administration

Secure messaging

Vast offerings with tremendous growth

Cloud Computing

“Software as a service”

E.g. EHR hosted by vendor

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Optimizing Clinical Effectiveness of Health Information Technology

Clinical Informaticists may use quality improvement techniques as a tool to optimize technology

Increased ability to capture data through the use of clinical systems, but can also lead to increased:

Burden of documentation

Interoperability challenges

Health IT safety consideration Clinician stress

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Workflow Redesign

Used as a quality improvement

technique

Identify how the work is currently being done, the current or “as is”

state

Often uses visual representations which allow role

and responsibility

mapping as well as determining when actions and decisions

are made within the workflow

Can be useful in identifying the “root cause” of

an adverse event and then

mitigate the error from happening

again, often through a redesign

producing a “future” workflow

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What Is Workflow?

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How work gets done,

not protocols

May involve

root cause analysis

May be mapped visually

Measuring: Process,

Outcomes, Balance

Current State Gap Analysis Future State


Common Clinical Metrics Used in Healthcare

Defined across three categories

• Process• Reflective of a clinical guideline and key interventions that impact a clinical outcome

• e.g. 90-minute door to balloon time for a myocardial infarction (heart attack)• Outcome

• Outcome measures are often “risk-adjusted” and consider things such as comorbidities and other factors that may have influenced the metric• e.g. mortality rates, 30-day readmission rate, surgical site infection rate

• Balancing• Address potential unintended consequences of quality improvement interventions used

to improve process or outcomes• e.g. decreased patient satisfaction due to the reluctance of a provider to prescribe

pain medications for a patient due to the opioid crisis

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QualityThe National Quality Forum is an organization tasked through federal contract to oversee quality measures development in the USCritical juncture in transforming how we pay for healthcare

Three interdependent levels of measurement, including individual performance measures, measure sets, and measurement systemsEstablishes a next generation approach to measuring quality in healthcare

Takeaway: Clinical Informatics key to quality measures, data analytics

More information see http://www.qualityforum.org/Home.aspx.

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http://www.qualityforum.org/Home.aspx


Data Visualization

Clinical Informaticists

should understand

best practices in developing

and presenting data

Common methods

include graphs, charts and

tables (examples of

these on following slides)

Graphical display of data

can covey complex ideas

with clarity, precision and

efficiency

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Data Visualization Best Practices

Clear display of the dataInduce the viewer to think about substance rather than methodsAvoid distortionPresent numbers in small spaceMake a large data set coherentEncourage the eye to compare different pieces of dataReview the data at multiple levelsServe a clear purpose to describe, explore, tabulate or enhance a reportBe closely integrated with verbal or descriptive information in a report

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Line Chart / Line Graph

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• Often used to reflect a metrics variability over time

• May show multiple series of data points over time


Bar Chart

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Variables for Use of Computers and the Internet

• Used to reflect frequency, counts or percentages as reflected as a total frequency


Table and Translation to a Bar Chart

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Frequency of Males and Females in a Population


Histogram

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• Reflect distributions of data for discrete (categories) or continuous data

• Bars represent numerical data by showing the number of data points that fall within a specified range of values often called “bins”


Pie Chart

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• Can be effective at comparing differences to illustrate the percentage breakdown of a small number of data points


Common Data Analytics Tools and Terminology

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Tool Purpose/Definition Example

FieldsVertical column in a database that contains data with common characteristics for the entire record

“First Name”“Last Name” “Date of Birth”

RecordsHorizontal rows in a database containing different pieces of data belonging to a given entity

All of the fields related to the row of “Billy”

TablesConsists of all records; combinations of all fields and records together

All horizontal and vertical rows together

ReportsAlternate view of data; typically assembled from a query

Generally generated on paper, can also be electronic for distribution of data

QueryProcess of selecting desired records; pulling the data

Pulling data related to all female patients older than 50 with a history of colon polyps

Graphs and ChartsTool for examining and presenting data Scatter plot, pie charts, bar charts, flowcharts,

Control Charts (Shewhart)Tool for looking at a process over time Common and special-cause variation, upper and lower

control limits

Predictive ModelingInstead of retrospective data analytics, the data is used to predict future outcomes

Pulling last five years of financial data to predict next years’ budget needs


Database Samples

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Database Table Query based on data elements

Report – Output of querying database for specific elements


Clinical Decision Support

Office of the National Coordinator for Health Information Technology (ONC) defines clinical decision support (CDS) as:•a component that “provides clinicians, staff, patients, or other individuals with

knowledge and person-specific information, intelligently filtered or presented at appropriate times, to enhance health and healthcare.”

CDS tools may include:•Computerized alerts and reminders to care providers and patients •Clinical guidelines•Condition-specific order sets •Focused patient data reports and summaries •Documentation templates;•Diagnostic support•Contextually relevant reference information

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Five Rights of CDSCombine all the tools and types to strategically use CDS within

an organization following a “five rights” framework

Who, what, when, where and how

Emphasize the clear goals and objectives of all five

components

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Right information Right person Right intervention format Right channel Right time

in workflow


Summary

Clinical Informaticists must understand and master:• Basics of clinical vocabulary• Common terminology represented in health informatics• Technology vocabulary• Types of metrics• Methods to optimize technology to improve care delivery

• Process improvement• Data visualization

• Proper use and development of clinical decision support tools

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Questions/Comments

All images courtesy HIMSS or public domain

module 3: clinical informatics

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