Medical Informatics Introduction and Overview James J. Cimino, M.D. Departments of Medicine and Medical Informatics

Medical Informatics l Medical l Information l Science

We Are All Medical Informaticians l Medical Education l Patient Data Collection and Recording l Clinical Information Retrieval l Medical Knowledge Retrieval l Medical Decision Making

Some Definitions l Medical Informatics: the science of medical information collection and management l Medical Decision Making: quantitative methods for reasoning under uncertainty l Medical Computing: computer applications for information management l Medical Decision Support: computer-based information processing to help human decision makers

A Brief History - Past to Future l Ledley and Lusted - Reasoning foundations of medical diagnosis; Science 1959 l El Camino Hospital l Help System l Financial systems - driven by billing and reporting requirements l Clinical Systems l Information Resources l Expert Systems

Medical Computing l Patient-Oriented Systems l Medical Information Resources l Medical Knowledge Systems

Patient Oriented Systems l Definition: systems which collect, store and retrieve data about individual patients l Financial systems l Electronic medical records l Research databases

Medical Information Resources l Definition: systems which contain general medical knowledge l Medline l Electronic textbooks l Computer-assisted instruction

Medical Knowledge Systems l Definition: systems which apply general medical knowledge, whether through pattern matching or application of clinical algorithms, to specific patients l Stand-alone: Mycin, Internist-I/QMR, DXplain l Integrated: Help, Columbia CIS

Case Presentation Case 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. l Actions: »Transfer to Emergency Room »Examination »Bloodwork »Chest Xray »Cardiogram »Admission and therapy

CIS Demo - Part I l Lab Data: ABG and CPK/Isoenzymes l Radiology: CXR, VQ, Doppler l Cardiology: ECG, Cardiac Cath l Medications l Alerts l 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 l Discharge Plan »Where? »What happened? l Outpatient Follow-up »Medications »Laboratory »Health Maintenance

CIS Demo - Part II l Demographic Information l Additional Hospitalizations? l More Discharge Summaries? l Recent Lab Results l Outpatient Notes

How Did We Do It? l Information Science l Standards l Integration

Medical Informatics - Lecture II l Information Science l Standards l Integration

Information Science l Expert Systems l Decision Support Systems l Research Databases l Computer Assisted-Instruction

Standards l Messaging l Vocabulary l Logic l Databases

Standards for Messaging l Structured Query Language l Z39.50 l Health Level 7 (HL7)

HL7 Example MSH!^~\&!resquery!cicsu9!socratesqry!wash! !!ORF! !! MSA!AA! !RESULT LIST COMPLETED.!! QRD! !R!I! !!!99! !res!32309!! QRF!*! ! !PDQRES2~*~OPSTA!95~95~95~PF~~ OBR!!!M ^0001!35422^^L!!! !!!!!!!!!!!!!!!!!F!!!!!!!!! OBX!!TX!35456^^L!1^0!138$ ]mM/l!!!!!!! OBR!!!M ^0001!35423^^L!!! !!!!!!!!!!!!!!!!!F!!!!!!!!! OBX!!TX!35456^^L!1^0!136$ ]mM/l!!!!!!! OBR!!!X ^0001!35422^^L!!! !!!!!!!!!!!!!!!!!F!!!!!!!!! OBX!!TX!35456^^L!1^0!140$ ]mM/l!!!!!!!

Standards for Vocabulary l International Classification of Diseases, 9th Edition, with Clinical Modifications (ICD9-CM) l Diagnosis-Related Groups (DRGs) l Medical Subject Headings (MeSH) l Unified Medical language System (UMLS) l Systematized Nomenclature of Medicine (SNOMED) l Read Codes l Knowledge-Based Vocabularies

ICD9- CM Example 003 Other Salmonella Infections Salmonella Gastroenteritis Salmonella Septicemia Localized Salmonella Infections Localized Salmonella Infection, Unspecified Salmonella Meningitis Salmonella Pneumonia Salmonella Arthritis Salmonella Osteomyelitis Other Localized Salmonella Infection Other specified salmonella infections 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 Respiratory infection with no minor complication, age greater than Simple Pneumonia with minor complication, age greater than Simple Pneumonia with no minor complication, age greater than Respiratory disease with ventilator support Respiratory disease with major chest operating room procedure and major complication or comorbidity

MeSH Example Respiratory Tract Diseases Lung Diseases Pneumonia Bronchopneumonia Pneumonia, Aspiration Pneumonia, Lipid Pneumonia, Lobar Pneumonia, Mycoplasma Pneumonia, Pneumocystis Carinii Pneumonia, Rickettsial Pneumonia, Staphylococcal Pneumonia, Viral Lung Diseases, Fungal Pneumonia, Pneumocystis Carinii

SNOMED Example D SECTIONS DISEASES OF THE LUNG D NON-INFECTIOUS PNEUMONIAS D Bronchopneumonia, NOS (T-26000) (M-40000) D Lobular pneumonia (T-28040) (M-40000) D Segmental pneumonia (T-280D0) (M-40000) D Bronchial pneumonia (T-280D0) (M-40000) D Peribronchial pneumonia (T-26090) (M-40000) D Hemorrhagic bronchopneumonia (T-26000) (M-40790) D Terminal bronchopneumonia (T-26000) (M-40000) D Pleurobronchopneumonia (T-26000) (M-40000) D Pleuropneumonia (T-26000) (M-40000) D Pneumonia, NOS (T-28000) (M-40000) D Pneumonitis, NOS (T-28000) (M-40000) D Catarrhal pneumonia (T-28000) (M-40000) D Unresolved pneumonia (T-28000) (M-40000) D Unresolved lobar pneumonia (T-28770) (M-40000) D Granulomatous pneumonia, NOS (T-28000) (M-44000) D Airsacculitis, NOS (T-28850) (M-40000)

Standards for Logic l HELP Sectors l CARE System l Arden Syntax for Medical Logic Modules

MLM Example maintenance: title: Creatinine clearance;; version: 1.09;; author: George Hripcsak, M.D. ;; 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 l Definitions for Computer-Based Patient Records l Data Model Standards

Integration l IAIMS: Integrated Advanced (Academic) Information Management Systems l Five Levels of Integration l World Wide Web (WWW)

Architecture at CPMC Workstations Local Area Network Internet Clinical Departments Web Browser Web Server Vocabulary Server Additional Information Sources Clinical Data Server Clinical Information System Resident Signout Editor (RSE)

World Wide Web Demo l Visual Bed Browser l JMW’s CIS Menu l JMW’s Labs l Lab Trend l Medline Button Q's l Medline Button Results l Medline button Abstract l DXplain Button Extract l DXplain Button Results l DXplain Button Disease l Cholesterol Guideline Input l Cholesterol Guideline Result l ECG l Xray l Xray Medline Q's l Xray Medline Abstract l Medications l Single Drug Order l Drug/Diet Information l PDR l JMW’s Discharge Summary

Summary l Classification of Systems l Development of Standards l Intelligent Integration

Challenges l Security and Confidentiality l Vocabulary l Data Entry l Changing Behavior »Outcomes assessment »Managed care »New paradigms for information use