Grades Distribution Tow major exams each 20 = 40 Final 30 ( 20 Theory and 10 Practical ) Project and assignments 15 Quizzes 15

Text Books Main reference:

Another important reference

Chapter 1 Overview of Medical Informatics

The Study of Computers in Biomedicine The actual and potential uses of computers in health care and biomedicine form a remarkably broad and complex topic. However, just as you do not need to understand how a telephone or an ATM machine works to make good use of it and to tell when it is functioning poorly, its also true that technical biomedical-computing skills are not needed by health workers and life scientists who simply wish to become effective computer users. On the other hand, such technical skills are of course necessary for individuals with a career commitment to developing computer systems for biomedical environments. Thus, this course will neither teach you to be a programmer, nor show you how to fix a broken computer. It also will not tell you about every important biomedical-computing system or application; an extensive bibliography will direct you to a wealth of literature where review articles and individual project reports can be found. Specific systems will be used only as examples that can provide you with an understanding of the conceptual and organizational issues to be addressed in building systems for such uses.

The Need for a Course in Biomedical- Computing Applications Medical institutes has recommended the formation of new academic units in biomedical informatics in our medical schools, and subsequent studies and reports have continued to stress the importance of the field and the need for its inclusion in the educational environments of health processionals.

The reason for this strong recommendation is clear: The practice of medicine is inextricably entwined with the management of information. In the past, practitioners handled medical information through resources such as the nearest hospital or medical-school library; personal collections of books, journals, and reprints; files of patient records; consultation with colleagues; manual office bookkeeping; and (all-too-often flawed) memorization. Although all these techniques continue to be valuable, the computer is offering new methods for finding, filing, and sorting information: online bibliographic retrieval systems, including full-text publication; personal computers or PDAs, with database software to maintain personal information and reprint files; office-practice and clinical information systems to capture, communicate, and preserve key elements of the medical record; consultation systems to provide assistance when colleagues are inaccessible or unavailable; practice-management systems to integrate billing and receivable functions with other aspects of office or clinic organization; and other online information resources that help to reduce the pressure to memorize in a field that defies total mastery of all but its narrowest aspects. With such a pervasive and inevitable role for computers in clinical practice, and with a growing failure of traditional techniques to deal with the rapidly increasing information-management needs of practitioners, it has become obvious to many people that a new and essential topic has emerged for study in schools that train medical and other health professionals.

Learning Objectives: After reading this chapter the reader should be able to: State the definition and origin of Medical Informatics Identify the forces behind Medical Informatics Describe the key players involved in Medical Informatics State the impact of the HITECH Act on Medical Informatics List the barriers to health information technology (HIT) adoption Describe the educational and career opportunities in Medical Informatics

medical informatics has evolved as a new field in a relatively short period of time. Its emergence is partly due to the multiple challenges facing the practice of medicine today. As an example, clinicians need to: be more efficient, migrate away from paper based records, reduce medication errors and have educational and patient related information at their fingertips. Technology has the potential to help with each of those areas. With the advent of the Internet, high speed computers, voice recognition, wireless and mobile technology, healthcare professionals today have many more tools available at their disposal. However, technology is advancing faster than healthcare professionals can assimilate it into their practice of medicine. In this chapter we will present an overview of Medical Informatics with emphasis on the factors that helped create this new field and the key players involved.

The definition of Medical Informatics is dynamic due to the rapidly changing nature of both medicine and technology. The following are three definitions frequently cited: “scientific field that deals with resources, devices and formalized methods for optimizing the storage, retrieval and management of biomedical information for problem solving and decision making” “application of computers, communications and information technology and systems to all fields of medicine - medical care, medical education and medical research” "understanding, skills and tools that enable the sharing and use of information to deliver healthcare and promote health" Medical Informatics is also known as Health Informatics, Clinical Informatics and Bioinformatics in some circles. However, the consensus is that Bioinformatics involves the integration of biology and technology and can be defined as the: “analysis of biological information using computers and statistical techniques; the science of developing and utilizing computer databases and algorithms to accelerate and enhance biological research” Some prefer Biomedical Informatics because it encompasses Bioinformatics and medical, dental, nursing, public health, pharmacy, medical imaging and veterinary informatics.5 As we move closer to integrating human genetics into the day-to-day practice of medicine this more global definition may gain traction. We have chosen to use Medical Informatics throughout the book for consistency.

Key Players in Health Information Technology Information Technology is important to multiple players in the field of Medicine. The common goals of these different groups are to: Reduce medical errors and resultant litigation Provide better return on investment (ROI) Improve communication and continuity among the key players Improve the quality of care Reduce duplication of tests or prescriptions ordered Improve patient outcomes, like morbidity and mortality Standardize care among clinicians, organizations and regions Improve clinician productivity Speed up access to care and administrative transactions Protect privacy and ensure security

The key players in HIT and how they utilize health information technology Patients Online searches for health information Web portals for storing personal medical information, making appointments, checking lab results, e-visits, etc Research choice of physician, hospital or insurance plan Online patient surveys Online chat, blogs, podcasts, vodcasts and support groups and Web 2.0 social networking Personal health records Limited access to electronic health records Telemedicine and home telemonitoring

Clinicians Online searches with MEDLINE, Google and other search engines Online resources and digital libraries Patient web portals, secure and e-visits Physician web portals Clinical decision support, e.g. reminders and alerts Electronic health records (EHRs) Personal Digital Assistants (PDAs) and smartphones loaded with medical software Telemedicine and telehomecare Voice recognition software Online continuing medical education (CME) Electronic (e)-prescribing Disease management and registries Picture archiving and communication systems (PACS) Pay for performance Health Information Organizations (HIOs) E-research

Nursing and support staff Patient enrollment Electronic appointments Electronic billing process EHRs Web based credentialing Telehomecare monitoring Practice management software Secure patient-office communication Electronic medication administration record (e-Mar) Online educational resources and CME Disease registries

Public Health Incident reports Syndromic surveillance as part of bio-terrorism program Establish link to all public health departments (Public Health Information Network) Geographic information systems to link disease outbreaks with geography Telemedicine Remote reporting using mobile technology

Government Nationwide Health Information Network Financial support for EHR adoption Information technology pilot projects and grants o Disease management o Pay for performance o Electronic health records and personal health records o Electronic prescribing o Telemedicine o Broadband adoption o Health Information Organizations

Medical Educators Online medical resources for clinicians, patients and staff Online CME (Continuing Medical Education) MEDLINE searches Video teleconferencing, web conferencing, podcasts, etc

Insurance Companies Electronic claims transmission Trend analysis Physician profiling Information systems for “pay for performance” Monitor adherence to clinical guidelines Monitor adherence to preferred formularies Promote claims based personal health records and information exchanges Reduce litigation by improved patient safety through fewer medication errors

Hospitals Interoperable electronic health records Electronic billing Information systems to monitor outcomes, length of stay, disease management, etc Bar coding and radio frequency identification (RFID) to track patients, medications, assets, etc Wireless technology E-intensive care units Patient and physician portals E-prescribing Health Information Organizations (HIOs) Telemedicine Picture archiving and communication systems (PACS)

Research Database creation to study populations, genetics and disease states Online collaborative web sites e.g. CaBIG Service Oriented Architecture (SOA) initiatives to pull together multiple participants e.g. the National Institute of Health Electronic case report forms (eCRFs) Software for statistical analysis of data e.g. SPSS Literature searches with multiple search engines Randomization using software programs Improved subject recruitment using EHRs and Online submission of grants

Technology Vendors Applying new technology innovations in the field of medicine: hardware, software, genomics, etc Data mining Interoperability

Organizations involved with HIT Can give me some example from Saudi Arabia

Recommendations Recommendation 1: “improve access to clinical information and support clinical decision making” Recommendation 2: “Congress, the executive branch, leaders of health care organizations, public and private purchasers and health informatics associations and vendors should make a renewed national commitment to building an information infrastructure to support health care delivery, consumer health, quality measurement and improvement, public accountability, clinical and health services research, and clinical education. This commitment should lead to the elimination of most handwritten clinical data by the end of the decade”

Barriers to Health Information Technology (HIT) Adoption Inadequate time. This complaint is a common thread that runs throughout most discussions of technology barriers. Busy clinicians complain that they don't have enough time to read, learn new technologies or research vendors. They are also not reimbursed to become technology experts. They usually have to turn to physician champions, local IT support or others for technology advice Cost. It is estimated that a Nationwide Health Information Network (NHIN) will cost $156 billion dollars over five years and $48 billion annually in operating expenses.52 Technologies such as picture archiving and communications systems (PACS) and electronic health records are also associated with high price tags. The ARRA will help underwrite the initial purchase of some technologies but long term support will be a different challenge. Lack of interoperability. Electronic health records and the NHIN cannot function until data standards are adopted and implemented nationwide. Interoperability and data standards are covered in more detail in chapter 4.

Barriers to Health Information Technology (HIT) Adoption Change in workflow. Significant changes in workflow will be required to integrate technology into the inpatient and outpatient setting. As an example, clinicians may be accustomed to ordering lab or x-rays by giving a handwritten request to a nurse who actually places the order. Now they have to learn to use computerized physician order entry (CPOE). As with most new technologies, older users have more difficulty changing their habits, even if it will eventually save time or money. According to Dr Carolyn Clancy, the director of AHRQ: “The main challenges are not technical; it’s more about integrating HIT with workflow, making it work for patients and clinicians who don’t necessarily think like the computer guys do” Privacy. The Health Information Portability and Accountability Act (HIPAA) of 1996 was created initially for the portability, privacy and security of personal health information (PHI) that was largely paper-based. HIPAA regulations were updated in 2009 to better cover the electronic transmission of PHI. This Act has caused healthcare organizations to re-think healthcare information privacy and security. Legal. The Stark and Anti-kickback laws prevent hospital systems from providing or sharing technology such as computers and software with referring physicians.49 Exceptions were made to these laws in 2006, as will be pointed out in other chapters. This is particularly important for hospitals in order to share electronic health records and e-prescribing programs with clinician’s offices.

Behavioral change. Perhaps the most challenging barrier is behavior. In The Prince by Machiavelli, it was stated “there is nothing more difficult to be taken in hand, more perilous to conduct, or more uncertain in its success, than to take the lead in the introduction of a new order of things”. Dr. Frederick Knoll of Stanford University described the five stages of medical technology acceptance: (1) abject horror, (2) swift denunciation, (3) profound skepticism, (4) clinical evaluation, then, finally (5) acceptance as the standard of care. It is unrealistic to expect all medical personnel to embrace technology. In 1962 Everett Rogers wrote Diffusion of Innovations in which he delineated different categories of acceptance of innovation: o the innovators (2.5%) are so motivated they may need to be slowed down o early adopters (13.5%) accept the new change and teach others o early majority adopters (34%) require some motivation and information from others in order to adopt o the late majority (34%) require encouragement to get them to eventually accept the innovation o laggards (16%) require removal of all barriers and often require a direct order 56 It is important to realize, therefore, that at least 50% of medical personnel will be slow to accept any information technology innovations and they will be perceived as dragging their feet or being “Luddites”. With declining reimbursement and emphasis on increased productivity, clinicians have a natural and sometimes healthy dose of skepticism. They dread widespread implementation of anything new unless they feel certain it will make their lives or the lives of their patients better. In this situation, selecting clinical champions and conducting intensive training are critical to implementation

Inadequate workforce. As pointed out by Dr. William Hersh of the Oregon Health and Science University, there is a need for a work force capable of leading implementation of the electronic health record and other technologies.57 The first Work Force for Health Information Transformation Strategy Summit, hosted by the American Medical Informatics Association (AMIA) and the American Health Information Management Association (AHIMA) made several strategic recommendations regarding how to improve the work force.58 The American Medical Informatics Association has been the leader in attempting to increase the workforce of information technology workers with its AMIA 10x10 Program.59 Clearly, with the new influx of federal government support from the stimulus package there is a great need for health informaticians. According to Dr. Detmer, president and chief executive of the American Medical Informatics Association, he estimates that about 70,000 health informaticians will be needed for the expansion of HIT in the United States.60 In addition to skilled informaticians, we will need to educate residents in training and faculty at medical schools, given the rapidly changing nature of HIT. The APA Summit on Medical Student Education Task Force on Informatics and Technology recommended that instead of CME, we need “longitudinal, skills-based tutoring by informaticians”.61 Family Medicine residency programs are generally ahead of other specialty training programs in regards to IT training. They also recommend a longitudinal approach to IT competencies.62

Discussion questions ● Why is information management a central issue in biomedical research and clinical practice? ● What are integrated information management environments, and how might we expect them to affect the practice of medicine, the promotion of health, and biomedical research in coming years? ● What do we mean by the terms medical computer science, medical computing, biomedical informatics, clinical informatics, nursing informatics, bioinformatics, and health informatics? ● Why should health professionals, life scientists, and students of the health professions learn about biomedical informatics concepts and informatics applications? ● How has the development of modern computing technologies and the Internet changed the nature of biomedical computing? ● How is biomedical informatics related to clinical practice, biomedical engineering, molecular biology, decision science, information science, and computer science? ● How does information in clinical medicine and health differ from information in the basic sciences? ● How can changes in computer technology and the way medical care is financed influence the integration of medical computing into clinical practice?