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

2. Medical Informatics l Medical l Information l Science

3. 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

4. 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

5. A Brief History - Past to Future l Ledley and Lusted - Reasoning foundations of medical diagnosis; Science 1959 l El Camino Hospital - 1965 l Help System - 1970 l Financial systems - driven by billing and reporting requirements l Clinical Systems l Information Resources l Expert Systems

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

7. 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

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

9. 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

10. 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

11. 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

12. 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

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

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

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

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

18. Standards l Messaging l Vocabulary l Logic l Databases

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

20. 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!!!!!!!

21. 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

22. ICD9- CM Example 003 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

23. 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

24. 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

25. SNOMED Example D2-50000SECTIONS 2-5-6 DISEASES OF THE LUNG D2-501002-501 NON-INFECTIOUS PNEUMONIAS D2-50100Bronchopneumonia, NOS (T-26000) (M-40000) D2-50100Lobular pneumonia (T-28040) (M-40000) D2-50100Segmental pneumonia (T-280D0) (M-40000) D2-50100Bronchial pneumonia (T-280D0) (M-40000) D2-50104Peribronchial pneumonia (T-26090) (M-40000) D2-50110Hemorrhagic bronchopneumonia (T-26000) (M-40790) D2-50120Terminal bronchopneumonia (T-26000) (M-40000) D2-50130Pleurobronchopneumonia (T-26000) (M-40000) D2-50130Pleuropneumonia (T-26000) (M-40000) D2-50140Pneumonia, NOS (T-28000) (M-40000) D2-50140Pneumonitis, NOS (T-28000) (M-40000) D2-50142Catarrhal pneumonia (T-28000) (M-40000) D2-50150Unresolved pneumonia (T-28000) (M-40000) D2-50152Unresolved lobar pneumonia (T-28770) (M-40000) D2-50160Granulomatous pneumonia, NOS (T-28000) (M-44000) D2-50170Airsacculitis, NOS (T-28850) (M-40000)

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

27. MLM Example maintenance: 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:

28. Standards for Databases l Definitions for Computer-Based Patient Records l Data Model Standards

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

31. 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)

32. 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

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

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