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 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.

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

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

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

Standards for Logic

HELP Sectors
CARE System Arden Syntax for Medical Logic Modules

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:

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
Clinical Departments Local Area Network Web Browser
Clinical Information System Clinical Data Server Vocabulary Server

Internet

Workstations

Web Server

Additional Information Sources

Resident Signout Editor (RSE)

World Wide Web Demo

Visual Bed Browser JMWs CIS Menu JMWs 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 JMWs 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