Medical Informatics

Medical Informatics Representation and Computation on Medical and Health Care Information

Medical Informatics • Health records in paper • Problems: • High chances of damage of patient records. • Automated processing of records is impossible. • Increased use of electronic media, devices. • Advantages: • Less chances of damage, ease of maintenance. • Data insertion and retrieval is simple. • Easily interoperable. • Migration of healthcare industry to electronic domain.

Targeted at Design and Development of Information System for • Medical Science and Technology • Health Care Services • Business world involving health care

E X T R A N E T S I N T R A N E T S Providers’ Enterprise Systems • ERP • GDSS • DSS • CDSS Suppliers’ Enterprise Systems • Pharmacies • Medical suppliers • Insurance providers P R M Physicians And Specialists Patients Internet Health Care Informatics Src: K.Siau, “Health Care Informatics”, IEEE trans. On Info. Tech. In Biomedicine, 7(1), March, 2003, pp. 1-7

Enterprise Resource Planning • Full integration of an organization's information from pay-roll and human resources to accounting and finance. • Database integration (Information Sharing) • Information logged once and accessed by different modules maintaining the data consistency. • Track inventory, order information and delivery requirements • Determine equipment usage and maintenance schedule

Decision Support System (DSS) • Conventional DSS: financial and scheduling. • Clinical DSS (CDSS): diagnosis, pharmacy, emergency and nursing practices. • CDSS used to send alerts and reminders to patients about preventive care.

Patient Relationship Management (PRM) • Primary focus on determining and meeting patients' needs. • Tracking patients’ information from diet and exercise data to past diagnosis information from family history and allergy information. • Send E-mails satisfying queries, informing newly published health care studies and reminding about preventive measures.

Medical Informatics and Tele-consultation • In early days tele-consultation means • Sending all hardcopies of patient records. • takes significant amount of time. • Send the patient to a remote center. • nearly impossible for emergency patient. • Using medical informatics tele-consultation means • Sending the medical records only. • Most of the time, no need to send the patient. • Online consultation among doctors. • Large scope of knowledge sharing.

Standards HL7:Health Level Seven. It is an international healthcare standard for medical data exchange between computer systems in healthcare. http://www.hl7.org/ LOINC:Logical Observation Identifiers Names and Codes. These identify the test results or clinical observations uniquely. http://www.loinc.org/ ICD-10:International Statistical Classification of Diseases and Related Health Problems. ICD provides codes to classify diseases and a wide variety of signs, symptoms etc. Every health condition can be assigned to a unique category and given a code.http://www.who.int/classifications/icd/en/ ICD-10-PCS:ICD-10 Procedure Coding System. This is a system of medical classification used for procedural codes which is developed as a replacement of ICD-9-CM volume 3 (contains inpatient procedures). DICOM:Digital Imaging and Communications in Medicine. This is a standard for handling, storing, printing, and transmitting information on medical imaging. http://medical.nema.org/

MSH|^~\&|REGAEVN|A05|199901PID|1||191919^NK1|1|MASSIEÊNK1|2|MASSIEÎ…MSH|^~\&|REGAEVN|A05|199901PID|1||191919^NK1|1|MASSIEÊNK1|2|MASSIEÎ… HL7 Standard HL7 Standard HL7 Message Parsing Sender Receiver HL7 Message Creation HL7 Message Data Data HL7-enabled system Hospital A HL7-enabled system Hospital B Message Transmission

HL7 Message Structure Event MessageN Message1 SegN Terminated by <CR> Seg1 Separated by '|' Field1 Field1 CompN Comp1 Separated by '^'

Message Encoding • Sequence of segments separated by '|' • Compulsory and optional segments • Segments as sequence of fields separated by '^' • Compulsory and optional fields • A field is described by a data type (e.g. AD data-type denoting an Address)

An example of HL7 message for patient admission MSH | ^~ \ & | Clinic || Central|Reg ||| ADT^A01 |MSG00005 | P | 2.3 EVN | A01 | 199601051530 PID ||| 2-687005 || Evans^Carolyn || 19620324 | F ||| 903 Diane Circle^^Phoenixville^PA^19460 || (610) 555 – 1212 | (610) 555 – 1212 || S | C ||156 – 96 – 2542 PV1|| E | Emergency |||| 0148^Addison^James ||| SUR

Admit/Visit Notification 1. Message Header (i) From: Clinic (ii) To : Central 2. Event (i) Date: 1996-01-05 (ii) Time: 15:30 3. Patient Identification (i) Internal Patient ID Number: 2-687005 (ii) Family Name: Evans (iii) Given Name: Carolyn (iv) Birth Date: 1962-03-24 (v) Sex: F

Admit/Visit Notification (Contd.) 3. Patient Identification (contd.) (vi) Street Address: 903 Diane Circle (vii) City: Phoenixville (viii) State of Province: PA (ix) Zip or Postal Code: 19460 (x) Phone (Home): (610) 555 – 1212 (xi) Phone (Office): (610) 555-1212 (xii) Marital Status: S (xiii) Religion: C (xiv) Social Security Number: 156-96-2542 4. Patient Visit (i) Patient Class: E (ii) Point of Care: Emergency (iii) Attending Doctor's ID: 0148 (iv) Family Name: Addison (v) Given Name: James (vi) Hospital Service: SUR

File as Reference Pointer (RP) of OBX MSH|^~\&|TELEMEDICINE||TELEMEDICINE||200808141246||ORU^R01|SUR|P|2.4| EVN|R01|200808141246| PID|||SUR05032008000||Mandal^Pulin^Bihari||198003050000|M|||Block - D^VSRC, IIT Kharagpur^Kharagpur^West Bengal^721302Îndia|91|754123||||Hindu| NK1|1|Sumita Mandal|Mother|Parikpur, Hansda West Midnapore| OBR|4|||ZIITKGP9903^Patient Images^HL7IITKGP|||200808141246| OBX||RP|ZIITKGP9903-1^Sample blood slide^HL7IITKGP||SUR0503200800005032008BLD00.JPG^TELEMEDIK 2005ÎM||||||X|||20080209||||||20080305| OBX||RP|ZIITKGP9903-2^Routine Blood tests and Grouping {Blood R/E}^HL7IITKGP||SUR0503200800005032008i0000.JPG^TELEMEDIK 2005ÎM||||||X|||20080305||||||20080305| • Multimedia file is not contained within HL7 message. • Reference path to the file is kept in the message. • Multimedia file has to be sent with HL7 message.

File as Encoded Data (ED) of OBX MSH|^~\&|TELEMEDICINE||TELEMEDICINE||200705091251||ORU^R01|SUR|P|2.4| EVN|R01|200705091251| PID|||SUR17012007000||Kijhari^Punam^||196801170000|F|||aaaa^bbbbêeee^West Bengal^897454Îndia|91|7855596||||Hindu| NK1|1|kkkk|hhhh|gdagsv fg jfsgfgjadsg gdsa g fagsg| OBR|6|||ZIITKGP9903^Patient Images^HL7IITKGP|||200705091251| TXA|1|IM|multipart|200705091251||20040404||||||ZIITKGP9903-1|ZIITKGP9903||||AU| OBX||ED|ZIITKGP9903-1^blood slide^HL7IITKGP||^multipart^relatedÂ^MIME-Version: 1.0 Content-Type: multipart/related; boundary="HL7-CDA-border-CDA-HL7" EXT:=JPG TYPE:=BLD ENTRYDATE:=20070117 SIZE:=16601 --HL7-CDA-border-CDA-HL7 Content-Location:SUR1701200700017012007BLD00.JPG Content-Transfer-Encoding:BASE64 Content-Type:image/pjpeg /9j/4AAQSkZJRgABAgEASABIAAD/7RBKUGhvdG9zaG9wIDMuMAA4QklNA+0AAAAAABAASAAAAAEA DAwRDAwMDAwMDAwMDAwMDAwMDAwMDAwMDAwMDAwMDAENCwsNDg0QDg4QFA4ODhQUDg4ODhQRDAwM CgAyADAAMAAgADMANgAzAAoA --HL7-CDA-border-CDA-HL7--||||||X|||200705091251|

Reference Information Model (RIM) • Root of all information models. • Provides a static view of the information. • A HL7-wide common reference model that integrates all Technical Committees’ domain views. • Committees and SIGs generally work with a small subset of the RIM - called Domain Information Model or DIM.

Reference Information Model (RIM) contd.. • Foundation Classes • Acts  an intentional action in the business domain of HL7. Ex: patient observation • Participations  exists only in the scope of one act. Ex: surgeon • Roles  a socially expected behavior pattern usually determined by an individual's status in a particular society. Ex: doctor • Entities  physical thing or organization and grouping of physical things. Ex: a person • Act Relationship  To relate 2 acts. • Role Link  To relate 2 entity roles.

LOINC • Logical Observation Identifiers Names and Codes. • Names & codes uniquely identify observations. • Laboratory Observations • Clinical Observations • Administrative Observations • Compatible with HL7 and SNOMED • Represent observation in HL7 message.

LOINC • The fully specified name of a test result or clinical observation has five or six main parts • <Analyte / component>: • <kind of property of observation or measurement>: • <time aspect>: • <system (sample)>: • <scale>: • <method> QRS AXIS representation in LOINC: QRS AXIS : ANGLE : PT : HEART : QN : EKG  2951-2

LOINC in HL7 • Message generator generates a message with observation results using LOINC. • System supports LOINC, parse HL7 message, retrieve observation result. OBX-3: Observation Identifier OBX||TX|2093-3^Total cholesterol^LN|0|78|^mg/dl|||||F|||20050223| Text Coding System Code

DICOM • Digital Imaging and Communications in Medicine • Standard for handling, storing, printing, and transmitting information on medical imaging. • Specifies the following- • protocols for devices claiming conformance to DICOM • syntax and semantics of data to be exchanged. • format for storing media in DICOM compatible devices etc.

DICOM Composite Image IOD Information Model Patient 1 is subject of 1,n Study 1 Frame of Reference contains Equipment 1 1 1,n Spatiallyor Temporally defines 1,n 0,n series creates 1 contains 0,n 0,n 0,n 0,n 0,1 0,n Curve Overlay Image (Pixels) VOILUT Modality LUT Waveform

Patient 1 is subject of 1,n Study 1 Frame of Reference contains Equipment 1 1 1,n 1,n 0,n temporally defines series creates 1 contains 1,n Waveform DICOM Waveform IOD Information Model

DICOM Waveform Information Model Patient Waveform Attribute 1 Waveform is subjec of Time of Acquisition Acquisition Context Annotation 1 1,n contains Study 1,n Multiplex Group Attributes 1 Multiplex Group contains Number of Channels Sampling Frequency Timing 1 1,n Series contains 1 Channel Definition Attributes 1,n Channel Contains Channel Source Metric Anatomic Location(s) Function Technique Channel Sensitivity Baseline Skew Filter Characteristics 1 1,n Waveform contains 1,n Sample

DICOM File Structure Preamble (128 bytes) DICM (4 bytes) DE1 DEn

Data Element Data Element D E …………… Data Element Tag VR VL VF Tag VL VF Dicom Information Structure DICOM Data format Explicit VR < 4 bytes > < 2 bytes > < 2 bytes > Implicit VR < 4 bytes >

Patient Information Patient Name VL VF VR 0010 0010 PN 000C Sridhar Raja 0010 0010 0000 000C Sridhar Raja An Example of Data Element Explicit VR Implicit VR

Tag Description Hex Encoding (Group, Element) (0x0002, 0x0010) (0x0028, 0x0002) (0x0028, 0x0008) (0x0028, 0x0010) (0x0028, 0x0011) (0x0028, 0x0100) (0x0028, 0x0101) (0x7FE0, 0x0010) Transfer Syntax Tag Samples per pixel Numbers of Frames Number of Rows Number of Columns Number of Bits Allocated Number of Bits Stored Pixel Data Some vital tags for rendering images in DICOM Standard

PACS • Picture Archiving and Communication Systems. • Goals of PACS are to improve operational efficiency while maintaining or improving diagnostic ability • Computers or networks dedicated to the storage, retrieval, distribution and presentation of images. • PACS network consists of a central server that stores a database containing the images. Web based PACS system is becoming more and more common. • Based on DICOM standard, also accepts other media formats.

PACS(Ref: http://www.advantech.com.cn/)

ICD-10 • International Statistical Classification of Diseases and Related Health Problems. • Provides codes to classify • Diseases • Signs, symptoms • Abnormal finding • Complaints • External cause for injury and disease etc.

ICD-10 • Every health condition can be assigned to a unique category and a given code. • Can be used for • Morbidity, mortality statistics • Clinical decision support system. • The limitations of ICD-9-CM • Lack of specificity and details. • Can’t support transition of IHDE etc.

ICD-10 in HL7 • Segment for diagnosis: DG1 • 2nd field of DG1: diagnosis coding method (deprecated). • 4th field of DG1: diagnosis description (deprecated). • 3rd field of DG1: diagnosis code • ICD-10 is used to construct 3rd field Identifier Code DG1-3: Diagnosis Code DG1|||H11.2^Conjunctival scars^ICD10|||F|||||||||||||20050223| Diagnosis description. Coding System

ICD-10-PCS (ICD-10 Procedure Coding System.) • Medical classification used for procedural codes. • Codes are comprised of seven components. Each component is called a “character”. • All codes are seven characters long • Individual units for each character are represented by a letter or number. • Each unit is called a “value” • 34 possible values for each character • Digits 0- 9 • Letters A-H, J-N, P-Z

SNOMED • Systematized Nomenclature of Medicine. • Collection of medical terminology covering most areas of clinical information. • Diseases • Findings • Procedures • Microorganisms • Pharmaceuticals etc.

Standardization: Complexity in Medical World • Vast and dynamic knowledgebase. • Close interaction of different complex systems. Patient Management, Diagnosis and Investigations, Treatment and Procedures, Drug and pharmacology, Disease classification etc. • Process Standardization. • Regional and demographic variations. • Adjustment with real-life constraints. Infrastructure, Human resource, Material resource.

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Medical Informatics