INFO-I530 (Foundation to Health Informatics)

INFO-I530 (Foundation to Health Informatics) The Evolution of Health Information Systems Lecture #15

Lecture in a Nutshell • Technology’s Promise • Electronic Health Records (EHR) • Inadequacy of the Traditional Paper Record • The Medical Record and Clinical Trials • Major Recurring Issues • Integration with other Resources • A Model of Integrated Disease Surveillance • The Cycle of Information Flow in Clinical Care • Terminology • Relationship to Biomedical Science • Relationship to Computer Science • Relationship to Biomedical Engineering • Functional Perspective • Hospital Information Systems • Community Health Information Systems • Clinical Information Systems • Technology Perspective • Object-Oriented and Component-Based Computing • Middleware • Mobile Communications • Architectural Perspective • Mainframe Architectures • Departmental Systems (Federated Architecture) • Distributed Systems (Client/Server era) • Network-Centric Architectures and Web Services • Component-Based Clinical Information Systems

Technology’s Promise • First digital computers in the 1940s • First personal computers late 1970s • World Wide Web dates to the early 1990s • This dizzying rate of change, combined with equally pervasive and revolutionary changes in almost all international health care systems during the past decade, makes it difficult for health care planners and institutional managers to try to deal with both issues at once. • No clinical computing topic is gaining more attention currently than is the issue of electronic health records (EHRs).

Electronic Health Records (EHR) • Need for a single-entry points which assist in: • Clinical matters • reporting results of tests, allowing direct entry of orders by clinicians, facilitating access to transcribed reports and … • Financial topics • tracking of patients within the hospital, managing materials and inventory, supporting personnel functions and … • Research • analyzing the outcomes associated with treatments and procedures, performing quality assurance, supporting clinical trials, and implementing various treatment protocols and … • Scholarly information • accessing digital libraries, bibliographic search and … • Office automation • providing access to spreadsheets, word processors and …

Electronic Health Records (EHR) cont. • Inadequacy of the Traditional Paper Record • Difficulty in obtaining information, either about a specific patient or about a general issue related to patient management, is a frustrating but common occurrence for practitioners. • The traditional paper medical record is created by a variety of organizational processes that capture varying types of information. • The record thus becomes a merged collection of such data, generally organized in chronological order. • Implementing electronic records is a systems-integration task; it is not possible to buy a medical record system for a complex organization as an off-the-shelf product.

Electronic Health Records (EHR) cont. Inputs to the medical record.

Electronic Health Records (EHR) cont. Outputs from the medical record. Secondary users

Electronic Health Records (EHR) cont. Complex processes demanded of the record

Electronic Health Records (EHR) cont. • The Medical Record and Clinical Trials • One argument that warrants emphasis is the importance of the electronic record in supporting clinical trials — experiments in which data from specific patient interactions are pooled and analyzed in order to learn about the safety and efficacy of new treatments. • Current methods (manual) are labor-intensive, fraught with opportunities for error, and adds to the high costs associated with randomized prospective research protocols. • EHR helps to eliminate the manual task of extracting data from charts or filling out specialized datasheets and …

Electronic Health Records (EHR) cont. Conventional data collection for clinical trials

Electronic Health Records (EHR) cont. Role of electronic health records (EHRs) in supporting clinical trials.

Electronic Health Records (EHR) cont. • Major Recurring Issues • the need for standards in the area of clinical terminology • concerns regarding data privacy, confidentiality, and security • challenges of data entry by physicians • difficulties associated with the integration of record systems with other information resources in the health care setting.

Electronic Health Records (EHR) cont. • Integration with other Resources • Diverse clinical, financial, and administrative databases all need to be accessed and integrated, typically by using networks to tie them together and a variety of standards for sharing data among them. • The enterprise intranet is a locally controlled network that extends throughout a health care system. Such systems are often called clinical data repositories. An electronic health record (EHR) emerges from such an architecture. • The creation of clinical (evidence based) guidelines and pathways: an effort to reduce practice variability and to develop consensus approaches to recurring management problems. Integrating Decision Support Systems in EHR is intended to provide clinical guidelines at the point of care.

Electronic Health Records (EHR) cont. Networking the organization.

Electronic Health Records (EHR) cont. Health Information Infrastructure

Electronic Health Records (EHR) cont. National Health Information Infrastructure (NHII)

A Model of Integrated Disease Surveillance A future vision of surveillance databases

A Model of Integrated Disease Surveillance cont. • Practical issues that must be addressed: • Encryption of data • Health Insurance Portability and Accountability Act: HIPAA -compliant policies • Standards for data transmission and sharing: HL7 • Standards for data definitions: Terminologies • Quality control and error checking • Regional and national surveillance databases

The Cycle of Information Flow in Clinical Care Flow of Information

The Cycle of Information Flow in Clinical Care cont. • The ultimate goal is to create a cycle of information flow, whereby data from distributed electronic health records (EHRs) are automatically submitted to registries and research databases. • The resulting new knowledge then can feed back to practitioners at the point of care, using a variety of computer-supported decision support delivery mechanisms. • Requirements for this vision are: • Large-Scale Networking • Education and Training • Organizational and Management Change

Terminology • The terms biomedical computing or biocomputation have been used for a number of years. They are nondescriptive and neutral, implying only that computers are employed in biology or medicine. • A term originally introduced in Europe is medical informatics, which is broader than medical computing (it includes such topics as medical statistics, record keeping, and the study of the nature of medical information itself) and deemphasizes the computer. • Since the rise of bioinformatics, many observers have expressed concern that the adjective “medical” is too focused on physicians. Thus, the term health informatics, or health care informatics, has gained some popularity • Biomedical informatics has other component sciences in addition to computer science such as decision sciences, statistics, cognitive science, information science, and even management sciences

Terminology cont. • Definition: In summary, biomedical informatics is the scientific field that deals with biomedical information, data, and knowledge—their storage, retrieval, and optimal use for problem solving and decision making. • The federal government has played a key role in funding the work of the last four decades, mainly through the NIH and the Agency for Health Care Research and Quality (AHRQ). The National Library of Medicine (NLM) has assumed a primary role for biomedical informatics, especially with support for basic research in the field.

Relationship to Biomedical Science • Biomedical informatics is intrinsically entwined with the substance of biomedical science. It determines and analyzes the structure of biomedical information and knowledge, whereas biomedical science is constrained by that structure. • Biomedical informatics is perhaps best viewed as a basic biomedical science, with a wide variety of potential areas of application. • The term biomedical informatics refers to the basic science discipline in which the development and evaluation of new methods and theories are a primary focus of activity. • Work in biomedical informatics is motivated totally by the application domains that the field is intended to serve such as: Bioinformatics, Imaging informatics, Clinical informatics and Public Health informatics.

Relationship to Biomedical Science cont. Biomedical informatics as basic science and its application domains

Relationship to Biomedical Science cont. Phases in the transfer of research into clinical practice.

Relationship to Biomedical Science cont. Breadth of the biomedical informatics field

Relationship to Computer Science • Computers have not been developed specifically for biomedical applications. • MGH Utility Multi-Programming System, known as the MUMPS language (M language) was specially developed for use in medical applications. • Successful biomedical informatics research will often draw on, and contribute to, computer science, but it may also be closely related to: • the decision sciences (probability theory, decision analysis, or the psychology of human problem solving), • cognitive science, • information sciences, • or the management sciences

Relationship to Computer Science cont. Component sciences in biomedical informatics

Relationship to Biomedical Engineering • Biomedical engineering departments emerged 35 to 45 years ago, when technology began to play an increasingly prominent role in medical practice. • In recent years, computing techniques have been used both in the design and building of medical devices and in the medical devices themselves. • In biomedical engineering, the emphasis is on medical devices; in biomedical informatics, the emphasis is on biomedical information and knowledge and on their management with the use of computers. • In both fields, the computer is secondary, although both use computing technology.

Functional Perspective • Hospital Information Systems • Since their early beginning in the 1960s. hospital information systems (HISs) have been developed to cover both administrative and medical functions. • In 1980s on one hand reimbursement systems gradually evolved from fee-for-service basis to a fixed budget system where figures on resource consumption played a central role. On the other hand. medical systems initially developed to simply automate existing processes became systems supporting physicians and other healthcare providers.

Functional Perspective cont. Changing destiny of information technology in the health sector.

Functional Perspective cont. • Community Health Information Systems • A CHIS (or CHIN) provides comprehensive and integrated sets of health care and information services between primary and secondary care institutions, social and administrative institutions. and it offers on-line information resources for education and training. • CHISs may have a tremendous impact on health care, provide a more detailed picture of patient health. and enhance the analysis of the health of the communities served by these systems.

Functional Perspective cont. • Evolution of hospital information systems.

Functional Perspective cont. • Clinical Information Systems • The development of clinical information systems (CISs) was a natural evolution within the HIS and CHIS frameworks in order to expand their functions to include better management of patient care. • CISs arc driven by an economic and medical motivation to achieve quality of care combined with an increased level of control.

Technology Perspective • Object-Oriented and Component-Based Computing • Component-based technologies foster the evolution from a data-driven to a knowledge-driven architecture. They allow embedding the organization' s knowledge practices and policies into business rules located in the component layer. • Componentry: The intersection of two dynamic forces

Technology Perspective cont. • Middleware • In a world of component-based applications. middleware will take an important place • First-generation elementary middleware originated in the mid-1980s. It enhances the portability of applications over different platforms. It refers to remote procedure calls (RPC) and enables applications to call other systems. • Second-generation middleware is characterized by an increased availability of other services. Examples arc CORBA (Common Object Request Broker) and Microsoft COM/DCOM. • Third-generation middleware provides generic services to applications tailored within a specific application domain. Example s arc CORBAmed and the CEN TC251 HISA. • Mobile Communications • Personal digital assistants and wireless technologies bring computing to disconnected workers , a group that seldom has the inclination to type or the ability to lug around unwieldy devices

Architectural Perspective • Mainframe Architectures • Computer company developed its own chips, own computers, own/proprietary OS as and very often proprietary application software. • They were difficult to use and expensive to modify and maintain. • Vertically oriented computer industry in the 1980s

Architectural Perspective cont. • Departmental Systems (Federated Architecture) • By the birth of the minicomputer and personal computers in 1980s, computer industry gradually shifted away from vertical alignment and horizontal computer industry emerged. Information was frequently distributed by application domains. • Disadvantage: dealing with various vendors and various products (components) that require seamless interworking. • Horizontally oriented computer industry in the 1990s.

Architectural Perspective cont. • Distributed Systems (Client/Server era) • Applications are basically composed of interoperable components such as data objects, application objects and … • Disadvantage: increase network traffic • Three places business logic can reside.

Architectural Perspective cont. • Network-Centric Architectures and Web Services • Web service is a network-accessible piece of business logic located somewhere on the Internet and accessible through standard based Internet technologies (HTTP, XML, SOAP) • Disadvantage: increase network traffic • SOAP: Simple Object Access Protocol • UDDI: Universal Description Discovery and Integration initiative • WSDL: Web Service Description Language • Anatomy of a web service.

Component-Based Clinical Information Systems • A component-based approach enables scalable, cost-effective three- or N-tier hardware deployment. Scaling can occur in either the middle layer or the data layer in a much less expensive manner. • Advantages: • enhanced load balancing, flexibility of application partitioning, enabled embedment of decision support for business logic, complete upgrade, changes are isolated to fewer tiers, easier integration of heterogeneous resources, easier reuse of components as well as code. • Disadvantages: • complex design and development phase, there are too many choices, tool insertion is associated with increasing costs, incompatibilities between diverse software and hardware components originating from multiple vendors.

Summary • Technology’s Promise • Electronic Health Records (EHR) • Inadequacy of the Traditional Paper Record • The Medical Record and Clinical Trials • Major Recurring Issues • Integration with other Resources • A Model of Integrated Disease Surveillance • The Cycle of Information Flow in Clinical Care • Terminology • Relationship to Biomedical Science • Relationship to Computer Science • Relationship to Biomedical Engineering • Functional Perspective • Hospital Information Systems • Community Health Information Systems • Clinical Information Systems • Technology Perspective • Object-Oriented and Component-Based Computing • Middleware • Mobile Communications • Architectural Perspective • Mainframe Architectures • Departmental Systems (Federated Architecture) • Distributed Systems (Client/Server era) • Network-Centric Architectures and Web Services • Component-Based Clinical Information Systems

INFO-I530 (Foundation to Health Informatics)