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A Personal History of Medical Informatics

A Personal History of Medical Informatics.

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A Personal History of Medical Informatics

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  1. A Personal History of Medical Informatics W. Ed Hammond. Ph.D., FACMI, FAIMBE, FIMIA, FHL7Director, Duke Center for Health InformaticsDirector, Applied Informatics Research, DHTSAssociate Director, Biomedical Informatics Core, DTMIProfessor, Department of Community and Family MedicineProfessor Emeritus, Department of Biomedical EngineeringAdjunct Professor, Fuqua School of BusinessDuke University Chair Emeritus and Secretary, HL7

  2. e-hammond The Medical Record - TMR • Over 40 different implementations • 14 different medical specialties • support from 1 to 350 providers • maximum of 750,000 patients in one system • operational in 28 different sites

  3. e-hammond Early Years Automated 19 page screening medical history

  4. e-hammond Early Systems • Interactive Neurology Questionnaires • OB Computer-based Patient Record • Automation of manual process • Output duplication of paper system • Data overflow • Replacing required manual task • External to program storage of display and flow control characteristics

  5. e-hammond PDP 12 4Kbytes12 bit word 300K mass storage • Programming Languages • Assembly • -Basic • -GEMISCH

  6. e-hammond Programming Language Assembly Language - Focused set of tools to do specific tasks InputFramesMassagePrintRetrieveStore GEMISCH

  7. e-hammond GEMISCH • Powerful text manipulating functionality • Smart print generating capability • Variable and flexible file types • Programmable display functionality within constraints of character-based terminals • Total control of interface capability

  8. Example of Gemisch coding D %-3 S "[H#,-176,1]" D AN -3 O "$" I AN ,A2X2A D %-2 S "[H#,13,1]" ;BF PAT ADJUSTMENT NODE F AI=1,AN D %-1 S "[H$,-3,AI]" D %-2 S "[B-2=F[N-2]$][N-1]" P "[H,,-1,1,AK][H,,-1,3,AM]" M AL^AK+ACCPTR-1 P "[X$,AL,4,AK]" M AM^((AK=1)-(AK=2))*AM M AO^AO+AM M AB^AB+AM E D %-1 S "[VAO]" D %1 R -1 1 # D %13 R -2 1 # D %-194 S "ZA:[A91][K],12[A93]TMR.DBD" O D =-194 P "[X$,1,1,TMP]" Z TMP D %-1 S "[D2]" D JDATE -1 S SS8 ?1=MDATE,'1=0 M BUFF^-4 P "[X$,5,1,ENCOFF][X$,9,1,SAPOFF][X$,9,3,ASAPOFF]\ [X$,23,1,SAPPTR][X$,37,2,NFILE][X$,37,14,NEFILE]\ [X$,37,15,NSFILE]" P "[S][U11]ENTER CODE FOR WEIGHT => " R (F:-1) D WT -1 M LINE^WT+SAPPTR-1 P "[X$,LINE,14,BMI]" P "[M1,2]ENTER CODE FOR HEIGHT => " R (F:-1) D HT -1 P "[M1,3]CODE FOR BMI IS [VBMI]" M LINE^BMI+SAPPTR-1 D %-300 S "[X$,LINE,5,BMIDO][X$,LINE,8]" ;CAL SET F FILE=1,NFILE D %-193 S "[X$,37,6]:[A91][K],11[A93]TMR.[~FILE,3,0]" L0:NEXTRECORD DONE =-193

  9. e-hammond Continued Development • University Health Services Clinic • Transaction-oriented architecture • Added practice management functionality • Scheduling • Accounting • Family Medical Center • Quickly evolved into different system Four sites - required programming staff of 25 persons

  10. e-hammond Clinical Focus

  11. e-hammond Practice Management

  12. e-hammond The Medical Record • Modular construction - simplifies programming, documentation, evolution and maintenance • Independence of data capture, data storage and data use • Combination of problem-oriented, encounter-oriented and time oriented formats

  13. e-hammond The Medical Record • Multiple input modes • parameter-oriented direct input mode for source data entry • use of paper or dictation to capture physician input for subsequent input by 3rd party • automated input from machine • data message input - MAPS then HL7

  14. e-hammond Renal Direct Entry

  15. e-hammond Renal Encounter Entry Form

  16. e-hammond The Medical Record • Direct coupling of protocols to data entry and data display • Knowledge required for system behavior defined in a dictionary of metadata

  17. e-hammond Quality Assurance Protocol

  18. e-hammond Continued Growth • Cardiology • Clinical database for research purposes • New data types • New displays and presentations • Crude graphics • Cross patient retrievals

  19. e-hammond Cardiology

  20. e-hammond Continued Growth • Inpatient system • New program navigation required • Multiple day encounters • Preorders for tests and treatments • Increase in volume of data • Late charges • Increased importance of time stamp on data • Patient tracking within institution

  21. e-hammond Continued Growth • Surgical Intensive Care Unit • Increased volume • Increased interfaces • Bedside interfaces • Nurse Charting • Additional linkages

  22. Generalizable lessons about clinical systems and databases e-hammond

  23. e-hammond data element definitions vocabulary and external code sets physical resources data capture protocols billing algorithms decision support rules work flow rules information flow linkages report generation drug-drug interactions people and places security Dictionary of Metadata

  24. e-hammond Dictionary, Problems • Code Set (ICD,ICPC,SNOMED,Read,…) • Name • Type • Classification • Category • Linkage to causal diagnosis • Linkage to manifestations

  25. e-hammond Dictionary, Problems • Code Set (ICD,ICPC,SNOMED,Read,…) • Name • Type • Classification • Category • Linkage to causal diagnosis • Linkage to manifestations

  26. e-hammond Dictionary, Problems • Linkage to S&P • Linkage to Related Studies • Linkage to Medications • Linkage to Management Plan • Problem-oriented display specification • Protocol linkage • Parent diagnoses

  27. e-hammond Dictionary, Problems • Coded modifiers • Intervention linkage set • Outcome linkage set • Evaluation Linkage set

  28. e-hammond GEMISCH Record Structure

  29. e-hammond TMR Data StorageTime-oriented data 54!2!5$87023!2@1230|3@1015$87022!1@1015

  30. e-hammond Database structure for studies • Codes in display order • DateTime • Data 10|15|25|21|22|67|32|45|148|53 990600800|9823510156|981501500|971891215 150||155|165 |||20 3|3|3|3

  31. e-hammond Demographics Payors Providers Summary Problems Therapies Studies History and Physical Findings Appointments Encounters Accounting TMR Record Structure

  32. Composite Tests Past Medications Past Medications Past Medications H&P Pages Lab Pages Encounter Pages Narrative Reports Narrative Reports Narrative Reports Accounting Pages Primary TMRPatient Record Demographic Clinical Management Narrative Reports e-hammond

  33. e-hammond TMR Files EventLog DailyRecord TMRPatient Record AuditSummary BackupTotal ProtocolTracking AccessLog

  34. e-hammond Implications for MI • Critical mass of functionality • Visible benefit • Partnership within development teams • Ability to maintain and evolve • Ability to prototype and later incorporate • Ability to accommodate preferences • Open interfaces • Scalability

  35. e-hammond Changing Technology

  36. e-hammond Input/Output Devices

  37. e-hammond Hostile (?) Environments

  38. Technological progress will continue. It merely changes the challenges, but never eliminates them. e-hammond

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