Health Information System

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2. Content. ?????? Health Information Management?????? Health Information Standard?????? Outpatient Information System ?????? Inpatient Information System ?????? Emergency Information System ?????? Laboratory Information System ?????? PACS???? Telemedicine ???? Electronic Health Records ???

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1. 1 Health Information System Feipei Lai National Taiwan University

2. 2 Content ?????? Health Information Management ?????? Health Information Standard ?????? Outpatient Information System ?????? Inpatient Information System ?????? Emergency Information System ?????? Laboratory Information System ?????? PACS ???? Telemedicine ???? Electronic Health Records ?????? Health Information Security

3. 3 Reference 1. Medical Informatics: Computer Applications in Health Care and Biomedicine, By Shortliffe & Perreault, Pub. Springer 2. Essentials of Health Information Management - Principles and Practices: By Green & Bowie, Pub. Thomson 3. Medical Informatics 20/20 – Quality and Electronic Health Records through Collaboration, Open Solutions, and Innovation: By Goldstein, Groen, Ponkshe and Wine, Pub. Jones and Barlett

4. 4 Outline Introduction IHE Vision for Consumer-centric and Information-rich Care EHR Dimensions of the AP Framework Computer Technology and Clinical Work Still Waiting for Godot

5. 5 Medical Informatics Medical information science is the science of using system-analytic tools . . . to develop procedures (algorithms) for management, process control, decision making and scientific analysis of medical knowledge.

6. 6 ????????? ??????? ???????? ???????? ???? ?????? ??

7. 7 ??????? (Medical Information Interoperability) ???????????,???????????,?????????????????? ???? ?????????????,????????????????,?? : HL7, ICD code, LOINC, SNOMED CT????,????????????????????????????????????????????????????????????,???????????????,????????????????,?????????????????? (Lifetime electronic health record data),?????????????,?????????

8. 8 ???? (Clinical Guideline) ????????????????????,?????????????????,?????????????????,??????????????????,?????????????????

9. 9 Microsoft HealthVault Make more informed health decisions for you and your family. Store your health information in one convenient place and share it with others you trust. Explore a growing community of Web sites that can work with your information to help you take charge of your family’s health.

10. 10 Google Health Google Health puts you in charge of your health information. Organize your health information all in one place Gather your medical records from doctors, hospitals, and pharmacies Keep your doctors up-to-date about your health Be more informed about important health issues

11. 11 ???????? ????? ??????????????????,?????????????????????????????,???????????????????????? ?????????? ??????????????????,??????????????????????????,??,???????????????,???????,????????????,???????????: RAMEDIS (Rare Metabolic Diseases Database)?

12. 12 ?????????? ????????????,????????????????,????????????????Protégé,??????????? ????????,????????????????????,??? Pubmed-indexd papers???,??????? (Citation data) ??????? ??? (Semantic web) ??????????????????????????????????????????????

13. 13 ???????? (Healthcare Knowledge Management) ??????????????????? CDSS (Clinical Decision Support System) ?????,?????????????????,????????????????,?Protégé,?????? (open source) ???? ???? (Clinical Guideline) ??????????????????????,??????????????????????????,?? Arden syntax, Asbru, PROforma, GLIF, GELLO, EON, PRODIGY??? ????????????????????? SAGE (Standards-Based Sharable Active Guideline Environment),????????? (Stanford) ?????????????

14. 14 ?????? (Patient Clinical Data) ??????????????????,?????????????,?????????????????? ???????? ??????????????????????,??????????,???????????????????,????????????e-Learning?????????

15. 15 ???? (Data Mining) ??????????????,?????????,????????(Machine Learning) ?????????????????????????? ???????? ???????????????????????,??????????????????????,??:?????????????,???????????????,???????????? ????????????,?????????????????,?????????????????

16. 16 ??????????????????,???????????????,???????????????????,????????????,??????????????? (Order Set) ???????? ???? (Clinical Path) ????????????,????????????,?????????????,???????????????

17. 17 ?????? ????????????????????????????,?????????????????????? ????? (Smart Hospital) ???????? RFID (Radio frequency identification) ??????,?????????????????????????????????,????????????????????????????????

18. 18 ????????????????????????,?????? (e-mail) ????????????????????????????? ????????? ????????????????,?????????????????????????????????,??????????????????????????

19. 19 ????????????????? ????????????? (Web-based application),?????????????????????? ????????,???????????????,??????????????????????????????????,??,????????????????,????????????,???????????????????? ???????????????????????????,????e-Learning??????????????

20. 20 ?? (Grid) ????????????? (Computing power),??????,?????????????????? (Sharable storage)? ?????? ???????????????,???????????????????? ???????? ????????????,??????????????? (Parkinson's disease) ????????????????????????,?????????????????????? ?????????,????????????????,?????,???????????????????????????????,??????????????????????????

21. 21 Grid computing What distinguishes grid computing from typical cluster computing systems is that grids tend to be more loosely coupled, heterogeneous, and geographically dispersed. Also, while a computing grid may be dedicated to a specialized application, it is often constructed with the aid of general purpose grid software libraries and middleware.

22. 22 National Health Information Infrastructure (NHII) Includes not only just technologies but, more importantly, values, practices, relationships, laws, standards, systems, and applications that support all faces of individual health, health care, and public health.

23. 23 NHII Encompasses tools such as clinical practice guidelines, educational resources for the public and health professionals, geographic information systems, health statistics at all levels of government, and many forms of communication among users. http://aspe.hhs.gov/sp/nhii/

24. 24 Integrating the Healthcare Enterprise (IHE) To stimulate integration of healthcare information resources to improve clinical care. IHE develops and publishes detailed frameworks for implementing established data standards to meet specific healthcare needs and supports testing, demonstration and educational activities to promote the deployment of these frameworks by vendors and users. http://www.ihe-europe.org/

25. 25 IHE User Success Story Johannes Gutenberg, University Hospital, Mainz, Germany Implementation of Scheduled Workflow Transactions and Consistent Presentation of Images

26. 26 Summary In a university hospital with 1500 beds, performing 120,000 exams/year (7,000,000 images or 5 TB/year) with a major PACS and more than 30 imaging modalities, different transactions are implemented using IHE conformant standard transactions, including. DICOM Modality Worklist (MWL), Modality Performed Procedure Step (MPPS), Storage commitment, Structured Reporting and DICOM N-services for database updates.

27. 27 Goal To realize interoperability in a multi-vendor PACS environment with different vendors for modalities and workstations.

28. 28 IHE IT Infrastructure Technical Framework Nine IHE IT Infrastructure Integration Profiles are specified as Final Text in the Version 2.0 ITI Technical Framework: Cross-Enterprise Document Sharing (XDS), Patient Identifier Cross-Referencing (PIX), Patient Demographics Query (PDQ), Audit trail and Node Authentication (ATNA), Consistent Time (CT), Enterprise User Authentication (EUA), Retrieve Information for Display (RID), Patient Synchronized Applications (PSA), Personnel White Pages (PWP).

29. 29 Cross-Enterprise Document Sharing A patient record constructed as a collection of clinical documents and organized by a document registry is a key component of an electronic health record (EHR). The goal of this project is to develop a standards-based registry prototype that will allow healthcare professionals to find and access all pertinent documents of clinical information regarding a patient regardless of the healthcare organization that creates and manage the documents.

30. 30 Cross-Enterprise Document Sharing The use of document registries for sharing clinical information intra-organizationally presents unique challenges. Standardized metadata, interfaces and formats are required for interoperability and interchange. The strict adherence to security and privacy policies related to healthcare information must be supported by the technology. Document registries, an emerging technology for indexing documents on a network, provide solutions to many of these challenges.

31. 31 Metadata (Greek meta "after" and Latin data "information") are data that describe other data. Business Intelligence is the process of analyzing large amounts of corporate data, usually stored in large databases such as the Data Warehouse, tracking business performance, detecting patterns and trends, and helping enterprise business users make better decisions. Business Intelligence metadata describes how data is queried, filtered, analyzed, and displayed in Business Intelligence software tools, such as Reporting tools, OLAP tools, Data Mining tools.

32. 32 OnLine Analytical Processing is an approach to quickly providing answers to analytical queries that are multidimensional in nature. for complex queries OLAP cubes can produce an answer in around 0.1% of the time for the same query on OLTP relational data. The single most important mechanism in OLAP which allows it to achieve such performance is the use of aggregations. Aggregations are built from the fact table by changing the granularity on specific dimensions and aggregating up data along these dimensions.

33. 33 Cross-Enterprise Document Sharing NIST/ITL is the primary author of the IHE Profile: Cross-Enterprise Document Sharing. This profile tailors an ebXML registry to the healthcare environment. NIST/ITL has also developed a reference implementation for the XDS profile and web-based test suite, allowing vendors to determine conformance to the XDS profile.

34. 34 Information Technology Laboratory (ITL) National Institute of Standards and Technology (NIST) Technology Administration US Department of Commerce

35. 35 ebXML Electronic Business using eXtensible Markup Language ebXML was started in 1999 as an initiative of OASIS and the United Nations/ECE agency CEFACT. The original project envisioned and delivered five layers of substantive data specification, including XML standards for: Business processes Core data components Collaboration protocol agreements Messaging Registries and repositories

36. 36 OASIS (Organization for the Advancement of Structured Information Standards)

37. 37 Patient Identifier Cross-Referencing (PIX) The PIX profile supports the Cross-referencing of patient identifiers from multiple Patient Identification Domains. These Cross-referenced patient identifiers can then be used by "identity consumer" systems to correlate information about a single patient from sources that "know" the patient by different identifiers. This allows a Clinician to have more complete view of the patient information.

38. 38 Consistent Time (CT) The Consistent Time Integration Profile (CT) provides a means to ensure that the system clocks and time stamps of the many computers in a network are well synchronized. This profile specifies synchronization with a median error less than 1 second. This is sufficient for most purposes.

39. 39 Personnel White Pages (PWP) provides access to basic human workforce user directory information. This information has broad use among many clinical and non-clinical applications across the healthcare enterprise. The information can be used to enhance the clinical workflow (contact information), enhance the user interface (user friendly names and titles), and ensure identity (digital certificates).

40. 40 This Personnel White Pages directory will be related to the User Identity provided by the Enterprise User Authentication (EUA) Integration Profile previously defined by IHE. http://wiki.ihe.net/ This Wiki is for collaborative creation of IHE materials and ongoing activities.

41. 41 Vision for Consumer-centric and Information-rich Care Medical information follows the consumer Information tools guide medical decisions Clinicians have appropriate access to a patient’s complete treatment history, Medical records Medication history Laboratory results Radiographs

42. 42 A medical record, health record, or medical chart is a systematic documentation of a patient's medical history and care. A medication is a licenced drug taken to cure or reduce symptoms of an illness or medical condition.

43. 43 Vision for Consumer-centric and Information-rich Care Clinicians order medications with computerized systems that eliminate handwriting errors And automatically check for doses that are too high or too low, for harmful interaction with other drugs, and for all allergies.

44. 44 Vision for Consumer-centric and Information-rich Care Prescriptions are also checked against the health plan’s formulary, And out-of-pocket costs of the prescribed drug can be compared with alternative treatments Clinicians receive electronic reminders in the form of alerts about treatment procedures and medical guidelines.

45. 45 Strategic Framework Goal 1: Inform Clinical Practice. Centered largely around efforts to bring EHRs directly into clinical practice. Strategy 1. Incentivize EHR adoption Strategy 2. Reduce risk of EHR investment. Strategy 3. Promote EHR diffusion in rural and underserved areas.

46. 46 Strategic Framework Goal 2: Interconnect Clinicians. Strategy 1. Foster regional collaborations. Strategy 2. Develop a national health information network. Mobile authentication Web services architecture Security technologies Strategy 3. Coordinate federal health information systems

47. 47 Strategic Framework Goal 3: Personalize Care. Strategy 1. Encourage use of Personal Health Records. Strategy 2. Enhance informed consumer choice Strategy 3. Promote use of telehealth systems

48. 48 Strategic Framework Goal 4: Improve Population Health. Strategy 1. Unify public health surveillance architectures Strategy 2. Streamline quality and health status monitoring. Strategy 3. Accelerate research and dissemination of evidence.

49. 49 To do list Establishing a Health Information Technology Leadership Panel to evaluate the urgency of investments and recommend immediate actions Private sector certification of health information technology products Funding community health information exchange demonstrations

50. 50 To do list Planning the formation of a private interoperability consortium Requiring standards to facilitate electronic prescribing Commitment to standards

51. 51 Study Data Tabulation Model (SDTM) FDA and NIH, together with the Clinical Data Interchange Standards Consortium (CDISC) have developed a standard for representing observations made in clinical trials. Will facilitate the automation of the largely paper-based clinical research process

52. 52 Cancer Biomedical Informatics Grid (caBIG) National Cancer Institute The informatics infrastructure connects teams of cancer and biomedical researchers to enable them to better develop and share tools and data in an open environment with common standards, creating a network that links individual and national and international institutions.

53. 53 caBIG is contributing standards-based applications from basic science in genomic and proteomics through those supporting clinical research to provide researchers with state-of-the-art tools to accelerate the discovery and development process.

54. 54 Proteomics is the large-scale study of proteins, particularly their structures and functions. This term was coined to make an analogy with genomics, and while it is often viewed as the "next step", proteomics is much more complicated than genomics. Most importantly, while the genome is a rather constant entity, the proteome differs from cell to cell and is constantly changing through its biochemical interactions with the genome and the environment. One organism has radically different protein expression in different parts of its body, in different stages of its life cycle and in different environmental conditions.

55. 55 Metabolomics is the "systematic study of the unique chemical fingerprints that specific cellular processes leave behind" - specifically, the study of their small-molecule metabolite profiles. The metabolome represents the collection of all metabolites in a biological organism, which are the end products of its gene expression. Thus, while mRNA gene expression data and proteomic analyses do not tell the whole story of what might be happening in a cell, metabolic profiling can give an instantaneous snapshot of the physiology of that cell. One of the challenges of systems biology is to integrate proteomic, transcriptomic, and metabolomic information to give a more complete picture of living organisms.

56. 56 Transcriptome ??? is the set of all messenger RNA (mRNA) molecules, or "transcripts", produced in one or a population of cells. The term can be applied to the total set of transcripts in a given organism, or to the specific subset of transcripts present in a particular cell type. Unlike the genome, which is roughly fixed for a given cell line (excluding mutations), the transcriptome can vary with external environmental conditions. Because it includes all mRNA transcripts in the cell, the transcriptome reflects the genes that are being actively expressed at any given time, with the exception of mRNA degradation phenomena such as transcriptional attenuation. The study of transcriptomics examines the expression level of mRNAs in a given cell population, often using high-throughput techniques based on DNA microarray technology.

57. 57 physiome of an individual's or species' physiological state is the description of its functional behavior. The physiome describes the physiological dynamics of the normal intact organism and is built upon information and structure (genome, proteome, and morphome). The term comes from "physio-" (life) and "-ome" (as a whole). In its broadest terms, it should define relationships from genome to organism and from functional behavior to gene regulation. In context of the Physiome Project, it includes integrated models of components of organisms, such as particular organs or cell systems, biochemical, or endocrine systems.

58. 58 The Physiome Project is a worldwide effort to define the physiome through the development of databases and models which will facilitate the understanding of the integrative function of cells, organs, and organisms. The project is focused on compiling and providing a central repository of databases, linking experimental information and computational models from many laboratories into a single, self-consistent framework. This coalescence of research effort will promote comprehensive databases and an integrative, analytical approach to the study of medicine and physiology.

59. 59 Computerized Provider Order Entry (CPOE) A computer application that allows a physician’s order for diagnostic and treatment services to be entered electronically. The computer compares the order against standards for dosing, checks for allergies or interaction with other medications, and warns the physician about potential problems.

60. 60 Electronic Health Record (EHR) A real-time patient health record with access to evidence-based decision support tools that can be used to aid clinicians in decision-making.

61. 61 Health Information Technology (HIT) The application of information processing involving both computer hardware and software that deals with the storage, retrieval, sharing, and use of health care information, data and knowledge for communication and decision making. http://www.hhs.gov/healthit/

62. 62 EHR Capabilities Health information and data Results management Orders management Decision support Electronic communications and connectivity Patient support Administrative process reporting

63. 63 Dimensions of the AP Framework Applications architecture Presentation (UI) Business (program) Data (data structure) Integration level Transport Data process Industry domain specificity

64. 64 Applications architecture Presentation logic Business logic Data logic

65. 65 Presentation logic Provides the ability to manage the interactions between an application system and its various presentation interfaces, including Web browsers, interactive voice recognition, mobile computing devices, fat clients, and dumb terminals.

66. 66 Business logic Implements the business rules that represent the business processes of an application system.

67. 67 Data logic Provides the ability to access and map data into a form that can be processed by business logic.

68. 68 Integration level Transport level Provides the infrastructure and abstraction over the communication protocols needed to move data between similar and dissimilar entities in a transparent manner. (SOAP) Data level Facilitates integration of business applications by addressing the representation data elements in different systems, and associated transformation rules. (XML)

69. 69 Integration level Process level Pertains to the integration of at least two different entities; tasks at this level include orchestrating process interactions based on business rules and events providing process context, and handling process exceptions. (Web services)

70. 70 Industry domain specificity Industry domain independence Standards are generic, providing capabilities across multiple industry domains; examples are HTTP 1.1 and SQL. Industry domain dependence Standards are specific to a particular vertical industry domain; examples are RosettaNet and HL7.

71. 71 RosettaNet (RN) RosettaNet is a non-profit consortium aimed at establishing standard processes for the sharing of business information (B2B). RosettaNet is a consortium of major Computer and Consumer Electronics, Electronic Components, Semiconductor Manufacturing, Telecommunications and Logistics companies working to create and implement industry-wide, open e-business process standards. These standards form a common e-business language, aligning processes between supply chain partners on a global basis.

72. 72 Rodent Phenotyping Measurements of behavioral, physiological and biochemical traits of genetically developed models, for the study of human disease, focusing on the rat as the model animal species. genotype + environment + random-variation ? phenotype

73. 73 Information Content of DNA The double-helix structure of DNA (deoxyribonucleic acid) was discovered in 1954 by James Watson and Francis Crick. A DNA molecule is composed of four different bases, guanine, thymine, cytosine and adenine (G, T, C, and A, respectively) called nucleotide bases. The bases bind in pairs via a hydrogen bond, and the pairs of bases form a long string, shaped in the form of a double helix. The pairs can only appear as guanine opposite cytosine (G-C) or thymine opposite adenine (T-A), as sketched below: T A C C G T A G G T C A . . . | | | | | | | | | | | | | | | A T G G C A T C C A G T . . .

74. 74 DNA The string of base pairs forms a coded message, in which the bases are the characters of the "alphabet.“ If one of the pairs of the string is known, then the other one is also known. This property is used during cell division, when the helices unwind themselves and each half is copied. This copying activity can be considered information transfer, but errors in the code may also occur.

75. 75 DNA If we consider a long string of, say, 100,000 bases, then the first "letter" may be either G, T, C, or A, or one of four possibilities. For all 100,000 characters we then have 4 x 4 x 4 x ... 4 = 4100,000 = 2200,000 possible strings of codes. If the probability of occurrence of all strings of codes is equal, then the probability of finding a specific string is p =  2-200,000. By Shannon's formula, the information content of the code described by this molecule is therefore I = -log2 p = -log2 2-200,000 = 200,000 (bits).

76. 76 DNA A DNA molecule of 100,000 base pairs has a length of approximately 500,000 Å and is 20 Å thick (1 Å = 10-10 m), which is impressive compared to the amount of space required to store a code of 100,000 bits in a computer. A chromosome that contains on the order of 5 x 109 nucleotides, may code for 10 x 109 bits. For the 23 chromosome pairs in the human genome, this would mean on the order of 5 x 1011 bits (equivalent to about 60 gigabytes).

77. 77 Computer Technology and Clinical Work Still Waiting for Godot Health Care - the most complex enterprise in modern society – from an organizational standpoint

78. 78 Still Waiting for Godot Many of the difficulties do not result from bad parts of the systems but are inherent in the perspectives and theories of medical work that are prevalent among health informaticians and those who make decisions on acquisition and implementation.

79. 79 Still Waiting for Godot Rather than framing the problem as “not developing the systems right,” these failures demonstrate “not developing the right systems” due to widespread but misleading theories about both technology and clinical work.

80. 80 Still Waiting for Godot a more useful approach views the clinical workplace as a complex system in which technologies, people, and organizational routines dynamically interact. This view holds the following: (1) Organizations are simultaneously social (e.g., consisting of people, values, norms, culture) and technical (i.e., without tools, equipment, procedures, technology, and facilities, the people could not work and the organization would not exist).

81. 81 Still Waiting for Godot (2) These social and technical elements are deeply interdependent and interrelated—hence, the term sociotechnical systems. Every change in one element affects the other. (3) Accordingly, good design or implementation is not a technical problem but rather one of jointly optimizing the combined sociotechnical system.

82. 82 Henry Ford Health System in Detroit A general physician may be able to order one of thousands of medications One of hundreds of clinical laboratory tests and radiological procedures Along with changing patient condition and co-morbidity, the sequencing and timing of all these events will ultimately determine the relative utility of a selected approach to patient treatment.

83. 83 There are more than 1,000 diseases, each of which, in theory could have a different pathway or guideline.

84. 84 Still Waiting for Godot The play is in two acts. The plot concerns Vladimir (also called Didi) and Estragon (also called Gogo), who arrive at a pre-specified roadside location in order to await the arrival of someone named Godot. Vladimir and Estragon appear to be tramps, as their clothes are ragged and do not fit, while another theory suggests that Vladimir and Estragon could be refugees or soldiers displaced from a conflict, such as World War II, which had recently ended when Beckett wrote the play and which provided him with much inspiration.

85. 85 Still Waiting for Godot Vladimir and Estragon pass the time in conversation, and sometimes in conflict. Estragon complains of his ill-fitting boots, and Vladimir struts about stiff-legged due to a painful bladder condition. Though they make vague allusions to the nature of their circumstances and to their reasons for meeting Godot, the audience never learns who Godot is or why he is important.

86. 86 Still Waiting for Godot They are soon interrupted by the arrival of Pozzo, a cruel but lyrically gifted man who claims to own the land they stand on, and his servant Lucky, whom he appears to control by means of a lengthy rope. Pozzo sits down to feast on chicken, and afterwards throws the bones to the two tramps. He entertains them by directing Lucky to perform a lively dance, and then deliver an ex tempore lecture, loosely based around the theories of the Irish philosopher Bishop Berkeley.

87. 87 Still Waiting for Godot After Pozzo and Lucky depart, a boy arrives with a message supposedly from Godot, which states that Godot will not come today, "but surely to-morrow"[2]. The boy also confesses that Godot beats his brother and that he and his brother sleep in the loft of a barn.

88. 88 Still Waiting for Godot The second act follows a similar pattern to the first, but when Pozzo and Lucky arrive, Pozzo has inexplicably gone blind and Lucky has gone mute. Again the boy arrives in order to announce that Godot will not appear. The much-quoted ending of the play might be said to sum up the stasis of the whole work: Vladimir: Well, shall we go? Estragon: Yes, let's go. They do not move.[3]

89. 89 Delivering Mobile Point of Care with Pervasive Wireless Networks At EL Camino Hospital in California, the number of errors per 1000 patient days dropped from six to four following the implementation of electronic medical records and a WLAN. In the United Kingdom, staff at the George Eliot Hospital admitted to saving up to 4 hours per week after they were given wireless access to hospital and patient information.

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