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Medical Informatics

Shmuel Rotenstreich

Friedman
Medical Informatics is not about using Microsoft Word to enter patient information Charles Friedman, PhD
University of Pittsburgh at the UW Symposium, Fall 2000

Shortliffe
Medical informatics is the rapidly developing scientific field that deals with resources, devices and formalized methods for optimizing the storage, retrieval and management of biomedical information for problem solving and decision making
Edward Shortliffe, MD, PhD 1995

Computers in Medicine
Information central to biomedical research and clinical practice Type
integrated information-management environments affect on practice of medicine and biomedical

Method
medical computing medical informatics clinical informatics bioinformatics

Value
Value of medical-informatics and informatics applications Computers and the Internet in biomedical computing Relation among
medical informatics clinical practice biomedical engineering molecular biology decision support

Difference
information in clinical medicine and regular information Changes in computer technology and change in medical care and finance Integration of medical computing into clinical practice and regular computing integration

Areas
Medical Decision making Probabilistic medical reasoning Patient care and monitoring systems Computer aided surgery Electronic patient records Clinical decision support Standards in medical informatics Imaging Image management systems Telemedicine

Medical Informatics
Medical Education Patient Data Collection and Recording

Clinical Information Retrieval


Medical Knowledge Retrieval

Medical Decision Making

Medical Informatics is Multidisciplinary


Applies methodologies developed in multiple areas of science to different tasks Often gives rise to new, more general methodologies that enrich these scientific disciplines

Example of Scientific Areas Relevant to Medical Informatics


Medicine/ Biology Mathematics Information Systems Computer Science Statistics Decision Analysis Economics/Health Care Policy Psychology

The Diagnostic-Therapeutic Cycle

Data collection: Data


-History -Physical examinations -Laboratory and other tests

Information

Patient

Decision making

Therapy plan

Planning

Diagnosis/assessment

Levels of Automated Support


(Van Bemmel and Musen, 1997)

Medical Decision-Support Systems


Task:
Diagnosis/interpretation Therapy/management

Scope:
Broad (e.g., Internist-I/QMR: internal medicine Dx; DxPlain; Iliad; EON for guideline-based therapy) Narrow (e.g., a system for diagnosis of acute abdominal pain; MYCIN: infectious diseases Dx; ECG interpretation systems; ONCOCIN: support of application of oncology protocols)

Types of Clinical Decision-Support Systems


Control level:
Human-initiated consultation (e.g., MYCIN, QMR) Data-driven reminder (e.g., MLMs) Closed loop systems (e.g., ICU ventilator control)

Interaction style:
Prescriptive (e.g., ONCOCIN) Critiquing (e.g., VT Attending)

Diagnostic/Prognostic Methods
Flow charts/clinical algorithms Statistical and other supervised and nonsupervised classification methods
Neural networks, ID3, C4.5, CART, clustering

Bayesian/probabilistic classification
Nave Bayes, belief networks, influence diagrams

Rule-based systems (MYCIN) Ad hoc heuristic systems (DxPlain) Cognitive-studies inspired systems (Internist I)

de Dombals System (1972)


Domain: Acute abdominal pain (7 possible diagnoses) Input: Signs and symptoms of patient Output: Probability distribution of diagnoses Method: Nave Bayesian classification Evaluation: an eight-center study involving 250 physicians and 16,737 patients Results:
Diagnostic accuracy rose from 46 to 65% The negative laparotomy rate fell by almost half Perforation rate among patients with appendicitis fell by half Mortality rate fell by 22%

Results using survey data consistently better than the clinicians opinions and even the results using human probability estimates!

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

Case Presentation
Description: 74 female, history of right CVA (cerebrovascular accident*) 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 * Of or relating to the blood vessels that supply the brain

Demo - Part I
Lab Data: ABG and CPK/Isoenzymes Radiology: CXR, VQ, Doppler Cardiology: ECG, Cardiac Cath Medications Alerts Discharge Summary

ABG - Arterial blood gas CPK - blood test CXR Chest X-Ray EKG: Electrocardiogram (ECG) Cardiac Cath - Interventional heart catheterization

Case Summary
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

Demo - Part II
Demographic Information Additional Hospitalizations? More Discharge Summaries? Recent Lab Results

Outpatient Notes

How Did We Do It?

Information Science
Standards Integration

Ambulatory Care
Aka Primary Care, Office Medicine Roles (information specific):
Patient Scheduling, Registration Nursing, Triage Physician Ancillary Services
Radiology

Patient
Able to request an appointment! Check meds! Self reported SF-36 functional Insurance Information!

Clinic Receptionist
Appointment scheduling Check-in Insurance Information Billing Follow-up visit

Nurse
Triage (certain settings) Chief Complaint Brief History Vital signs & Initial Exam Pulse, BP, Respirations, Pulse Oximeter Psychosocial Assessment Discharge Instructions (Pt Education)

Physician
Review Chart Data, Studies Document History and Physical Exam Dx, Tx plan (orders, follow-up) SOAP note
Subjective Objective Assessment Plan

Ancillary Studies: Radiology Tech


Schedule Exam Review Allergies, Pregnancy Review Clinical Indication Enter Exam Data

Conventional data collection for clinical trial


Medical records

Data sheets Clinical trial design Definition of data elements Definition of eligibility Process descriptions Stopping criteria Other details of the trial Computer database Analyses

Results

Role of EMR in supporting clinical trials


Medical records systems

Clinical data repository

Clinical trial design Definition of data elements Definition of eligibility Process descriptions Stopping criteria Other details of the trial

Clinical trial database Analyses Results

Networking the organization


Personnel systems Enterprise network Clinical databases Electronic medical records Pharmacy Billing and financial systems Clinical workstations Library resources Cost accounting Microbiology

Patient workstation

Clerical workstation

Research databeses

Radiology Material management Clinical Data laboratory warehouse Administrative systems (e.g. admissions, discharges and transfers)

Educational programs

Moving beyond the organization


The Internet 3rd party payers Patients Pharmaceuticals regulators Healthy individuals Communicable disease agencies Providers in offices or clinics Information resources (Medline..) Government medical research agencies Vendors of various types (e.g. pharmaceuticals companies Government health insurance programs Other hospitals and physicians

Health Science Schools

Healthcare institutes Needs


Healthcare institutes are seeking Integrated clinical work stations that will assist with clinical matters by: Reporting results of tests Allowing direct entry of orders Facilitating access to transcribed reports Supporting telemedicine applications Supporting decision-support functions

The Heart of the Evolving Clinical Workstation


Electronic Confidential Secure Acceptable to clinicians and patients. Integrated with non-patient-specific information

Bioinformatics vs. Clinical


Bioinformatics - The study of how information is represented and transmitted in biological systems, starting at the molecular level. Clinical informatics deals with the management of information related to the delivery of health care Bioinformatics focuses on the management of information related to the underlying basic biological sciences.

NIH maintains a database and tools of macromolecular 3D structures for visualization and comparative analysis MMDB - Molecular Modeling Database - contains experimentally determined biopolymer structures obtained from the Protein Data Bank

National Library of Medicine Medline

Medical Informatics Standards


Medical Information Bus - IEEE 1073
Standard for connecting up to 255 medical devices Not all devices compatible Decreases errors in data capture

HL-7 Health Level 7


Domain: clinical and administrative data. Mission: "provide standards for the exchange, management and integration of data that support clinical patient care and the management, delivery and evaluation of healthcare services. Specifically, to create flexible, cost effective approaches, standards, guidelines, methodologies, and related services for interoperability between healthcare information systems."

DICOM - Digital Imaging and Communications in Medicine

HL7
A protocol for the exchange of health care information

7 Application 6 Presentation 5 Session 4 Transport 3 Network 2 Data Link 1 Physical

Medical Information Bus IEEE 1073


Standard for medical device communication A family of standards for providing interconnection and interoperability of medical devices and computerized healthcare information systems. Medical devices include a broad range of clinical monitoring, diagnostic, therapeutic equipment Computerized healthcare information systems include broad range of clinical data management systems, patient care systems and hospital information systems

THE DICOM STANDARD


applicable to a networked environment. applicable to an off-line media environment. specifies how devices claiming conformance to the Standard react to commands and data being exchanged. specifies levels of conformance

DICOM Application Domain


LiteBox

Storage, Query/Retrieve, Study Component


Print Management Query/Retrieve Results Management Media Exchange

MAGN ETOM

Query/Retrieve, Patient & Study Management Information Management System

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
Knowledge-Based Vocabularies

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)

Temporal Reasoning and Planning in Medicine


Almost all medical data are time stamped or time oriented (e.g., patient measurements, therapy interventions) It is virtually impossible to plan therapy, apply the therapy plan, monitor its execution, and assess the quality of the application or its results without the concept of time

Time in Natural Language


From Mr. Jones was alive after Dr. Smith operated on him Does it follow that

Dr. Smith operated on Mr. Jones before Mr. Jones was alive?
Is Before the inverse of After?

Understanding a Narrative
List all, find at least one, or prove the impossibility of a legal scenario for the following statements:
John had a headache after the treatment While receiving treatment, John read a paper before the headache, John experienced a visual aura

One legitimate scenario (among many) is:


John read the paper from the very beginning of the treatment until some point before its end; after reading the paper, he experienced a visual aura that started during treatment and ended after it; then he had a headache. Aura Headache Treatment Paper

Monitoring
Determine if an oncology patients record indicates a second episode that has been lasting for more than 3 weeks, of Grade II bone-marrow toxicity (as derived from the results of several different types of blood tests), due to a specific chemotherapy drug.

Planning and Execution


If the patient develops sever anemia for more than 2 weeks, reduce the chemotherapy dose by 25% for the next 3 weeks and in parallel monitor the hemoglobin level every day.

Display and Exploration of Time-Oriented Data

Temporal Abstraction
Many clinical tasks require a great deal of [time-oriented] patient data of multiple types to be measured and captured for interpretation, often using electronic media. This is particularly true in the management of patients with chronic conditions. Diagnostic or therapeutic decisions depend on context sensitive interpretation of these data. Most stored data include a time stamp at which a particular datum is valid. Temporal trends and patterns in clinical data add significant insights to static analysis. Thus it is desirable automatically to create abstractions (short, informative, and context-sensitive interpretations*) of time-oriented clinical data, and to be able to answer queries about these abstractions. The provision of this capability would benefit both a physician and a decision support tool (e.g., for patient management, quality assessment and clinical research). To be of optimum use, a summary should not only use time points such as dates when data were collected; it should also be capable of aggregating significant features over intervals of time.

Temporal Abstraction
Clinical tasks require time-oriented patient data of multiple types to be measured and captured for interpretation.
Particularly true in the management of patients with chronic conditions.

Diagnostic or therapeutic decisions depend on context sensitive interpretation of these data. Most stored data include a time stamp at which a particular datum is valid. Temporal trends and patterns in clinical data add significant insights to static analysis. Desirable automatically create abstractions (short, informative, and context-sensitive interpretations*) of time-oriented clinical data, and to be able to answer queries about these abstractions. The provision of this capability would benefit both a physician and a decision support tool (e.g., for patient management, quality assessment and clinical research). Of optimum use, a summary should not only use time points such as dates when data were collected; it should also be capable of aggregating significant features over intervals of time.

Three Basic Temporal Abstraction A model of three basic temporalabstraction mechanisms:


Point temporal abstraction - a mechanism for abstracting the values of several parameters into a value of another parameter; Temporal inference, a mechanism for inferring sound logical conclusions over a single interval or two meeting intervals; and Temporal interpolation, a mechanism for bridging non-meeting temporal intervals.

A Temporal-Reasoning Task: Temporal Abstraction


Input:

time-stamped clinical data and relevant

events Output: interval-based abstractions Identifies past and present trends and states Supports decisions based on temporal patterns modify therapy if the patient has a second episode of Grade II bone-marrow toxicity lasting more than 3 weeks Focuses on interpretation, rather than on forecasting

Temporal Abstraction: A Bone-Marrow Transplantation Example


BMT

PAZ protocol

Expected CGVHD
M[0] Platelet counts ( )
150K

M[1] M[2] M[3] M[1]

M[0] Granulocyte counts (D)


2000 1000

D D

D D D D

D D

D
D D

D D D

100K 0 50 100 200

400

Time (days)

Uses of Temporal Abstractions In Medical Domains


Planning therapy and monitoring patients over time

Creating high-level summaries of time-oriented patient records


Supporting explanation in medical decision-support systems Representing the intentions of therapy guidelines

Visualization and exploration of time-oriented medical data

Temporal Reasoning Versus Temporal Maintenance Temporal reasoning supports inference tasks involving time-oriented data; often connected with artificial-intelligence methods Temporal data maintenance deals with storage and retrieval of data that has multiple temporal dimensions; often connected with database systems Both require temporal data modeling
DB TM Clinical decision-support application TR

Medical Image Processing


Input: X-Ray, CT-scan, MRI, PET, etc. Tasks:
Correction of multiple artifacts Registration:Superimposition to enhance visualization Segmentation: Decomposition into semantically meaningful regions

Conclusion
Multidisciplinary research, development, and application
inspired by and benefits underlying core scientific/engineering areas

Medical Decision support systems:


Tasks: Diagnosis, therapy Mode: Human initiated, data driven, closed loop Interaction style: Prescriptive, critiquing Multiple diagnostic/therapeutic methodologies

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