Medical Informatics

1
Medical Informatics

• Representation and Computation on Medical and
  Health Care Information

2
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.

3
Targeted at Design and Development of Information
System for

• Medical Science and Technology
• Health Care Services
• Business world involving health care

4
Health Care Informatics
Src K.Siau, Health Care Informatics, IEEE
trans. On Info. Tech. In Biomedicine, 7(1),
March, 2003, pp. 1-7
5
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

6
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.

7
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.

8
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.

9
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/
10
Message Transmission
11
HL7 Message Structure
Event
MessageN
Message1
SegN
Terminated by ltCRgt
Seg1
Separated by ''
Field1
Field1
CompN
Comp1
Separated by ''
12
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)

13
An example of HL7 message for patient admission
MSH \ Clinic CentralReg
ADTA01 MSG00005 P 2.3 EVN A01
199601051530 PID 2-687005 EvansCarolyn
19620324 F 903 Diane CirclePhoenixville
PA19460 (610) 555 1212 (610) 555 1212
S C 156 96 2542 PV1 E
Emergency 0148AddisonJames
SUR
14
Admit/Visit Notification
1. Message Header (i) From Clinic (ii)
To Central 2. Event (i) Date
1996-01-05 (ii) Time 1530 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
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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) [phone] (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
16
File as Reference Pointer (RP) of OBX
MSH\TELEMEDICINETELEMEDICINE200808141246
ORUR01SURP2.4 EVNR01200808141246 PIDSU
R05032008000MandalPulinBihari198003050000M
Block - DVSRC, IIT KharagpurKharagpurWest
Bengal721302India91754123Hindu NK11Sumi
ta MandalMotherParikpur, Hansda West
Midnapore OBR4ZIITKGP9903Patient
ImagesHL7IITKGP200808141246 OBXRPZIITKGP99
03-1Sample blood slideHL7IITKGPSUR050320080000
5032008BLD00.JPGTELEMEDIK 2005IMX200802
0920080305 OBXRPZIITKGP9903-2Routine
Blood tests and Grouping Blood
R/EHL7IITKGPSUR0503200800005032008i0000.JPGTE
LEMEDIK 2005IMX2008030520080305

• 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.

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File as Encoded Data (ED) of OBX
MSH\TELEMEDICINETELEMEDICINE200705091251
ORUR01SURP2.4 EVNR01200705091251 PIDSU
R17012007000KijhariPunam196801170000Faaa
abbbbeeeeWest Bengal897454India917855596
Hindu NK11kkkkhhhhgdagsv fg jfsgfgjadsg
gdsa g fagsg OBR6ZIITKGP9903Patient
ImagesHL7IITKGP200705091251 TXA1IMmultipar
t20070509125120040404ZIITKGP9903-1ZIITKG
P9903AU OBXEDZIITKGP9903-1blood
slideHL7IITKGPmultipartrelatedAMIME-Version
1.0 Content-Type multipart/related
boundary"HL7-CDA-border-CDA-HL7" EXTJPG TYPE
BLD ENTRYDATE20070117 SIZE16601 --HL7-CDA-bord
er-CDA-HL7 Content-LocationSUR1701200700017012007
BLD00.JPG Content-Transfer-EncodingBASE64 Content
-Typeimage/pjpeg /9j/4AAQSkZJRgABAgEASABIAAD/7RB
KUGhvdG9zaG9wIDMuMAA4QklNA0AAAAAABAASAAAAAEA DAwR
DAwMDAwMDAwMDAwMDAwMDAwMDAwMDAwMDAwMDAENCwsNDg0QDg
4QFA4ODhQUDg4ODhQRDAwM CgAyADAAMAAgADMANgAzAAoA --
HL7-CDA-border-CDA-HL7--X200705091251
18
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.
• 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.

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HL7 v3 Message Construction
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HL7 v3 Message (Partial)

• lt?xml version"1.0" ?gt
• lt!DOCTYPE Pt SYSTEM "admitexamp1.dtd" gt
• ltPtgt
• ltid V"12345" AA"100.12.92.81.5.7" APN"MRN"
  /gt
• ltstatus V"L" S"HL7003" R"3.0" /gt
• ltisAroleOfPersnAsPtgt
• ltadminvGendr V"M" S"HL7001" R"3.0" PN"Male"
  /gt
• ltbrthDttm V"19790924162403-0800" /gt
• ltphongt
• lt_TEL ADR"tel[phone]" USE"PRN EMR" /gt
• lt/phongt
• lthasSetPrsnNameForPtgt
• lt_PrsnNameForPtgt
• ltnmgt
• ltG V"Irma" CLAS"R" /gt
• ltG V"Corine" CLAS"R" /gt
• ltF V"Jongeneel" CLAS"R M" /gt
• ltD V"-" /gt
• ltF V"de Haas" CLAS"R B" /gt

21
HL7 in TelemediK

• Developed under HL7 v2.4 specification.
• Uses FTP for HL7 message transmission.
• Migrating to HL7 v3.0 in coming days.

22
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.

23
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.

24
HL7 v3 Message An example

• lt?xml version"1.0" ?gt
• lt!DOCTYPE Pt SYSTEM "admitexamp1.dtd" gt
• ltPtgt
• ltid V"12345" AA"100.12.92.81.5.7" APN"MRN"
  /gt
• ltstatus V"L" S"HL7003" R"3.0" /gt
• ltisAroleOfPersnAsPtgt
• ltadminvGendr V"M" S"HL7001" R"3.0" PN"Male"
  /gt
• ltbrthDttm V"19790924162403-0800" /gt
• ltphongt
• lt_TEL ADR"tel[phone]" USE"PRN EMR" /gt
• lt/phongt
• lthasSetPrsnNameForPtgt
• lt_PrsnNameForPtgt
• ltnmgt
• ltG V"Irma" CLAS"R" /gt
• ltG V"Corine" CLAS"R" /gt
• ltF V"Jongeneel" CLAS"R M" /gt
• lt/nmgt
• ltpurpse V"L" S"HL7005" R"3.0" /gt

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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.

26
LOINC

• The fully specified name of a test result or
  clinical observation has five or six main parts
• ltAnalyte / componentgt
• ltkind of property of observation or measurementgt
• lttime aspectgt
• ltsystem (sample)gt
• ltscalegt
• ltmethodgt
• QRS AXIS representation in LOINC
• QRS AXIS ANGLE PT HEART QN EKG ? 2951-2

27
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
OBXTX2093-3Total cholesterolLN078mg/dl
F20050223
Code
Text
Coding System
28
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.

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DICOM Composite Image IOD Information Model
30
DICOM Waveform IOD Information Model
31
DICOM Waveform Information Model
32
DICOM File Structure
Preamble (128 bytes)
DICM (4 bytes)
DE1
DEn
33
Dicom Information Structure
DICOM Data format
Explicit VR
lt 4 bytes gt
lt 2 bytes gt
lt 2 bytes gt
Implicit VR
lt 4 bytes gt
34
An Example of Data Element
Explicit VR
Implicit VR
35
Some vital tags for rendering images in DICOM
Standard
36
DICOM in TelemediK

• Embedded DICOM Viewer module.

37
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.

38
PACS (Ref http//www.advantech.com.cn/)
39
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.
• 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.

40
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.

41
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.
• Cant support transition of IHDE etc.

42
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
DG1H11.2Conjunctival scarsICD10F
20050223
Diagnosis description.
Coding System
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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

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SNOMED

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

45
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.

46
Indian Healthcare Scenario

• Presence of disparate healthcare delivery
  mechanism.
• Paper based transaction across the healthcare
  spectrum.
• Sheer variety of administrative systems makes
  the process inefficient and cumbersome.
• Lack of industry standards lead to further
  confusion and increases the gap.

• Consequences
• Unable to achieve the benefits of automation of
  work.
• Several health centers but no interconnection.

47
Interoperability Two ways

• Compatible Systems
• Communicating system should be compatible for
  seamless data communication.
• Medical Standardization
• Several healthcare standards available currently.
• Acceptability varies with respect to healthcare
  scenarios in different countries.
• HL7, LOINC, DICOM, ICD-10, PACS are most popular
  standards.

Contd.
48
Effort for Standardization in India

• Health Unite Effort of MCIT, AHSL
• Built a national framework for Information
  Technology Infrastructure for Health through
  health information standards.
• Areas for Recommendations
• Data Elements
• Health Identifiers
• Clinical Data Representation (Clinical Standards)
• Minimum Data Sets
• Healthcare Billing Formats
• Message Standards
• Public Informatics Education
• Privacy and Confidentiality Information

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Principal Patient Care Components

• Data Elements
• Patient Demographics
• Hospital Administration
• Health Insurance
• Health Identifier
• Healthcare Professional
• Healthcare Provider Organizations
• Support Service Provider
• Individual
• Employee
• Payers

50
Principal Patient Care Components

• Minimum Data Sets
• Common across all diseases
• Referrals
• Demographics
• Specific to some diseases.
• Disease Assessment Stage, Risk Factors,
  Complications
• Treatment
• Outcomes
• Data Representation Standards
• Clinical data representation standard
• Messaging standard

51
Clinical standardization

• Identified three critical areas of
  standardization through coding
• Disease Codes
• Recommendation ICD-10
• Procedure Codes
• Recommendation ICD-10-PCS
• Clinical Observation Codes
• Recommendation LOINC

52
Messaging standardization

• Two types of messaging standard
• Text messaging standard
• Recommendation HL7
• - version is not specified.
• - needed to be customized to Indian
  requirement.
• Imaging standard DICOM
• No strict recommendation of imaging standard.

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Thank You