Health Information System

1
Health Information System

• Feipei Lai
• National Taiwan University
• September 17, 2007

2
Content

• ?????? Health Information Management
• ?????? Health Information Standard
• ?????? Outpatient Information System
• ?????? Inpatient Information System
• ?????? Emergency Information System
• ?????? Laboratory Information System
• ?????? PACS
• ??????? Computerized Medical Instrument
• ???? Telemedicine
• ???? Electronic Health Records
• ?????? Health Information Security

3
Reference

• Medical Informatics Computer Applications in
  Health Care and Biomedicine, By Shortliffe
  Perreault, Pub. Springer

4
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.

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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.
• 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.

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NHII

• http//aspe.hhs.gov/sp/nhii/

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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/

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IHE User Success Story

• Johannes Gutenberg, University Hospital, Mainz,
  Germany
• Implementation of Scheduled Workflow Transactions
  and Consistent Presentation of Images

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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.

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Goal

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

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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).

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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.

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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.

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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.

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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.

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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.

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

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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

19

• OASIS (Organization for the Advancement of
  Structured Information Standards)

20
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.

21
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.

22
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).
• 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.

23

• http//wiki.ihe.net/
• This Wiki is for collaborative creation of IHE
  materials and ongoing activities.

24
Vision for Consumer-centric and Information-rich
Care

• Medical information follows the consumer
• Information tools guide medical decisions
• Clinicians have appropriate access to a patients
  complete treatment history,
• Medical records
• Medication history
• Laboratory results
• Radiographs

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• 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.

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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.

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Vision for Consumer-centric and Information-rich
Care

• Prescriptions are also checked against the health
  plans 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.

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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.

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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

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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

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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.

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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

33
To do list

• Planning the formation of a private
  interoperability consortium
• Requiring standards to facilitate electronic
  prescribing
• Commitment to standards

34
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

35
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.

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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.

37
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.

38
Computerized Provider Order Entry (CPOE)

• A computer application that allows a physicians
  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.

39
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.

40
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/

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EHR Capabilities

• Health information and data
• Results management
• Orders management
• Decision support
• Electronic communications and connectivity
• Patient support
• Administrative process
• reporting

42
Dimensions of the AP Framework

• Applications architecture
• Integration level
• Industry domain specificity

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Applications architecture

• Presentation logic
• Business logic
• Data logic

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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.

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Business logic

• Implements the business rules that represent the
  business processes of an application system.

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Data logic

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

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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)

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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)

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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.

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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.

51
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

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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 . . .

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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.

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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).

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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).

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Computer Technology and Clinical WorkStill
Waiting for Godot

• Health Care - the most complex enterprise in
  modern society from an organizational standpoint

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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.

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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.

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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).

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Still Waiting for Godot

• (2) These social and technical elements are
  deeply interdependent and interrelatedhence, 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.

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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.

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

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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.
• 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.

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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.
• 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.

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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

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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.