Ahmed AlBarrak PhD Medical Informatics Associate Professor, Family & Community Med. Chairman, Medical Informatics Department College of Medicine King

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1 Ahmed AlBarrak PhD Medical Informatics Associate Professor, Family & Community Med. Chairman, Medical Informatics Department College of Medicine King Saud University

2 What are Medical Data? Data provide the basis for categorizing the problems apatient may be having, Data help physician to decide what action should be taken, Medical Data are multiple observations about patient, Data is important in guiding healthcare decisionmaking.

3 What are the types of Medical Data? Narrative Description of patient illness Responses to questions from physician Patients and family history Hospitalization information Numeric Values Laboratory tests Vital signs Measurements during physical examination continued

4 Recorded Signals Electrocardiogram (ECG) Visual Images Radiological Images Drawings, sketches, notes

5 information is a major resource which is crucial to the health of individual patients, the population in general, and to the success of the organization; Healthcare IS AND will increasingly be an information-driven service; ENTER THE DATA ONE TIME AND USE IT MANY TIMES

6 Use of Medical Data Create the basic for Historical Record, Support Communication Among Providers, Anticipate Future Health Problems, Record Standard Preventive Measures, Identify Deviations from Expected Trends, Provide a Legal Record, Support Clinical Research and training.

7 Electronic Medical Record Computer-Based Patient Record (CPR) Provides multiple advantages vs. manual records: Record can be used by multiple personnel at the same time Record is accessible from anywhere Clear, well-organized, legible documentation, searchable Data can be reused for other purposes Data can be integrated from multiple sources transparently Data can be validated automatically Enables multiple automated research and decisionsupport functions (analysis, machine learning and data mining, automated diagnosis, reminders, guidelinebased care) Decision support can be integrated with use of the patient records

8 Coding & Grouping Diagnosis related group (DRG): code used for diagnosis; hospital reimbursement by insurers is based on a formula using DRGs. Current Procedure Terminology (CPT): codes lab tests, treatments, and other procedures. ICD9-CM (International Classification of Disease): classifies diseases using 4-5 digit codes. ICD 10-AM Etc.

9 EMRs: Major Issues Data Entry Data capture: the scope of the data that it can be represented in the EMR Data input: un-coded data are difficult to input by physicians and health professionals; text is less useful for processing Errors can be reduced by multiple validity checks and coding

10 Validity Checks During Data Entry in an EMR Range checks (Hemoglobin in [0..30] Gr/Dl) Pattern checks (a telephone number pattern) Numeric and other inter-data constraint checks (total of WBC differential is 100%) Consistency checks (pregnant male??) Temporal-abstraction checks (weight cannot change by 50 Kgs in 2 days) Spelling checks

11 Physician-Entered Data The main challenge to EMR implementations Patient histories, physical findings, interpretations, diagnostic and treatment plans, etc. Several very different entry methods Transcription of dictated or written notes Structured encounter forms from which notes are transcribed and even encoded Direct entry of data by physician via computer Speech recognition might alleviate some of the difficulties

12 Security Issues in EMRs Authorization Is my dentist allowed to see my gynecological record? Which fields of my record can my or another GP view? Who has asked to view my records last month? Authentication Is this user really my physician? Encryption Can an eavesdropper understand the message sent to my doctor? Eventually, security depends on people

13 The Need for Standards EMRs and almost any other information-oriented system in a clinical environment cannot be used without well-defined standards for representing and communicating information Data need to be exchanged between multiple, heterogeneous systems and might be used by very different applications Standards are needed for several different uses: Identifying patients, providers, health-care plans, employers Transferring patient data across different systems within the same organization or across different organizations Representing medical knowledge that can be utlized

14 How are Standards Developed? Ad hoc A group of interested people and organizations agree on an informal specification (ACR/NEMA DICOM) De facto A single vendor creates standard through monopoly (Microsoft Windows) Government mandate Agency creates a standard and legislates it (HCFA UB92 claim form) Consensus A group of volunteers work openly to create standard (HL7).

15 Examples of Information-Standards Organizations American National Standards Institute (ANSI) Private, nonprofit Accredits organizations that create standards Technical Committee 251 (CEN TC 251) The European Standardization Committee s technical committee for medical informatics standards American Society for Testing and Materials (ASTM) Largest non-government source of standards in the USA ASTM committee E31 is responsible for development of medical information standards

16 Terminologies and Controlled Vocabularies Pre-coordinated All concepts encoded beforehand no possibility of creating new terms Post-coordinated New combinations can be formed from existing terms to describe new concepts

17 International Classification of Diseases (ICD) Strict hierarchy with core 3-digit codes, possibly 4 th digit ICD-9 (1977) common; inadequate for clinical reporting ICD-9-CM (Clinical Modifications) adds extra levels of details by 4 th and 5 th digits, popular in USA ICD-10 (1992) exists, clinical modifications introduced (ICD10 AM Australian modifications) Intended mostly for talking about dead people (reporting mortality statistics to the WHO)

18 Codes in The International Classification of Diseases (ICD-9 CM) 724 Unspecified disorders of the back Spinal stenosis, other than cervical Spinal stenosis, unspecified region Spinal stenosis, thoracic region Spinal stenosis, lumbar region Spinal stenosis, other Pain in thoracic spine Lumbago Sciatica Thoracic or lumbosacral neuritis Backache, unspecified Disorders of sacrum Disorders of coccyx Unspecified disorder of coccyx Hypermobility of coccyx Coccygodynia Other symptoms referable to back Other unspecified back disorders

19 Diagnosis-Related Groups (DRGs) A USA (Yale) abstraction of the ICD-9-CM codes A small number of codes grouping multiple diagnosis codes by similar expected costs of hospitalization Modifies the major diagnosis by associated conditions, severity, and procedures to determine specific DRG code

20 Current Procedural Terminology (CPT) Encodes diagnostic and therapeutic procedures Adopted in the USA for billing and reimbursement Similar to DRG, classifies procedures by cost and reasons CPT-4: The main code used for reporting physician services to government and private insurance reimbursement

21 Diagnostic Statistical Manual of Mental Disorders (DSM) Published by the American Psychiatric Association Provides nomenclature as well as definitions (diagnostic criteria) of psychiatric disorders Coordinated with ICD; e.g., DSM-IV is coordinated with ICD-10

22 Systemized Nomenclature of Medicine (SNOMED) Developed by the American College of Pathologists Evolved from SNOP, A multi-axial system for describing pathological findings by post-coordination of topographic (anatomic), morphologic, etiologic, and functional terms SNOMED III: 11 axes, more than 130,000 terms SNOMED-RT (Reference terminology) created to encourage more consistent use of terms Main problem: Too expressive several ways of defining the same term (e.g. acute appendicitis)

23 Read Clinical Codes Developed by James Read during the 1980s Adopted by the British National Health Service (NHS) in 1990 Version 3 is a multiple hierarchy, and version 3.1 added ability for post-coordination of modifiers Work undergoing to map to SNOMED

24 The Unified Medical Language System (UMLS) A project of the National Library of Medicine (within the National Health Institutes [NIH]) Main resource: The Metathesaurus contains over 330,000 terms relates terms from over 40 different sources Supports searching the medical literature Uses Medical Subject Headings (MeSH) which are used to index medical literature

25 Logical Observations, Identifiers, Names and Codes (LOINC) A naming system developed by McDonald and Huff for tests and observations (now includes also vital signs, ECG, etc) Uses six semantic axes to encode the test, such as substance measured (urine) and analysis method used Coordinated development with the European Clinical Data Exchange Standard (EUCLIDES) standard

26 Data Interchange Standards Allow a sender to transmit data (a transaction set) to a receiver in unambiguous fashion Closely related to the Open Systems Interconnection (OSI) 7-layer communication model of the International Standards Organization (OSI) Physical, data link, network, transport, session, presentation, and application (semantic-specification) layers Typically use position dependent or tagged field format

27 Example Data-Interchange Standards ACR/NEMA American College of Radiologists with the National Electronic Manfacturers Association Current version: DICOM 3.0; uses an object oriented model and supports ISO communications ASTM E31 Published E1238, Standard Specification for Transferring Clinical Observations Between Independent Systems E1460: Defining and Sharing Modular Health Knowledge Bases is the Arden Syntax for Medical Logical Modules

28 Health Level 7 (HL7) Today, includes more than 500 industrial and academic organizational members and over 1800 individual members Name refers to OSI application layer 7 A standard for exchange of data among different hospital computer applications Built upon ASTM 1238 and other protocols Version 3 (1999) is object oriented and uses a Reference Information Model (RIM)

29 Health Insurance Portability and Accountability Act (HIPAA) OF 1996 first federal privacy protection identifiable medical information; encourages the use of the electronic medical record. Guidelines to protect electronic medical records.

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