《医学影像信息学概论》课程参考资源：Biomedical Informatics - Computer Applications in Health Care and Biomedicine（Fourth Edition，Edward H. Shortliffe • James J. Cimino）

Contributors Philip R.O. Payne, PhD, FACMI Department of Biomedical Informatics, The Ohio State University Wexner Medical Center, Columbus, OH, USA David a. ross. D Sc public health Informatics institute/ The Task Force for Global Health. Decatur, GA. USA Daniel L. Rubin, MD, MS, FACMI Departments of Radiology and Medicine, Stanford University, Stanford, CA, USA Robert s Rudin, BS, SM, PhD Health Unit, Rand Corporati Boston. MA USa Titus K.L. Schleyer, DMD, PhD, FACMI Center for Biomedical Informatics Regenstrief Institute, Inc, Indianapolis, IN Nigam H Shah, MBBS, PhD Department of Medicine, Stanford University, Stanford, CA, USA Edward H Shortliffe, MD, PhD, MACP, FACMI Departments of Biomedical Informatics, Arizona State University, Columbia University, Weill Cornell Medical College, and the New York Academy of medicine, New York, NY, USA Jonathan C. Silverstein, MD, MS, FACMI Research Institute North Shore University Health System, Evanston, IL, USA Harold C Sox, MD, MACP Dartmouth Institute Geisel School of Medicine, Dartmouth College, West Lebanon, NH, USA Justin B Starren, MD, PhD, FACMI Division of Health and Biomedical Informatics, Department of Preventive Medicine and Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago IL. USA Paul C. Tang, MD, MS, FACMI David Druker Center for Health Systems Innovation Palo alto medical foundation Mountain view CA. USA Jessica D. Tenenbaum, PhD Duke Translational Medicine Institute Duke University, Durham, NC, USA David K. Vawdrey, PhD Department of Biomedical Informatics, Columbia University, New York, NY, USA ynn Harold Vogel, PhD LH Vogel Consulting, LLC Ridgewood, NJ. USA Adam B. wilcox, PhD, FACMI Department of Biomedical Informatics, Intermountain healthcare. New York. NY USA Jeremy C. Wyatt, MB BS, FRCP, FACMI Leeds Institute of Health Sciences, University of Leeds, Leeds, UK William A. Yasnoff, MD. PhD. FACMI NHII Advisors, Arlington VA USA

xxvi Philip R.O. Payne , PhD, FACMI Department of Biomedical Informatics , The Ohio State University Wexner Medical Center , Columbus , OH , USA David A. Ross , D.Sc Public Health Informatics Institute/ The Task Force for Global Health , Decatur , GA , USA Daniel L. Rubin , MD, MS, FACMI Departments of Radiology and Medicine , Stanford University , Stanford , CA , USA Robert S. Rudin , BS, SM, PhD Health Unit , Rand Corporation , Boston , MA , USA Titus K.L. Schleyer , DMD, PhD, FACMI Center for Biomedical Informatics Regenstrief Institute, Inc. , Indianapolis , IN Nigam H. Shah , MBBS, PhD Department of Medicine , Stanford University , Stanford , CA , USA Edward H. Shortliffe , MD, PhD, MACP, FACMI Departments of Biomedical Informatics , Arizona State University, Columbia University, Weill Cornell Medical College, and the New York Academy of Medicine , New York , NY , USA Jonathan C. Silverstein , MD, MS, FACMI Research Institute , NorthShore University Health System , Evanston , IL , USA Harold C. Sox, MD, MACP Dartmouth Institute, Geisel School of Medicine, Dartmouth College, West Lebanon , NH , USA Justin B. Starren , MD, PhD, FACMI Division of Health and Biomedical Informatics, Department of Preventive Medicine and Medical Social Sciences , Northwestern University Feinberg School of Medicine , Chicago , IL , USA Paul C. Tang , MD, MS, FACMI David Druker Center for Health Systems Innovation , Palo Alto Medical Foundation , Mountain View , CA , USA Jessica D. Tenenbaum , PhD Duke Translational Medicine Institute, Duke University , Durham , NC , USA David K. Vawdrey , PhD Department of Biomedical Informatics , Columbia University , New York , NY , USA Lynn Harold Vogel , PhD LH Vogel Consulting, LLC , Ridgewood , NJ , USA Adam B. Wilcox , PhD, FACMI Department of Biomedical Informatics , Intermountain Healthcare , New York , NY , USA Jeremy C. Wyatt , MB BS, FRCP, FACMI Leeds Institute of Health Sciences , University of Leeds , Leeds , UK William A. Yasnoff , MD, PhD, FACMI NHII Advisors , Arlington , VA , USA Contributors

Part Recurrent Themes in Biomedical Informatics

Part I Recurrent Themes in Biomedical Informatics

Biomedical informatics: The Science and the Pragmatics Edward H. Shortliffe and marsden S blois er readin ng this chapter, you should know the . How does information in clinical medicine answers to these questions and health differ from information in the basic Why is information and knowledge manage scIence ment a central issue in biomedical research How can changes in computer technology and the way patient care is financed influence the What are integrated information management integration of biomedical computing into clin- environments, and how might we expect them to ical practice? affect the practice of medicine, the promotion of health, and biomedical research in coming years What do we mean by the terms biomedical 1.1 The Information Revolution informatics, medical computer science, medi Comes to medicine cal computing, clinical informatics, nursing informatics, bioinformatics, public health After scientists had developed the first digital informatics, and health informatics? computers in the 1940s, society was told that Why should health professionals, life scien- these new machines would soon be serving rou- tists, and students of the health professions tinely as memory devices, assisting with calcu- learn about biomedical informatics concepts lations and with information retrieval. Within and informatics applications? the next decade, physicians and other health How has the development of modern comput- professionals had begun to hear about the dra- ing technologies and the Internet changed the matic effects that such technology would have nature of biomedical computing? How is biomedical informatics related to clinical practice, public health, biomedical engineering, molecular biology, decision science, informa- Dr. Blois coauthored the 1990(Ist edition) version of tion science, and computer science? this chapter shortly before his death in 1988, a year prior to the completion of the full manuscript. Although the chapter has evolved in subsequent editions, we con tAuthor was deceased at the time of publication tinue to name dr. blois as a coauthor because of his seminal contributions to the field as well as to this chap E H. Shortliffe. MD. PhD ter. Section 1.5 was written by him and, since it is time- Departments of Biomedical Informatics less, remains unchanged in each edition of the book. To at Columbia University and Arizona State University, learn more about this important early leader in the field Weill Cornell Medical College, of informatics, see his classic volume(Blois 1984 )and and The New York Academy of Medicine. atributetohimathttp://www.amia.org/about-amia/ 272 w107th St #5B. New York 10025.NY USA leadership/acmi-fellow/marsden-s-blois-md-facm e-mail:ted@shortliffe.net ( Accessed3/3/2013). E.H. Shortliffe, J.J. Cimino(eds ) Biomedical informatics DOI 10.1007/978-1-4471-4474-81, e Springer-Verlag London 2014

E.H. Shortliffe, J.J. Cimino (eds.), Biomedical Informatics, 3 DOI 10.1007/978-1-4471-4474-8_1, © Springer-Verlag London 2014 After reading this chapter, you should know the answers to these questions: • Why is information and knowledge manage￾ment a central issue in biomedical research and clinical practice? • What are integrated information management environments, and how might we expect them to affect the practice of medicine, the promotion of health, and biomedical research in coming years? • What do we mean by the terms biomedical informatics , medical computer science , medi￾cal computing , clinical informatics , nursing informatics , bioinformatics , public health informatics , and health informatics ? • Why should health professionals, life scien￾tists, and students of the health professions learn about biomedical informatics concepts and informatics applications? • How has the development of modern comput￾ing technologies and the Internet changed the nature of biomedical computing? • How is biomedical informatics related to clinical practice, public health, biomedical engineering, molecular biology, decision science, informa￾tion science, and computer science? • How does information in clinical medicine and health differ from information in the basic sciences? • How can changes in computer technology and the way patient care is fi nanced infl uence the integration of biomedical computing into clin￾ical practice? 1.1 The Information Revolution Comes to Medicine After scientists had developed the fi rst digital computers in the 1940s, society was told that these new machines would soon be serving rou￾tinely as memory devices, assisting with calcu￾lations and with information retrieval. Within the next decade, physicians and other health professionals had begun to hear about the dra￾matic effects that such technology would have 1 Dr. Blois coauthored the 1990 (1st edition) version of this chapter shortly before his death in 1988, a year prior to the completion of the full manuscript. Although the chapter has evolved in subsequent editions, we con￾tinue to name Dr. Blois as a coauthor because of his seminal contributions to the fi eld as well as to this chap￾ter. Section 1.5 was written by him and, since it is time￾less, remains unchanged in each edition of the book. To learn more about this important early leader in the fi eld of informatics, see his classic volume (Blois 1984 ) and a tribute to him at http://www.amia.org/about-amia/ leadership/acmi-fellow/marsden- s-blois-md-facmi (Accessed 3/3/2013). Biomedical Informatics: The Science and the Pragmatics Edward H. Shortliffe and Marsden S. Blois† E. H. Shortliffe , MD, PhD Departments of Biomedical Informatics at Columbia University and Arizona State University , Weill Cornell Medical College, and The New York Academy of Medicine , 272 W 107th St #5B , New York 10025 , NY , USA e-mail: ted@shortliffe.net † Author was deceased at the time of publication

E.H. Shortliffe and m.s. blois on clinical practice. More than six decades of deal with both issues at once. Yet many observers remarkable progress in computing have followed now believe that the two topics are inextricably those early predictions, and many of the original related and that planning for the new health care prophesies have come to pass. Stories regard- environments of the coming decades requires a ing the" information revolution"and"big data" deep understanding of the role that information fill our newspapers and popular magazines, and technology is likely to play in those environments todays children show an uncanny ability to make What might that future hold for the typi use of computers (including their increasingly cal practicing clinician? As we shall discuss mobile versions) as routine tools for study and detail in Chap. 12, no applied clinical comput entertainment. Similarly, clinical workstations ing topic is gaining more attention currently than have been available on hospital wards and in out- is the issue of electronic health records(EHrs) patient offices for years, and are being gradually Health care organizations have recognized that supplanted by mobile devices with wireless con- they do not have systems in place that effectively nectivity. Yet many observers cite the health care allow them to answer questions that are crucially system as being slow to understand information important for strategic planning, for their better technology, slow to exploit it for its unique prac- understanding of how they compare with other tical and strategic functionalities, slow to incor- provider groups in their local or regional com- porate it effectively into the work environment, petitive environment, and for reporting to regu- and slow to understand its strategic importance latory agencies. In the past, administrative and and its resulting need for investment and com- financial data were the major elements required mitment. Nonetheless, the enormous technologi- for such planning, but comprehensive clinical cal advances of the last three decades-personal data are now also important for institutional self- computers and graphical interfaces, new methods analysis and strategic planning. Furthermore, the for human-computer interaction, innovations inefficiencies and frustrations associated with the in mass storage of data(both locally and in the use of paper-based medical records are now well cloud), mobile devices, personal health moni- accepted (Dick and Steen 1991(Revised 1997), toring devices and tools, the Internet, wireless especially when inadequate access to clinical communications, social media, and more--have information is one of the principal barriers that all combined to make the routine use of comput- clinicians encounter when trying to increase their ers by all health workers and biomedical scientists efficiency in order to meet productivity goals for inevitable. A new world is already with us, but its their practices greatest influence is yet to come. This book will teach you both about our present resourc accomplishments and about what you can 1.1.1 Integrated Access to Clinical in the years ahead Information: The Future When one considers the penetration of com- Is Now uters and communication into our daily lives today, it is remarkable that the first personal Encouraged by health information technology computers were introduced as recently as the late (HIr) vendors(and by the US government, as 1970s; local area networking has been available is discussed later), most health care institutions only since -1980: the World Wide Web dates are seeking to develop integrated computer-based only to the early 1990s; and smart phones, social information-management environments. These networking, and wireless communication are are single-entry points into a clinical world in even more recent. This dizzying rate of change, which computational tools assist not only with combined with equally pervasive and revolution- patient-care matters(reporting results of tests ary changes in almost all international health care allowing direct entry of orders or patient infor- systems, makes it difficult for public-health plan- mation by clinicians, facilitating access to tran ners and health-institutional managers to try to scribed reports, and

4 on clinical practice. More than six decades of remarkable progress in computing have followed those early predictions, and many of the original prophesies have come to pass. Stories regard￾ing the “information revolution” and “big data” fi ll our newspapers and popular magazines, and today’s children show an uncanny ability to make use of computers (including their increasingly mobile versions) as routine tools for study and entertainment. Similarly, clinical workstations have been available on hospital wards and in out￾patient offi ces for years, and are being gradually supplanted by mobile devices with wireless con￾nectivity. Yet many observers cite the health care system as being slow to understand information technology, slow to exploit it for its unique prac￾tical and strategic functionalities, slow to incor￾porate it effectively into the work environment, and slow to understand its strategic importance and its resulting need for investment and com￾mitment. Nonetheless, the enormous technologi￾cal advances of the last three decades—personal computers and graphical interfaces, new methods for human-computer interaction, innovations in mass storage of data (both locally and in the “cloud”), mobile devices, personal health moni￾toring devices and tools, the Internet, wireless communications, social media, and more—have all combined to make the routine use of comput￾ers by all health workers and biomedical scientists inevitable. A new world is already with us, but its greatest infl uence is yet to come. This book will teach you both about our present resources and accomplishments and about what you can expect in the years ahead. When one considers the penetration of com￾puters and communication into our daily lives today, it is remarkable that the fi rst personal computers were introduced as recently as the late 1970s; local area networking has been available only since ~1980; the World Wide Web dates only to the early 1990s; and smart phones, social networking, and wireless communication are even more recent. This dizzying rate of change, combined with equally pervasive and revolution￾ary changes in almost all international health care systems, makes it diffi cult for public-health plan￾ners and health-institutional managers to try to deal with both issues at once. Yet many observers now believe that the two topics are inextricably related and that planning for the new health care environments of the coming decades requires a deep understanding of the role that information technology is likely to play in those environments. What might that future hold for the typi￾cal practicing clinician? As we shall discuss in detail in Chap. 12, no applied clinical comput￾ing topic is gaining more attention currently than is the issue of electronic health records (EHRs). Health care organizations have recognized that they do not have systems in place that effectively allow them to answer questions that are crucially important for strategic planning, for their better understanding of how they compare with other provider groups in their local or regional com￾petitive environment, and for reporting to regu￾latory agencies. In the past, administrative and fi nancial data were the major elements required for such planning, but comprehensive clinical data are now also important for institutional self￾analysis and strategic planning. Furthermore, the ineffi ciencies and frustrations associated with the use of paper-based medical records are now well accepted ( Dick and Steen 1991 (Revised 1997) ), especially when inadequate access to clinical information is one of the principal barriers that clinicians encounter when trying to increase their effi ciency in order to meet productivity goals for their practices. 1.1.1 Integrated Access to Clinical Information: The Future Is Now Encouraged by health information technology ( HIT ) vendors (and by the US government, as is discussed later), most health care institutions are seeking to develop integrated computer-based information-management environments. These are single-entry points into a clinical world in which computational tools assist not only with patient-care matters (reporting results of tests, allowing direct entry of orders or patient infor￾mation by clinicians, facilitating access to tran￾scribed reports, and in some cases supporting E.H. Shortliffe and M.S. Blois

1 Biomedical Informatics: The Science and the Pragmatics telemedicine applications or decision-support to ask the following questions: What is a health functions) but also administrative and financial record in the modern world? Are the available topics(e. g, tracking of patients within the hospi- products and systems well matched with the al, managing materials and inventory, supporting modern notions of a comprehensive health personnel functions, and managing the payroll), record? Do they meet the needs of individual research(e.g, analyzing the outcomes associ- users as well as the health systems themselves? ated with treatments and procedures, perform- The complexity associated with automating ing quality assurance, supporting clinical trials, clinical-care records is best appreciated if one and implementing various treatment protocols ), analyzes the processes associated with the cre- scholarly information (e. g, accessing digital ation and use of such records rather than think libraries, supporting bibliographic search, and ing of the record as a physical object that can be providing access to drug information databases), moved around as needed within the institution and even office automation(e. g, providing access For example, on the input side(Fig. 1. 1), the to spreadsheets and document-management soft- EHR requires the integration of processes for ware). The key idea, however, is that at the heart data capture and for merging information from of the evolving integrated environments lies an diverse sources. The contents of the paper record electronic health record that is intended to be have traditionally been organized chronologi accessible, confidential, secure, acceptable to cally--often a severe limitation when a clinician clinicians and patients, and integrated with other seeks to find a specific piece of information that types of useful information to assist in planning could occur almost anywhere within the chart To and problem solving be useful, the record system must make it easy to access and display needed data, to analyze them, and to share them among colleagues and 1.1.2 Moving Beyond the Paper with secondary users of the record who are not Record involved in direct patient care(Fig. 1. 2). Thus, the ehr is best viewed not as an object, or a The traditional paper-based medical record is product, but rather as a set of processes that an now recognized as woefully inadequate for meet- organization must put into place, supported by ing the needs of modern medicine. It arose in technology(Fig. 1.3). Implementing electronic the nineteenth century as a highly personalized records is inherently a systems-integration task; it lab notebook"that clinicians could use to record is not possible to buy a medical record system for their observations and plans so that they could a complex organization as an off-the-shelf prod- be reminded of pertinent details when they next uct. Joint development and local adaptation are saw the same patient. There were no regulatory crucial, which implies that the institutions that requirements, no assumptions that the record purchase such systems must have local expertise would be used to support communication an that can oversee and facilitate an effective imple varied providers of care, and few data or test mentation process, including elements of process results to fill up the records pages. The record re-engineering and cultural change that are inevi that met the needs of clinicians a century ago tably involved. struggled mightily to adjust over the decades and Experience has shown that clinicians are"hori to accommodate to new requirements as health zontal"users of information technology(Greenes care and medicine changed. Today the inability and Shortliffe 1990). Rather than becoming of paper charts to serve the best interests of the "power users"of a narrowly defined software patient, the clinician, and the health system has package, they tend to seek broad functionalit become clear(see Chaps. 12 and 14) across a wide variety of systems and resources. an most organizations have found it challenging Thus, routine use of computers, and of EHRs,is expensive) to move to a paperless, elec- most easily achieved when the computing envi- tronic clinical record. this observation forces us ronment offers a critical mass of functionality

5 telemedicine applications or decision-support functions) but also administrative and fi nancial topics (e.g., tracking of patients within the hospi￾tal, managing materials and inventory, supporting personnel functions, and managing the payroll), research (e.g., analyzing the outcomes associ￾ated with treatments and procedures, perform￾ing quality assurance, supporting clinical trials, and implementing various treatment protocols), scholarly information (e.g., accessing digital libraries, supporting bibliographic search, and providing access to drug information databases), and even offi ce automation (e.g., providing access to spreadsheets and document- management soft￾ware). The key idea, however, is that at the heart of the evolving integrated environments lies an electronic health record that is intended to be accessible, confi dential, secure, acceptable to clinicians and patients, and integrated with other types of useful information to assist in planning and problem solving. 1.1.2 Moving Beyond the Paper Record The traditional paper-based medical record is now recognized as woefully inadequate for meet￾ing the needs of modern medicine. It arose in the nineteenth century as a highly personalized “lab notebook” that clinicians could use to record their observations and plans so that they could be reminded of pertinent details when they next saw the same patient. There were no regulatory requirements, no assumptions that the record would be used to support communication among varied providers of care, and few data or test results to fi ll up the record’s pages. The record that met the needs of clinicians a century ago struggled mightily to adjust over the decades and to accommodate to new requirements as health care and medicine changed. Today the inability of paper charts to serve the best interests of the patient, the clinician, and the health system has become clear (see Chaps. 12 and 14). Most organizations have found it challenging (and expensive) to move to a paperless, elec￾tronic clinical record. This observation forces us to ask the following questions: “What is a health record in the modern world? Are the available products and systems well matched with the modern notions of a comprehensive health record? Do they meet the needs of individual users as well as the health systems themselves?” The complexity associated with automating clinical-care records is best appreciated if one analyzes the processes associated with the cre￾ation and use of such records rather than think￾ing of the record as a physical object that can be moved around as needed within the institution. For example, on the input side (Fig. 1.1 ), the EHR requires the integration of processes for data capture and for merging information from diverse sources. The contents of the paper record have traditionally been organized chronologi￾cally—often a severe limitation when a clinician seeks to fi nd a specifi c piece of information that could occur almost anywhere within the chart. To be useful, the record system must make it easy to access and display needed data, to analyze them, and to share them among colleagues and with secondary users of the record who are not involved in direct patient care (Fig. 1.2 ). Thus, the EHR is best viewed not as an object, or a product, but rather as a set of processes that an organization must put into place, supported by technology (Fig. 1.3 ). Implementing electronic records is inherently a systems-integration task; it is not possible to buy a medical record system for a complex organization as an off-the-shelf prod￾uct. Joint development and local adaptation are crucial, which implies that the institutions that purchase such systems must have local expertise that can oversee and facilitate an effective imple￾mentation process, including elements of process re-engineering and cultural change that are inevi￾tably involved. Experience has shown that clinicians are “hori￾zontal” users of information technology ( Greenes and Shortliffe 1990 ). Rather than becoming “power users” of a narrowly defi ned software package, they tend to seek broad functionality across a wide variety of systems and resources. Thus, routine use of computers, and of EHRs, is most easily achieved when the computing envi￾ronment offers a critical mass of functionality 1 Biomedical Informatics: The Science and the Pragmatics