《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）

1 Biomedical Informatics: The Science and the Pragmatics 11 or social, political, financial, scientific, and and hence it is affecting the way that individuals entertainment ventures. Many people point to the seek health-related information and it is also nternet as a superb example of the facilitating enhancing how patients can gain access to their role of federal investment in promoting innova- health care providers and to their clinical data tive technologies. The Internet is a major societal Just as individual hospitals and health care force that arguably would never have been cre- systems have come to appreciate the importance ated if the research and development, plus the of integrating information from multiple clinical coordinating activities, had been left to the pri- and administrative systems within their orga- vate sector nizations(see Chap. 14), health planners and The explosive growth of the Internet did governments now appreciate the need to develop ot occur until the late 1990s, when the World integrated information resources that combine wide Web(which had been conceived initially clinical and health data from multiple institutions by the physics community as a way of using the within regions, and ultimately nationally(see Internet to share preprints with photographs and Chaps. 13 and 16). As you will see, the Internet diagrams among researchers) was introduced and the role of digital communications has there- popularized. Navigating the Web is highly intui- fore become a major part of modern medicine and tive, requires no special training, and provides health. Although this topic recurs in essentially a mechanism for access to multimedia informa- every chapter in this book, we introduce it in the tion that accounts for its remarkable growth as a following sections because of its importance to worldwide phenomenon. modern technical issues and policy directions. The societal impact of this communications phenomenon cannot be overstated, especially given the international connectivity that has 1.2.1 A Model of Integrated Disease grown phenomenally in the past two decades Surveillance Countries that once were isolated from infor- mation that was important to citizens, ranging To emphasize the role that the nation's network from consumers to scientists to those interested ing infrastructure is playing in integrating clini in political issues, are now finding new options cal data and enhancing care delivery, consider for bringing timely information to the desktop one example of how disease sur irvelllanc ce, prever machines and mobile devices of individuals with tion, and care are increasingly being influenced an Internet connection by information and communications technology. There has in turn been a major upheaval in the The goal is to create an information-management telecommunications industry, with companies infrastructure that will allow all clinicians, regard- that used to be in different businesses(e. g, cable less of practice setting(hospitals, emergency television, Internet services, and telephone) now rooms, small offices, community clinics, military finding that their activities and technologies have bases, multispecialty groups, etc. ) to use Ehrs merged. In the United States, legislation was in their practices both to assist in patient care and passed 96 to allow new competition to to provide patients with counsel on illness pre develop and new industries to emerge. We have vention. The full impact of this use of electronic subsequently seen the merging of technologies resources will occur when data from all such such as cable television, telephone, networking, records are pooled in regional and national sur and satellite communications. High-speed lines veillance databases(Fig. 1.6), mediated through into homes and offices are widely available, secure connectivity with the Internet. The chal wireless networking is ubiquitous, and inexpen- lenge, of course, is to find a way to integrate data sive mechanisms for connecting to the Internet from such diverse practice settings, especially without using conventional computers (e.g, using cell phones or set-top boxes) have also 2 This section is adapted from a discussion that originally emerged. The impact on everyone has been great appeared in( Shortliffe and Sondik 2004

11 for social, political, fi nancial, scientifi c, and entertainment ventures. Many people point to the Internet as a superb example of the facilitating role of federal investment in promoting innova￾tive technologies. The Internet is a major societal force that arguably would never have been cre￾ated if the research and development, plus the coordinating activities, had been left to the pri￾vate sector. The explosive growth of the Internet did not occur until the late 1990s, when the World Wide Web (which had been conceived initially by the physics community as a way of using the Internet to share preprints with photographs and diagrams among researchers) was introduced and popularized. Navigating the Web is highly intui￾tive, requires no special training, and provides a mechanism for access to multimedia informa￾tion that accounts for its remarkable growth as a worldwide phenomenon. The societal impact of this communications phenomenon cannot be overstated, especially given the international connectivity that has grown phenomenally in the past two decades. Countries that once were isolated from infor￾mation that was important to citizens, ranging from consumers to scientists to those interested in political issues, are now fi nding new options for bringing timely information to the desktop machines and mobile devices of individuals with an Internet connection. There has in turn been a major upheaval in the telecommunications industry, with companies that used to be in different businesses (e.g., cable television, Internet services, and telephone) now fi nding that their activities and technologies have merged. In the United States, legislation was passed in 1996 to allow new competition to develop and new industries to emerge. We have subsequently seen the merging of technologies such as cable television, telephone, networking, and satellite communications. High-speed lines into homes and offi ces are widely available, wireless networking is ubiquitous, and inexpen￾sive mechanisms for connecting to the Internet without using conventional computers (e.g., using cell phones or set-top boxes) have also emerged. The impact on everyone has been great and hence it is affecting the way that individuals seek health-related information and it is also enhancing how patients can gain access to their health care providers and to their clinical data. Just as individual hospitals and health care systems have come to appreciate the importance of integrating information from multiple clinical and administrative systems within their orga￾nizations (see Chap. 14), health planners and governments now appreciate the need to develop integrated information resources that combine clinical and health data from multiple institutions within regions, and ultimately nationally (see Chaps. 13 and 16). As you will see, the Internet and the role of digital communications has there￾fore become a major part of modern medicine and health. Although this topic recurs in essentially every chapter in this book, we introduce it in the following sections because of its importance to modern technical issues and policy directions. 1.2.1 A Model of Integrated Disease Surveillance 2 To emphasize the role that the nation’s network￾ing infrastructure is playing in integrating clini￾cal data and enhancing care delivery, consider one example of how disease surveillance, preven￾tion, and care are increasingly being infl uenced by information and communications technology. The goal is to create an information- management infrastructure that will allow all clinicians, regard￾less of practice setting (hospitals, emergency rooms, small offi ces, community clinics, military bases, multispecialty groups, etc.) to use EHRs in their practices both to assist in patient care and to provide patients with counsel on illness pre￾vention. The full impact of this use of electronic resources will occur when data from all such records are pooled in regional and national sur￾veillance databases (Fig. 1.6 ), mediated through secure connectivity with the Internet. The chal￾lenge, of course, is to fi nd a way to integrate data from such diverse practice settings, especially 2 This section is adapted from a discussion that originally appeared in ( Shortliffe and Sondik 2004 ). 1 Biomedical Informatics: The Science and the Pragmatics

E.H. Shortliffe and m.s. blois Internet Provider HR Provider HR- Regional and National Provider EHR Surveillance Databases Protocols and Guidelines for standards of care Different Vendors Fig. 1.6 A future vision of surveillance databases, in security s discussed in the text). when informa- hich clinical data are pooled in regional and national tion is gathered, pooled, and analyzed, there repositories through a process of data submission that are sig ortunities for feeding back the results occurs over the Internet(with attention to privacy and of de to practitioners at the point of care since there are multiple vendors and system Standards for data transmission and sharing: developers active in the marketplace, compet haring data over networks requires that all ing to provide value-added capabilities that will developers of EHRs and clinical databases excite and attract the practitioners for whom their adopt a single set of standards for communi- EHR product is intended. cating and exchanging information. The de The practical need to pool and integrate clini facto standard for such sharing, Health Level cal data from such diverse resources and systems 7(HL7), was introduced decades ago and, emphasizes the practical issues that need to be after years of work, is beginning to be uni addressed in achieving such functionality and formly adopted, implemented, and utilized resources. Interestingly, most of the barriers are (see Chap. 7) logistical, political, and financial rather than Standards for data definitions: A uniform technical in nature envelope"for digital communication, such as Encryption of data: Concerns regarding pri- HL7, does not assure that the contents of such vacy and data protection require that Internet messages will be understood or standardized transmission of clinical information occur The pooling and integration of data requires only if those data are encrypted, with an estab- the adoption of standards for clinical termi lished mechanism for identifying and authen- nology and potentially for the schemas used to ticating individuals before they are allowed to store clinical information in databases(see decrypt the information for surveillance or Chap. 7) research use Quality control and error checking: Any HIPAA-compliant policies: The privacy and tem for accumulating, analyzing, and utilizing security rules that resulted from the 1996 clinical data from diverse sources must be Health Insurance Portability and complemented by a rigorous approach to qual Accountability Act(HIPAA) do not prohibit trol and error checking. It is crucial th the pooling and use of such data(see Chap. users have faith in the accuracy and compre 10), but they do lay down policy rules and hensiveness of the data that are collected in technical security practices that must be part such repositories, because policies, guide- of the solution in achieving the vision we are lines, and a variety of metrics can be derived discussing here. over time from such information

12 since there are multiple vendors and system developers active in the marketplace, compet￾ing to provide value-added capabilities that will excite and attract the practitioners for whom their EHR product is intended. The practical need to pool and integrate clini￾cal data from such diverse resources and systems emphasizes the practical issues that need to be addressed in achieving such functionality and resources. Interestingly, most of the barriers are logistical, political, and fi nancial rather than technical in nature: • Encryption of data : Concerns regarding pri￾vacy and data protection require that Internet transmission of clinical information occur only if those data are encrypted, with an estab￾lished mechanism for identifying and authen￾ticating individuals before they are allowed to decrypt the information for surveillance or research use. • HIPAA - compliant policies : The privacy and security rules that resulted from the 1996 Health Insurance Portability and Accountability Act ( HIPAA ) do not prohibit the pooling and use of such data (see Chap. 10), but they do lay down policy rules and technical security practices that must be part of the solution in achieving the vision we are discussing here. • Standards for data transmission and sharing : Sharing data over networks requires that all developers of EHRs and clinical databases adopt a single set of standards for communi￾cating and exchanging information. The de facto standard for such sharing, Health Level 7 (HL7), was introduced decades ago and, after years of work, is beginning to be uni￾formly adopted, implemented, and utilized (see Chap. 7). • Standards for data defi nitions : A uniform “envelope” for digital communication, such as HL7, does not assure that the contents of such messages will be understood or standardized. The pooling and integration of data requires the adoption of standards for clinical termi￾nology and potentially for the schemas used to store clinical information in databases (see Chap. 7). • Quality control and error checking : Any sys￾tem for accumulating, analyzing, and utilizing clinical data from diverse sources must be complemented by a rigorous approach to qual￾ity control and error checking. It is crucial that users have faith in the accuracy and compre￾hensiveness of the data that are collected in such repositories, because policies, guide￾lines, and a variety of metrics can be derived over time from such information. Provider Provider Provider Provider Provider EHR Internet Regional and National Surveillance Databases Protocols and Guidelines for Standards of Care EHR EHR EHR EHR Different Vendors Fig. 1.6 A future vision of surveillance databases, in which clinical data are pooled in regional and national repositories through a process of data submission that occurs over the Internet (with attention to privacy and security concerns as discussed in the text). When informa￾tion is effectively gathered, pooled, and analyzed, there are signifi cant opportunities for feeding back the results of derived insights to practitioners at the point of care E.H. Shortliffe and M.S. Blois

1 Biomedical Informatics: The Science and the Pragmatics Regional and national surveillance databases: 1.2.2 The Goal: A Learning Health Any adoption of the model in Fig. 1.6 will Care System require mechanisms for creating, funding, and maintaining the regional and national data- We have been stressing the cyclical role of bases that are involved(see Chap. 13). The role information--its capture, organization, interpreta- of state and federal governments will need to and ultimate use. You can easily understand be clarified, and the political issues addressed nall cycle that is implied: patient-specific (including the concerns of some members of data and plans entered into an EHR and subse- the populace that any government role in man- quently made available to the same practitioner or aging or analyzing their health data may have others who are involved in that patients care societal repercussions that threaten individual (Fig. 1.7). Although this view is a powerful con- liberties, employability, and the like) tributor to improved data management in the care with the establishment of surveillance data- of patients, it fails to include a larger view of the bases, and a robust system of Internet integration societal value of the information that is contained with EHRs, summary information can flow back in clinical-care records. In fact, such straightfor to providers to enhance their decision making at ward use of EhRs for direct patient care does not the point of care(Fig. 1.6). This assumes stan- meet some of the requirements that the US govern dards that allow such information to be integrated ment has specified when determining eligibility into the vendor-supplied products that the clini- for payment of incentives to clinicians or hospitals cians use in their practice settings. These may be who implement EHRs(see the discussion of this EHRs or, increasingly, order-entry systems that government program in Sect. 1.3) clinicians use to specify the actions that they Consider, instead, an expanded view of want to have taken for the treatment or manage- the health surveillance model introduced in ment of their patients(see Chaps. 12 and 14). Sect. 1. 2. 1( Fig. 1.8). Beginning at the left of Furthermore, as is shown in Fig. 1.6, the data- the diagram, clinicians caring for patients use bases can help to support the creation of evidence- electronic health records, both to record their based guidelines, or clinical research protocols, observations and to gain access to informa which can be delivered to practitioners through tion about the patient. Information from these the feedback process. Thus one should envision a records is then forwarded automatically to day when clinicians, at the point of care, will receive integrated, non-dogmatic, supportive information regarding: Electronic Recommended steps for health promotion and Patient Health disease prevention Detection of syndromes or problems, either in their community or more widely patterns of blic health Providers Importance Caring for Clinical guidelines, adapted for execution and integration into patient-specific decision Access support rather than simply provided as text Patient nformation documents Opportunities for distributed(community Knowlege and based) clinical research, whereby patients Advice from others are enrolled in clinical trials and protocol idelines are in turn integrated with the cli nicians'EHR to support protocol-compliant Fig. 1. 7 There is a limited view of the role of EHRs that sees them as intended largely to support the ongoing care management of enrolled patients of the patient whose clinical data are stored in the record

13 • Regional and national surveillance databases : Any adoption of the model in Fig. 1.6 will require mechanisms for creating, funding, and maintaining the regional and national data￾bases that are involved (see Chap. 13). The role of state and federal governments will need to be clarifi ed, and the political issues addressed (including the concerns of some members of the populace that any government role in man￾aging or analyzing their health data may have societal repercussions that threaten individual liberties, employability, and the like). With the establishment of surveillance data￾bases, and a robust system of Internet integration with EHRs, summary information can fl ow back to providers to enhance their decision making at the point of care (Fig. 1.6 ). This assumes stan￾dards that allow such information to be integrated into the vendor-supplied products that the clini￾cians use in their practice settings. These may be EHRs or, increasingly, order-entry systems that clinicians use to specify the actions that they want to have taken for the treatment or manage￾ment of their patients (see Chaps. 12 and 14). Furthermore, as is shown in Fig. 1.6 , the data￾bases can help to support the creation of evidence￾based guidelines, or clinical research protocols, which can be delivered to practitioners through the feedback process. Thus one should envision a day when clinicians, at the point of care, will receive integrated, non-dogmatic, supportive information regarding: • Recommended steps for health promotion and disease prevention • Detection of syndromes or problems, either in their community or more widely • Trends and patterns of public health importance • Clinical guidelines, adapted for execution and integration into patient-specifi c decision support rather than simply provided as text documents • Opportunities for distributed (community￾based) clinical research, whereby patients are enrolled in clinical trials and protocol guidelines are in turn integrated with the cli￾nicians’ EHR to support protocol-compliant management of enrolled patients 1.2.2 The Goal: A Learning Health Care System We have been stressing the cyclical role of information—its capture, organization, interpreta￾tion, and ultimate use. You can easily understand the small cycle that is implied: patient-specifi c data and plans entered into an EHR and subse￾quently made available to the same practitioner or others who are involved in that patient’s care (Fig. 1.7 ). Although this view is a powerful con￾tributor to improved data management in the care of patients, it fails to include a larger view of the societal value of the information that is contained in clinical-care records. In fact, such straightfor￾ward use of EHRs for direct patient care does not meet some of the requirements that the US govern￾ment has specifi ed when determining eligibility for payment of incentives to clinicians or hospitals who implement EHRs (see the discussion of this government program in Sect. 1.3 ). Consider, instead, an expanded view of the health surveillance model introduced in Sect. 1.2.1 (Fig. 1.8 ). Beginning at the left of the diagram, clinicians caring for patients use electronic health records, both to record their observations and to gain access to informa￾tion about the patient. Information from these records is then forwarded automatically to Electronic Health Records Access Patient Information Record Patient Information Provider’s Knowlege and Advice from Others Providers Caring for Patients Fig. 1.7 There is a limited view of the role of EHRs that sees them as intended largely to support the ongoing care of the patient whose clinical data are stored in the record 1 Biomedical Informatics: The Science and the Pragmatics

E.H. Shortliffe and m.s. blois and Clinical Providers Public Caring for Health and Patients Creation of Prevention Decision-Support Protocols TReatment and Order-Entry Guidelines and A"Learning Healthcare Materials Fig. 1. 8 The ultimate goal is to create a cycle of care, using a v computer-supported decision- tion flow, whereby data from distributed electr records(EHRs) are routinely and effortlessly edge, driven by ce, and fed back to clinicians, has registries and research databases. The res been dubbed a health care system knowledge then can feed back to practitioners at the point regional and national registries as well as to Medicine, which has published a series of research databases that can support retrospec- reports on the topic (OM 2007: 2011; 2012) tive studies(see Chap. 11) or formal institu tional or community-based clinical trials(see Chap. 26). The analyzed information from reg- 1.2.3 Implications of the Internet stries and research studies can in turn be used to for Patients develop standards for prevention and treatment, with major guidance from biomedical research. As the penetration of the Internet continues to Researchers can draw information either directly grow, it is not surprising that increasing numbers from the health records or from the pooled data of patients, as well as healthy individuals, are in registries. The standards for treatment in turn turning to the internet for health information it is can be translated into protocols, guidelines, and a rare North American physician who has not educational materials. This new knowledge and encountered a patient who comes to an appoint decision-support functionality can then be deliv- ment armed with a question, or a stack of pri ered over the network back to the clinicians so outs, that arose due to medically related searches that the information informs patient care, where on the net. The companies that provide search it is integrated seamlessly with EHRs and order- engines for the Internet report that health-related entry systems sites are among the most popular ones being a This notion of a system that allows us to learn explored by consumers. As a result, physicians from what we do, unlocking the experience that and other care providers must be prepared to deal has traditionally been stored in unusable form in with information that patients discover on the net paper charts, is gaining wide attention now that and bring with them when they seek care from we can envision an interconnected community of clinicians. Some of the information is timely and clinicians and institutions, building digital data excellent; in this sense physicians can often learn resources using EHRs. The concept has been dubbedalearninghealthcaresystemandisanhttp://www.iom.edw/activities/quality/learningheaLthcare ongoing subject of study by the Institute of aspx(Accessed 3/3/2013)

14 regional and national registries as well as to research databases that can support retrospec￾tive studies (see Chap. 11) or formal institu￾tional or community- based clinical trials (see Chap. 26). The analyzed information from reg￾istries and research studies can in turn be used to develop standards for prevention and treatment, with major guidance from biomedical research. Researchers can draw information either directly from the health records or from the pooled data in registries. The standards for treatment in turn can be translated into protocols, guidelines, and educational materials. This new knowledge and decision-support functionality can then be deliv￾ered over the network back to the clinicians so that the information informs patient care, where it is integrated seamlessly with EHRs and order￾entry systems. This notion of a system that allows us to learn from what we do, unlocking the experience that has traditionally been stored in unusable form in paper charts, is gaining wide attention now that we can envision an interconnected community of clinicians and institutions, building digital data resources using EHRs. The concept has been dubbed a learning health care system and is an ongoing subject of study by the Institute of Medicine, 3 which has published a series of reports on the topic (IOM 2007 ; 2011 ; 2012 ). 1.2.3 Implications of the Internet for Patients As the penetration of the Internet continues to grow, it is not surprising that increasing numbers of patients, as well as healthy individuals, are turning to the Internet for health information. It is a rare North American physician who has not encountered a patient who comes to an appoint￾ment armed with a question, or a stack of print￾outs, that arose due to medically related searches on the net. The companies that provide search engines for the Internet report that health-related sites are among the most popular ones being explored by consumers. As a result, physicians and other care providers must be prepared to deal with information that patients discover on the net and bring with them when they seek care from clinicians. Some of the information is timely and excellent; in this sense physicians can often learn 3 http://www.iom.edu/Activities/Quality/LearningHealthCare. aspx (Accessed 3/3/2013). Creation of Protocols. Guidelines, and Educational Materials A ‘’Learning Healthcare System’’ Information, Decision-Support, and Order-Entry Systems Providers Caring for Patients Electronic Health Records Regional and National Public Health and Disease Registries Biomedical and Clinical Resarch Standards for Prevention and Treatment Fig. 1.8 The ultimate goal is to create a cycle of informa￾tion fl ow, whereby data from distributed electronic health records (EHRs) are routinely and effortlessly submitted to registries and research databases. The resulting new knowledge then can feed back to practitioners at the point of care, using a variety of computer-supported decision￾support delivery mechanisms. This cycle of new knowl￾edge, driven by experience, and fed back to clinicians, has been dubbed a “learning health care system” E.H. Shortliffe and M.S. Blois

1 Biomedical Informatics: The Science and the Pragmatics about innovations from their patients and will availability of the Internet, there are many other need to be increasingly open to the kinds of ques- areas that need attention if the vision of a learn- tions that this enhanced access to information ing health care system is to be achieved will generate from patients in their practices. On the other hand, much of the health information on 1. 2. 4.1 Education and Training the Web lacks peer review or is purely anecdotal. There is a difference between computer literacy People who lack medical training can be misled (familiarity with computers and their routine uses by such information, just as they have been in our society) and knowledge of the role that poorly served in the past by printed information computing and communications technology can in books and magazines dealing with fad treat- and should play in our health care system. We ar ments from anecdotal sources. In addition, some generally doing a poor job of training future chi sites provide personalized advice, sometimes for nicians in the latter area and are thereby leaving a fee, with all the attendant concerns about the them poorly equipped for the challenges and quality of the suggestions and the ability to give opportunities they will face in the rapidly chan valid advice based on an electronic mail or Web- ing practice environments that surround them based interactio (Shortliffe 2010). In a positive light, the new communications Furthermore, much of the future vision we technologies offer clinicians creative ways to have proposed here can be achieved only if edu interact with their patients and to provide higher cational institutions produce a cadre of talented quality care. Years ago medicine adopted the individuals who not only comprehend computing telephone as a standard vehicle for facilitating and communications technology but also have a patient care, and we now take this kind of inter- deep understanding of the biomedical milieu and action with patients for granted. If we extend the of the needs of practitioners and other health audio channel to include our visual sense as well, workers. Computer science training alone is not typically relying on the Internet as our commu- adequate. Fortunately, we have begun to see the nication mechanism, the notion of telemedicine creation of formal training programs in what has emerges( see Chap. 18). This notion of"medicine become known as biomedical informatics(see at a distance"arose early in the twentieth cen- Sect. 1. 4)that provide custom-tailored educa- tury(see Fig. 1.9), but the technology was too tional opportunities. Many of the trainees are life limited for much penetration of the idea beyond science researchers, physicians, nurses, pharma telephone conversations until the last 30-40 cists, and other health professionals who see the years. The use of telemedicine has subsequently career opportunities and challenges at the inter- grown rapidly, and there are specialized settings sections of biomedicine, information science in which it is already proving to be successful computer science, decision science, cognitive and cost-effective(e. g, rural care, international science, and communications technologies. As medicine, teleradiology, and video-based care of has been clear for over two decades( Greenes and patients in prisons). Shortliffe 1990), however, the demand for such individuals far outstrips the supply, both for aca- demic and industrial career pathways. We need 1.2.4 Requirements for Achieving the vision Effortsthatcontinuetopushthestateoftheartin4http://www.healthcare-informa /news-item/ Internet technology all have significant implica- survey-strong-demand-health-in technology tions for the future of health care delivery in gen- workers (Accessed 3/3/2013) wchide. org/ eral and of EHRs and their integration in about/press/press/803-ehealth-initi rvey-reveals- high-demand-for-health-information-technology-workers particular(Shortliffe 1998b, 2000). But in addi-(Accessed 9/11/20\.,S/HITtalent(Accessed 4/21/13) tiontoincreasingspeedreliabilitysecurityandhttp://www.pwc.com

15 about innovations from their patients and will need to be increasingly open to the kinds of ques￾tions that this enhanced access to information will generate from patients in their practices. On the other hand, much of the health information on the Web lacks peer review or is purely anecdotal. People who lack medical training can be misled by such information, just as they have been poorly served in the past by printed information in books and magazines dealing with fad treat￾ments from anecdotal sources. In addition, some sites provide personalized advice, sometimes for a fee, with all the attendant concerns about the quality of the suggestions and the ability to give valid advice based on an electronic mail or Web￾based interaction. In a positive light, the new communications technologies offer clinicians creative ways to interact with their patients and to provide higher quality care. Years ago medicine adopted the telephone as a standard vehicle for facilitating patient care, and we now take this kind of inter￾action with patients for granted. If we extend the audio channel to include our visual sense as well, typically relying on the Internet as our commu￾nication mechanism, the notion of telemedicine emerges (see Chap. 18). This notion of “medicine at a distance” arose early in the twentieth cen￾tury (see Fig. 1.9 ), but the technology was too limited for much penetration of the idea beyond telephone conversations until the last 30–40 years. The use of telemedicine has subsequently grown rapidly, and there are specialized settings in which it is already proving to be successful and cost-effective (e.g., rural care, international medicine, teleradiology , and video-based care of patients in prisons). 1.2.4 Requirements for Achieving the Vision Efforts that continue to push the state of the art in Internet technology all have signifi cant implica￾tions for the future of health care delivery in gen￾eral and of EHRs and their integration in particular ( Shortliffe 1998b , 2000 ). But in addi￾tion to increasing speed, reliability, security, and availability of the Internet, there are many other areas that need attention if the vision of a learn￾ing health care system is to be achieved. 1.2.4.1 Education and Training There is a difference between computer literacy (familiarity with computers and their routine uses in our society) and knowledge of the role that computing and communications technology can and should play in our health care system. We are generally doing a poor job of training future cli￾nicians in the latter area and are thereby leaving them poorly equipped for the challenges and opportunities they will face in the rapidly chang￾ing practice environments that surround them (Shortliffe 2010 ). Furthermore, much of the future vision we have proposed here can be achieved only if edu￾cational institutions produce a cadre of talented individuals who not only comprehend computing and communications technology but also have a deep understanding of the biomedical milieu and of the needs of practitioners and other health workers. Computer science training alone is not adequate. Fortunately, we have begun to see the creation of formal training programs in what has become known as biomedical informatics (see Sect. 1.4 ) that provide custom-tailored educa￾tional opportunities. Many of the trainees are life science researchers, physicians, nurses, pharma￾cists, and other health professionals who see the career opportunities and challenges at the inter￾sections of biomedicine, information science, computer science, decision science, cognitive science, and communications technologies. As has been clear for over two decades ( Greenes and Shortliffe 1990 ), however, the demand for such individuals far outstrips the supply, both for aca￾demic and industrial career pathways. 4,5 We need 4 http://www.healthcare-informatics.com/news-item/ survey- strong-demand-health-information-technology￾workers (Accessed 3/3/2013); http://www.ehidc.org/ about/press/press/803-ehealth-initiative-survey-reveals￾high-demand-for-health-information-technology-workers (Accessed 9/11/2013). 5 http://www.pwc.com/us/HITtalent (Accessed 4/21/13). 1 Biomedical Informatics: The Science and the Pragmatics