Kun, L, Baretich, MF."Biocomputing The Electrical Engineering Handbook Ed. Richard C. Dorf Boca raton crc Press llc. 2000
Kun, L., Baretich, M.F. “Biocomputing” The Electrical Engineering Handbook Ed. Richard C. Dorf Boca Raton: CRC Press LLC, 2000
117 Biocomputing 117.1 Clinical Information Systems Luis Ki and the Cis Integration.Smart/Optical Cards Matthew e. Baretich 117.2 Hospital Information Systems niversity of Colorado The Clinical Environment Healthcare Codes and Standards 117.1 Clinical Information Systems Luis Kun The main objective of this section is to provide the reader with a summary of areas that relate to clinical information systems. Since this field is so wide, the following topics will be covered mainly because of their importance within the field of medical informatics and the impact that these areas will have in healthcare delivery in the near future. At the end of this section there is a list of definitions that should help the reader not used to related acronyms and a list of suggested bibliographic references which should allow those interested to further increase their knowledge Computer-Based Record Besides improvements in patient care, enhancing the productivity of physicians, nurses, and all healthcare related personnel is very high on the agenda of all hospitals Hospitals, clinics, HMOs, doctors offices, emer- gency care centers, group practices, laboratories, radiology clinics, and nursing homes among others have a need to share patients' records. Aside from the direction that all of these medical-related centers will have with a required connection to the insurance companies/agencies to speed up payments and their accuracy, the growing need is to have the ability to transfer patients'medical files electronically anywhere in the world. As medical centers become more competitive, they will become worldwide centers of excellence for their given cialties. In turn then, their services will be marketed to the entire world population, becoming true global resources The trend of converting hospitals into"paperless hospitals"is becoming one of the most important topics of the 1990s. In 1970, chartered by the National Academy of Sciences, the Institute of Medicine working under the Policy Matters for Public Health has actively pursued the creation of a computer-based record( CBr). In July of 1991 a book was published by the Institute of Medicine in regards to the CBr. The requirements to ompile an all-digital medical record(ADMR)will require ways to combine data, graphics, voice, signals, and images, both clinical and document. The architecture that will accommodate all these forms of information for capturing, storing, communicating, and displaying is extremely complex. Some of the technologies involved include optical fibers, LANS, compact/optical disks, bedside terminals, medical image display stations, image diagnostic workstations, and picture archival and communications systems to name a few The High Performance Computing and Communications Initiative(HPCCI)was signed into law in Decem- ber of 1991. Although most of the emphasis for this initiative was from a research and academic sense, some c 2000 by CRC Press LLC
© 2000 by CRC Press LLC 117 Biocomputing 117.1 Clinical Information Systems Computer-Based Record • Clinical Information Standards • Bedside Terminals/Point-of-Care Systems • Imaging and the CIS • Systems Integration • Smart/Optical Cards 117.2 Hospital Information Systems The Clinical Environment • Healthcare Codes and Standards 117.1 Clinical Information Systems Luis Kun The main objective of this section is to provide the reader with a summary of areas that relate to clinical information systems. Since this field is so wide, the following topics will be covered mainly because of their importance within the field of medical informatics and the impact that these areas will have in healthcare delivery in the near future. At the end of this section there is a list of definitions that should help the reader not used to related acronyms and a list of suggested bibliographic references which should allow those interested to further increase their knowledge. Computer-Based Record Besides improvements in patient care, enhancing the productivity of physicians, nurses, and all healthcarerelated personnel is very high on the agenda of all hospitals. Hospitals, clinics, HMOs, doctors’ offices, emergency care centers, group practices, laboratories, radiology clinics, and nursing homes among others have a need to share patients’ records. Aside from the direction that all of these medical-related centers will have with a required connection to the insurance companies/agencies to speed up payments and their accuracy, the growing need is to have the ability to transfer patients’ medical files electronically anywhere in the world. As medical centers become more competitive, they will become worldwide centers of excellence for their given specialties. In turn then, their services will be marketed to the entire world population, becoming true global resources. The trend of converting hospitals into “paperless hospitals” is becoming one of the most important topics of the 1990s. In 1970, chartered by the National Academy of Sciences, the Institute of Medicine working under the Policy Matters for Public Health has actively pursued the creation of a computer-based record (CBR). In July of 1991 a book was published by the Institute of Medicine in regards to the CBR. The requirements to compile an all-digital medical record (ADMR)will require ways to combine data, graphics, voice, signals, and images, both clinical and document. The architecture that will accommodate all these forms of information for capturing, storing, communicating, and displaying is extremely complex. Some of the technologies involved include optical fibers, LANs, compact/optical disks, bedside terminals, medical image display stations, image diagnostic workstations, and picture archival and communications systems to name a few. The High Performance Computing and Communications Initiative (HPCCI) was signed into law in December of 1991. Although most of the emphasis for this initiative was from a research and academic sense, some Luis Kun Cedars-Sinai Medical Center Matthew F. Baretich University of Colorado
of the true practical values of these highways of information will occur at the clinical level. While advances are taking place in different parts of the world in fighting diseases such as cancer, AIDS, heart disease, cystic fibrosis, Alzheimers, Parkinsons, Gaucher's, and malignant hyperthermia, not sharing the knowledge learned by all the groups would be a terrible underutilization of extremely costly resources, causing duplication of effort and enormous waste of time and resources The four technologies that have been considered critical by the National Institutes of Health for the con years are molecular medicine, vaccine development, structural biology, and biotechnology. The four will greatly be affected by the HPCCI. Finally, the integration of all medical-related information will be the most complex ask that the healthcare arena will face this decade Clinical Information Standards One of the most demanding and key areas for successfully integrating the hospital information system(HIS) with the clinical information systems( CIS) from multiple clinical departments and/or clinical areas deals with clinical information standards. Two of the driving forces behind the automation of the patient record deal with national concerns related to healthcare costs and quality of healthcare. These concerns have generated demand for managed care. The automated patient record could then be one of the vehicles to achieve managed care. Clinical information standards are constantly evolving. They were developed(some are still in the process of development;e.g, IEEE/MIB P1073)by very different sets of requirements. What follows is a brief description and structure of most of these standards Communications Storage (e.g, HL/7, IEEE/MEDIX P1157, ANSI ASC X12, ACR/NEMA, IEEE/MIB P1073 The HL/7 standards group aimed to define vendor-independent communications standards among components of hospital information systems. The IEEE, ANSI, ACR/NEMA, and AsTM have been very active in creating standards through subcommittees from organizations within. As an example, ASTM has the following Health care Automation Committees(E31.XX): E31.10: Computer automation in the Hospital Pharmacy E31. 11: Data exchange standards for Clinical Laboratory results E31. 12: Medical Informatics E31. 13: Clinical Laboratory Systems E31. 14: Clinical Laboratory Instrument Interface E31. 15: Health Knowledge Representation The MEDIX mission was to establish a robust and flexible communications standard for the exchange of data between heterogeneous healthcare information systems. The MiB was created mainly to allow the exchange of data from medical instrumentation, e.g., monitoring devices and hospital information systems. Many of the manufacturers of these devices have proprietary hardware, e.g., buses and/or software, which complicates this exchange. Bedside terminals in the intensive care environment will benefit immensely from such a standard since most hospitals'ICUs and CCUs have many vendors equipment in their units. To effectively integrate and manage the data are major goals of the MIB. Classification/Reimbursement(e.g, ICD, DRG, SNOMED, CPT, DSM, RCS, UMLS) ICDs were originally used for public health morbidity statistics; now in the United States they are primarily used for reimbursement. Its structure is numbered classification of diseases grouped by anatomical areas. The RGs facilitate the definition of case-mix for hospital reimbursement. Its structure is multi-axial: severity of illness, prognosis, treatment difficulty, need for intervention, and resource intensity. SNOMED Provides description of pathological tests related to patient identification. It has four axes: function(primary symptoms) etiology(cause of disease), morphology(description of disease form), and topology(area of body ) CPT is primarily used for reimbursement and utilization review. It derives codes from specialty nomenclatures divided into chapters: systemic(medicine, anesthesia, etc. ) topological (cardiovascular, lymphatic, etc. ) and technological e 2000 by CRC Press LLC
© 2000 by CRC Press LLC of the true practical values of these highways of information will occur at the clinical level. While advances are taking place in different parts of the world in fighting diseases such as cancer, AIDS, heart disease, cystic fibrosis, Alzheimer’s, Parkinson’s, Gaucher’s, and malignant hyperthermia, not sharing the knowledge learned by all the groups would be a terrible underutilization of extremely costly resources, causing duplication of effort and enormous waste of time and resources. The four technologies that have been considered critical by the National Institutes of Health for the coming years are molecular medicine, vaccine development, structural biology, and biotechnology. The four will greatly be affected by the HPCCI. Finally, the integration of all medical-related information will be the most complex task that the healthcare arena will face this decade. Clinical Information Standards One of the most demanding and key areas for successfully integrating the hospital information system (HIS) with the clinical information systems (CIS) from multiple clinical departments and/or clinical areas deals with clinical information standards. Two of the driving forces behind the automation of the patient record deal with national concerns related to healthcare costs and quality of healthcare. These concerns have generated demand for managed care. The automated patient record could then be one of the vehicles to achieve managed care. Clinical information standards are constantly evolving. They were developed (some are still in the process of development; e.g., IEEE/MIB P1073) by very different sets of requirements. What follows is a brief description and structure of most of these standards. Communications/Storage (e.g., HL/7, IEEE/MEDIX P1157, ANSI ASC X12, ACR/NEMA, IEEE/MIB P1073) The HL/7 standards group aimed to define vendor-independent communications standards among components of hospital information systems. The IEEE, ANSI, ACR/NEMA, and ASTM have been very active in creating standards through subcommittees from organizations within. As an example, ASTM has the following Healthcare Automation Committees (E31.XX): • E31.10: Computer automation in the Hospital Pharmacy • E31.11: Data exchange standards for Clinical Laboratory results • E31.12: Medical Informatics • E31.13: Clinical Laboratory Systems • E31.14: Clinical Laboratory Instrument Interface • E31.15: Health Knowledge Representation The MEDIX mission was to establish a robust and flexible communications standard for the exchange of data between heterogeneous healthcare information systems. The MIB was created mainly to allow the exchange of data from medical instrumentation, e.g., monitoring devices and hospital information systems. Many of the manufacturers of these devices have proprietary hardware, e.g., buses and/or software, which complicates this exchange. Bedside terminals in the intensive care environment will benefit immensely from such a standard, since most hospitals’ ICUs and CCUs have many vendors’ equipment in their units. To effectively integrate and manage the data are major goals of the MIB. Classification/Reimbursement (e.g., ICD, DRG, SNOMED, CPT, DSM, RCS, UMLS) ICDs were originally used for public health morbidity statistics; now in the United States they are primarily used for reimbursement. Its structure is numbered classification of diseases grouped by anatomical areas. The DRGs facilitate the definition of case-mix for hospital reimbursement. Its structure is multi-axial: severity of illness, prognosis, treatment difficulty, need for intervention, and resource intensity. SNOMED provides description of pathological tests related to patient identification. It has four axes: function (primary symptoms), etiology (cause of disease), morphology (description of disease form), and topology (area of body). CPT is primarily used for reimbursement and utilization review. It derives codes from specialty nomenclatures divided into chapters: systemic (medicine, anesthesia, etc.), topological (cardiovascular, lymphatic, etc.), and technological
(radiology, laboratory, etc. ) DSM provides consistent abbreviations for prescription and administrative use. It facilitates psychiatric education and research. Its structure is multi-axial: clinical syndromes, developmental and personality disorders, physical disorder, severity psychological stresses, and global assessment functioning RCS is a comprehensive nomenclature and classification of medical terms for computerized records. UML facilitates the unification of clinical data classification systems into a single unified medical language system. It will also facilitate the creation of data into compatible automated patient record systems. Its structure reconciles clinical terminology, semantics, and formats of the major clinical coding and reference systems Knowledge (e.g, ARDEN SYNTAX The ARDEN SYNTAX is a standard for sharing medical knowledge bases in the form of medical logic modules (MLM). Its structure is derived from the HELP (LDS Hospital)and the CARE (Regenstrief MC)systems. The MLMs accommodate alerts, management critiques, therapy suggestions, diagnosis scoring, etc. Each MLM is limited to the knowledge to make a single decision. HCFA (e. g, UCDS, WARP, UHDDS) UCDS provides an electronic clinical data set that Medicare can use to perform clinical quality reviews. The quality evaluation is done by using algorithms related to surgical procedures, disease specific, organ specific discharge status and disposition, etc. The UCDS permits the hospital to enter the data into a personal computer then this information can be sent electronically to the HCFA. warP provides an epidemiologic approach to quality assurance. It hopes to overcome about 50% of ICD miscoding and its initial focus is on ambulatory chart review rather than real-time patient care. It is not a diagnostic or procedural classification system. It basically provides a model for encoding clinical information. It is an object-oriented case tool. UHDDS was created for studies on quality of care and fraud. It is also used for auditing Medicare and Medicaid subsystems. Bedside Terminals/point-of-Care Systems Patient information is generated on an ongoing basis, wherever the patient may be. Almost two decades ago with the creation of the first programmable calculators, a trend started in terms of calculating hemodynamic variables in the OR, etc. This approach was improved with the creation of personal computers, ending with the development of what are now called bedside terminals. Companies such as Clinicom, Emtek, Hewlett Packard, Hospitronics, and Spacelabs offer systems that can go from doing simply patient monitoring, to a complete data acquisition, data management, and data analysis system that incorporates in some cases diagnosis and treatment therapy. From the patients' point of view, it is critical to integrate their demographic information with their clinical data. Usually the HIS contains all the ADT, orders, laboratory, pharmacy, etc. while the CIS may be more of a departmental system such as ICU/CCU, which contains hemodynamic variables, i. e, blood pressure, stroke volume, heart rate, etc. Both systems need to coexist. Point-of-care systems, many times known as bedside terminals, include both general med/surgery and the ICU/CCU type. The general type include functions such as patient assessment, nursing diagnosis, patient care plans, kardex, discharge planning, discharge summary medication administration record, I/O, vital signs, activities of daily living, patient classification/acuity, etc. The ICU/CCU systems in addition contain information regarding drug administration, fluid analysis, hemodynamic lysis (i.e, blood gas report, ECG, blood pressures, pulse oximeters, cardiac output), respiratory analysi (i.e, ventilator data, O /CO, analyzer), and real-time monitoring. Today's trends are incorporating imaging devices in both at the regular nursing stations, at the operating rooms, and at the recovery room/ICU/CCU. The motivation is to incorporate all patients' information and have it available wherever they may be. As a atient moves from a regular bed to the OR, back to an ICU, and later to a regular nursing station, the electronic record follows the patient. The one big difference with paper charts is that the electronic record can be shared simultaneously within and outside the institution Having the ability to look at electronic images in all of these locations not only opens the doors for consultation within the institution but also with outside institutions and/or expert individuals e 2000 by CRC Press LLC
© 2000 by CRC Press LLC (radiology, laboratory, etc.). DSM provides consistent abbreviations for prescription and administrative use. It facilitates psychiatric education and research. Its structure is multi-axial: clinical syndromes, developmental and personality disorders, physical disorder, severity psychological stresses, and global assessment functioning. RCS is a comprehensive nomenclature and classification of medical terms for computerized records. UMLS facilitates the unification of clinical data classification systems into a single unified medical language system. It will also facilitate the creation of data into compatible automated patient record systems. Its structure reconciles clinical terminology, semantics, and formats of the major clinical coding and reference systems. Knowledge (e.g., ARDEN SYNTAX) The ARDEN SYNTAX is a standard for sharing medical knowledge bases in the form of medical logic modules (MLM). Its structure is derived from the HELP (LDS Hospital) and the CARE (Regenstrief MC) systems. The MLMs accommodate alerts, management critiques, therapy suggestions, diagnosis scoring, etc. Each MLM is limited to the knowledge to make a single decision. HCFA (e.g., UCDS, WARP, UHDDS) UCDS provides an electronic clinical data set that Medicare can use to perform clinical quality reviews. The quality evaluation is done by using algorithms related to surgical procedures, disease specific, organ specific, discharge status and disposition, etc. The UCDS permits the hospital to enter the data into a personal computer; then this information can be sent electronically to the HCFA. WARP provides an epidemiologic approach to quality assurance. It hopes to overcome about 50% of ICD miscoding and its initial focus is on ambulatory chart review rather than real-time patient care. It is not a diagnostic or procedural classification system. It basically provides a model for encoding clinical information. It is an object-oriented case tool. UHDDS was created for studies on quality of care and fraud. It is also used for auditing Medicare and Medicaid subsystems. Bedside Terminals/Point-of-Care Systems Patient information is generated on an ongoing basis, wherever the patient may be. Almost two decades ago with the creation of the first programmable calculators, a trend started in terms of calculating hemodynamic variables in the OR, etc. This approach was improved with the creation of personal computers, ending with the development of what are now called bedside terminals. Companies such as Clinicom, Emtek, HewlettPackard, Hospitronics, and Spacelabs offer systems that can go from doing simply patient monitoring, to a complete data acquisition, data management, and data analysis system that incorporates in some cases diagnosis and treatment therapy. From the patients’ point of view, it is critical to integrate their demographic information with their clinical data. Usually the HIS contains all the ADT, orders, laboratory, pharmacy, etc. while the CIS may be more of a departmental system such as ICU/CCU, which contains hemodynamic variables, i.e., blood pressure, stroke volume, heart rate, etc. Both systems need to coexist. Point-of-care systems, many times known as bedside terminals, include both general med/surgery and the ICU/CCU type. The general type include functions such as patient assessment, nursing diagnosis, patient care plans, kardex, discharge planning, discharge summary, medication administration record, I/O, vital signs, activities of daily living, patient classification/acuity, etc. The ICU/CCU systems in addition contain information regarding drug administration, fluid analysis, hemodynamic analysis (i.e., blood gas report, ECG, blood pressures, pulse oximeters, cardiac output), respiratory analysis (i.e., ventilator data, O2/CO2 analyzer), and real-time monitoring. Today’s trends are incorporating imaging devices in both at the regular nursing stations, at the operating rooms, and at the recovery room/ICU/CCU. The motivation is to incorporate all patients’ information and have it available wherever they may be. As a patient moves from a regular bed to the OR, back to an ICU, and later to a regular nursing station, the electronic record follows the patient. The one big difference with paper charts is that the electronic record can be shared simultaneously within and outside the institution. Having the ability to look at electronic images in all of these locations not only opens the doors for consultation within the institution but also with outside institutions and/or expert individuals
Care HIS Graphics Intensive Care Bedside Terminal Aerospace Medicine Occupational Med Cardiovascular Disease Orthopaedic Surgery File Serve Child Psychiatry Otorhinolaryngology Dermatolog Diagnostic Radiology Pediatric Allergy Emergency Medicine Pediatric Cardiology Public Health Physical Med g logy Rehabilitation General rgery e General Surgery Radiology Home AdmissionsNeurological Surger Urological su FIGURE 117.1 An example of medical systems integration Imaging and the CIs Imaging plays two very important roles within the context of a computer-based record (CBR).Document imaging allows for all those records that exist today in storage for the medical records departments to be scanned and incorporated electronically with the rest of the patient's current records existing in the HIS and CIS. The second role is from the perspective of clinical images. Most imaging experts will call this PACS, which stands for picture archival and communications system and is mostly associated with the Radiology Department of the hospital. We can view clinical images as a form of data which can be generated in any department. Some of these typical clinical departments utilizing clinical images are radiology, cardiology(e.g, echocar diography, fluoroscopic techniques, cine cameras, 3D modeling, gamma cameras), orthopedic surgery, plastie surgery,obstetrics/gynecology, laboratories(e.g, genetics, chromosome analysis, cytology, hematology, clinical mistry, pathology, histology, electron microscope), maxillofacial clinics, sports medicine, and oncology(e.g radiation therapy, chemotherapy), emergency rooms, intensive care units, etc. There are five imaging modalities: x-ray, magnetic resonance imaging(MRI), computer tomography (Ct) nuclear medicine(NM), and ultrasound(US). These modalities create images which are very different not only in medical terms but in their size and content As a result there are three main areas under pacs which are critical in succeeding with such systems: communications (ie, network, transmission protocol, and image format), archiving (i. e, database and storage media), and image processing (i.e, display, user interface, and IP algorithms Systems Integration As an example of systems integration in the emergency care environment(see Fig 117.1),from an information- flow point of view we see the following: e 2000 by CRC Press LLC
© 2000 by CRC Press LLC Imaging and the CIS Imaging plays two very important roles within the context of a computer-based record (CBR). Document imaging allows for all those records that exist today in storage for the medical records departments to be scanned and incorporated electronically with the rest of the patient’s current records existing in the HIS and CIS. The second role is from the perspective of clinical images. Most imaging experts will call this PACS, which stands for picture archival and communications system and is mostly associated with the Radiology Department of the hospital. We can view clinical images as a form of data which can be generated in any department. Some of these typical clinical departments utilizing clinical images are radiology, cardiology (e.g., echocardiography, fluoroscopic techniques, cine cameras, 3D modeling, gamma cameras), orthopedic surgery, plastic surgery, obstetrics/gynecology, laboratories (e.g., genetics, chromosome analysis, cytology, hematology, clinical chemistry, pathology, histology, electron microscope), maxillofacial clinics, sports medicine, and oncology (e.g., radiation therapy, chemotherapy), emergency rooms, intensive care units, etc. There are five imaging modalities: x-ray, magnetic resonance imaging (MRI), computer tomography (CT), nuclear medicine (NM), and ultrasound (US). These modalities create images which are very different not only in medical terms but in their size and content. As a result, there are three main areas under PACS which are critical in succeeding with such systems: communications (i.e., network, transmission protocol, and image format), archiving (i.e., database and storage media), and image processing (i.e., display, user interface, and IP algorithms). Systems Integration As an example of systems integration in the emergency care environment (see Fig. 117.1), from an information- flow point of view we see the following: FIGURE 117.1 An example of medical systems integration