Medical Informatics:

Introduction

Yoon KimAssistant ProfessorDepartment of Social MedicineE-mail: gwheel@med.skku.ac.krPhone: 031-299-6301

Topics

Course overviewStudents’ expectations Requirements

Reading assignmentCourse projectExam and attendance

House keeping issuesE-mail address

Outline: Today’s lecture

Problems Motivate works in the MI

Emerging solutionsRemaining barriersCore themes

Underlie all applications of MI Unify the scientific approaches across the field of MI

Definition: Medical Informatics The field concerned with the management and use of information in health care

Hersh WR. Medical informatics: improving health care through information, JAMA, 2002, 288:1955-1958

The scientific field that deals with biomedical information, data, and knowledge ―their storage, retrieval, and optimal use for problem solving and decision-making.

Shortliff EH, Perreault LE. (eds) Medical Informatics: Computer Applications in Health Care and Biomedicine. New York: Springer-Verlag, 2000.

Medical informaticsMedical vs. Health care OR biomedicine

What is Important about This Discipline?

Medicine is fundamentally an information science

Clinicians and researchers spend a great deal of time acquiring and analyzing itThere is evidence it is not used optimally

e.g., misuse of services, medical errors, etc.

There are scientific ways to determine how to use information better

A larger view of Medical Informatics

Informatics

SocialInformatics

Medical Informatics

ChemicalInformatics

Bio-informatics

ImagingInformatics

ClinicalInformatics

Public Health Informatics

(Adapted from Hersh WR. Health/Medical/Biomedical Informatics A general Introduction. 2003)

Basic Science =Core Themes

• Standards and vocabulary • Decision-making• Usability • Implementation and evaluation

• Standards and vocabulary • Decision-making• Usability • Implementation and evaluation

Applied Science

PopulationCell and biomolecules

Organ People

Problems in Health Care ThatMotivate Use of Computers

Problems includeMedical errorsUnderuse of servicesOveruse of servicesVariations in use of servicesContinual increase in healthcare costUnclear cost-effectiveness or cost-benefit of medical tests or treatments

The Challenge and Potential for Assuring Quality Health Care for the 21st Century, Dept. of Health and Human Services, 1998 (www.hcqualitycommission.gov)

Might Information Technology(IT) Help?

Health care does not value ITSystems adversely affect workflowThere are advantages to poor documentationIT not viewed as strategic asset

Proportion of spending on IT by industryBanking and financial – 15-20%Manufacturing – 7-10%Health care and coal mining – 2-3%

Emergence of Medical Informatics As a Discipline: Driving Forces

Knowledge base of Knowledge base of medicine: medicine: unmanageable by unmanageable by traditional paper traditional paper based medicinebased medicine

Rapid Advances in Rapid Advances in Computing and Computing and Communication TechnologyCommunication Technology

Benefit of informed Benefit of informed decision makingdecision making

Expanding Expanding Evidence base Evidence base

Patients Move Patients Move Toward SelfToward Self--CareCare

Managed CareManaged CareCapitated PaymentsCapitated Payments

Medical InjuriesAs many as 48,000 to 98,000 Americans die each year from medical errors

More people die from medical injuries than from breast cancer or AIDS or motor vehicle accidents

Direct health care costs totaling $9 - 15 billion per yearA systems approach utilizing information technology is needed

http://www.nap.edu/catalog/9728.html

Problems of Traditional Paper-based Medical Records

IllegibleIncomplete

Wrong drug, wrong dose

Inaccessible from multiple sites

Drug allergy, drug interaction

Less organized Difficult to identify necessary information at the point of car

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Allison JJ et al. Relationship of hospital teaching with quality of care and mortality for Medicare patients with acute MI. JAMA 2000; 284(10):1256-62 (Sep 13).

How good is American health care?

How good is American health care?

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Allison JJ et al. Relationship of hospital teaching with quality of care and mortality for Medicare patients with acute MI. JAMA 2000; 284(10):1256-62 (Sep 13).

Beta blockers at discharge

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52 93 88 64 78 105 98 117 136 128 115 138 137 140 135 124n (ideal patients) =

Fundamental Theorem of Medical Informatics

such that an intelligent person (practitioner) working in combination with information resources/technology is “better” than the person without such support.

Creating an environment of “supported practice”

Adapted from Hersh WR. Health/Medical/Biomedical Informatics: A general Introduction. 2003

Exploding Knowledge BaseMore than 8,000 new articles per week

During 2000, the U.S National Library of Medicine added to its on-line archivesThat represented about 40% of all articles published world-wide, in biomedical and clinical journals.

National library of Medicine: Fact Sheet MEDLINE. 30 May 2001

To maintain current knowledge, a general internist would need to read

20 articles per day365 days of the year

An impossible task…

•Exploding Medical Knowledge

•Complexity of Medical System

•Exploding Medical Knowledge

•Complexity of Medical System

Current Practice of Medicine

CurrentMedical Knowledge

A Failure of Execution“It's not a question of knowing how to treat heart disease, diabetes or mental illness.

We know how. We're just not doing it.

We're literally dying, waiting for the practice of medicine

to catch up with medical knowledge.”Margaret E. O'Kane, president, NCQA

Two Basic Types of Clinical Information

Patient-specific information Generated in the care of patientsCan take the form of numerical values, free text, or images

Knowledge-based information Documents scientific knowledge based on research and practice

Clinical informaticsapplications

Can classify by the type of information they use

Patient-specificThe core application: the electronic medical recordAnother application: telemedicine

Knowledge-based Information retrieval systems

Combining the twoDecision-support systems

Functionalities of EMR Simple EMR

Data entry and retrievalPrescriptions, lab resultsImages: PACS

Advanced EMREMR with CDSS (clinical decision support) Isolated CDSSs

Antibiotic-associated medication errors, ADEComputerized physician order entry (CPOE)

Medication error reduction Practice guideline implementation

Efficacy of DSSs to Improve Care and Reduce Errors

Isolated Clinical DSSs4 out of 7 studies showed significant improvement Antibiotic-associated medication errors, ADE

Computerized physician order entry (CPOE) 5 out of 5 studies showed significant improvement Reduce medication errorsImprove corollary ordersNephrotoxic drug dose and frequency

No learning effect

Review article Kaushal et al. Effects of computerized physician order entry and clinical decision support systems on medication safety: a systematic review. Arch Intern Med. 2003 Jun 23;163(12):1409-16.

Decision Support System: Antibiotics Prescription Management

Patient Information: Coded Data• Culture results• Sensitivity• Ampicillin

Knowledge base: Decision Logic

•Machine-readable•Explicit & Detail•Update

Antibiotic Prescription Management

1988 1994 Total patients 25,288 21,898Antibiotic patients 8,051 (31.8%) 11,624 (53.1%)Overall LOS 5.11 4.50Antibiotic LOS 7.5 7.3Antibiotic cost/patient $122.66 $ 78.37Pharmacy costs $3,979,561 $7,185,817Antibiotic costs $ 987,547 $ 924,876

(24.8%) (12.9%)Mortality (infection-related) 3.65% 2.65%

higher severity of illness (case mix index)no change in patterns of bacterial resistance

more wide-spectrum antibiotic usehigher per unit pharmacy costs

(reduced total tonnage, better crop rotation)

Evans et al. A computer-assisted management program for antibiotics and other antiinfective agents.New Engl J Med 1998; 338(4):232-8 (Jan 22).

Challenges to EMR Implementations

Integration into clinical workflowCustomization vs. BPR

Productivity Add more time Time saving through automation & error reduction

Management of systemsTechnical: Complex applications, hardwares and networks Human: education, involvement, behavioral change

Core themes Standards and vocabularies Usability

Cost and reimbursement Cost of EMR implementations (typical, $50mil) Benefit: society vs. provider

Access to KnowledgebaseCustomized & Organized Information

Baorto DM et al.An "Infobutton" for Enabling Patients to Interpret On-line Pap Smear Reports.

Underuse: How Good is American Health Care?

Extensive literature review performed at RAND in 1998:

♦ Only 50% of Americans receive recommendedpreventive care

♦ Patients with acute illness:70% received recommended treatments30% received contraindicated treatments

♦ Patients with chronic illness:60% received recommended treatments20% received contraindicated treatments

Schuster MA, McGlynn EA, Brook RH. How good is the quality of healthcare in the United States? Milbank Quarterly 1998; 76(4):517-63.

미국에서의 예방가능한 사망: 예방서비스 미이용 및 질병관리 실패

계금연산전진찰당뇨병 관리고혈압 조절콜레스테롤 조절자궁경부암 검진유방암 검진베타차단제

NCQA. The state of health care quality: 2003. 2003

예방서비스 이용률 및 질병 관리율(상위 10%와 하위 10%)

우리나라는?

*Source: E-disease Management. FCG, 2001.

정보기술을 이용한 질병관리시스템E-disease Management

Telemedicine Application System: E-disease Management System

정의1)

정보기술을 만성질환관리에 활용하는 것

대상1)

질환: 당뇨병, 만성심부전 (chronic heart failure), 만성폐쇄성폐질환 (chronic obstructive pulmonary disease), 천식, 후천성면역결핍증, 암건강상태: 운동, 식이요법, 건강을 유지하기 위한 약물요법

배경2)

인구의 노령화, 만성질환의 증가

환자의 스스로 돌보기 (self-care) 능력이 질병관리에 중요

Information gap: 환자가 알고 있는 것 vs. 환자가 알아야 할 것

환자의 상태를 자주 객관적으로 평가할 수 있어야

필요할 경우 의료진과 즉시 또는 시의 적절하게 접촉할 수 있어야

Challenges ReimbursementPaucity of studies demonstrating clinical efficacy and cost-effectivenessRequiring clinical care processes and behavior of clinicians and patients

1) Mazzi CP, Kidd M. A Framework for the Evaluation of Internet-based Diabetes Management. Journal of Medical Internet Research 2002;4(1):e1

2) Spader JA. Telemedicine in Disease Management. In Nelson R, Ball MJ (Eds). Consumer Informatics. Springer. 2004

National Electronic Disease Surveillance System (NEDSS)

Use of data and information system standards

Efficient, integrated, and interoperable surveillance systems At federal, state and local levels.

A primary goal of NEDSS

Ongoing, automatic capture and analysis of data that are already available electronically http://www.cdc.gov/nedss/NedssArchitecture/NEDSSsysarch2.0.pdf

예방접종정보시스템의 현황영유아 예방접종 프로그램

접종내역입력

예방접종정보시스템의 현황영유아 예방접종 프로그램

예방접종정보시스템의 현황예방접종포탈사이트(보호자용)

자녀의 출생일을 기준으로 한표준예방접종 스케쥴표

보호자가 웹상에서 직접 등록한 자료

자녀의 예방접종등록 내역

MedlinePlus 제공 정보: 질병정보 제공 중심

MedlinePlus질병 정보건강건강••질병질병 정보정보

의약품의약품 정보정보

의학백과사전의학백과사전

의학용어사전의학용어사전

의료제공자의료제공자 정보정보

Recurrent Themes in MedicalInformatics

StandardsTo facilitate integration and interchange of data

TerminologyCommon descriptions of diagnoses, activities, etc.

UsabilityApplications must minimize impact on work flow and/or provide additional value

Demonstrated valueIf we are going to advocate and devote resources, must demonstrate return on investment

예방접종정보시스템의 문제점

전산등록 자료에

대한 연계 미비

전산등록 자료에

대한 연계 미비

지역별 서버 구분별로 데이터 교환이 되지 않음

의료기관별 전산망 구축 현황이 다름 (시군 보건소는 포스데이터 개발/운영, 국립보건원은 비트컴퓨터 개발/운영)

낮은 전산 등록률낮은 전산 등록률단순 실적보고에 그침 (미흡한 정보)

보고 건수의 약 28%만 전산 등록됨

보건소의 약 75%만 참여

민간 의료기관 참여율 저조 (민간의료기관이 참여할 incentive가 없음)

데이터관리 미비데이터관리 미비 예방 접종 도우미 사이트에서 개별 입력한 것은의료기관에서 입력한 것과 구분되어야 함 (?)

데이터

측면

데이터

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예방접종정보시스템: 참여율과 등록률 2002년9월

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서울부산대구인천광주대전울산경기강원충북충남전북전남경북경남제주

22%27%

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실적보고건수 전산등록건수 등록률

전산등록사업 참여율 전산등록률

- 전국 평균 75% -전국평균 28%

참여률 : 전산등록에 참여한 보건소/총 보건소

예방접종정보시스템의 문제점

잦은 담당자

교체(1-3년)잦은 담당자

교체(1-3년)자료입력 오류

전문성 확보의 어려움

사후관리 미비사후관리 미비Recall, Remind 시스템 활용이 안됨

시스템 기능성

미흡

시스템 기능성

미흡시스템 데이터 입력 시, 선택예방접종명(뇌수막염,A형간염 등)은 입력 불가

민간 의료기관 보고 서식 프로그램 부재

타 시스템과의

연계성 미흡

타 시스템과의

연계성 미흡주민등록번호 시스템과 연계 미흡

예방접종률 및 적기접종률 파악 기전 부재

개인정보보호개인정보보호 개인 정보 보호를 위한 보안 시스템 미비

접종 대상자의

정보 접근 불가

접종 대상자의

정보 접근 불가 접종 대상자의 본인 정보 접근 불가

시스템

측면

시스템

측면

관리체계측면

관리체계측면

Pressure & IncentiveIOM (Institute of Medicine)

Series of reports on medical injuries and patient safetyPropose IT(CPOE, EHR) to solve problems

Purchasing PowerCMS (Center for Medicare &Medicaid)

Proposes an incentive bonus for providers having and using EHR system

Leapfrog Group One of patient safety measures: CPOE in hospital

Mandate California’s legislative mandate for urban hospitals

To Implement CPOE system by 2005To have plan to Implement CPOE system by 2002

Organizations Concerned with Medical Informatics

American Medical Informatics Association - www.amia.orgInternational Medical Informatics Association - www.imia.orgNational Library of Medicine - www.nlm.nih.govAgency for Healthcare Quality and Research - www.ahrq.gov

Health Information Management Systems Society -www.himss.orgAssociation of Medical Director of Information Systems -www.amdis.orgAmerican Health Information Management Association -www.ahima.orgMedical Library Association - www.mlanet.org

Reading Assignment

Hersh WR. Medical informatics: improving health care through information, JAMA, 2002, 288:1955-1958