1. 1 Medical Informatics Dr. Shahram Yazdani © 2002 ATGCIATGCI

2. Dr. Shahram Yazdani © 2002 ATGCIATGCI 2 Medical Informatics Medical informatics is the application of computers, communications and information technology and systems to all fields of medicine-medical care, medical education and medical research

3. Dr. Shahram Yazdani © 2002 ATGCIATGCI 3 Biomedical Information Care Providers Patients Databases Search engines Value added Pub. EB Pub. POEM collections Information mastery Critical appraisal Data acquisition Data storage Vocabularies Organization of data Machine interfaces Data retrieval Data Dx/Tx Research Information Electronic medical records Laboratory IS Digital imaging and Radiological IS Patient monitoring systems Medical information directed to: –a specific need –at the right time –in the right place –to the right person Decision-Support Systems Diagnosis / Interpretation Therapy / Management Automated reminders and alert systems Electronic prescription and order entry Drug IS and Automated dispensing Telemedicine National health databank National health code National health card Computer Assisted Instruction Web Based Learning Clinical Judgment Diagnostic Reasoning Therapeutic Planning

4. Dr. Shahram Yazdani © 2002 ATGCIATGCI 4 Medical Informatics is Multidisciplinary Medicine/ Biology Mathematics Information Systems Computer Science Statistics Decision Analysis Economics/Health Care Policy Psychology

5. 5 Medical Records

6. Dr. Shahram Yazdani © 2002 ATGCIATGCI 6 Investment in medical records In UK, the cost of medical records units run between 2% and 6% of NHS turnover Healthcare providers spend 20-75% of their time reading, writing, sorting and searching through the notes

7. Dr. Shahram Yazdani © 2002 ATGCIATGCI 7 Shortcomings of the paper medical record Find the record (lost, being used elsewhere) Find data within the record (poorly organized, missing) Read data (legibility) Update data Record fragmentation Moving records Redundancy (re-enter data in multiple forms) Statistics and Research (can not search across patients) Passive (no automated decision support)

8. Dr. Shahram Yazdani © 2002 ATGCIATGCI 8 Benefits of electronic medical record Access, Availability, transfer and retrieval Legibility, Abstraction, reporting Saves time: find data 4 times faster Reduced data entry (reuse data) Better organization by imposing structure Storage space Allow multiple views including aggregation Automated checks on data entry (spelling checks,k=50, sum of WBC, pregnant man) Data quality and standards Automated decision support Statistics and research

9. 9 Images

10. Dr. Shahram Yazdani © 2002 ATGCIATGCI 10 Picture Archiving and Communications System

11. Dr. Shahram Yazdani © 2002 ATGCIATGCI 11 Image management Traditional Film libraries –Expensive –Inefficient –Film can only be in one place –Problem in interpretation (20% on detection, 10- 50% on diagnosis) Digital image library –Less expensive –More efficient –Tele-radiology –Automated interpretation

12. Dr. Shahram Yazdani © 2002 ATGCIATGCI 12 3 Dimensional Imaging

13. 13 Medical Errors and Point of Care Delivery of Information

14. Dr. Shahram Yazdani © 2002 ATGCIATGCI 14 Lots of lives to save Medical error is the 3 rd largest cause of death in the U.S. exceeded only by heart disease and cancer. (JAMA, July 26, 2000, p 483) –12,000 deaths/year from unnecessary surgery –7,000 deaths/year from medication errors in hospitals –20,000 deaths/year from other errors in hospitals –80,000 deaths/year from nosocomial infections in hospitals –106,000 deaths/year from adverse effects of medications (4 th leading cause of death) 50-90% of medication errors can be eliminated at time of installation of automation at the point of care.

15. Dr. Shahram Yazdani © 2002 ATGCIATGCI 15 Source: Wireless and Mobile Computing. First Consulting Group, Oct 2001.

16. Dr. Shahram Yazdani © 2002 ATGCIATGCI 16 Point of Care Automation Results Malcolm, BEliminating Medication Errors Through Point of Care Devices. Proceedings of HIMSS 2000, Session 73, Dallas.

17. Dr. Shahram Yazdani © 2002 ATGCIATGCI 17 PDA Medical Record All essential medical data on a Palm Pilot or PocketPC. Designed to integrate with global medical data system.

18. 18 Decision Support Systems

19. Dr. Shahram Yazdani © 2002 ATGCIATGCI 19 Levels of Automated Support (Van Bemmel and Musen, 1997)

20. Dr. Shahram Yazdani © 2002 ATGCIATGCI 20 Computerized reminders Computerized reminders can improve compliance with recommended guidelines –Increase preventive services –Increase use of appropriate medications –Increase use of other interventions Hunt et al. JAMA. 1998; Shea et al. J Am Med Inform Assoc. 1996

21. Dr. Shahram Yazdani © 2002 ATGCIATGCI 21 Computerized decision support Computerized decision support can improve quality –Prevention of venous thromboembolism –Use of antibiotics Durieux et al. JAMA. 2000; Teich et al. Arch Intern Med. 2000; Evans et al. N Engl J Med. 1998

22. Dr. Shahram Yazdani © 2002 ATGCIATGCI 22 EMR with Decision Support Electronic medical records with decision support can reduce costs –Reducing medical errors and adverse events –Recommending equally effective but less costly alternative interventions –Reducing the use of inappropriate tests –Reducing the ordering of redundant tests Teich et al. Arch Intern Med. 2000; Bates et al. JAMA. 1998; Glaser et al. Proc Healthcare Information and Management Systems Society Annual Conf. 1996

23. Dr. Shahram Yazdani © 2002 ATGCIATGCI 23 de Dombal’s System Domain: Acute abdominal pain Input: Signs and symptoms of patient Output: Probability distribution of diagnoses Method: Bayesian Evaluation: an eight-center study involving 250 physicians and 16,737 patients Results: –Diagnostic accuracy rose from 46 to 65% –The negative laparotomy rate fell by almost half –Perforation rate among patients with appendicitis fell by half –Mortality rate fell by 22% Results using survey data consistently better than the clinicians’ opinions and even the results using human probability estimates!

24. 24 Electronic Prescription

25. Dr. Shahram Yazdani © 2002 ATGCIATGCI 25 Prescription warning messages generated by computerised system from October 1998 to August 1999 Category No of warning messages No (%) of prescriptions completed Disallowed 580 Contraindications 370 Interactions 210 Password level warnings 749 322 (43) Contraindications 141 103 (73) Interactions 99 84 (85) Maximum recommended single dose exceeded 206 89 (43) Maximum recommended daily dose exceeded 303 46 (15) Low level warnings16 60715 350 (92) Contraindications 793 677 (85) Interactions 15 74314 635 (93) Maximum recommended single dose exceeded 46 25 (54) Maximum recommended daily dose exceeded 25 13 (52) BMJ 2000;320:750–3

26. Dr. Shahram Yazdani © 2002 ATGCIATGCI 26 Computerized order entry Computerized order entry systems can reduce medication errors –Improve drug prescribing –Improve drug dosing –Drug-drug interactions –Drug allergies Bates et al. JAMA. 1998; Bates et al. J Am Med Inform Assoc. 1999; Teich et al. Arch Intern Med. 2000

27. 27 Automated Dispensing

28. 28 Card Technologies in Health Care

29. Dr. Shahram Yazdani © 2002 ATGCIATGCI 29 Functions of health care cards Identification Access control Data carrier (portable record) Information transfer Authentication Encryption/Decryption

30. Dr. Shahram Yazdani © 2002 ATGCIATGCI 30 Card technologies Unit cost($)Major benefits Paper with barcode0.01- 0.04Inexpensive, bar code Plastic, embossed0.1- 0.15Familiar, paper transfer Serial memory card1.5- 4.0Additional storage Computer chip card3.5- 15.0Additional data security, difficult to copy Optical card6.0- 8.0Much more storage IC optical card10.0- 15.0Large storage and data security PC card50.0- 100.0More storage and computational capacity

31. 31 Computer Literacy among Physicians

32. Dr. Shahram Yazdani © 2002 ATGCIATGCI 32 Barriers are neither technology nor cost, Barriers are cultural: the doctors Michael L. Millenson

33. Dr. Shahram Yazdani © 2002 ATGCIATGCI 33

34. Dr. Shahram Yazdani © 2002 ATGCIATGCI 34 Do you personally use a computer? Personal Computer Use % of the NOs who plan to do so in the next 12 months TotalYESNO No response Overall312878.6%20.2%1.2%100.0%37.2% Females93873.0%25.9%1.1%100.0%42.0% Males219081.0%17.7%1.3%100.0%34.3% < 3532076.3%22.2%1.6%100.0%43.7% 35-44103384.2%15.1%0.7%100.0%44.2% 45-5495783.4%15.3%1.4%100.0%33.6% 55-6458572.1%26.3%1.5%100.0%39.0% 65+23353.6%44.6%1.7%100.0%25.0% GP/FP168574.7%24.0%1.4%100.0%38.4% Med Spec103584.6%14.3%1.1%100.0%38.5% Surg Spec 40879.7%19.4%1.0%100.0%29.1% Rural30273.8%24.2%2.0%100.0%38.4% Urban282679.1%19.7%1.1%100.0%37.1% CMAJ - October 19, 1999

35. Dr. Shahram Yazdani © 2002 ATGCIATGCI 35 Barriers Lack of technology infrastructure Lack of standards Cultural barriers –Eminence-based medicine –Tradition –Resistance to change Complexity of medicine Workflow issues Human factor issues

36. 36 Web Based Learning

37. Dr. Shahram Yazdani © 2002 ATGCIATGCI 37 Transformed view of knowledge Dynamic, open ended, multidimensional, and public Static, finite, linear, and private.

38. Dr. Shahram Yazdani © 2002 ATGCIATGCI 38 Defining web-based teaching & networked learning materials + human interaction

39. Dr. Shahram Yazdani © 2002 ATGCIATGCI 39 Online learning, Teaching, Tutoring Classroom teaching Tutor enhanced online learning Computer-enhanced classroom teaching Independent online learning

40. Dr. Shahram Yazdani © 2002 ATGCIATGCI 40 Online learning, Teaching, Tutoring Classroom teaching Computer-enhanced classroom teaching Tutor enhanced online learning Collaborative and independent online learning Distance learning

41. Dr. Shahram Yazdani © 2002 ATGCIATGCI 41 Advantages of CAI and WBL Self directed learning Interactivity Privacy Individualized to student: –Pace –Weak area 24 hr access Social interaction and Group work

42. Dr. Shahram Yazdani © 2002 ATGCIATGCI 42 Immediate Feedback Permanent record Economy of scale Promote active engagement Multimedia Access to global resources Information retrieval Advantages of CAI and WBL

43. Dr. Shahram Yazdani © 2002 ATGCIATGCI 43 Uses of CAI in clinical medicine Focus on diagnosis and therapy rather than on facts Encourage experimentation and exploration Greater scope-see outpatient cases Prototypic cases that are not complex Include rare cases Better measure of competency than multiple choice test

44. Dr. Shahram Yazdani © 2002 ATGCIATGCI 44 Can experiment without danger to patient Follow course of patient over time Uses physiologic models, production rules, … Uses of CAI in clinical medicine

45. 45 Virtual Reality

46. Dr. Shahram Yazdani © 2002 ATGCIATGCI 46 Using the MIST system (Mentice Medical Simulation AB, Gothenburg, Sweden) for training and assessment of psychomotor skills for minimally invasive surgery BMJ VOLUME 323 20 OCTOBER 2001

47. Dr. Shahram Yazdani © 2002 ATGCIATGCI 47 The da Vinci Surgical System (Intuitive Surgical, California, USA) for performing minimally invasive surgery. The surgeon sits at a control console with 3D visualization of the surgical field and the robotic surgical instruments BMJ VOLUME 323 20 OCTOBER 2001

48. Dr. Shahram Yazdani © 2002 ATGCIATGCI 48 Virtual Reality

49. Dr. Shahram Yazdani © 2002 ATGCIATGCI 49 Virtual Reality

50. Goals of Collaborative eHealth: Saving Time, Saving Money, Saving Lives Turning the Promise of Mobile Computing into a Reality