Medical Informatics

By

Engr. Adeel Mehdi

Biomedical Engineer IBT LUMHS, Jamshoro

Senior Lecturer IIRS, Isra University, Hyderabad

Medical Informatics
"the theory and practice of using information
responsibly in the context of healthcare.
The study of how Medical information is collected,
organized, manipulated, classified, stored, retrieved,
and visualized
Medical informatics is seen to be rooted in medicine
and computer science
the social, organizational, and policy aspects of
information technology are not usually taken into
consideration

Informatics
Bioinformatics

Really bio-molecular
informatics
Medical informatics

Really clinical informatics

Biomedical informatics

Covers both and more

Existing Hospital
Records .......
Paper Charts of Patient Medical Records are the
norm worldwide for recording patient
information.
All relevant patient information is documented in
one file for reference - including Lab. results,
test results and progress notes.
These charts are easy to use.
The same file is used on subsequent admission
to the same institution.
And as source of reference for medico-legal
cases.

The Medical (Patient) Record

A historical record of patient care
A communication tool among care
providers
A research and knowledge-gaining tool
A teaching tool
An operational tool (e.g., order entry)
A business tool (e.g. to support billing)
An administration record (e.g., to manage
resources)
A legal record with considerable longevity

Electronic Medical Record

(EMR)
AKA: Computer-Based Patient Record (CPR)
Provides multiple advantages vs. manual records:
Record can be used by multiple personnel at the same
time
Record is accessible from anywhere (even from home)
Clear, well-organized, legible documentation
Data can be reused for other purposes
Data can be integrated from multiple sources
transparently
Data can be validated automatically
Enables multiple automated research and decision-support
functions (analysis, machine learning and data mining,
automated diagnosis, reminders, guideline-based care)
Decision support can be integrated with use of the patient
record

Order Entry
CPRS (Clinical patient Record system)
includes the ability to place orders by CPOE,
including medications, special procedures,
x-rays, patient care nursing orders, diets,
and laboratory tests
A major function of an EMR system, allowing
care providers to enter clear, legible orders for
patient care anytime, anywhere
Supports validation of order, issuing of alerts,
suggestion of relevant information and
knowledge, and even actions
Quick effect on physician ordering behavior

The Electronic Medical

Record.
The Electronic Medical Record (EMR) is the
future of patient record documentation.
There is very wide scope for applications
and additions around a centralized record.
The EMR can be accessed conveniently by
appropriate health professionals to ensure
ultimate maximum and optimal patient
care.

E- Health Standards
Data interchange Standards (OSI)
Electronic Medical Record Standards
(HL7)
Terminology / Vocabulary standards
Medical Imaging standards

E-Health Standards
Open Systems Interconnection (OSI)
7-layer communication model of the
International Standards Organization
(OSI)
Allow a sender to transmit data (a
transaction set) to a receiver in
unambiguous fashion

HL7
Name refers to OSI application layer 7
A standard for exchange of data among
different hospital computer applications

 ICD (International Classification of

Diseases)
Intended mostly for talking about dead
people (reporting mortality statistics to
the WHO)
Strict hierarchy with core 3-digit codes,
possibly 4th digit
ICD-9-CM (Clinical Modifications) adds
extra levels of details by 4th and 5th
digits, popular in USA

Codes in The International

Classification of Diseases (ICD-9 CM)
724 Unspecified disorders of the back
724.0
Spinal stenosis, other than cervical
724.00 Spinal stenosis, unspecified region
724.01 Spinal stenosis, thoracic region
724.02 Spinal stenosis, lumbar region
724.09 Spinal stenosis, other
724.1
Pain in thoracic spine
724.2
Lumbago
724.3
Sciatica
724.4
Thoracic or lumbosacral neuritis
724.5
Backache, unspecified
724.6
Disorders of sacrum
724.7
Disorders of coccyx
724.70 Unspecified disorder of coccyx
724.71 Hypermobility of coccyx
724.71 Coccygodynia
724.8
Other symptoms referable to back
724.9
Other unspecified back disorders

 Current procedural terminology (CPT

Encodes diagnostic and therapeutic procedures
CPT-4: The main code used for reporting physician
services to government and private insurance
reimbursement

Diagnostic Statistical Manual (DSM)

Provides nomenclature as well as definitions
(diagnostic criteria) of psychiatric disorders

Systemized Nomenclature of Medicine

(SNOMED)
Systematically organized computer accessible
collection of medical terminology cover most areas
such as Diseases, findings, procedures,
microorganisms, pharmaceuticals, etc

Functions of a Health-Care
Information System (HCIS) (I)
Patient management
Admission, Discharge, Transfer (ADT)
Patient tracking

Departmental management
Ancillary departmental systems support
clinical departments; laboratory, radiology,
pharmacy, blood bank and medical records
are most commonly automated

Care delivery and Clinical documentation

Mostly order entry and results reporting

Functions of a Health-Care
Information System (HCIS) (II)
Clinical decision support
Built upon other HCIS components and need to
be integrated with them (e.g. during order
entry)

Financial and resource management

Typically the first functions to be centralized

44,000 to 98,000 patients die from

medical errors every year in US
hospitals.
More people die from medical errors in
hospitalization than from motor vehicle
accidents, breast cancer, or AIDS.
Institute of Medicine (Dec. 1999)

CONTENTS
Electronic Clinical Information Systems with
practicals
E-health standards (CDA, HL7, etc)
Controlled vocabulary standards (SNOMED,
etc)
Medical imaging & Communication standard
(DICOM)
Statistical Package for Social Sciences (SPSS)
Ebrary, End note, Medical related resources
on web, personal management software