Medical Informatics
Human Variation
Medical Practice
Ethical Issues
Informatics Issues
10/3/2015
Chuck Staben
1
Medical Informatics
storage, retrieval, and optimal use of
biomedical information, data, and
knowledge for problem solving,
decision making, and research
10/3/2015
Chuck Staben
2
Issues
• Nature of medical information
• Technical challenges
• Uses of medical information
– medicine
– research
• Status of development in field
• Ethical concerns
• (Professional Career Trajectories)
10/3/2015
Chuck Staben
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Uses of Medical Records
• Medical decision making-individual
cases
• Contractual (HMO, insurance…)
– Legal
• Process improvement
– Clinical trials, evaluation of therapy
• Basic human research
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Chuck Staben
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Patient Medical Record
• Time oriented
– Visit1, 2, 3…
• Source-oriented
– Physician, labtest, imaging
• Problem-oriented
– Bronchitis, auto accident, depression
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Chuck Staben
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Information Types
• Textual
– chief complaint, symptoms, history of
present illness, history, family history,
physical exam, insurance information…
• Graphical
– ECG, ultrasound, X-ray, hand-drawn
figures…
– longitudinal data (blood pressure graph)
• Digital/Image(X-rays, …)
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Chuck Staben
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Text Information
• Structured Data Entry (forms)
• Natural Language
– Processing essential for interpretation
• “parsing” algorithms
• Thesauri
– thrombophlebitis=phlebothrombosis, DVT,
blood clot in the leg, milk leg, phlegmasia
caerulea dolens, dropsy…
– generalized idiopathic lymphandenopathy
(1980) => AIDS!!!
» “Change over time”
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Chuck Staben
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Text Standards
• Ideal Terminology
– Complete, Formal, Universal,
Translatable
• Candidate languages
– SNOMED, UMLS, ICD, Read Codes,
DSM
• Digital
– Entry, storage, retrieval, usage?
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Chuck Staben
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Graphs/Images
•
•
•
•
•
Archivable
Sharable
Searchable
Transmittable
Multiple input/output formats
– X-rays, ultrasounds, cameras…
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Chuck Staben
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Problems in Patient Records
• Errors, omissions, uncertainties
• Variability
– Patient (day to day)
– Physician
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Chuck Staben
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Current Provider Interface
…48 yo wm  7d h/o N/V/Abd
pain  bilious emesis 3xQd –D –
melena/BRBPR/mucous +
f/c(t102) uop –UTI Sx +
postprandial pain + EtOH (1case
Qd)…
Pancreatitis/obstruction
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Chuck Staben
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Provider Input Interface
• Direct computer entry
• Pen input/Speech recognition
• Customizable, adaptable interface
DO NOT WANT
a data entry clerk
paid $200,000/year!
10/3/2015
Chuck Staben
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Provider Display Interface
• Terminal
– Patient Records
– Supplementary info
• Drug characteristics
• Medline records…
• Palmtop/PocketPC
– http://epocrates.com/
• Pocket reference
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Chuck Staben
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Patient Interface?
• WWW?
• Physician
• Physician
extender
10/3/2015
• Synchronous
• Asynchronous
• Reliable?
Chuck Staben
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Impediments to Electronic Records
• Terminology/data types
• Data entry methods
• Diverse information needs
– ear infection vs bone-marrow
transplant
• Impact on physician-patient
• Impact on physician-patient-society
– confidentiality, responsibility
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Chuck Staben
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Experience with
Electronic Records
• Reliability problems
– Why not as good as electronic banking!
– Beth Deaconnes recently had 3.5 days
down!!!
• Free-text fields (clinical notes)
– Nomenclature
• Interfacing with other systems
• Enormous cost of switchover
– who pays that cost, especially in era of
direct accountability in patient care?
10/3/2015
Chuck Staben
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Medical Uses of
Enhanced Records
• Enhance clinical decision making
• UKHMO: what are your current meds?
• Rapid, rational query of records
• Potential for increased use of knowledge
systems (eg. Drug interactions)
– ACE inhibitor sensitivity, ER doc
• Enhanced delivery of care
• Monitoring clinical success
– all patient records become clinical trials
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Chuck Staben
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Medical Delivery Issues
• Periodic health screening
– enhanced reminders
• Physician variability
– managed care can reduce variability
• Data quality, type varies from
physician to physician
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Chuck Staben
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Research Uses
• Epidemiology
– Infectious disease
– Life history, risk factor...
• Tissue Banks
• Pedigrees/Populat
ions
• DATAMINING
• Medical Genetics
– Basic disease work
• Pharmacogenomics
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Chuck Staben
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Genetic Polymorphisms
and Environmental Effects
• Disease susceptibility
– Cancer, Dependency, Depression
• Pharmacogenomics
– Drug metabolism
• P450 variation (CYP2C9, 2D6, 1A1…)
• Thiopurine methyltransferase…
– Drug targets
• ACE, Potassium channels, Dopamine
transporters…
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Chuck Staben
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Heritability in human traits
• Mole Count (melanoma risk)
– Am J Hum Genet 1999 Aug;65(2):483-92
– 68% genetic effect, 26% heritable, 6%
variable environment
• ~30% due to CDKN2A
• Sun exposure
• Skin color, freckling…
• Nicotine/Alcohol Dependency
– ~60% heritable (twin studies in males)
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Chuck Staben
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Medical Informatics-Status
• Medicare/Medicaid/Managed Care
“Coding”, HIPAA
• NIH
– major initiatives in electronic records
• Company initiatives
– HMO, Healtheon/WebMD…
• Pharmacogenomics companies
– Iceland, Scandinavian records
• DeCode Genetics/Roche ($200M in ’98-03)
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Chuck Staben
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Companies
• WebMD (Healtheon)
– HIPAA compliant, records for billing, etc.
– PATIENT information
• Software improvement needed (eg,
lack of validation…)
• Custom
– $$
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Chuck Staben
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BIG BROTHER
$200 x
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Chuck Staben
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10
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ELSI
• http://www.mannvernd.is/english/ho
me.html
• http://www.nhgri.nih.gov/ELSI/
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Chuck Staben
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Training
• Physicians
– Clinical-based information, not CS
or MIS!
• Formal Training (representative)
– Medical Information Scientist Training
Program, (Stanford University,
Hopkins, etc.)
– National Library of Medicine
• http://www.amia.org/
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Chuck Staben
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Medical Informatics - Amirkabir University of Technology