Medical informatics computer applications in health care and biomedicine

Health Informatics (formerly Computers in Health Care) Kathryn J Hannah Marion J Ball Series Editors Springer Science+Business Media, LLC Health Informatics Series (formerly Computers in Health Care) Series Editors Kathryn J Hannah Marion J Ball Dental Informatics Integrating Technology into the Dental Environment L.M Abbey and J Zimmerman Ethics and Information Technology A Case-Based Approach to a Health Care System in Transition J.G Anderson and K.W Goodman Aspects of the Computer-Based Patient Record M.J Ball and M.F Collen Performance Improvement Through Information Management Health Care's Bridge to Success M.J Ball and J.V Douglas Strategies and Technologies for Healthcare Information Theory into Practice M.J Ball, J.V Douglas, and D.E Garets Nursing Informatics Where Caring and Technology Meet, Third Edition M.J Ball, K.J Hannah, S.K Newbold, and J.V Douglas Healthcare Information Management Systems A Practical Guide, Second Edition M.J Ball, D.W Simborg, J.W Albright, and J.V Douglas Healthcare Information Management Systems Cases, Strategies, and Solutions, Third Edition M.J Ball, C.A Weaver, and J.M Kiel Clinical Decision Support Systems Theory and Practice E.S Berner Strategy and Architecture of Health Care Information Systems M.K Bourke Information Networks for Community Health P.F Brennan, S.J Schneider, and E Tornquist Informatics for the Clinical Laboratory A Practical Guide D.F Cowan (continued after index) Edward H Shortliffe Leslie E Perreault Editors Gio Wiederhold Lawrence M Fagan Associate Editors Medical Informatics Computer Applications in Health Care and Biomedicine Second Edition With 199 Illustrations ~ Springer Edward H Shortliffe, MD, PhD, FACP, FACMI Professor and Chair Department of Medical Informatics in Medicine Professor of Medicine and Computer Science Science Vanderbilt Clinic Columbia University College of Physicians and Surgeons Columbia-Presbyterian Medical Center New York, New York 10032-3720, USA Leslie E Perreault, MS NewYork,NY USA Gio Wiederhold, PhD, FIEEE, FACM, FACMI Emeritus Professor of Computer Science, Electrical Engineering, and Medicine Stanford University Stanford, CA 94305-9040, USA Lawrence M Fagan, MD, PhD, FACMI Senior Research Scientist and Associate Director, Stanford Medical Informatics Co-Director, Medical Information Sciences Training Program Director, Medical Informatics Short Course Stanford University School of Medicine Stanford, CA 94305-5479, USA Series Editors: Kathryn J Hannah, PhD, RN Adjunct Professor Department of Community Health Sciences Faculty of Medicine The University of Calgary Calgary, Alberta, Canada T2N 4Nl Marion J Ball, EdD Vice-President, Clinical Solutions Healthlink, Inc Baltimore, MD 21210, USA and Adjunct Professor Johns Hopkins University School of Nursing Baltimore, MD 21205, USA Library of Congress Cataloging-in-Publication Data Medical informatics: computer applications in health care and biomedicine / editors, Edward H Shortliffe, Leslie E Perreault; associated editors, Gio Wiederhold, Lawrence M Fagan-2nd ed p cm - (Health informatics series) Includes bibliographical references and index ISBN 978-1-4899-0517-8 Medical informatics Shortliffe, Edward Hance II Health informatics R858.M397 2000 610'.285-dc21 99-089476 Printed on acid-free paper ISBN 978-1-4899-0517-8 DOI 10.1007/978-0-387-21721-5 ISBN 978-0-387-21721-5 (eBook) © Springer Science+Business Media New York 2001 Originally published by Springer Science+Business Media, Inc in 2001 Softcover reprint of the hardcover 2nd edition 2001 All rights reserved This work may not be translated or copied in whole or in part without the written permission of the publisher Springer Science+Business Media, LLC, except for brief excerpts in connection with reviews or scholarly analysis Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden The use in this publication of trade names, trademarks, service marks and similar terms, even if they are not identified as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights (MPIMVY) 987 springeronline.com Where is the knowledge we have lost in information? Where is the wisdom we have lost in knowledge? -T.S Elliot, "The Rock" To the memory of Scott Blois, innovator, philosopher, and scholar, who showed us how to look beyond technology to the concepts and perspectives that help to define the scientific underpinnings for the field of medical informatics Series Preface This series is directed to healthcare professionals who are leading the transformation of health care by using information and knowledge Launched in 1988 as Computers in Health Care, the series offers a broad range of titles: some addressed to specific professions such as nursing, medicine, and health administration; others to special areas of practice such as trauma and radiology Still other books in the series focus on interdisciplinary issues, such as the computerbased patient record, electronic health records, and networked healthcare systems Renamed Health Informatics in 1998 to reflect the rapid evolution in the discipline now known as health informatics, the series continues to add titles that contribute to the evolution of the field In the series, eminent experts, serving as editors or authors, offer their accounts of innovations in health informatics Increasingly, these accounts go beyond hardware and software to address the role of information in influencing the transformation of healthcare delivery systems around the world The series also increasingly focuses on "peopleware" and the organizational, behavioral, and societal changes that accompany the diffusion of information technology in health services environments These changes will shape health services in the new millennium By making full and creative use of the technology to tame data and to transform information, health informatics will foster the development of the know ledge age in health care As co-editors, we pledge to support our professional colleagues and the series readers as they share advances in the emerging and exciting field of health informatics Kathryn J Hannah Marion J Ball vii Preface Just as banks cannot practice modem banking without financial software, and airlines cannot manage modem travel planning without shared databanks of flight schedules and reservations, it has become impossible to practice modem medicine without information technologies Health professionals recognize that a large percentage of their activities relates to information management-for example, obtaining and recording information about patients, consulting colleagues, reading the scientific literature, planning diagnostic procedures, devising strategies for patient care, interpreting results of laboratory and radiologic studies, or conducting case-based and population-based research It is complexity and uncertainty, plus society's overriding concern for patient well-being and the resulting need for optimal decision-making, that set medicine apart from many other information-intensive fields Our desire to provide the best possible health and health care for our society gives a special significance to the effective organization and management of the huge bodies of data with which health professionals must deal It also suggests the need for specialized approaches and for skilled scientists who are knowledgeable about both medicine and information technologies Information Management in Biomedicine Although the application of computers to biomedicine is recent, the clinical and research influence of medical-computing systems is already remarkably broad Clinical information systems, which provide communication and informationmanagement functions, are now installed in essentially all healthcare institutions Physicians can search entire drug indexes in a few seconds, using the information provided by a computer program to anticipate harmful side effects or drug interactions Electrocardiograms often are analyzed initially by computer programs, and similar techniques are being applied for interpretation of pUlmonaryfunction tests and a variety of laboratory and radiologic abnormalities Microprocessor systems routinely monitor patients and provide warnings in critical-care settings, such as the intensive-care unit or the operating room Both biomedical ix x Preface researchers and clinicians regularly use computer programs to search the medical literature, and modem clinical research would be severely hampered without computer-based data-storage techniques and statistical-analysis systems Advanced decision-support tools also are emerging from research laboratories, are being integrated with patient-care systems, and are likely to have a profound effect on the way medicine is practiced in the future Despite this growing use of computers in healthcare settings and the resulting expansion of interest in learning more about medical computing, many health students and professionals have found it difficult to obtain a comprehensive and rigorous, but nontechnical, overview of the field Both practitioners and basic scientists are recognizing that thorough preparation for their professional futures requires that they gain an understanding of the state of the art in biomedical computing, of the current and future capabilities and limitations of the technology, and of the way in which such developments fit within the scientific, social, and fmancial context of biomedicine In turn, the future of the medical-computing field will be largely determined by how well health professionals and other people are prepared to guide the discipline's development This book is intended to meet this growing need for well-equipped professionals The first edition appeared in 1990 and has been used throughout the world in courses on medical informatics Like the first edition, this new version provides a conceptual framework for learning about computer applications in medical care, for critiquing existing systems, and for anticipating future directions that the field may take In many respects, however, this new edition is very different from its predecessor Most importantly, it reflects the remarkable changes in computing and communications that have occurred in the past decade For example, the Internet was barely mentioned in the first edition, but it and the World Wide Web are now discussed in almost every chapter in light of their pervasive societal influence in recent years In addition, new chapters are included, and others have been deleted or revamped We include new chapters on bioinformatics, standards development, systems evaluation, technology assessment, legal topics, and ethical considerations The former chapter on "hospital information systems" has now given way to a discussion of enterprise computing for integrated delivery networks Those who are familiar with the first edition will find that the organization and philosophy are unchanged, but the content is almost entirely new.! This book differs from other introductions to the field in its broad coverage and in its emphasis on the field's conceptual underpinnings Our book does not presume that readers have a health-science or computer-science background, but lAs in the first edition, the book tends to draw both its examples and its contributors from North America There is excellent work in other parts of the world as well, although variations in healthcare systems, and especially in financing, tend to change the way in which systems evolve from one country to the next The basic concepts are identical, however, so the book is intended to be useful in educational programs in other parts of the world as well Preface xi it does assume that they are interested in a comprehensive summary of the field that stresses the underlying concepts, and it introduces technical details only to the extent that they are necessary to meet the principal goal It thus differs from an impressive early text in the field (Ledley, 1965) that emphasized technical details but did not dwell on the broader social and clinical context in which medical computing systems are developed and implemented Overview and Guide to Use of This Book This book is written as a text so that it can be used in formal courses, but we have adopted a broad view of the population for whom it is intended Thus, it may be used not only by students of medicine and of the other health professions but also by future medical-computing professionals as an introductory text as well as a text for self-study and for reference by practitioners The book is probably too detailed for use in a 2- or 3-day continuing-education course, although it could be introduced as a reference for further independent study Our principal goal in writing this text is to teach concepts in medical informatics-the study of biomedical information and its use in decision-making-and to illustrate them in the context of descriptions of representative systems that are in use today or that taught us lessons in the past As you will see, medical informatics is more than the study of computers in medicine, and we have organized the book to emphasize this point Chapter first sets the stage for the rest of the book by providing a glimpse of the future, defining important terms and concepts, describing the content of the field, explaining the connections between medical informatics and related disciplines, and discussing the forces that have influenced research in medical informatics and its integration into medical practice Broad issues regarding the nature of data, information, and knowledge pervade all areas of application, as concepts related to optimal decision-making Chapters and focus on these topics but mention computers only in passing They serve as the foundation for all that follows Chapters and introduce the central ideas of computer hardware and software that are important for understanding the applications described later Also included is a discussion of computer-system design, with explanations of important issues for you to consider when you read about specific applications and systems throughout the remainder of the book Chapter summarizes the issues of standards development, focusing in particular on data exchange and issues related to sharing of clinical data This important and rapidly evolving topic was not covered in our fIrst edition but warrants inclusion here given the increasingly central role of standards in enabling clinical systems to have their desired influence on healthcare practices Chapter addresses the key legal and ethical issues that have arisen when health information systems are considered Then, in Chapter 8, the challenges associated with technology assessment and the evaluation of clinical information systems are introduced 842 Subject Index Infonnation, 18, 29, 39, 65 credentialing, 415 management, ix needs, 541 overload, 574 ranking of documents, 556-567 relationship to healthcare financing, 686 retrieval, 77, 185, 514, 539-572, 639, 655 science,17, 19,32 See also Medical infonnation science theory, 19 Infonnation Network for Public Health Officials (INPHO), 401 Infonnation Sources Map, 566-567 Infonnation Vizualizer Toolkit, 702 Ink-jet printers, 146 INPHO See Infonnation Network for Public Health Officials Input, devices, 140, 330 voice See Voice recognition Institute of Electrical and Electronic Engineers (IEEE), 247, 478,698 Institute of Medicine, 284, 355 Institutional review board (lRB), 268 Instruction, computer-aided See Computer-aided instruction Instrumentation, 33 Insurance See Healthcare insurance Integrated Academic Infonnation Management Systems (lAIMS), 434, 698 Integrated circuit, 133 Integrated delivery network (IDN), 214, 267,359-396,403,429,523-524, 528 Integrated infonnation-management, 18 Integration, of computer-based services, 9, 18, 134, 700, 703 of decision-support tools, 592 of delivery systems See Integrated delivery network of infonnation management, 362-368, 686, 697 of medicine and public health, 398 of processes, 367 of software systems, vertical, 361 Intel, Inc., 27 Intellectual property, 277, 569 Intelligent Systems for Molecular Biology (ISMB),659 Intelligent tutoring systems (ITS), 620-621, 630 Intensive-care unit, 443 484 Interactive Patient, 626 Interdisciplinary sciences, 32 Interface engine, 333, 334 Intennountain Healthcare Corporation (IRC), 337, 391, 395 Intern See House staff Internal Revenue Service, 215 International Classification of Disease (lCD), 62-64, 225-226, 428, 566, 588, 698 International Classification of Primary Care (ICPC), 227 International Council of Nursing, 437 International Electrotechnical Commission (1EC),220 International medicine, 16 International Society of Computational Biology (ISCB), 659 International Standards Organization (ISO), 166,213,220,241,247, 506 Internet, 12, 15, 133, 149, 155ff, 273, 334, 372, 388, 394, 397, 410 416, 418,514,528,530,562,570,605, 615, 616, 621, 625, 626, 633, 645, 692-693, 695,696,698ff Internet-2, 17 See also University Consortium for Advanced Internet Development Internet Mail Access Protocol, 167 Internet service provider (ISP), 151 Internet Society, 13 Internist-I, 576, 592-596 See also Quick Medical Reference Interpreter, 156 Interviews, 318 Intranet, 11, 372,418,457, 514, 692-693, 708 Ionizing radiation See Radiation IPA See Independent-practice association Subject Index ISCB See International Society for Computational Biology ISDN See Integrated Services Digital Network ISMB See Intelligent Systems for Molecular Biology ISO See International Standards Organization ISO OSI reference model, 166,241,506, 507 Isotopes, 493 ISP See Internet Service Provider i-STAT Corporation, 463 ITS See Intelligent tutoring systems J Java, 205, 493, 525, 528, 535, 565, 603 JCAHO See Joint Commission for Accreditation of Healthcare Organizations Johns Hopkins University, 386, 527 Joint Commission for Accreditation of Healthcare Organizations (JCAHO), 364, 404, 406, 430 Joint Photographic Experts Group (JPEG), 505 Journal of Digital Imaging, 517 Journal of the American Medical Informatics Association (JAMIA), 434 Joy stick, 141, 611 JPEG See Joint Photographic Experts Group K Kaiser Family Foundation, 684, 686 Kaiser-Permanente, 22, 395-396, 411, 414,668,673,675,685 Kernal (operating system), 159 Keyboard, 135-136, 141,433 Knowledge, 29, 64, 69, 215 base, 41, 65, 277, 586, 598, 615 relationship to data, 64 representation, 582-583 resources, 340 structural See Structural informatics 843 Knowledge-based system, 65, 254, 579, 586, 659, 712 Knowledge Finder, 555, 560 L Laboratory information system, 190,217, 463 Laboratory of Computer Science (at MGH),612 LAN See Local-area network Laser printers, 135, 145 Latency (in networks), 16 Latter Day Saints Hospital See LDS Hospital LCD See Liquid-crystal display LDS Hospital, 22, 332, 337, 391, 429, 446,465,467,470,471,474,475, 478,480,481,579,580 Leeds abdominal pain system, 577-578, 593 Legacy systems, 372, 387, 528 Legal considerations/implications, 177, 255, 274f~285,288, 355,697, 709 Legal record, 53 Legibility, 56-57, 329, 343 Liability (legal), 274ff, 604 Library, 27, 571 film, 501, 526 Light pen, 74, 141, 206 Likelihood ratio, 97-98 Liquid-crystal displays, 145 LIS See Laboratory information system LISP, 156 Lister Hill Center for Biomedical Communications, 614 Literature search See Bibliographic retrieval Local-area network, 149, 185, 245, 374, 384-386,447,483,506,510,582 Lockheed Corporation, 23, 429 Logician EMR, 340 Logical Observations, Identifiers, Names & Codes (LOINC), 233, 333, 347 LOINe See Logical Observations, Identifiers, Names & Codes Los Alamos National Laboratory, 520 844 Subject Index Lotus 1-2-3, 158 LR See Likelihood ratio Luminance, 511 M M See MUMPS Machine language See Assembly language Macintosh, 277, 633 Macros, 155 Magnetic disk, 138 resonance angiography (MRA), 499 functional, 499, 500 imaging (MRI), 183, 486, 494, 520 nuclear (NMR), 644 spectroscopy (MRS), 499 venography (MRV), 499 tape, 139 Magnetoencephalography (MEG), 500, 520 Mainframe computer, 13, 133, 213, 381, 382 Maintenance of systems, 195,201 Mallinckrodt Institute of Radiology, 510 Malpractice lawsuits, 275 Mammography, 512, 518, 523, 536 Managed care, 38, 260, 270, 328, 331, 361,380,399,403,404,411,430, 469, 582, 603, 672ff, 710 Managed competition, 682-684, 695 Management science, 20, 32 applied to health information systems, 371-375 mapping, functional, 488 Markov models, 117 MARS See Missouri Automated Radiology System Marshall University, 626 Maryland Hospital Indicator Program, 431 Massachusetts General Hospital, 22, 526, 612, 613, 614 Master patient index (MPI), 375, 377, 388,389 Mathematical model, modeling, 509, 516, 585,613 Mathematics, 31, 193 Mayo Health Advisor, 411 McMaster University, 560 MD Consult, 564 Measurement, 302-304 Measure of preference See Utility MED See Medical Entities Dictionary Medicaid, 364, 404, 668ff, 680ff Medical data, 41-75, 574 devices, 34, 49 See also Instrumentation education, 17,531,606,610-637, 700 informatics, as a biomedical discipline, xiii, 29ff component sciences, 32 defmed,21 future, 697-712 and healthcare financing, 663ff history, 20, 39 organizational issues, 395 relationship to biomedical engineering,33f relationship to computer science, 31ff research, 27 specialist, xiv terminology, 19-20 training, xiv, 17,606 information, 35 information bus (MID), 248, 478, 698 information science, 20 record, 184, 327ff access to, 328 advantages of a computer-stored, 49ff,328 ambulatory, 332, 356 and bioinformatics, 640 computer-based See Computer-based medical record paper-based, 4ff, 328 problem-oriented, 331, 356, 707 processes to be automated, 6ff system See Computer-based medical record users of, 7ff virtual, 15 weaknesses of, 55, 60, 328 students, 31, 66 See also Medical education Subject Index Medical Decision Making (Journal), 127, 131 Medical Entities Dictionary (MED), 389 Medical Library Association (MLA), 278 Medical Literature Analysis and Retrieval System (MEDLARS), 540 Medical Logic Module (MLM), 245, 580 581 Medical Matrix, 563, 565 MedicaLogic, Inc., 340, 341 Medical Subject Headings (MeSH), 236-237,247,401,540ff,698, 702 Medicare, 226, 364, 404, 668ff, 680ff Medication administration record, 467, 468 MEDINET,22 MEDINFO,3 MEDIX (IEEE), 247 MEDLARS See Medical Literature Analysis and Retrieval System Medline, 140,392,418,426, 540ff, 624, 633,645 Medscape, 625 Meducation, 626 MedVVeaver, 568-569 MedVVeb, 563, 565 Memorandum of understanding, 316 Memory, 134 random-access (RAM), 137,511 read-only (ROM), 137 Menu, 141 MeSH See Medical Subject Headings Meta-analysis, 95-96, 543-544, 570 Metacontent, 632 Metathesaurus, 239, 389, 566-569 See also UMLS MGH See Massachusetts General Hospital Mm See Medical information bus Microcomputer, 455ff See also Personal computer Microprocessor, 4, 23, 25, 443, 444, 449 Microsoft Corporation, 277 Excel,158 VVindows, 216 VVord,158 Middleware, 524, 525 MIME See Multipurpose Internet Mail Extensions 845 MlNDscape, 530 Minicomputer, 23, 214 MIR See Mallinckrodt Institute of Radiology MIS See Medical information systems Missouri Automated Radiology System (MARS),527 MLM See Medical Logic Module Mobile Assistant, 705 Modem, 135, 147,457 Modular computer system See System, modular Monitoring See also Patient monitoring systems archival of data, 477 arrhythmia See Arrhythmia monitoring devices, 33 intermittent versus continuous, 476 invasive versus noninvasive, 477 Moore's Law, 27, 353 Morbidity and Mortality Weekly Report, 400,408 Morphometrics, 488 Mouse pointing device, 74, 141,433 MPI See Master patient index MRI See Magnetic resonance imaging Multimedia, 289, 394, 411, 487, 510, 514, 543,570,611,630,631 Multiprocessing, 160 Multiprogramming, 160 Multipurpose Internet Mail Extensions (MIME),167 ~S,32, 157,213,392 Mutually exclusive, 104-105,613 MYCIN, 577-579, 583ff, 596, 614 N Name servers, 151 NANDA, See North American Nursing Diagnosis Association Narrative text, 44, 144, 315, 329, 347 NASA See National Aeronautics Space Administration National Aeronautics and Space Administration (NASA), 151 National Board of Medical Examiners, 623 National Center for Biological Information (NCBI), 646, 647, 655 846 Subject Index National Center for Nursing Research, 434 National Committee for Quality Assurance (NCQA), 364,404-407,683 National Council for Prescription Drug Programs (NCPDP), 241, 248, 252 National Drug Codes (NDC), 235, 347 National Electrical Manufacturers' Association (NEMA), 241, 507 See also ACRINEMA National Health and Nutrition Examination Survey (NHANES), 407 National Health Service (UK), 231 National Institute for Standards and Technology (NIST), 216 National Institutes of Health, 24, 205, 482,625,642,647,700 National League for Nursing, 436 National Library of Medicine, 25, 27, 205, 236-237, 436, 514, 531, 540ff, 613, 622 National Noticeable Diseases Surveillance System, 400 National Provider Identifier, 214 National Research Council (NRC), 266267,277,369 National Science Foundation, 13, 151-152 Natural language, 207, 436, 442, 550, 554,618 syntactic versus semantic analysis, 555 NBME See National Board of Medical Examiners NCHSR See National Center for Health Services Research and Technology Assessment NCQA See National Committee for Quality Assurance Negative predictive value, 100 Negligence law, 261, 275, 604 NEMAS See Nursing Education Modular Authoring System NeoPath,518 Network, 9, 14, 140, 179, 245, 708 addressing, 151 ARPANET, 13, 153 computer, 390, 399 data communication, 37 domain name system, 13, 151 fiberoptic See Cable, fiberoptic local-area See Local-area networks neural See Neural networks node, 149 protocol, 165 regional, 151 reliability, 16 seven-level model, 166,241 stack, 165 strategy, 588 wide-area See Wide-area networks wireless, 588, 698 Neural networks, 585, 586 Neuroimage,517 Neuroinformatics, 532, 537 New York Academy of Medicine, 229 New York City Department of Health, 409 Next Generation Internet (NGI), 16 NGI See Next Generation Internet NIH See National Institutes of Health NIS See Nursing information system NIST See National Institute for Standards & Technology NLM See National Library of Medicine Noise, 171 Nomenclature, 61, 224 See also Terminology North American Nursing Diagnosis Association (NANDA), 233, 428, 435, 437 North Mississippi Health Services, 396 Northwestern Memorial Hospital, 395 Notifiable disease, 397, 403, 407-408 NPC See Nursing Protocol Consultant NP hard, 289 NPV See Net present value NSF See National Science Foundation NSFnet, 153 Null hypothesis, 308 Nurses/nursing, 48, 182, 191, 422ff, 448, 469, 698 advice, 678 information systems, 186 intervention, 423 shift report, 469, 470 team, 430 See also Team, healthcare terminologies, 233, 435 Nursing home, 361-362, 366,443 Nursing informatics, 29,434-436,441 Subject Index Nursing Information and Data Systems Evaluation Center (NIDSEC), 436 Nursing Interventions Classification (NlC), 428, 437 Nursing Minimum Dataset, 435 Nursing Outcomes Classification (NOC), 428,437 Nyquist frequency, 476 NYSERnet, 151 o Object Management Group, 204 Objectivist view, 294ff Object-oriented programming/model, 204, 210, 254, 507, 643 OC-3,152 Odds, 79 Office of Technology Assessment (OTA), 310,480 Office practice information system, xiii Ohio State University, 612, 613, 614 Omaha Visiting Nurses' Association System, 233, 428, 435 OMG See Object Management Group OMIM See Online Mendelian Inheritance inMan Omnibus Budget Reconciliation Act (OBRA), 671, 672 ONCOCIN, 141-143, 590, 609 Online Mendelian Inheritance in Man (OMIM), 645, 650 OPAL, 590 Open Systems Interconnection, 166, 241, 244,246,254,506 Operating characteristic, 88 Operating system, 159 Ophthalmology, 46 Optical carrier, 152 Optical-disc technology, 37 Order-entry system, 337, 348, 378, 392 Organizational change, 17, 210, 373, 393, 429, 606 ORYX, 404-407 OSI See Open Systems Interconnection OSIIISO See ISO OSI model Outcome measure, 110, 290, 299, 302, 310 847 Outcomes research, 244, 270 See also Clinical research Output device, 144 Ovid Technologies, Inc., 547, 564 p Pacific Business Group on Health, 683 Pacific Health Advantage, 683 Pacific Symposium on Biocomputing (PSB),659 Packets/packet switching, 149, 151 PACS See Picture-archiving and communication system PACS Workbench, 510 Pagers See Warnings, pager-delivered Paperchase, 392 Paper record(s) See Medical records Paradigm shift, 12 Parameter, derived, 469 Partners' Healthcare System, 528 Pascal, 157 Patents, 277 Pathfinder, 582 Patient assessment, 31 care information system, 421-442 education, 52, 700 history, 44, 68 record See Medical record Patient Care Data Set, 428, 435, 437 Patient-identifiable information, 266 Patient-monitoring system, 77, 134, 183, 384,443-484 Patient-tracking system, 377 Pattern recognition, 455, 507, 516, 585, 586 PBX See Private branch exchange PCIS See Patient-care information system PDA See Personal digital assistant PDB See Protein Data Bank PDQ See Physicians' Data Query Peer review, 273, 542, 570 Pen-based computing, 74, 433, 588, 698, 702 PEN-Ivory, 73 Per capita payment See Capitation Perimeter definition, 174 848 Subject Index Personal computer, xiii, 23-24, 133, 582 Personal digital assistant (PDA), 390, 698 PET See Psitron-emission tomography Pharmaceutical benefits manager (PBM), 266, Pharmacokinetics, 32 Pharmacy/pharmacists, 49, 191 information system, 184, 190 PHO See Physician-hospital organization Physical examination, 44, 68 Physician-hospital organization (PHO), 677,678 Physicians' Data Query (PDQ), 567 Physicians Online, 564 Physics, 35ff, 61 Physiological monitoring See Patient monitoring systems Picture-archiving and communication systems (PACS), 243, 502ff, 512-513,522,528,535,536,704 Pixel, 145, 243, 491, 516 PKI See Public key infrastructure Placebo effect, 309 Planning, 364, 375 surgical, 487, 530 PLATO, 613, 614 Pocket rounds, 344-345 Pointing devices, 135 See also Mouse, pen, light pen Point-of-service (POS) system, 677, 678 Point-to-point interfaces, 215 See also Network Political issues, 209 POMR See Problem-oriented medical record POP See Post Office Protocol Population-health informatics See Publichealth informatics POS See Point-of-service system Positive predictive value, 99 Positron-emission tomography (PET), 496 Post Office Protocol (POP), 167 PPI See Preferred-provide insurance PPO See Preferred-provider organization PPS See Prospective-payment system Practice-management systems, xiii, 360 Precision, 44, 170, 302, 559 Predictive value (of a test), 70-71, 99f Preferred-provider organization (PPO), 214 Present illness, 44, 68 Pressure Ulcer Prevention and Management System, 426 Prevalence, 70-71, 82ff Prevention, 52, 399, 404 Primary care, 371 Principal investigator, 314 Printers, 146-147 PRISM, 529 Privacy, 9, 15, 174-177,215, 258, 264f~ 276,355,420,604,641 Private branch exchange, 150 Probabilistic approach, 69 Probabilistic relationship, 123 Probability, 69ff, 76ff pretest, 71, 80ff, 96 posterior, 70, 82ff posttest, 70, 82ff, 96 prior, 71, 80ff role in medicine, 126ff theory, 32, 129 transition, 117 treatment threshold, 119-122 Problem-Oriented Medical Information System, 432, 707 Problem-oriented medical record See Medical record, problem-oriented Problem-solvers, 598 Procedures (in programs), 157 Process measure, 299 Process reengineering, 17, 689 Production rule, 578, 587, 591 Product liability law, 261, 275 Professional societies, 20 Professional-patient relationship, 262, 272-273 Professional-standards review organizations (PSRO), 430, 670 Prognostic assessment, 269 Programming languages, 154ff symbolic, 155 Projection (in imaging), 495 Project Team 007,220,252 PROMIS See Problem-Oriented Medical Information System PROSITE, 649 Prospective-payment system (PPS), 671 Prospective study, 59 Prosthesis, 34 Protege, 590, 598-602 Subject Index Protein Data Bank (PDB), 644, 650, 657 Protein Identification Resource (PIR), 645 Protocol, data transmission, 149 Provider-profiling system, 380 PSROs See Professional-standards review organizations Psychology, 32, 69, 83, 92 Public health, 22, 267, 397-420 informatics, 29,400-409,420 Public Health Service, 205,340,398,401 Public key infrastructure (PIG), 176 Pub~ed,545,645,655 Punched card, 22 PV See Present value p value, 307 Q QA See Quality assurance QALY See Quality-adjusted life-year Q~R See Quick ~edical Reference Qualitative arrangement, 515 Quality control, 60, 490 of data, 575 improvement, 371, 430, 685 of information, 415ff of patient care, 187 Quality-adjusted life-years, IlIff, 300, 311 Quality of Patient Care System (QUALPACS),430 Query formulation, 541, 549, 550-556 Query language, 163 Quick ~edical Reference (Q~), 566, 576,592-597,623 R Radiation, 486 nonionizing versus ionizing, 491-492 treatment planning, 529 Radio waves (networking), 147 Radiography, 492 computed, 498 See also Radiology Radiological Society of North America (RSNA), 244, 537 849 Radiology, 485-538 interventional, 488 Radiology information system (RlS), 503, 504,510,522-524 Radiology Information System Consortium, 526 Radiology reporting, 46 ~ See Randomized-access memory Randomization, 59 Randomized-access memory See ~emory Randomized controlled/clinical trial See Clinical trial, randomized RBRVS See Resource-based relative value scale RCT See Randomized clinical trial Read Codes, 231 Real-time data acquisition, 169,484 See also Patient monitoring systems Recall,559 Receiver operating characteristic curve, 92ff,513 RECO~,659 Record (in database), 162, Record keeping, 184 Reference Information ~odel (~), 246 Regenstrief Institute, 336, 338, 345, 351, 356,396 Regenstrief ~edical Record System, 332, 348,356,432 regional health information network (RHIN),402 Regional network, 15 Region-detection, 516 Register, 135 Registries, 401, 407 Regulatory oversight (software), 258, 274ff,603 Reliability, 302 Reminder See Warning Remindersystems,304,596 Report generation, 163,465 Representativeness, 83 Requirements analysis, 188 Research basic, 25 funding, 24 protocol, 59 Resident See House staff Resolution (of an image), 145, 491, 499 850 Subject Index Resource-based relative value scale (RBRVS), 672 Results reporting system, 342, 378 RESUME, 599 Retrieval, 351, 362, 628 See also Information retrieval Retrospective chart review, 59 Review of systems, 68 RHIN See Regional health information network RiboVVeb, 657-658 RIM See Reference Information Model RIS See Radiology information system RISC See Radiology Information System Consortium Risk adjustment, 691 attitude, 114 RMRS See Regenstrief Medical Record System ROC curve See Receiver operating characteristic curve Role-limited access, 174 RSNA See Radiological Society of North America Rule in/rule out (a disease), 102-103 Rules, 481 See also Production rules s Sampling rate, 170, 451 San Jose Mercury News, 27 SAS See Statistical Analysis System Satellite communications, 14, 148, 702 SCAMC See Symposium on Computer Applications in Medical Care SCC See Standardized coding and classification Scheduling system, 377, 526 Schema, 163 Science, 642 SCOP See Systematic Classification of Proteins Screening, 352, 512, 518 SDO See Standards development organization SDR See Shared Data Research Section on Medical Informatics See Stanford Medical Informatics Security, 9, 39, 174ff, 207, 215, 355, 369-370,416,604,707 Segmentation See Image segmentation Semantics, 156 Sensitivity, 69, 77, 90ff, 96, 484 analysis, 76, 109, 115-117,312 calculation, 90 and specificity, 70, 575 Sensors See Patient monitoring systems Sequence/sequencing, 639, 642ff, 656 Sequence Retrieval System (SRS), 646, 655 Servers, 133 SesquiNet, 151 SGML See Standardized General Markup Language Shadow file, 366 SHINE, 624 Short Rounds, 623 Siemens, 527 Signal artifact, 459 processing, 498, 701 Signs, 78 Silicon Graphics Incorporated (SGI), 532 Simple Mail Transport Protocol, 167 Simulation, 612, 613, 619, 703 Single-photon-emission computed tomography,496 SIREP,527 Site visit, 298 SMTP See Simple Mail Transport Protocol SNOMED See Systematized Nomenclature of Medicine SNOP See Systematized Nomenclature of Pathology Social change, 418, 429, 697 Society of Critical Care Medicine, 480 Sociological consequences, 182, 269ff, 697, 703 Software, 12, 154ff, 182ff design, 201 engineering, 199ff, 209 evaluation, 482 general-purpose, 23 life cycle, 199 oversight committees, 278 protection, 277 Spatial resolution See Resolution Specification phase, 200 Subject Index Specificity, 70, 77, 90ff, 96, 484 and sensitivity, 70, 575 SPECT See Single-photon-emission computed tomography Speech recognition, 144, 172,207, 349, 433,523,525,528,535,588,702 Spiral model, 202 Spreadsheet, 12 SQL See Structured Query Language SRS See Sequence Retrieval System Stakeholders, 285, 354 Standard gamble, 114 Standardized coding and classification (SCC),437 Standardized General Markup Language (SGML),627 Standard of care, 275 Standards, standardization, 212ff, 257, 354f~ 388,428, 694 development organization (SDO), 219 need for, 9, 18, 213-216 Stanford Medical Informatics, 30, 143 Stanford University, 23, 30,466, 598, 621,623,624,628,695 Statistical-analysis, x, 55, 158, 186, 585 Statistical Analysis System (SAS), 158 Statistical approaches and techniques, 55 Statistical Package for the Social Sciences, 158 STOR See Summary Time Oriented Record Storage, 134 active, 138 archival, 138 of images, 502-506 requirements, 185 Structural biology, 643, 644 informatics, 490 Structured Meta Knowledge (SMK), 233 Structured programming, 199 Structured Query Language (SQL), 158, 164, 253 Study controls, 304 demonstration, 303 descriptive, 305 design, 293 measurement, 303 naturalistic, 315, 321 851 objectivist, 294, 301-313 observational, 317 popUlation, 94 setting, 291 subjectivist, 294, 313-319 typologies, 292-294 Subjective probability, 83 Subjectivist view, 294ff Summary Time Oriented Record, 332, 356,432 Surface rendering, 519 Surgeons, 192 Surveillance, 185,351,399,407 Swiss-Prot, 645, 648 Symptoms, 78 Syntax, 156 System, acquisition, 194 analysis, 314 bibliographic-retrieval See Bibliographic-retrieVal system central, 381 clinical decision-support See Clinical decision-support system computer, 182 computer-based medical record See Computer-based medical record system contract-management See Contractmanagement system database-management See Databasemanagement system decision-support See Decision-support system defined, 181 distributed, 384-386, 708 expert See Expert system failures, 330 hospital information See Hospital information system imaging See Imaging systems legacy See Legacy systems limitations, 187 maintenance, 196 modular, 383 office practice See Office practice information system order-entry See Order-entry system patient-monitoring See Patient-monitoring system 852 Subject Index System (continued) patient-tracking See Patient-tracking system phannacy See Phannacy information system picture-archiving and communication See Picture-archiving and communication system prototype, 208 provider-profiling See Provider-profiling system radiology information See Radiology information system reliability, 207 results-reporting See Results-reporting system scheduling See Scheduling system turnkey See Turnkey system validation of, 202 Systematic Classification of Proteins (SCOP), 643, 650, 653 Systematized Nomenclature of Medicine (SNOMED), 62-64, 229-231, 333, 392,428,438,514,566,588 Systematized Nomenclature of Pathology (SNOP),229 Systems integration, 6, 202, 207 T Tagged field, 242 Tax Equity and Fiscal Responsibility Act of 1982, 671 TCPIIP See Transmission Control Protocol/Intemet Protocol TDB See Toxicology Data Bank IDS Healthcare Systems Corporation, 382 Team, healthcare, 47, 51, 372,424 Technical Advisory Group (TAG), 221 Technicon Corporation, 23 Technicon Medical Information System (TMIS), 382, 429, 432 Technological Innovations in Medical Education (TIME), 613 Technology assessment, 283, 695 stages, 298-299 TEFRA See Tax Equity and Fiscal Responsibility Act of 1982 Telecommunications industry, 14 Telemedicine, 16, 388, 394, 395, 440, 487, 530, 699, 700 Telephone, 14, 16, 147,277,342,399 Telepresence, 487, 536, 704 Teleradiology, 16,502,510,513-514, 535 Telerobotics, 487 Telnet, 167-168 Terminal interface processor, 385 Terminology, 19, 61, 223ff, 333, 389, 435,436, 545f~566, 588, 694, 704 TES See Tutorial Evaluation System Testing, 68, 72, 76ff Text-scanning devices, 144 Text-word searching, 332, 356 T-Helper See Therapy-Helper The Medical Record, 432 Therapy Helper (T-Helper), 599 600 Thesaurus, 628 See also Metathesaurus Third-party payers, payment See Healthcare insurance Three-dimensional display, 134,508,515, 518,643,702 Time, 42, 349 Time sharing, 23, 160 TIME system See Technological Innovations in Medical Education Time-tradeoff technique, 114 TIP See Terminal interface processor TMIS See Technicon Medical Information System TMR See The Medical Record TNR See True negative rate Token ring, 166 Total quality improvement See Quality improvement Touch-sensitive screen, 74, 141, 206 TPR See True positive rate TQI See Total quality improvement Track ball, 141 Training, ixff, 17, 30, 261, 487, 490 Transcription, 44, 348,442, 467, 523 Transducer, 33,448 Transmission Control Protocol/Intemet Protocol (TCPfIP), 151, 242, 245, 255, 506 Subject Index Treatment advisor, 471 See also Decision-support system planning, 529 protocol, 479 See also Clinical guidelines Trend analysis, 52 Trigger event, 242 TRIMIS See Tri-Service Medical Information System Tri-Service Medical Information System (TRIMIS), 432 True negative, 88ff True-negative rate, 90ff True positive, 88ff True-positive rate, 90ff Turnaround document, 350 Turnkey system, 180, 195,208 TUTOR,614 Tutorial Evaluation System (TES), 612 Twisted pair, 149 Type checking, 157 u UB92,216 UCAID See University Consortium for Advanced Internet Development UCSF See University of California, San Francisco Ultrasonic (ultrasound) imaging, 486, 494 UMLS See Unified Medical Language System Uncertainty, 43, 79 Unified Medical Language System (UMLS), 64, 140, 237-240, 389, 514,532,535,566-569,698 Unified Nursing Language System, 436, 437 Uniform Code Council (UCC), 250 Universal Product Number Repository, 251 Universal Resource Locator (URL), 168, 564-565 University Consortium for Advanced Internet Development, 17 University of California Irvine, 517 853 San Diego, 499 San Francisco, 386, 436 University of Florida, 623 University of Illinois, 612, 613, 614 University of Iowa, 413, 435 University of Leeds, 577 University of Maryland, Baltimore, 436 University of Miami, 269 University of Michigan Hospital, 386 University of Missouri, Columbia, 432, 527 University of Pennsylvania, 510, 526 University of Pittsburgh, 517, 592 University of Southern California, 517 University of Texas at Austin, 436 University of Utah, 436, 582 University of Washington, 500, 529-534, 621 University of Wisconsin, 615 UNIX, 34 URL See Universal Resource Locator Usenet, 414 User feedback and guidance, 181 User interface, 354, 390, 704 See also Human-computer interaction Usual, customary, and reasonable fee See Fee, usual Utility, 76, 107, 113,586 assessment, 113ff, 129 theory, 111 Utility Multi-Programming System, See MUMPS Utilization review/management, 676 v VA See Department of Veterans' Affairs Vaccination, 52 Validity, 302 Validity check, 329, 347 Vanderbilt University Hospital, 337 Variables, 302 dependent/independent, 302 internal/external, 307 vBNS See Very high speed Backbone Network System VDT See Video display terminal Vector-space model, 548 854 Subject Index Very high speed Backbone Network System (vBNS), 152 Veterans Administration Hospitals, 384, 513,537 See also Department of Veterans' Mfairs Veterinary informatics, 29 Video display terminal, 135, 141, 381, 382 View, 164 Virtual address, 160 memory, 160 reality, 289, 487, 530, 588, 636 Virtual Emergency Room, 531 Virtual Hospital, 413 Virtual Reality Modeling Language (VRML),633 Virus (software), 175 Visible Human, 531, 622 Visual-analog scale, 114 Vital signs, 447ff VM See Ventilator Manager Vocabulary, 224ff See also Terminology Voice input, 144,390,393,433,523, 527, 705 Voice recognition See Speech recognition Volume performance standard (VPS), 672 Volume rendering, 508, 515, 518 VoxelMan,532 VOXWARE, 336 VPS See Volume performance standard VRML See Virtual reality modeling language WEDI See Workgroup for Electronic Data Interchange Well-Being Scale, 115 WHO Drug Dictionary, 235 Wide-area network, 12, 149, 185,245, 505,510 Windows, 167,633 WIZ Order, 337 WONDER System, 400, 412, 418 Woodruff Foundation, 401 Word (computer memory), 137 Word processing, 12,44 Workflow, 368, 378,489,522,577,606, 704 Workgroup for Electronic Data Interchange (WEDI), 251 Workstation, 133 clinical, 4, 214, 253, 255 imaging See Image viewing knowledge-management, 576 universal, 386 Worldcom, Inc., 14 World Health Organization (WHO), 227, 235,437 World Wide Web, 4, 13, 15, 127, 153, 165,168,205,208,273,277-278, 336,351,394,410-415,417,420, 498,509,514,528,530,535,540, 553,562,570,603,604,617,625, 629,633,645,646,655 WORM See Write once, read many times Write once, read many times, 140 w x WAN See Wide-area network Warning (computer-generated), 60, 185, 335,339,351,445,459,471,580 pager-delivered, 471, 475 See also Decision support Waterfall model, 199 Water sluice model, 204 Waveform processing, 456, 460 See also Signal processing Wearable computer, 705 Web browser, 158,205,617 WebMedline, 553-554, 557-558, 568-569 X12 See ANSI X12 Xerox Corporation, 277, 558 Palo Alto Research Center (PARC), 702 XML,206 X-ray, 492 See also Radiology crystallography, 644 Xybemaut, 705 y Y2K problem, 43 Yale University, 226, 515 Health Informatics Series (formerly Computers in Health Care) (continued from page ii) Introduction to Clinical Informatics P Degoulet and M Fieschi Behavioral Healthcare Informatics N.A Dewan, N.M Lorenzi, R.T Riley, and S.R Bhattacharya Patient Care Information Systems Successful Design and Implementation E.L Drazen, I.B Metzger, I.L Ritter, and M.K Schneider Introduction to Nursing Informatics, Second Edition K.I Hannah, M.I Ball, and M.I.A Edwards Strategic Information Management in Hospitals An Introduction to Hospital Information Systems R Haux, A Winters, E Ammenwerth, and B Brigl Information Retrieval A Health and Bwmedk:al Perspective, Second Edition W.R Hersh The Nursing Informatics Implementation Guide B.C Hunt, S.B Sproat, and R.R Kitzmiller Information Technology for the Practicing Physician I.M Kiel Computerizing Large Integrated Health Networks The VA Success R.M Kolodner Medical Data Management A Practical Guide F Leiner, W Gaus, R Haux, and P Knaup-Gregori Organizational Aspects of Health Informatics Man/lging Technological Clumge N.M Lorenzi and R.T Riley Transforming Health Care Through Information, Second Edition N.M Lorenzi, I.S Ash, I Einbinder, W McPhee, and L Einbinder Trauma Informatics K.I Maull and I.S Augenstein Consumer Informatics Applications and Strategies in Cyber Health Care R Nelson and M.I Ball Public Health Infonnatics and Infonnation Systems P.W O'Carroll, W.A Yasnoff, M.E Ward, L.H Ripp, and E.L Martin Advancing Federal Sector Health Care A Model for Technology Transfer P Rarnsaroop, MJ Ball, D Beaulieu, and J.V Douglas Medical Infonnatics Computer Applications in Health Care and Biomedicine, Second Edition E.H Shortliffe and L.E Perreault Filmless Radiology E.L Siegel and RM Kolodner Cancer Infonnatics Essential Technologies for Clinical Trials I.S Silva, MJ Ball, c.G Chute, J.V Douglas, c.P Langlotz, I.C Niland, and W.L Scherlis Clinical Infonnation Systems A Component-Based Approach R Van de Velde and P Degoulet Knowledge Coupling New Premises and New Toolsfor Medical Care and Education L.L Weed Healthcare Infonnation Management Systems Cases, Strategies, and Solutions, Third Edition M.J Ball, c.A Weaver, and I.M Kiel Organizational Aspects of Health Infonnatics, Second Edition Managing Technological Change N.M Lorenzi and RT Riley ... terms medical computer science, medical computing, medical informatics, clinical informatics, nursing informatics, bioinformatics, and health informatics? • Why should health professionals and. .. Johns Hopkins University School of Nursing Baltimore, MD 21205, USA Library of Congress Cataloging -in- Publication Data Medical informatics: computer applications in health care and biomedicine /... medicine and information technologies Information Management in Biomedicine Although the application of computers to biomedicine is recent, the clinical and research influence of medical- computing