A Personal History of Medical Informatics W. Ed Hammond. Ph.D., FACMI, FAIMBE, FIMIA, FHL7 Director,...
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A Personal History of Medical Informatics W. Ed Hammond. Ph.D., FACMI, FAIMBE, FIMIA, FHL7 Director, Duke Center for Health Informatics Director, Applied
A Personal History of Medical Informatics W. Ed Hammond. Ph.D.,
FACMI, FAIMBE, FIMIA, FHL7 Director, Duke Center for Health
Informatics Director, Applied Informatics Research, DHTS Associate
Director, Biomedical Informatics Core, DTMI Professor, Department
of Community and Family Medicine Professor Emeritus, Department of
Biomedical Engineering Adjunct Professor, Fuqua School of Business
Duke University Chair Emeritus and Secretary, HL7
Slide 2
11/8/00 e-hammond 2 The Medical Record - TMR Over 40 different
implementations 14 different medical specialties support from 1 to
350 providers maximum of 750,000 patients in one system operational
in 28 different sites
Slide 3
11/8/00 e-hammond 3 Early Years Automated 19 page screening
medical history
Slide 4
11/8/00 e-hammond 4 Early Systems Interactive Neurology
Questionnaires OB Computer-based Patient Record Automation of
manual process Output duplication of paper system Data overflow
Replacing required manual task External to program storage of
display and flow control characteristics
Slide 5
11/8/00 e-hammond 5 PDP 12 4Kbytes 12 bit word 300K mass
storage Programming Languages -Assembly -Basic -GEMISCH
Slide 6
11/8/00 e-hammond 6 Programming Language GEMISCH Input Frames
Massage Print Retrieve Store Assembly Language - Focused set of
tools to do specific tasks
Slide 7
11/8/00 e-hammond 7 GEMISCH Powerful text manipulating
functionality Smart print generating capability Variable and
flexible file types Programmable display functionality within
constraints of character-based terminals Total control of interface
capability
Slide 8 " R (F:-1) D WT -1 M LINE^WT+SAPPTR-1 P
"[X$,LINE,14,BMI]" P "[M1,2]ENTER CODE FOR HEIGHT => " R (F:-1)
D HT -1 P "[M1,3]CODE FOR BMI IS [VBMI]" M LINE^BMI+SAPPTR-1 D
%-300 S "[X$,LINE,5,BMIDO][X$,LINE,8]";CAL SET F FILE=1,NFILE D
%-193 S "[X$,37,6]:[A91][K],11[A93]TMR.[~FILE,3,0]" L0:NEXTRECORD
DONE =-193 D %-3 S "[H#,-176,1]" D AN -3 O "$" I AN,A2X2A D %-2 S
"[H#,13,1]";BF PAT ADJUSTMENT NODE F AI=1,AN D %-1 S "[H$,-3,AI]" D
%-2 S "[B-2=F[N-2]$][N-1]" P "[H,,-1,1,AK][H,,-1,3,AM]" M
AL^AK+ACCPTR-1 P "[X$,AL,4,AK]" M AM^((AK=1)-(AK=2))*AM M AO^AO+AM
M AB^AB+AM E D %-1 S "[VAO]" D %1 R -1 1 # D %13 R -2 1 #">
Example of Gemisch coding D %-194 S
"ZA:[A91][K],12[A93]TMR.DBD" O D =-194 P "[X$,1,1,TMP]" Z TMP D %-1
S "[D2]" D JDATE -1 S SS8 ?1=MDATE,'1=0 M BUFF^-4 P
"[X$,5,1,ENCOFF][X$,9,1,SAPOFF][X$,9,3,ASAPOFF]\
[X$,23,1,SAPPTR][X$,37,2,NFILE][X$,37,14,NEFILE]\
[X$,37,15,NSFILE]" P "[S][U11]ENTER CODE FOR WEIGHT => " R
(F:-1) D WT -1 M LINE^WT+SAPPTR-1 P "[X$,LINE,14,BMI]" P
"[M1,2]ENTER CODE FOR HEIGHT => " R (F:-1) D HT -1 P "[M1,3]CODE
FOR BMI IS [VBMI]" M LINE^BMI+SAPPTR-1 D %-300 S
"[X$,LINE,5,BMIDO][X$,LINE,8]";CAL SET F FILE=1,NFILE D %-193 S
"[X$,37,6]:[A91][K],11[A93]TMR.[~FILE,3,0]" L0:NEXTRECORD DONE
=-193 D %-3 S "[H#,-176,1]" D AN -3 O "$" I AN,A2X2A D %-2 S
"[H#,13,1]";BF PAT ADJUSTMENT NODE F AI=1,AN D %-1 S "[H$,-3,AI]" D
%-2 S "[B-2=F[N-2]$][N-1]" P "[H,,-1,1,AK][H,,-1,3,AM]" M
AL^AK+ACCPTR-1 P "[X$,AL,4,AK]" M AM^((AK=1)-(AK=2))*AM M AO^AO+AM
M AB^AB+AM E D %-1 S "[VAO]" D %1 R -1 1 # D %13 R -2 1 #
Slide 9
11/8/00 e-hammond 9 Continued Development University Health
Services Clinic Transaction-oriented architecture Added practice
management functionality Scheduling Accounting Family Medical
Center Quickly evolved into different system Four sites - required
programming staff of 25 persons
Slide 10
11/8/00 e-hammond 10 Clinical Focus
Slide 11
11/8/00 e-hammond 11 Practice Management
Slide 12
11/8/00 e-hammond 12 The Medical Record Modular construction -
simplifies programming, documentation, evolution and maintenance
Independence of data capture, data storage and data use Combination
of problem-oriented, encounter-oriented and time oriented
formats
Slide 13
11/8/00 e-hammond 13 The Medical Record Multiple input modes
parameter-oriented direct input mode for source data entry use of
paper or dictation to capture physician input for subsequent input
by 3rd party automated input from machine data message input - MAPS
then HL7
Slide 14
11/8/00 e-hammond 14 Renal Direct Entry
Slide 15
11/8/00 e-hammond 15 Renal Encounter Entry Form
Slide 16
11/8/00 e-hammond 16 The Medical Record Direct coupling of
protocols to data entry and data display Knowledge required for
system behavior defined in a dictionary of metadata
Slide 17
11/8/00 e-hammond 17 Quality Assurance Protocol
Slide 18
11/8/00 e-hammond 18 Continued Growth Cardiology Clinical
database for research purposes New data types New displays and
presentations Crude graphics Cross patient retrievals
Slide 19
11/8/00 e-hammond 19 Cardiology
Slide 20
11/8/00 e-hammond 20 Continued Growth Inpatient system New
program navigation required Multiple day encounters Preorders for
tests and treatments Increase in volume of data Late charges
Increased importance of time stamp on data Patient tracking within
institution
Slide 21
11/8/00 e-hammond 21 Continued Growth Surgical Intensive Care
Unit Increased volume Increased interfaces Bedside interfaces Nurse
Charting Additional linkages
Slide 22
11/8/00e-hammond 22 Generalizable lessons about clinical
systems and databases
Slide 23
11/8/00 e-hammond 23 Dictionary of Metadata data element
definitions vocabulary and external code sets physical resources
data capture protocols billing algorithms decision support rules
work flow rules information flow linkages report generation
drug-drug interactions people and places security
Slide 24
11/8/00 e-hammond 24 Dictionary, Problems Code Set
(ICD,ICPC,SNOMED,Read,) Name Type Classification Category Linkage
to causal diagnosis Linkage to manifestations
Slide 25
11/8/00 e-hammond 25 Dictionary, Problems Code Set
(ICD,ICPC,SNOMED,Read,) Name Type Classification Category Linkage
to causal diagnosis Linkage to manifestations
Slide 26
11/8/00 e-hammond 26 Dictionary, Problems Linkage to S&P
Linkage to Related Studies Linkage to Medications Linkage to
Management Plan Problem-oriented display specification Protocol
linkage Parent diagnoses
Slide 27
11/8/00 e-hammond 27 Dictionary, Problems Coded modifiers
Intervention linkage set Outcome linkage set Evaluation Linkage
set
Slide 28
11/8/00 e-hammond 28 GEMISCH Record Structure
Slide 29
11/8/00 e-hammond 29 TMR Data Storage Time-oriented data
54!2!5$87023!2@1230|3@1015$87022!1@1015
Slide 30
11/8/00 e-hammond 30 Database structure for studies Codes in
display order DateTime Data 10|15|25|21|22|67|32|45|148|53
990600800|9823510156|981501500|971891215 150||155|165 |||20
3|3|3|3
Slide 31
11/8/00 e-hammond 31 TMR Record Structure Demographics Payors
Providers Summary Problems Therapies Studies History and Physical
Findings Appointments Encounters Accounting
11/8/00 e-hammond 33 TMR Files TMR Patient Record Daily Record
Backup Total Event Log Audit Summary Protocol Tracking Access
Log
Slide 34
11/8/00 e-hammond 34 Implications for MI Critical mass of
functionality Visible benefit Partnership within development teams
Ability to maintain and evolve Ability to prototype and later
incorporate Ability to accommodate preferences Open interfaces
Scalability
Slide 35
11/8/00 e-hammond 35 Changing Technology
Slide 36
11/8/00 e-hammond 36 Input/Output Devices
Slide 37
11/8/00 e-hammond 37 Hostile (?) Environments
Slide 38
11/8/00e-hammond 38 Technological progress will continue. It
merely changes the challenges, but never eliminates them.