Guide to Health Informatics 2nd Edition
Enrico Coiera
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Much background material supporting
the book can be found in a comprehensive
listing of my own published research and commentary, which is updated
regularly.
Errors and corrections to the text can
be found on the errata page .
The Web is constantly reinventing
itself and links to a resource may no longer work. If so, please tell me. Also
remember that at times, failure to retrieve a document may be temporary -
traffic can become congested at a site or on your connection, or the site may
be temporarily shut down.
"The map is not the
territory" is the motto that begins our journey into the study of health
informatics. It reminds us to never make the mistake of confusing a thing with
its representation. In a world where we are bombarded with representation
rather than reality, its an often essential rule to help us navigate between
what is, and what others would like us to believe. You can make up your own
versions of the rule - "the policy is not the politician", "the
advertisment is not the product", or "The Matrix is not the Earth".
For health informatics, where almost everything we do is with representations of reality, from patient test results through to scientific papers published in the biomedical literature, this rule of thumb comes as close to a fundamental law of nature as we have. In later chapters, we will learn that "the chart is not the patient" and explore why the data we use to guide decision making are always distorted, whether becuase of human limitations and biases, the inherent unreliabilty of communication, or the limits of measurement.
The human weakness for confusing
representation and reality is one that has often been the subject of
philosophy, literature and the arts. For me, no-one has made the point more
simply or cleverly than the Belgian surrealist artist Rene Magritte. His famous painting 'Ceci
n'est pas un pipe' tries to confuse us. It's a painting of a pipe, and yet
Magritte tells us its not a pipe. What's going on? Well. Magritte is right,
it's not a pipe. It's a painting of a pipe. Never confuse the two again! (If
you still dont get it, next time you are hungry look at the Endearing truth and tell
me if your belly is now full.)
Further Reading:
One of the most important themes of
the first part of the book revolves around the way our assumptions about the
world affect the way we model the world, and eventually build objects or
systems to work within it. Donald
Norman's beautifully simple book, The
Design of Everyday Things, is now a classic, and explores the way the way
that design and function interrelate. The book is easy to read, and worth a
look. However you may never be able to look at a doorknob in the same way.
Further Reading:
This chapter introduces the idea that
we can explicitly represent knowledge in a way that can be manipulated by
computer, and underlines the wide range of different roles that computers can
take. The theme is returned to in more detail in Chapter 25, when we come to
discuss how computers can start to be 'intelligent'. Since The Guide is
not a book about programming, it does not go into great detail about the
science of how programs are contructed, which is the domain of Computer
Science. Readers who want to delve further, but who lack a formal computer or
mathematical background, may wish to look at David Harel's book Algorithmics:
The Spirit of Computing . This is an unusually well-written and clear book
on what it means to create computable structures, often used by
computer-science undergraduates as a general and non-technical introduction to
their field. Harel covers many advanced topics which would not normally cross
the paths of healthcare informatics enthusiasts, but does so in fairly
down-to-earth style.
One of the fundamental goals of this book is to emphasise the importance
of the scientific discipline of informatics to healthcare and in so doing,
de-emphasise technology, which so often seems more master than slave. As a
result, these five chapters define five basic areas of informatics skills
modern clinicians will need to master to effectively engage in the health care
system. However, defining what elements of the science of informatics are
central to the routine practice of healthcare is still a matter for debate.
Some see it solely in terms of training people to surf the Internet, conduct Medline
searches, and use word-processors, slide packages and spreadsheets. Others look
to the information skills one needs to have an evidence-based practice. In an
editorial on Medical
Informatics and Education I suggested 10
essential clinical informatics skills that should be a part of every
healthcare worker's skill set, and these skills guided the writing of these
chapters. Careful readers might want to keep these skills in mind as they work
through the text, deciding how take this material back into their daily
practice. A comprehensive document outlining the NHS’s views of the information
and communication skills that may be needed by practicing clinicians is
presented in a report on Health
Informatics Competencies.
In
this chapter we underline the importance of structuring clinical documents to
maximise their effectiveness in communicating the message intended. Sometimes
the guidance on good structure is based upon practical experience, but increasingly
there is an evidence base to support different recommendations. For example, the
National Cancer Institute provides a set
of evidence-based guidelines on
how to structure web pages to enhance their usefulness.
William Hersh’s excellent text Information Retrieval: A health and biomedical perspective critically assembles a large amount of research material. It gives detailed coverage of the main biomedical on-line resources, and explores the best ways to conduct searches using them.
Medical decision-making has been studied extensively over the last few decades, and there is a rich body of work that explores both the cognitive basis of human thinking, as well as the structure of well-formed decisions. The most modern and comprehensive entry-level text in decision-making is Decision-making in Health and Medicine – Integrating Evidence with Values. The classis 1988 text Medical Decision-making is also well worth a look.
What does an electronic medical record
(EMR) do? For many it is much more than an electronic replacement of existing
paper systems. The EMR can start to actively support clinical care by providing
a wide varied of information services. However, it is hard to understand what
information is really important to clinical care, and what is simply
occasionally desirable. A
review of clinician's information needs, written by the editor of the
British Medical Journal, provides a comprehensive and up-to-date review of
research focused on uncovering the true information needs of clinicians, as
opposed to the much longer list of clinicians' 'wants'. This theme is returned
to in the next chapter, where the different methods for studying information
requirements are presented.
The US Institute of Medicine’s
comprehensive report The
Computer-based Patient Record has been influential in defining both what
the EMR is, and in pushing for its widespread development and adoption.
Further Reading:
While this chapter devotes some time
to the important issue of evaluating systems once they have been completed, a
much richer and comprehensive treatment of the subject can be found in Evaluation
Methods in Medical Informatics by C. P. Freidman, J. C. Wyatt. This is book
is probably the definitive text in the area of evaluation for medical
informatics.
The US National Guideline Clearinghouse™ is a
public resource for evidence-based clinical practice guidelines. NGC is
sponsored by the Agency for Healthcare Research and Quality (AHRQ),
U.S. Department of Health and Human Services, in partnership with the American
Medical Association and the American Association of Health Plans.
Other AHRQ clinical guidelines are
also available online.
The Cochrane Collaboration Homepage:
The Cochrane Collaboration is an international network of individuals and
institutions committed to preparing, maintaining, and disseminating systematic
reviews of the effects of health care. In pursuing its aims, the Cochrane
Collaboration is guided by six principles: collaboration, building on people's
existing enthusiasm and interests, minimizing duplication of effort, avoidance
of bias, keeping up to date, and ensuring access. This Web site contains
important contact information, the Cochrane library, as well as a description
of the evidence-based methodology adopted by the group, which is described in
the Cochrane Handbook.
The Oxford
Centre for Evidence-Based Medicine offers numerous resources to assist evidence-
based practice. The Centre for
Evidence-Based Medicine (Mount Sinai Hospital) website also provides
materials to help develop, disseminate, and evaluate resources that can be used
to practise and teach EBM for undergraduate, postgraduate and continuing
education for health care professionals from a variety of clinical disciplines.
Openclinical provides a good summary of key evidence-based medicine publications.
Chapter 13 – Computer-based
protocol systems in healthcare
Openclinical
is an
international organisation that has been created to promote awareness and use
of decision support, clinical workflow and other advanced knowledge management
technologies for patient care and clinical research. Researchers into the
design of protocol-based systems have developed many different technical
approaches to representing and implementing protocols or guidelines in computer
systems. Openclinical offers a comprehensive summary of the different
guideline modelling methods as well as links to key articles on guideline
systems and clinical
pathways.
Chapter 15 – Designing protocols
Passive protocol systems increasingly
are available electronically, and many of the recommendations provided by the National Cancer Institute at their web site
of evidence-based guidelines on
how to structure web pages are directly relevant to the electronic presentation
of passive clinical guidelines.
The International Statistical
Classification of Diseases and Related Health Problems, tenth revision is
developed and supported by the World Health
Organization.
SNOMED CT is jointly developed from
the UK Clinical Terms and SNOMED RT. The NHS Information
Authority and SNOMED
both provide web sites to support SCT.
The Unified Medical
Language System (UMLS) Project: This is a large research activity funded by
the US National Library of Medicine. The UMLS itself is actually a number of
interlocking resources for the management of medical languages, and is designed
to allow uniform access to machine-readable medical resources.
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construction – items below this line need updating
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Further Reading:
This chapter covers the basic types of
communication networks, but only at a very introductory level. For those who
want a deeper understanding of computer networks and the way they function,
then you cannot probably do much better than by reading Andrew Tanenbaum's
classic Computer
Networks, now in its 3rd edition. The book describes networks in relation
to their different layers, and has been updated to discuss Internet
technologies.
HospitalWeb
provides a list of medical institutions currently on the Internet, and attempts
to facilitate communication between clinicians and researchers by publishing
contact information and relevant background information about institutions and
individuals within them.
An enormous amount of
health-related material is now available on the Internet. The number of books,
journals and Internet sites devoted to collating such information themselves collectively
amount to a new industry. In the selection below, some of the more prestigious
sites are mentioned, along with examples of information sites that could in
some way be considered innovative or substantive.
Medical Journals on the Web: Most of the major medical journals now have
an Internet presence, where they as a minimum publish tables of contents and
abstracts for each edition. Many, like the BMJ, will make some full papers
available and provide search facilities for back issues. The Medical Journal of
Australia has an exciting on-line peer review program, which permits readers to
comment on articles that have been submitted but not yet accepted for final
publication:
The Visible
Human and the Visible Human Female:
An impressive and imaginative program, under the auspices of the US National
Library of Medicine, the Visible Human program is collecting together
cross-sectional digital images taken from two cadavers, and making these
available to researchers. Special viewing programs are also available from different
research sites who work with this data set, permitting various renderings of
the 3-D images for research and educational purposes.
Medical Resources on the Web: A number of Internet sites are devoted to
collecting health-related information. These 'sites about sites' have various
methods for deciding whether information should be included. Some, like OMNI
have particularly stringent criteria. Others simply include whatever they feel
is relevant based upon local criteria:
Patient Resources for health-related
material on the Internet:
There are an ever-growing number of sites providing information for patients.
Sites may include standard information regarding medications and common
diseases. More adventurous ones, like MedicineNet, provide a question answering
services, where members of the public can have their email questions replied to
by a medical 'expert':
List of Artificial Intelligence
Systems in Routine Clinical Use : Based on contributions from the public,
this list contains summaries of Artificial Intelligence based computer systems
that are in routine use in medical settings. List entries range from simple
knowledge-based or expert systems, to quite advanced systems capable of
performing complex inferences.
A comprehensive history of Artificial
Intelligence in Medicine prepared by students at MIT.
The
Data Mining and Knowledge Discovery Resource Center: One of the major
applications for various machine learning systems is to 'extract' knowledge
from large collections of data. This process of looking for regular patterns in
data is sometimes called knowledge discovery or data mining. This site keeps an
up-to-date list of resources, including programs for data mining, public domain
databases for experimental research, and access to discussions on current
research and application topics.
Further Reading:
Russell and Norvig's Artificial
Intelligence - A modern approach is now probably the standard teaching text
for AI classes, especially in the US. It is a big book (over 900 pages), and
will probably be a good introduction, as well as reference work, for those
interested in delving deeper into AI.
If you want a slightly thinner volume,
then Patrick Winston's Artificial
Intelligence, now in its 3rd edition, is also excellent. It is probably the
classic introduction to AI, and remains, I believe, one of the best selling AI
book to date.
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ewc@pobox.com ©
Enrico Coiera 1997-2003
updated
19 Dec 03
