Biomedical Informatics: An Introduction (2015) - PDF

Biomedical Informatics An Introduction to Information Systems and Software in Medicine and Health Biomedical Informatics An Introduction to Information Systems and Software in Medicine and Health David J. Lubliner New Jersey Institute of Technology, Newark, USA...

Biomedical Informatics An Introduction to Information Systems and Software in Medicine and Health Biomedical Informatics An Introduction to Information Systems and Software in Medicine and Health David J. Lubliner New Jersey Institute of Technology, Newark, USA Illustration by Amy Cassandra Lubliner CRC Press Taylor & Francis Group 6000 Broken Sound Parkway NW, Suite 300 Boca Raton, FL 33487-2742 © 2016 by Taylor & Francis Group, LLC CRC Press is an imprint of Taylor & Francis Group, an Informa business No claim to original U.S. Government works Printed on acid-free paper Version Date: 20150831 International Standard Book Number-13: 978-1-4665-9620-7 (Hardback) This book contains information obtained from authentic and highly regarded sources. Reasonable efforts have been made to publish reliable data and information, but the author and publisher cannot assume responsibility for the valid­ ity of all materials or the consequences of their use. 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Visit the Taylor & Francis Web site at http://www.taylorandfrancis.com and the CRC Press Web site at http://www.crcpress.com  Contents Preface......................................................................................................................vii Author....................................................................................................................... ix Contributors............................................................................................................. xi 1 Introduction to Biomedical Informatics...........................................................1 2 Framework for Implementing the U.S. Medical Records Infrastructure...... 27 3 Electronic Health Records.............................................................................. 45 4 Data Interoperability........................................................................................81 5 Security........................................................................................................... 121 6 Telehealth....................................................................................................... 139 7 Medical Sensors.............................................................................................. 163 8 Imaging.......................................................................................................... 223 9 Ethics.............................................................................................................. 251 10 Critical Care Nursing Perspective on the Electronic Health Record.......... 269 Cathy Lubliner 11 Healthcare Management Information Technology in the Full Service Facility....................................................................................... 309 Philomena Diquollo 12 Future Directions for Biomedical Informatics.............................................. 321 Appendix A: Application Development for Electronic Health Records–Mobile Applications Development...................................................... 349 Daniel Nasello Appendix B: Mobile Applications Development............................................... 367 Daniel Nasello v vi Contents Appendix C: Cascading Style Sheets................................................................... 381 Daniel Nasello Appendix D: JavaScript........................................................................................ 393 Daniel Nasello Glossary..................................................................................................................401 Index.......................................................................................................................413  Preface The inspiration for writing this textbook was fourfold: First, to create a cohesive narrative of the multi­ disciplinary concepts linking the Biomedical Informatics field; second, to introduce an improved text­ book organizational structure so students will have a clear demarcation between essential and optional materials; third, to provide a primer on the theoretical concepts that underpin the science in this field including an Anatomy & Physiology essentials guide; and lastly, to provide a tutorial on application development so students can understand the tools that can be applied to provide improved user inter­ faces for EHRs on mobile platforms. I believe that the current spate of textbooks could be improved. Most textbooks in either health, medical, or biomedical informatics are usually a compendium of dispa­ rate facts cobbled together from distinct concepts, albeit appropriate for this field, lacking the narrative and content that ties together concepts. Most books in this field are written by 20–30 individual authors; although experts in their field, their narrow charge and scope limit the cohesive connection between concepts. This textbook attempts to build a cohesive narrative beginning with the forces and government mandates that facilitated this expo­ nential rise in the universal acceptance of the structure and standards that created this new discipline. Later, the science behind these technologies is explored, including a necessary basic primer on anatomy and physiology and in later chapters feedback from nursing experts and managers who have imple­ mented and used electronic health records. The last chapter attempts to define a series of parameters for predictive biomedical informatics so professionals can extrapolate forces that may expand or impede future desired advances. Technological forces are only one factor that leads to innovation; often financial, governmental, and intangible public perceptions need to be factored into the equations for predictive analysis. Appendices A through D are a basic primer on writing applications for portable devices. These devices will play a more important role in healthcare delivery and monitoring in the future. The second motivation to writing this textbook was to create a structure that facilitated learning. Most books introduce concepts but are not easily structured for the reader or instructor. In a typical 40-page chapter, how do you determine which concepts are essential facts, which are applied concepts, and which ideas fall into the advanced topic realm? The book attempts to create a clear delineation between Level I, basic concepts every biomedical informatics professional should master, Level II, applied concepts and examples, and Level III, advanced topics. Undergraduate and graduate instruc­ tors and professionals in the field can quickly focus on the essential topics but if interested can delve in Level III advanced topics. I appreciate feedback from the readers regarding unintentional errors or suggestions for enhancing future editions. The journey of writing this or any book is transformative. The authors believe they are experts in their fields, but then after, for example, reading 10,000 pages of the DICOM medical imaging standards Parts 1–20, their perceptions evolve and they begin to appreciate the complexities and in-depth interop­ erability that underlie these standards that they were not privy to before. It also leads readers to explore and hopefully extrapolate meaning that allows them to begin their own journey of exploration and learning. “When you reach that point in life where you realize how little you actually know, that’s the vii viii Preface first step in your journey to learning.” This concept has been echoed from the teaching of the Buddha to the fictional character Don Juan by Tirso de Molina in 1630. There is always more to learn, and I hope this book motivates a few to continue this journey. I have tried to include links to all documents and standards sources so students can explore, in detail, each idea described in this book. The research process for the book took several years. It was challenging, or agonizing, depending on your perspective. The web provides virtually infinite resources, but extracting the wheat from the chaff is often difficult. Exploring tenuous linkages between concepts, falling deep into the rabbit hole and then trying to extract myself was a challenge. Where do you stop? You could write an entire book on MRIs or HL7 standards, but extracting the essential meaning of concepts so students can begin their own exploration is difficult. The goal was to create a textbook that would provide a teacher or a student with clear, engaging, in-depth explanations and links to resources to explore concepts in more detail if desired. The book was written to be read in sequential order but allows students the ability to explore topics in detail. The structure of the book allows that mode of exploration. Level I of every chapter is recom­ mended. In addition, Chapter 10, “A Critical Care Nurse’s Perspective of EHRs,” should be read. How we use technology is as important as the technology itself. Enjoy the journey; this is an exciting, evolving field that will transform healthcare. David J. Lubliner, PhD MATLAB® is a registered trademark of The MathWorks, Inc. For product information, please contact: The MathWorks, Inc. 3 Apple Hill Drive Natick, MA 01760-2098 USA Tel: 508-647-7000 Fax: 508-647-7001 E-mail: [email protected] Web: www.mathworks.com  Author David J. Lubliner is a member of the faculty at a northeastern university where he runs a medical infor­ matics program that he developed a decade earlier. He earned his PhD in information systems and has graduate degrees in biomedical engineering and computer science. He is currently part of a team devel­ oping a handheld medical scanner. Prior to teaching, he worked for 10 years at a Fortune 500 company as a divisional vice president of an architecture–computer security group and before that worked as an engineer on the Patriot missile system. Dr. Lubliner believes we are at the dawn of a new age of medicine, where instant access to data will change the current top-down model of healthcare to a more user-centric system. At the beginning of the twentieth century, technological advances doubled life spans, and we are poised to recreate that with the exponential growth of medical research and real-time access to information, creating a truly universal medical principia of all human knowledge: “Live long and prosper.” ix  Contributors Philomena M. DiQuollo is a working health-care IT professional who began her career in nursing and transitioned to IT&S 12 years later. Since 1985, she has been working in acute care facilities, implement­ ing clinical and business technology solutions as well as directing day-to-day operations and supporting strategic goals at a major urban teaching medical center in New Jersey. Currently, her position is sys­ tem director of analytics within a multifacility health-care system. Philomena DiQuollo is an adjunct faculty at New Jersey Institute of Technology, Newark, New Jersey, teaching in the medical informatics program. She received her BSN from Seton Hall University, South Orange, New Jersey and MA in nurs­ ing from New York University, New York, New York. In addition, she is a certified professional in health information management systems and is American Society for Quality Six Sigma Green Belt certified. She resides in New Jersey and is pursuing a master’s in analytics at Villanova University, Villanova, Pennsylvania. Cathy Lubliner is a critical care clinical nurse specialist at an academic teaching hospital. She has more than 30 years experience in the care of patients with end-stage heart failure, cardiogenic and septic shock, pre- and posttransplant procedures, and ventricular assist devices. During the implementation of the EHR, she served as one of the “super users” to facilitate the transition of the nursing staff to the computer-based documentation system. Daniel Nasello is an experienced mobile and web application developer and project manager, who cur­ rently resides in Nutley New Jersey. Having developed some highly successful applications (including multiple applications for various singers and actors) and having worked in multiple industries allow Daniel to bring the experience into the software he develops. Seeing the rapid growth of mobile applica­ tion development, Daniel has created groundbreaking and innovative applications that will be used in tomorrow’s market, and he is also developing mobile and web application opportunities in industries where they are nonexistent. Daniel currently holds a bachelor’s degree in computer technology a mas­ ter’s degree in information system from the New Jersey Institute of Technology, Newark, New Jersey. He is also a part-time instructor at NJIT, where he spearheaded the mobile application development class, which is rapidly growing in popularity. xi  1 Introduction to Biomedical Informatics Level I: Core Concepts.....................................................................................2 1.1 Introduction..........................................................................................2 1.2 Nomenclature........................................................................................2 1.3 Textbook Organization........................................................................5 1.4 Biomedical Informatics Challenges...................................................6 1.5 Biomedical Informatics Curriculum.................................................7 AMIA Core Biomedical Competencies National League for Nursing Informatics Bachelor’s in Medical/Biomedical Informatics Curriculum 1.6 Chapter Summaries............................................................................ 12 Glossary...........................................................................................................24 1.A Appendix...................................................................................................24 1 2 Biomedical Informatics Level I: Core Concepts 1.1 Introduction Biomedical Informatics (BMI) lies at the intersection of information technology (IT) and healthcare/ medicine. Integrating complex data, linking medical professionals and patients, staying abreast of the lightning changes in both fields, and providing real-time secure data make this field simultaneously exciting and challenging. The BMI professionals are well versed in IT since they will be working with hospitals’ IT staffs and radiol­ ogists to ensure seamless integration of digital imaging and communications, working with structured data and protocols; integrating all forms of wired and wireless data, facilitating secure communication protocols, and interfacing with medical professionals and patients will require a broad knowledge of interrelated fields. Electronic health records (EHRs) may be the most visible of technologies the BMI professional facilitates, incredibly complex in their own right, integrating data from a myriad of sources both internal and external and providing expertise in developing user interfaces and facilitating data capture from medical sensors/ monitors. Working with medical staff, their role is to customize user interfaces, which requires a knowl­ edge of medical terminology and standards such as ICD10 and SNOMED and knowledge of best practices meaningful use regulations. They will be at the forefront of the transition to “medical records 2,” creating user-friendly and efficient interfaces via mobile devices tailored to the needs of individual professionals. A nurse should not be a data entry specialist, but EHR tools and interfaces should facilitate not hinder their profession, so a knowledge of application development and user interfaces is a critical core knowledge. We are in the infancy of EHR technology, at the awkward stage of barely being able to walk and talk, and certainly not user-friendly, spitting up all over users. The baby was born with the help of HIPAA, the Stimulus Act, and the Affordable Care Act (ACA). BMI professionals have to guide and support the evolution of this infant to stage 2, toddler, walking, talking, and potty training them to be productive members of society. Buckle up, there will be all-night feeding sessions, changing dirty diapers, and ensuring the child becomes a productive member of society. 1.2 Nomenclature There are a number of medical/biological/health/research informatics fields with sometimes overlapping nomenclatures: Defined as “a set or system of names or terms used in a particular science or art, by an indi­ vidual or community.” The intent of this section is to provide precise definitions needed by the Biomedical Informatics (BMI) professional. The second goal is to explain the evolution of the term “Biomedical” as a more inclusive term rather than the older designation of Medical Informatics. Lastly, a brief description of the many related informatics subfields are provided (Figure 1.1). This new definition adds two concepts that I believe should enhance the descriptions of the science of BMI, i.e. the terms meaning and intuitive user interfaces, essential in the evolution of the science. Meaning refers to correlating the growing flood of medical data into an overall systems holistic view rather than simply displaying individual data points. The analogy would be between information and knowledge. The current EHR’s have not been tailored for the unique requirements of diverse health- care providers and often hinder rather than facilitate care. There are a number of chapters in this text describing the nursing perspective and challenges of current EHR implementations and an additional appendices that describe developing EHR applications (apps) for mobile devices. Definition Informatics creates meaning out of chaos; Biomedical Informatics extrapolates meaning from diverse biological, medical, nursing, health, and clinical research sources and structures that data via intuitive interfaces to enhance healthcare and delivery (Lubliner 2015).  Biomedical informatics Nomenclature/ Organization Chapter curricula Fields (Textbook) summaries (Core competencies) Biomedical informatics Chapter organization American Medical Informatics (Diagrams) Association (AMIA) Medical informatics Nursing informatics Level I is comprised of core National League of Nurses Introduction to Biomedical Informatics Translational bioinformatics topics that a Biomedical (NLN) Informatics Curriculum Bioinformatics Informaticist should master Clinical research informatics Biomedical engineering Level II contains applied Bachelors Program in Medical concepts that support the Informatics in Northeastern Consumer health informatics concepts in Level I University Health informatics Public health informatics Level III advanced topics, either for graduate courses or by instructor prerogative Level IV Anatomy and Physiology (A&P) primer FIGURE 1.1 Organization of topics covered in Chapter 1. 3 4 Biomedical Informatics Biomedical informatics syntax Before listing the current accepted nomenclatures for this field, which are sometimes confusing, an explana­ tion of the derivations of the terms will be introduced. The term medicine is derived from the Latin word medicina, meaning art of healing. Asclepius was the Greek god of medicine. A physician “practices medicine” through diagnosis, treatment, and prevention of disease. Physicians broadly are categorized as medical or sur­ gical. Medicine refers to the practice of nonoperative medicine. The American Medical Association’s (AMA) mission is to “to promote the art and science of medicine and the betterment of public health.” Bio is the Greek word for life. It also is defined as “indicating or involving living organisms.” Originally, this informatics field was referred to as Medical Informatics, but since medical refers to a subset of the health field, a more expansive term Biomedical Informatics was used. Other health professionals, nurses also use EHRs so “medical” alone would have been exclusionary. Nursing is defined by the American Nursing Association as “the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations.” In order not to have a dis­ cipline’s name with a hundred subfields, a compromise was reached that incorporates bio, life and living organisms, and medicine, which incorporates diagnosis, treatment, and prevention into BMI. Current informatics descriptors The following are widely accepted definitions of the various informatics fields related to medicine and healthcare. Informatics is “a field of study to apply information technology to another field—from healthcare to journalism to biology to economics” (Indiana University). Two additional BMI definitions: Biomedical Informatics is “the interdisciplinary field that studies and pursues the effective uses of biomedical data, information, and knowledge for scientific inquiry, problem solving, and decision mak­ ing, driven by efforts to improve human health” (AMIA Definition) (http://jamia.bmj.com/content/ early/2012/06/07/amiajnl-2012–001053.full) (Table 1.1). Biomedical Informatics is “the core scientific discipline that supports applied research and practice in several biomedical disciplines, including health informatics, which is composed of clinical informatics (including subfields such as medical, nursing, and dental informatics) and public health informatics” (American Medical Informatics Association [AMIA]). Nursing Informatics is the “science and practice (that) integrates nursing and implementation of com­ munication and information technology” (AMIA). Translational Bioinformatics is the development of analytic methods to optimize the transformation of biomedical data and genomic data, into proactive, predictive, preventive, and participatory health. The field of Bioinformatics has a research focus, analyzes datasets for genomics, proteins, etc. The branch of information science concerned with large databases of biochemical and pharmaceutical infor­ mation (world English dictionary) intersects with the field of computational biology. TABLE 1.1 Biomedical Informatics Association/Organization Name Link American Medical Informatics Associations www.AMIA.org American College of Medical Informatics http://www.amia.org/programs/acmi-fellowship Public Health Informatics http://www.amia.org/applications-informatics/ public-health-informatics International Medical Interpreters Association http://www.imiaweb.org/ American Nurses Association—Nursing Informatics http://www.nursecredentialing.org/InformaticsNursing Medical Informatics Association Medical Library Association http://www.medinfo.mlanet.org/ Association for Computing Machinery Human Computer www.acm.org Interfaces SIGCHI Introduction to Biomedical Informatics 5 Clinical Research Informatics is the discovery and management of new knowledge relating to health and disease. It includes management of information related to clinical trials. Biomedical Engineering is defined as a field dealing with the application of engineering principles to medical practice. It also lies at the intersection of electrical engineering and the biological sciences. Medical Informatics (often used interchangeably with BMI but the term biomedical is currently the pre­ ferred term used by the leading informatics body in this field the AMIA) is “the science and art of model­ ing and recording real-world clinical concepts and events into computable data used to derive actionable information, based on expertise in medicine, information science, information technology, and the schol­ arly study of issues that impact upon the productive use of information systems by clinical personnel” (S. Silverstein, MD). Consumer Health Informatics is the field “devoted to informatics from multiple consumer or patient views. These include patient-focused informatics, health literacy, and consumer education.” The focus is on infor­ mation structures and processes that empower consumers to manage their own health; for example, health information literacy, consumer-friendly language, personal health records, and Internet-based strategies and resources. The shift in this view of informatics analyzes consumers’ needs for easier to understand information. Health Informatics is “the interdisciplinary study of the design, development, adoption, and applica­ tion of IT-based innovations in healthcare services delivery, management, and planning.” 1.3 Textbook Organization The textbook is structured for both BMI undergraduate and graduate courses. It is sequenced to intro­ duce topics that build on each other. Most chapters have three levels of complexity. Level I is comprised of core topics that a BMI professional should master. Level II contains applied concepts that support the concepts in Level I. Level III has advanced topics that should be included in graduate courses but can be used for undergraduates in selected topic areas. Chapter 7, Medical Sensors, includes a Level IV section on Anatomy and Physiology (A&P) primer. All BMI students should have a basic A&P understanding, especially when working with physicians and nurses. Understanding the underlying medical concepts is the difference between a technologist and a professional. An BMI professional should aspire to the latter. This primer on BMI offers unique perspectives and core foundational materials not found in other text­ books in this field. In-depth examples of concepts introduced are linked to theoretical concepts with included real-world examples. In Chapter 3, Electronic Health Records, specific examples of EHRs are included. Medical nomenclatures, described in Chapter 4 Data Interoperability, specific HL7 and ICD10 coded mes­ sages and source tables are included so professions can understand the exact message structure exchanged between systems. In Chapter 10, a clinical nurse specialist and CERNER EHR expert discusses a current EHR implementation, its specific benefits and limitations, and specific recommendations necessary to evolve into the next generation of user-friendly interfaces and improved process flow. In Chapter 7, Medical Sensors, an in-depth explanation of electro-chemistry provides students with an understanding of the chemistry, phys­ ics, and electrical foundations needed for capturing and analyzing medical sensor data. Finally, a primer on the coding of medical apps, Appendices A through D, introduce a skill set that is essential for the evolution of the next generation of medical records; user-friendly interfaces for mobile devices that reduce the IT burden to essential data tailored for individual’s medical environments. In 2015, once the core EHR systems are in place for most, not all. A significant group of medical professionals dentists, optometrist, mental healthcare professionals, and a few others are still in the process of implementing EHR’s implementation. The next phase, will be “EHR 2” enhancing the user interfaces for more user-friendly and efficient process flow. Three chapters have been written by experts in their field to provide complementary perspectives and expertise. Two are mastered, prepared nurses who are experts in EHRs from users’ and implementers’ points of view. The first is a clinical nurse specialist (MSN, CCRN) and CERNER super user. The second is an IT director who implemented a new EHR system in a large medical center. The third is an expert in application development for wireless devices. He has taught several courses at a university in application development and is pursuing a PhD in Information Systems specializing in user interfaces. 6 Biomedical Informatics Bios Philomena M. DiQuollo is a working healthcare IT professional who began her career in nursing and tran­ sitioned to IT&S 12 years later. Since 1985, she has worked in acute care facilities implementing clinical and business technology solutions as well as directing day-to-day operations and supporting strategic goals at a major urban teaching medical center in New Jersey. Currently, her position is system director of analytics within a multifacility healthcare system. Philomena DiQuollo is an adjunct faculty at New Jersey Institute of Technology teaching in the medical informatics program. She received her BSN from Seton Hall University and MA in Nursing from New York University. In addition, Philomena DiQuollo is a certified professional in Health Information Management Systems and is American Society for Quality Six Sigma Green Belt certified. She resides in New Jersey and is pursuing a master’s in analytics at Villanova University. Cathy Lubliner is a critical care clinical nurse specialist at an academic teaching hospital. She has over 30 years experience in the care of patients with end stage heart failure, cardiogenic and septic shock, pre-and post transplant procedures, and ventricular assist devices. During the implementation of the hospital based EHR, she served as one of the “super users” to facilitate the transition of the nursing staff to the computer-based documentation/data entry system. Daniel Nasello is an experienced mobile and web application developer and project manager who currently resides New Jersey. Having developed some highly successful applications (including multiple applications for various singers and actors), Daniel’s variety of experience allows him to bring the expe­ rience of multiple industries into the software he develops. Seeing the rapid growth of mobile application development, Daniel has created groundbreaking and innovating applications that will be used in tomorrow’s markets and is developing mobile and web application opportunities in industries where they are nonexistent. Daniel currently holds a bachelor’s of science in computer technology and a master’s degree from the New Jersey Institute of Technology in Information Systems. He is also a part-time instructor at NJIT where he spearheaded the mobile application development class, which is rapidly growing in popularity. 1.4 Biomedical Informatics Challenges BMI initially focused on transitioning from paper to EHRs. The discipline has evolved to incorporate clinical research, interoperability standards and enhanced user interfaces. The EHR endeavor is by itself extremely complex—creating on-line equivalents for the pharmacy, intake and discharge forms, manual and automated data capture of real-time monitoring, status notes, etc., all tied into billing and inventory, changing docu­ mentation processes and education, developing secure, HIPAA Title II requirements and IT infrastructure for zero downtime and emergency procedures for system outages. This complex EHR conversion would be the equivalent of converting a paper-based corporation to all electronic systems in a few years, develop strate­ gies, training, debug the system, etc. These processes, in corporations, have evolved over many decades and still require a great deal of improvement and monitoring. The major difference is that in a hospital, medical staffs, especially nurses, are taking care of critically ill patients, life and death situations, and then pausing care to enter data into a EHR system. They then have to find the correct dropdown menu, enter the data, and review new medications and directives from doctors, and ensure there are no data entry errors, since the wrong dosage or incorrect data entry is not just a typo, it can be life threatening—and then move to another patient who is having a code. Prior to EHRs, medical staff filled out a tri-fold two-sided form and entered the data, and the process of review­ ing a patient status was simply flipping over a paper-based form to see a comprehensive view of a patient’s medical status. Medical professionals did not have to go into an often non-user-friendly system to quickly (in reality not so quickly) review a patient status. Can you imagine this scenario with any other disci­ pline—let’s say a pilot who not only is responsible for flying the plane but has to then document passenger data, inventory all the food, fuel, and document passenger issues, and they stop and go back to flying? Try doing this during takeoff and landing or an in-flight emergency. Currently, 8–10 hour shifts become 12 hour Introduction to Biomedical Informatics 7 with added documentation or patient care suffers since time has to be devoted to data entry. Nonhospital EHRs have different issues where additional staff are often required to manage EHR systems. The positive benefits, in the long run, will be substantial: preventing duplicate tests, sharing data between multiple medical practitioners, automatic drug interaction warnings. An evolved EHR system can cross-check patient IDs, medications, and procedures to reduce errors that are currently the cause of many deaths every year. A report in September 2013 by the Journal of Patient Safety estimates up to 98,000 deaths a year are caused by hospital mistakes. Preventable adverse effects add an additional 200,000 injuries http://journals.lww.com/journalpatientsafety/ Fulltext/2013/09000/A_New,_Evidence_based_Estimate_of_Patient_Harms.2.aspx. A seamless system will take a while to evolve. The deadline for the implementation of most EHRs is 2015. This involves some of the most basic functionality defined by meaningful use standards, which rate the functionality of EHRs discussed in Chapter 3. The next phase of EHR implementation, 2015+, will not only include specialties that were not in the initial mandates—dentists, optometrists, mental health workers, etc.—but enhancing automatic data entry from monitors, radio frequency (RF) tags on blood products, supplies and equipment, and user-friendly interfaces to simplify data entry and visual­ ization of medical trends. 1.5 Biomedical Informatics Curriculum Whether a college freshman or an experienced practitioner transitioning to this field—information tech­ nologist, nurse, radiologist, physicians assistant, etc.—guidelines for a course of study need to be quanti­ fied. Three perspectives will be introduced regarding possible Biomedical Informatics curricula. First are guidelines from an from an American Medical Informatics Association (AMIA) whitepaper. The second is from the National League for Nursing (NLN) which is comprised of nursing educators. Lastly, a current Biomedical Informatics bachelor’s degree program in place for 7 years will be described. The intent is to assist other programs in creating a curriculum for this new breed of professional. The AMIA suggested competencies are comprehensive and ambitious. They recommend that “one can select a subset that best complements an individual’s prior experience and future directions.” The AMIA curricula list virtually all computer science and IT courses taught at a university, without highlighting a recommended subset for BMI programs. The last example is a current BS curriculum in medical infor­ matics that illustrates a subset specifically selected to compliment BMI professions with a few targeted optional courses. The question arises, should BMI professionals have all these skills and in what depth? In the technological AMIA skills list, networking, security, databases are listed; each in its own right is a separate field of study; they suggest machine learning, data mining, and simulation and modeling. Very few computer scientists or information technologists are well versed in all those fields. Then, the BMI student needs some expertise in A&P, ethics, human computer interfaces. So, in part three, the BS in medical informatics/BMI will outline an existing bachelor’s program with optional concentrations so students can pursue their specific interests. One example is a database concentration that suggests three available courses including database administration if the BMI student wants to focus on backend sup­ port systems. General requirements and optional concentration needs to be clearly delineated. Following are three perspectives for curriculum guidelines 1. The AMIA created a document listing core competencies for graduate BMI training in June 17, 2010, voted and approved by its members. [link to all academic forum documents 2007–2014, http://www.amia.org/programs/academic-forum/annual-conference] 2. The NLN informatics curriculum 3. A bachelor’s program in medical informatics, in place for the past 7 years at a Northeastern University, which provides flexibility for students pursing one of the many informatics sub- fields designed to accommodate the evolving areas of expertise that will be required as this field evolves. 8 Biomedical Informatics 1.5.1 AMIA Core Biomedical Competencies The AMIA, in June 2010, created a framework primarily of core BMI competencies for graduate students acknowledging the diverse backgrounds of individuals transitioning to this field. 1.5.1.1 AMIA Introductory Course Outline The AMIA, a branch of the AMA, has recommended a 10 × 10 single 12-week introductory course of study. This outline provides a structure of representative topics that can be a starting point for this cur­ riculum (Table 1.2). 1.5.1.2 General Framework AMIA: Core Competencies Four Key Areas (Source: AMIA Board White Paper) It defines BMI and specifies core competencies for graduate education in the following disciplines (http://jamia.bmj.com/content/early/2012/06/20/amiajnl-2012–001053.full) (Figure 1.2): 1. Scope and breadth of discipline: BMI investigates and supports reasoning, modeling, simulation, experimentation, and translation across the spectrum from molecules to individuals and to popu­ lations and from biological to social systems, bridging basic and clinical research and practice and the healthcare enterprise. 2. Theory and methodology: BMI develops, studies, and applies theories, methods, and processes for the generation, storage, retrieval, use, management, and sharing of biomedical data, information, and knowledge. 3. Technological approach: BMI builds on and contributes to computer, telecommunication, and information sciences and technologies, emphasizing their application in biomedicine. 4. Human and social context: BMI, recognizing that people are the ultimate users of biomedical information, draws upon the social and behavioral sciences to inform the design and evaluation of technical solutions, policies, and the evolution of economic, ethical, social, educational, and organizational systems. 1.5.1.3 Specific Core Competencies 1.5.1.3.1 Technological Approach BMI builds on and contributes to computer telecommunication and information sciences and technolo­ gies, emphasizing their applications in biomedicine (Table 1.3). TABLE 1.2 AMIA 10 × 10 Course Outline AMIA: The 12 units of the on-line portion of the 10 × 10 course 1. Overview of discipline and its history 2. Biomedical computing 3. Electronic health records and health information exchange 4. Decision support: evolution and current approaches 5. Standards: privacy, confidentiality, and security 6. Evidence-based medicine and medical decision making 7. Information retrieval and digital libraries 8. Bioinformatics 9. Imaging informatics and telemedicine 10. Consumer health, nursing, public health informatics 11. Organization and management issues in informatics 12. Career and professional development Source: AMIA Curriculum. http://skynet.ohsu.edu/~hersh/ijmi-07–10x10.pdf. Introduction to Biomedical Informatics 9 Biomedical Informatics (BMI) core competencies Personalization of competencies Background and experience of graduate BMI candidates Background in mathematical, Background in physical or Background in biomedicine or computer/ cognitive the biosciences information and/or social sciences or sciences engineering FIGURE 1.2 AMIA biomedical informatics core competencies. (From http://jamia.bmj.com/content/early/2012/06/ 07/amiajnl-2012–001053.full.) TABLE 1.3 Information Technology Technological: Prerequisite knowledge and skills. Assumes familiarity with data structures, algorithms, programming, mathematics, and statistics Goals: Fundamental knowledge. Understand and apply technological approaches in the context of biomedical problems 1. Networking, security, databases 2. Information documentation, storage, and retrieval 3. Imaging and signal analysis 4. Machine learning, including data mining 5. Simulation and modeling 6. Representation of logical and probabilistic knowledge and reasoning 7. Natural language processing, semantic technologies 8. Software engineering 1.5.1.3.2 Biological Foundations Population health: detection, prevention, screening, education, stratification, spatiotemporal patterns, ecologies of health, and wellness (Table 1.4). 1.5.1.3.3 Human and Social Context Human and social context: Prerequisite knowledge and skills—familiarity with fundamentals of social, organizational, cognitive, and decision sciences (Table 1.5). 1.5.1.3.4 Procedural Knowledge Procedural knowledge and skills: Apply, analyze, evaluate, and create systems approaches to the solu­ tion of substantive problems in BMI (Table 1.6). The AMIA realizes that students will come from a number of diverse backgrounds and realizes these suggested competencies are ambitious and recommends “one can select a subset that best complements an individual’s prior experience and future directions.” 10 Biomedical Informatics TABLE 1.4 Biological Competencies Biological: Prerequisite knowledge and skills. Students must be familiar with biological, biomedical, and population health concepts and problems including common research problems Goals: Fundamental knowledge. Understand the fundamentals of the field in the context of the effective use of biomedical data, information, and knowledge. For example 1. Biology: molecule, sequence, protein, structure, function, cell, tissue, organ, organism, phenotype, populations 2. Translational and clinical research: genotype, phenotype, pathways, mechanisms, sample, protocol, study, subject, evidence, evaluation 3. Healthcare: screening, diagnosis (diagnoses, test results), prognosis, treatment (medications, procedures), prevention, billing, healthcare teams, quality assurance, safety, error reduction, comparative effectiveness, medical records, personalized medicine health economics, information security, and privacy 4. Personal health: patient, consumer, provider, families, health promotion, and personal health records 5. Population health: detection, prevention, screening, education, stratification, spatiotemporal patterns, ecologies of health, and wellness TABLE 1.5 Human and Social Contexts Human and Social Context: Prerequisite knowledge and skills. BMI, recognizing that people are the ultimate users of biomedical information, draws upon the social and behavioral sciences to inform the design and evaluation of technical solutions, policies, and evolution of economic, ethical, social, educational, and organizational systems. Familiarity with fundamentals of social, organizational, cognitive, and decision sciences. Goals: Fundamental knowledge. Understand and apply knowledge in the following areas: 1. Design: human-centered design (HCI), usability, human factors, cognitive, and ergonomic sciences and engineering 2. Evaluation: study design, controlled trials, observational studies, hypothesis testing, ethnographic methods, field observational methods, qualitative methods, mixed methods 3. Social, behavioral, communication, and organizational sciences: for example, computer-supported cooperative work, social networks, change management, human factors engineering, cognitive task analysis, project management. 4. Ethical, legal, social issues: for example, human subjects, HIPAA, informed consent, secondary use of data, confidentiality, privacy 5. Economic, social, and organizational context of biomedical research, pharmaceutical and biotechnology industries, medical instrumentation, healthcare, and public health TABLE 1.6 Procedural Knowledge and Skills Procedural knowledge and skills: Apply, analyze, evaluate, and create systems approaches to the solution of substantive problems in Biomedical Informatics 1. Analyze complex biomedical informatics problems in terms of people, organizations, and sociotechnical systems 2. Understand the challenges and limitations of technological solutions 3. Design and implement systems approaches to Biomedical Informatics applications and interventions 4. Evaluate the impact of Biomedical Informatics applications and interventions in terms of people, organizations, and sociotechnical systems 5. Relate solutions to other problems within and across levels of the biomedical spectrum 1.5.2 National League for Nursing Informatics The NLN has 33,000 individual and 1,200 institutional members. They have defined a core framework for Nursing Informatics into four curricular threads: IT, communication, issues, and nursing collaboration. There is a NLN white paper Preparing the Next Generation of Nurses to Practice in a Technology-Rich Environment: An Informatics Agenda introduced in May 2008 whose stated goal is “to prepare the next generation of nurses to practice in a technology-rich environment” that outlines its recommendations to nursing faculty and administration (see recommendations in the following text) http://www.nln.org/ aboutnln/PositionStatements/informatics_052808.pdf. Introduction to Biomedical Informatics 11 TABLE 1.7 NLN: Information Technology Curriculum Health IT Tools (Suggest the Curriculum Include Lectures on These Topics) 1. Computerized order entry: Clinical application that allows clinicians to order and process lab tests, medications, clinical procedures, and other services electronically. 2. Health information exchange enables clinical staff to access more information about a patient when it is needed. 3. Electronic prescribing: The use of computing devices to enter, modify, review, and output or communicate drug prescriptions. 4. Electronic medical record systems: A basic component of a health IT system, electronic medical record systems have the potential to provide substantial benefits. 5. Telehealth: Geographic disparities in access to care can be addressed partially using technologies that allow for remote audio, visual, and haptic communication between caregivers and specialists or patients. 6. Clinical decision support: Given the exponential growth in our knowledge of medicine, it is impossible for any clinician to know everything he or she needs to know. Source: http://www.nln.org/facultyprograms/facultyresources/facultyresources.htm. Definition “Nursing informatics is defined as combining nursing science, information management science, and computer science to manage and process nursing data, information, and knowledge to deliver quality care to the public” (HRSA, 2008). Nursing informatics facilitates the integration of data, information, and knowledge to support patients, nurses, and other providers in their decision making in all roles and settings. (http://www.nln.org/facultyprograms/facultyresources/informatics.htm) 1. Use of health IT to augment/support the nursing care process includes concepts such as safety, care improvement, decision assistance/support, outcome analysis and data analysis. 2. Communication includes EHR personal health records, standardized languages, and terminology. 3. Issues including legal, ethical, social, security, advocacy, and public policy. 4. Nursing involvement through teamwork/collaboration, covering nurses’ role in determining usability, workflow analysis, and systems selection/evaluation. 1.5.2.1 NLN Health IT Tools The NLN IT component lists a skill set of tools they suggest will have to be utilized as indicated by nursing practice (Table 1.7). Since the rest of the guidelines are generic nursing recommendations, such as ethics and teamwork that are not unique to biomedical informatics curriculum, the included links will provide that additional content. 1.5.3 Bachelor’s in Medical/Biomedical Informatics Curriculum This section is structured around a 4-year bachelor’s degree specifically focused on educating Biomedical/ Medical Informatics professionals. The challenge of training professionals, from their first encounter within this field provides an unprec­ edented opportunity to shape the future of the discipline. There are only a handful of BS programs in this field and even fewer associates degrees. But the employment opportunities are stellar for new graduates, not only evidenced by Department of Labor, but due to the change in demographics, i.e. the U.S. Census Bureau projects one-fifth of the U.S. population will be over 65 by 2030, and with the expanded Affordable Care Act (ACA), this expanded healthcare demand will necessitate more trained professionals to handle the millions of new individuals with healthcare coverage. New wearable wireless technologies, feeding data into EHRs, will also necessitate the need for more professionals in this field. The BS degree is structured into core areas that allow flexibility, so programs or students can develop additional expertise in areas of interest. 12 Biomedical Informatics Core medical/biomedical areas are as follows: 1. IT 2. Biological/medical 3. Medical informatics 4. Ethics/management/economics 1.5.3.1 Future Employment Prospects for BS Degrees in Medical/Biomedical Informatics 1. The U.S. Bureau of Labor Statistics has projected that the fastest-growing professions are in the computer and heathcare industries specifically in the medical records/informatics areas (http:// www.bls.gov/ooh/healthcare/medical-records-and-health-information-technicians.htm). a. They indicate in 2012, the last full-year statistics are available, that there were 186,300 indi­ viduals employed in this profession and projections call for 41,000 additional hires the next year. They project a 22% growth rate from 2102 to 2022. b. The U.S. Department of Labor 2012–2022 has projected that for the next decade 2012–2022 projections call, the medical records and health information technicians occupation will grow 22%. http://www.bls.gov/ooh/healthcare/medical-records-and-health-information­ technicians (htm#tab-6). 2. The projected doubling of the over 65 population in the next 2 decades one-fifth will be over 65 by 2030 indicated by the U.S. Census Bureau. Baby boomers, in the next 20 years, will necessitate the need for medical informatics professionals to upgrade the tens of thousands of medical prac­ tices across the United States. Subfields of medical informatics, i.e., wireless medical devices, will necessitate the need for additional trained personnel to integrate data from these devices. 3. Forty percent of all medical costs are related to medical documentation, billing, and administra­ tive overhead, costs that will necessitate the need of reducing the overhead by automated medical records systems. 4. The large population in the New York metropolitan area indicates the need for a large number of medical/biomedical informatics professionals. As per the 2012 U.S. census in the New York metropolitan area, tri-state area has 19.8 million people. It is the most populous metropolitan area in the United States defined by the Office of Management and Budget as the New York-Northern New Jersey-Long Island, NY-NJ-PA Metropolitan Statistical Area. 1.5.3.2 BS Medical/Biomedical Curriculum The Medical/Biomedical Informatics bachelor’s degree includes the traditional curriculum core courses: English I, II, and III (technical writing), and history/sociology/psychology, capstone core courses. The math courses are statistics, precalculus, calculus (business calculus is an alternative), several core computer and database courses. Management and (medical) economics courses round out the first 64 credits with a few electives. Some students can choose a management track, taking additional accounting, business, and cost-analysis courses. Others choices include additional biology and chemistry courses for their electives. Bachelor’s degree 128 credits are broken down into these general categories: 64 credits common core courses 64 medical/biomedical informatics and information technology The curriculum for a 2/year associates degree in Medical Informatics is provided in Table 1.8. 1.6 Chapter Summaries The chapters in this book are designed to be covered in sequential order. Concepts build on preceding chap­ ters. Chapter 7 on medical sensors is the exception where Level IV provides four optional sections on A&P basics. Some instructors add between 10 and 30 minutes of selected A&P lectures at the end of their lectures. The rationale is to create a basic core A&P knowledge base where students develop a balanced technological Introduction to Biomedical Informatics 13 TABLE 1.8 Medical/Biomedical Informatics Curriculum 64 Credits Bachelor’s Curriculum in Medical Informatics/Biomedical Informatics (64) (optional courses depend on program and student interests) Core Area(s) Required Electives Credits Information Technology Intro Information/Computer 3 Technologya 15 credits required Intro to Programming (object Advanced Programming 3 15 credits recommended oriented Python, VB)a (C++, JAVA) (Recommended) (3 credits) Intro to Database Design Ia Advanced Database design 3 II (3 credits) Database Administration III (3 credits) Intro Computer Security Wireless Networks Security 3 (Recommend) (3 credits) Web Design (optional in first App Design for Mobile 3 2 yearsa) Devices (recommend) (3 credits) Human Computer Interface (HCI) Design (3 credits) Biological–Medical Anatomy and Physiology Ia Biology I 4 14 credits required Anatomy and Physiology I Chemistry I 4 8 credits recommended Medical Terminologya 3 Pharmacologya 3 Ethics/Management/Economics Medical Ethics (optional in first 3 2 yearsa) 9 credits required 6 credits recommended Economics (Medical)a Cost Analysis (3 credits) 3 Intro Management Management in 3 Healthcare environments (3 credits) (Bio)medical Informatics Medical Informatics I (survey of the Internship I: 75 hours 3 field)a (2 credits) -9 credits required Medical Informatics II Advan: Internship II: 75 hours 3 -6 credits recommended management, case studies (2 credits) Medical Informatics III EHR’s hands Internship III: 75 hours 3 on exercises (2 credits) Totals (64 should be taken) 47 Credits At least 17 credits selected/35 a Courses taken at community colleges. and biological underpinning. The two chapters at the end of the book, written from the perspective of nurses utilizing EHRs and a managers perspective implementing EHRs, can be added at any point in the semester. Some instructors believe that right after Chapter 3 on EHRs is the time to introduce the real world per­ spectives by professionals utilizing EHRs. Lastly, the appendices on application (app) development for EHRs either can be instructor led or provided as exercises for students to pursue for a final class project. All EHRs will eventually evolve to provide user friendly intuitive interfaces simplifying user input and providing long- term trend analysis of medical conditions (Table 1.9). Most chapters include an illustration that summarizes the content of each chapter.  14 TABLE 1.9 Textbook Synopsis of Each Chapter Chapter Summary Illustration Summarizing the Content of Most Chapters 1. Introduction to Biomedical Biomedical Informatics Informatics: Nomenclature/ Organixzaton Chapter curricula This chapter Fields (Textbook) summaries (Core competencies) frames the challenges addressed by Chapter Organization American Medical Informatics Biomedical informatics Biomedical (Diagrams) Association (AMIA) Medical informatics Informatics (BMI). Nursing informatics Level I is comprised of core National League of Nurses A discussion Translational bioinformatics topics that a Biomedical (NLN) Informatics Curriculum on BMI Bioinformatics informaticist should master curricula Clinical research informatics introduces Biomedical engineering Level II contains applied Bachelors Program in Medical AMIA, NLN, Consumer health informatics concepts that support the Informatics in Northeastern and an concepts in Level I University Health informatics evolving BS Public health informatics program Level III advanced topics, curriculum either for graduate courses or that was by instructor prerogative introduced in 2007. Level IV Anatomy and Physiology (A&P) primer (Continued ) Biomedical Informatics TABLE 1.9 (Continued) Textbook Synopsis of Each Chapter Chapter Summary Illustration Summarizing the Content of Most Chapters 2. The U.S. legislation that Framework for implementing the U.S. Medical has spurred Records Infrastructure the explosion of electronic health records (EHR) adoption. Health Insurance Portability and American Recovery and Affordable Care Act Introduction to Biomedical Informatics Accountability Act (HIPAA) 1996 Reinvestment Act (2009) (2010) Obama Care Title I Health Insurance Reform Health Information Title I. Quality, Affordable Technology for Economic Healthcare for All Americans Title II and Clinical Health Act Administrative Simplification (HITECH) Security Privacy Subtitle A: Immediate Improvements in Healthcare Title III Subtitle C: Certified EHR Coverage for all Tax-Related Health Provisions Provide Technology Americans funding to Secure—Protected Individuals Title IV support the Meaningful use Families Application and Enforcement Prevention of Group Plan Requirements implementation Small Business Owners of EHR’s Standards Title V Revenue Offsets (Continued ) 15  16 TABLE 1.9 (Continued) Textbook Synopsis of Each Chapter Chapter Summary Illustration Summarizing the Content of Most Chapters 3. EHR are a collection of data Electronic Health Records (EHR) accumulated from various Architecture Lubliner 2015 sources that Office of the Personal Data National Coordinator Interoperability Standards Implementation document a Records patient’s (ONC) EHR Spec. (PDR) Health Meaningful Use journey HL 7 RIM Models Information Continuity of through the Exchanges -HL 7 -DICOM, Care Record (HIE) -ISO -ICD10, healthcare (CCR) system. -IEEE -SNOMED Arden Syntax DSS -FHIR -LOINC HITECH Affordable -CDA -CPT Data Entry Forms HIPAA Act Care Act -CCOW -HCPCS EHR-System Tools UMLS Functional Models Security Privacy Expert Systems Query Consumer Clinical Decision Support Directed Relationship Based Mediated Hierarchy diag. Systems (CDSS) (Continued ) Biomedical Informatics TABLE 1.9 (Continued) Textbook Synopsis of Each Chapter Chapter Summary Illustration Summarizing the Content of Most Chapters 4. Data interoperability focuses on HL7, NCPDP (pharmacy), ISO, IEEE, IHE (International Health Exchange) HL7 standards electronic 3: Mapping 1: Communication Protocols to facilitate interoperability of Electronic Health EHR-S medical Tools Information Arden syntax communication -UMLS FHIR Introduction to Biomedical Informatics and data sharing -UML-F CCOW standards. EHR, -OMG SysML CDA 2: Vocabularies/Codes ICD10 Virtual medical medical devices, Organizations ICD11 IEEE 1073 -AMA (14,000) Medical device LOINC Record laboratories -AMIA communication ICD10 ICD10 (lab, nursing data, imaging -HIMSS SNOMED CT and personal CMU.S. PCS U.S. documentation) studies, etc., -RSNA (300,000 terms) (78,000) medical devices Vocabularies: -ACC (68,000) have to agree on Disease and Procedural -ISO common diagnosis codes Lexi-comp Common -Regenstrief SNODENT protocols to DICOM and medi-span medical -HHS (dental) -NLM (imaging, CT, (drug reference exchange data. and clinical terminology -HL7 MRI, XRAY ) CPT services provided HCPCS codes support) -IEEE -OMG for reimbursement AMA Medicare-medicaid Lubliner 2015 -ANSI -IHTSDO Health information exchanges (data interoperability EHR’s) Caveat: includes dominant interoperability -EFMI standards, not inclusive of all specifications (Continued ) 17  18 TABLE 1.9 (Continued) Textbook Synopsis of Each Chapter Chapter Summary Illustration Summarizing the Content of Most Chapters 5. Privacy and Privacy and Security Security: HIPAA Title II describes HIPAA Title II Security primer Biometrics security as the (Health Insurance Portability and Accountability Act 1996) safeguards that must be DNA Administrative Defense in depth in place to (F5.com term is defense 13 COODIS Core STR Locl (Policies & procedures) in Breath) ensure with chromosomal positions appropriate Privacy: Security: protection of That sets limits and conditions on the use The safeguards that must be in place to ensure and disclosure of medical information appropriate protection of electronic Protected electronic without patient authorization Health Information (ePHI) protected health Physical Technical information (controls) (controls) (ePHI). A Exceptions Lubliner 2013 security primer Public health Research Breach notification Encrypted PHI introduces 1. Compromises a patient’s health; i.e., a basic security patient is unconscious (privacy rules waved) Penalties techniques. Retinal Scan Finger-Print 2. Public health is threatened -Breaches: -Involving more than 500 individuals the security 3. Research (anonimized data) rule require that they notify HHS immediately. 1. With the permission of an IRB or -More than 500 individuals requires media be notified Privacy board the patient’s privacy rights can be waived. They are: -Encrypted PHI: -Not required to provide breach notification because 4. Treatment, Payment, Healthcare operations Public-Private encryption the information is not considered “unsecured” (Continued ) Biomedical Informatics TABLE 1.9 (Continued) Textbook Synopsis of Each Chapter Chapter Summary Illustration Summarizing the Content of Most Chapters 6. Telehealth– Telehealth Telemedicine Telemedicine (Delivery of services and diagnosis) is the practice of medicine or M-health analyzing Communications (Mobile Wireless Medical Tele-radiology CCRN-E Cost/Need Tele-surgery Devices And Software) and medical consults AACN cert. medical data remotely. © Lubliner 2013 Introduction to Biomedical Informatics mHealth -90% radiologists are in WaveLan M-Health FDA Approved large remote groups -Monitor refers to IEEE 802.11n 600 Mbit/s 10,000 baby First generation wireless da Vinci System -In 2013 the top 100 firms critically ill medical IEEE 802.11ac 6.93 Gbit/s Boomers reach 65 medical devices 2013 1.5 million perf. have 5000 radiologists patients practice using Wireless-Personal-Networks every day Second generation 2014 -Specialists provide expert remotely mobile Bluetooth4 24 Mbits/s -Consultation iHealth, Fitbit, iWatch opinions 24/day monitoring IrDA-UFIR 96 Mbits/s Telemental Affordable Care devices. WUSB 480 Mbits/s Implantable medical devices health Nurse Act focus on Teleradiology, IrDA-GigalR 1024 Mbits/s Tele-education working in prevention telesurgery, Home monitoring of patients Crisis response tele-ICU and devices: EKG, implantable or eCCU and assist devices -Reduce inpatient Some Apps deliver services: fall under telemedicine certifications Electronic health costs are also records -Reimbursement Qualifications: -Reduce cost of 1. Doctors-on-demand app Mini clinics (will discussed. by Medicare RN 5 years large facilities 2. RingaDoc.com require remote consults) with critically -Rural Areas outpatient ER SNOMED, ICD11, HL 7, DICOM 3. 3GDoctor.com England ill patients (Continued ) 19  20 TABLE 1.9 (Continued) Textbook Synopsis of Each Chapter Chapter Summary Illustration Summarizing the Content of Most Chapters 7. Medical Medical sensors Sensors. This chapter Data Acquisition: Medical Sensors and Wireless medical Electrical and chemical conduction basics focuses on the basic theory Measurements monitoring exponential growth of Action potential Electrical conduction Body sensor Subatomic particles Current flow Valence electrons Heart Blood pressure medical networks (BNSs)c sensors. It introduces 20 foundations of + 10 ohms u – volts R chemistry, biology, i physics, and electronics to Battery chemistry Inductive charging ensure the Pulse oximetry Cods (ATP) Adenosine triphosphate Lambert-Bouguer Law BMI Primary Secondary professionals core core I = Io e–(ad) are well Beer’s Law n grounded in L1 L2 Ci = i V their field. It Beer Lambert law also includes Absorbance (ad) = εcd Data mining and big Magnetic field an anatomy data in healthcare and Anatomy and Physiology Primer physiology primer. Part I: Neurons and nervous system, Part II: Cells, ATP, hearing, kidneys, Part III: Lungs, immune system, strokes, Part IV: Heart disease, cancer brain, spinal cord, muscles, heart, eye pancreas, liver, digestive system blood flow, prostate (Continued ) Biomedical Informatics TABLE 1.9 (Continued) Textbook Synopsis of Each Chapter Chapter Summary Illustration Summarizing the Content of Most Chapters 8. Imaging: This Medical imaging chapter, first, (DICOM) Digital communications and communications in medicine discusses (framework supports communication, storage and handling of medical images) DICOM Standards imaging devices Object definitions Medical imaging hardware, physics and Picture archiving and retrieval system Data classes and the complex algorithms (PACS) Data structures physics and Data dictionary Introduction to Biomedical Informatics algorithms Message service Presentation involved in Storage media and file analyzing this service data; second, the Media storage standards used Media formats Gray scale standards for transmitting Security and System Management and visualizing Web Access Radio pharmacology Image analysis Content mapping these images; Transformations and third, the Principal component analysis Handling system for Storing storage and Printing Communications retrieval of images picture archiving and communication system. (Continued ) 21  22 TABLE 1.9 (Continued) Textbook Synopsis of Each Chapter Chapter Summary Illustration Summarizing the Content of Most Chapters 9. Ethics: This Medical Ethics chapter discusses the Hippocratic oath American Medical Association American Nurses Association Ethical case (original and revised) (AMA) ethics groups (ANA) ethics group studies American Medical Association, the American Nurses Association, and case studies relating to medical ethics. 10. Nursing The focus of this chapter is to explain the complexity of critical care nursing in the context of the data that are generated and the process of recording that data. Documentation Documenting patient care activities during emergency situations, which occur often in the critical care setting, is particularly challenging because many activities and the are occurring simultaneously. Electronic Health Records 11. Nursing In this chapter, the focus will be on what it takes to support a healthcare organization’s IT infrastructure and to understand the complexity of a