Telemedicină şi e-Sănătate

CURS 13 - Prof. dr. ing. Hariton Costin

SISTEME INFORMATICE DE SPITAL. FIŞA

ELECTRONICĂ A PACIENTULUI (E-HEALTH
RECORD – EHR)

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 Telemedicină şi e-Sănătate
CURS 13 - Prof. dr. ing. Hariton Costin

The development of a Hospital Information System (HIS) can take

many architectural forms.
It can be accomplished through interfacing of a central system to multiple
departmental or clinical information systems.
A second approach which has been developed is to have, in addition to a
set of global applications, departmental or clinical system applications.
Because of the limitation of all existing systems, any existing comprehensive
HIS is in fact a combination of interfaces to departmental/clinical
systems and the applications/database of the HIS.

1. Patient Database Strategies for the HIS

Today’s HIS database should be designed to support a longitudinal patient
record (the entire clinical record of the patient spanning multiple
inpatient, outpatient encounters), integration of all clinical and financial
data, and implementation of decision support functions.
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 Telemedicină şi e-Sănătate
CURS 13 - Prof. dr. ing. Hariton Costin

2. Data Acquisition
 

 
Flow of data, information and knowledge in a HIS
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 Telemedicină şi e-Sănătate
CURS 13 - Prof. dr. ing. Hariton Costin

3. Patient Admission, Transfer, and Discharge Functions

The admission application has three primary functions.
The first is to capture for the patient’s computer record pertinent demographic
and financial/insurance information.
A second function is to communicate that information to all systems existing on
the hospital network.
The third is to link the patient to previous encounters to ensure that the patient’s
longitudinal record is not compromised.
Two key patient files allow the HIS to meet its critical clinical functions. One is a
master patient index (MPI) and the second is the longitudinal clinical file.

4. Patient Evaluation
The second major focus of application development for the HIS is creation of
patient evaluation applications. The purpose is to provide to the care giver
information which assists in evaluating the medical status of the patient.
Depending on the level of data integration in the HIS, the evaluation
applications may be quite rudimentary till highly complex.
In the simplest form these applications are departmentally oriented. With this
departmental orientation the care giver can access through terminals in the
hospital departmental reports. Thus, laboratory reports, radiology reports,
pharmacy reports, nursing records, and the like can be displayed or printed
at the hospital terminals.
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 Telemedicină şi e-Sănătate
CURS 13 - Prof. dr. ing. Hariton Costin

5. Patient Management

Once the caregiver has properly evaluated the state of the patient, the next
task is to initiate therapy that ensures an optimal outcome for the patient.
At the simplest level management applications consist of order-entry
applications. The order-entry application is normally executed by
paramedical personnel.
Beyond simple test ordering, many newer HISs are implementing decision
support packages. With these packages the system can incorporate
medical knowledge usually as rule sets to assist the care provider in the
management of patients. Execution of the rule sets can be performed in
the foreground through direct calls from an executing application or in
the background with the storing of clinical data in the patient’s
computerized medical record.
This latter mode is called data-driven execution and provides an extremely
powerful method of knowledge execution and alerting. Executions of the
rule sets are sometimes, time-driven.
The inclusion of decision support functionality in the HIS requires that the
HIS be designed to support a set of knowledge tools. In general a
knowledge-based system consists of a knowledge base and an
inference engine (an application manager). 5
 Telemedicină şi e-Sănătate
CURS 13 - Prof. dr. ing. Hariton Costin

2. Computer-Based Patient Records (EHR)

Computer-based patient record (CPR) is a powerful tool for organizing patient care
data to improve patient care and strengthen communication of patient care data
among health care providers.
The CPR is even more powerful when used in a system that retrieves applicable
medical knowledge to support clinical decision making.
The primary role of the CPR is to support the delivery of medical care to a particular
patient. The CPR brings past and current information about a particular patient
to the physician, promotes communication among health care givers about that
patient’s care, and documents the process of care and the reasoning behind the
choices that are made.
The CPR can also be an instrument for building a clinical data repository that is
useful for collecting information about which medical treatments are effective in
the practice of medicine and for improving population – based health care.
Patient care data collected by a CPRS may be stored centrally or it may be stored
in many places (distributed) for retrieval at the request of an authorized user
through a database management system.
The CPR may present data to the physician as text, tables, graphs, sound, images,
full-motion video, and biosignals. The CPR may also point to the location of
additional patient data that cannot be easily incorporated into the CPR.

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 Telemedicină şi e-Sănătate
CURS 13 - Prof. dr. ing. Hariton Costin

3. Codes and Classifications

3.1. Nomenclatures and thesaurus
One of the problems of uniform registration in health care is the lack of a
common terminology. A thesaurus is a list of terms used for a
certain application area or domain. Examples are a list of diagnostic
terms or a list of terms for laboratory tests. A thesaurus is always
intended to be complete for its domain. For practical use, thesauri
that also contain a list of synonyms for each preferred term have
also been developed. In this way, a thesaurus stimulates the usage
of standardized terminology.
In a nomenclature, codes are assigned to medical concepts, and medical
concepts can be combined according to specific rules to form more
complex concepts. This leads to a large number of possible code
combinations. The difference between a classification system and a
nomenclature is that in the former possible codes are predefined,
whereas in the latter a user is free to combine codes for all aspects
involved. The retrieval of records for patients whose data fulfil
certain classification codes from a large database is relatively easy.
Retrieving records for patients stored by using a nomenclature is
more difficult because of the high degree of freedom, leading to
very complex codes. 7
 Telemedicină şi e-Sănătate
CURS 13 - Prof. dr. ing. Hariton Costin

3.2 Codes
1. ICD
ICD is the archetypal 4 digits coding system for patient record . The
most recent version is ICD-10, which was published in 1992.
WHO is responsible for its maintenance.
2. ICPC
ICPC is a two-axis system. The first axis, primarily oriented toward
body systems (the tracts), is coded by a letter, and the second
axis, the component, is coded by two digits.
3. SNOMED
SNOMED allows for the coding of several aspects of a disease. Its
current version is called SNOMED International (Systematized
Nomenclature of Human and Veterinary Medicine). SNOMED is
also a multiaxial system and has 11 axes or modules. Each of
these axes forms a complete hierarchical classification system.
Other medical coding systems: ICD-O, DSM, CPT, RCC, ATC, MeSH
and DRG. Diagnosis-related group (DRG) is a system to classify
hospital cases into one of approximately 500 groups. 8
 Telemedicină şi e-Sănătate
CURS 13 - Prof. dr. ing. Hariton Costin

5. Computer Networks in Health Care

1. Impact of Clinical Data
Clinical computing addresses the need for data related to patient care.
These data must be delivered to the providers (physicians, nurses,
technicians, therapists, social workers) in a timely fashion.
The data must be accurate and be delivered in patient care settings such
as bedside or nursing stations, intensive care units (ICUs),
emergency / operating rooms, clinics, and physicians' offices with
varying degree of delivery efficiency (the needs for data in ICUs, for
example, are more stringent than in a clinic).
The primary data of importance in an inpatient setting are laboratory
results. Other important sources of data include pharmacy, radiology,
pathology, cardiology, vital signs, neurology, nursing documentation,
obstetrics/gynecology, operative reports, discharge summaries, and
visit notes.
Clinical data may be collected from different sources and stored in a
central clinical database. Here, a network is necessary to
interconnect ancillary systems to a back-end central repository.

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 Telemedicină şi e-Sănătate
CURS 13 - Prof. dr. ing. Hariton Costin

2. Information Types
Health care data have tremendous variety, all of which are important in
patient care and have different implications for the performance required
of a network.
Most of the clinical data available today are in textual form as narrative
reports. Radiology, pathology, and so on generates reports about
specific tests; discharge summaries explain the entire episode of the
patient's stay in the hospital; operative reports explain the procedure
followed during operations. These reports range anywhere from a few
sentences (in a specific type of pathology report) to several pages
(autopsy reports).
Laboratory data tend to be in coded form, where each data item is
represented as a code (alphanumeric, integers). This is very useful as
providers need to look at trends in data over time. Furthermore, for
computer-based clinical decision support, more data need to be in
coded form so that a computer-based expert system can understand the
values and act upon them to send alerts to providers, if necessary.
Coded data, in general, are small in size, but in some cases (an EKG
tracing or medical imaging) the report may be of substantial size.
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 Telemedicină şi e-Sănătate
CURS 13 - Prof. dr. ing. Hariton Costin

4. Current Technologies
Networks are usually defined as a set of layers, each layer providing
service to the layer above it. The networking infrastructure suitable in
a campus environment is called a local area network (LAN). An
organization must have full control over its LANs.
When communication is required over long distances (e.g., an
organization which has offices all over the world), medical services
need what is called a wide area network (WAN). The protocols at
higher layers work transparently over LANs and WANs, thus providing
transparency to applications.
Currently, software solutions use distributed programs in order to achieve
total network transparency and data integration from the end-user
viewpoint. These are popularly termed (medical) middleware.
(a) Local Area Networks
• The lowermost layer in networking is the physical medium, which can
be copper cables (with different degrees of insulation, twists, and
impedance), fiber cables (with different diameter and refraction
indices), or even the atmosphere in the case of wireless,
communication based on radiofrequency transmissions. Examples of
physical medium standards include 10BaseT, 10Base5, and STP.
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 Telemedicină şi e-Sănătate
CURS 13 - Prof. dr. ing. Hariton Costin
• The next higher layer, the link layer consists of electronics or optics to drive
signals on the physical layer. The most popular LAN standards in this layer today
are Ethernet (or IEEE 802.3) at a rated 10 Mbits/s speed (or bandwidth) and
Token Ring (IEEE 802.5) at 4 or 16 Mbits/speed.
• Above these layers, several proprietary protocols and layer stacks may core side
in typical medical practice center LANs. These include IBM SNA and NetBIOS,
Novell SPX/IPX, DEC DECNet and LAT, and Apple AppleTalk. Among open
protocols, the TCP/IP stack is the most popular standard.
(b) Wide Area Networks
• Health care centers employ WANs mainly for three purposes: (1) to connect
networks at physically distant buildings, offices, or clinics; (2) to connect
networks to different organizations (affiliated hospitals, insurance agencies, state
or federal government regulatory bodies) or services (Internet, disaster recovery
backup locations); (3) to provide dial-in and dial-out capabilities for employees.
• The difference between the first two purposes is that of control and security:
access to medical information requires better control when connected to an
external organization. The concept of a firewall as part of networking topology
has become popular when connecting to the Internet in order to avoid
unwarranted access. A physician's office may connect to insurance networks for
billing, as well as to on-line services to connect to the large Internet. In all cases,
an external telecommunications carrier's service is used to provide underlying
long- distance, point-to-point communications capability.
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 Telemedicină şi e-Sănătate
CURS 13 - Prof. dr. ing. Hariton Costin

• The aggregate bandwidth in a WAN connection is

typically much smaller than the LANs bandwidth
because of the higher costs of WAN connections.
Popular leased line connections have speeds ranging
from 56 Kbits/s to 1.56 Mbits/s (T-1 circuits) to 45 Mbits/s
(T-3 circuits), and fractions thereof. Other modes of such
connections are accomplished by dedicated microwave
or laser communications. In all cases, end devices such
as modems are required to drive these connections.
Additionally, multiplexers are employed to effectively use
the available bandwidth. It is common to extend the LAN
protocols to run over the WAN connections, so that
applications run transparently regardless of location, but
perhaps at a slower speed due to the restricted
bandwidth.
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 Telemedicină şi e-Sănătate
CURS 13 - Prof. dr. ing. Hariton Costin

(c) Middleware
At higher layers of networking, the client-server computing paradigm is
becoming an alternative to central host-based computing. By
distributing the work over several nodes on the network, more
efficient and flexible solutions are created. These solutions integrate
data for the end-users at the front end while hiding the multiplicity of
origins of the data at the back end.
A reliable, distributed file system, distributed printing services,
consolidated directory services, network-based security service, and
transparent invocation of applications residing elsewhere are
examples of middleware.
In the medical center context, it is extremely important to establish
standards at this level to effectively approach the heterogeneity.
Specific examples of middleware include Open Software
Foundation’s Distributed Computing Environment (DCE), SUN’s
Open Network Computing (ONC), OSI X.500 directory services, MIT
Kerberos security service, and OMG Common Object Request
Broker Architecture (CORBA).

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 Telemedicină şi e-Sănătate
CURS 13 - Prof. dr. ing. Hariton Costin

6. Standards Related to the Health Care Informatics

• As the cost of health care is high, the focus on methods to improve
health care productivity and quality has increased. To address this need,
the concept of a health care information infrastructure has emerged.
• Major elements of this concept include patient-centered care facilitated
by computer-based patient record systems, continuity of care enabled by
the sharing of patient information across information networks, and
outcomes measurement aided by the greater availability and specificity
of health care information. Thus, the integration of existing and new
architectures, products and services needs health care information
standards (classifications, guides, practices, terminology).
6.1. Communications (Message Format) Standards
• The standards in this topic area are still in various stages of
development. They are typically developed by committees within
standards organizations and have generally been accepted by users and
vendors.
• Documents: the Computer-based Patient Record Institute’s (CPRI)
“Position Paper on Computer-based Patient Record Standards” and the
Agency for Health Care Policy and Research’s (AHCPR) “Current
Activities of Selected Health Care Informatics Standards Organizations”.
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 Telemedicină şi e-Sănătate
CURS 13 - Prof. dr. ing. Hariton Costin

(1) ASC X12N

• This committee is developing message format standards for
transactions between payers and providers.
(2) Digital Imaging and Communications [DICOM]
• This standard is developed by the American College of Radiology—
National Electronic Manufacturers’ Association (ACR–NEMA). It
defines the message formats and communications standards for
radiologic images. DICOM is supported by most radiology Picture
Archiving and Communications Systems (PACS) vendors and has
been incorporated into the Japanese Image Store and Carry (ISAC)
optical disk system as well as Kodak’s PhotoCD. ACR-NEMA is
recognized as an accredited organization by ANSI.
(3) Health Level Seven [HL7]
• Maybe the most famous standard in medical informatics, HL7 is used
for intra-institution transmission of orders; clinical observations and
clinical data, including test results; admission, transfer, and discharge
records; and charge and billing information. HL7 is being used in more
than 350 U.S. health care institutions and has been adopted by
Australia and New Zealand as their national standard. HL7 is
recognized as an accredited organization by ANSI.
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 Telemedicină şi e-Sănătate
CURS 13 - Prof. dr. ing. Hariton Costin

6.2. Content and Structure Standards

• Guidelines and standards for the content and structure of computer-
based patient record (CPR) systems are being developed within
ASTM Subcommittees E31.12 and E31.19. They have been
recognized by other standards organizations (e.g., HL7); however,
they have not matured to the point where they are generally
accepted or implemented by users and vendors.
• A major revision to E1384, now called a standard description for
content and structure of the computer-based patient record, has
been made within Subcommittee E31.19. This revision includes
work from HISPP on data modeling and an expanded framework
that includes master tables and data views by user.
• Companion standards have been developed within E31.19. They
are E1633, A Standard Specification for the Coded Values Used in
the Automated Primary Record of Care (ASTM, 1994), and E1239-
94, A Standard Guide for Description of Reservation/Registration-
A/D/T Systems for Automated Patient Care Information Systems
(ASTM, 1994).
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 Telemedicină şi e-Sănătate
CURS 13 - Prof. dr. ing. Hariton Costin

Standards Coordination and Promotion Organizations

• In the United States, two organizations have responsibility for the

coordination and promotion of health care standards development: the
ANSI Health Care Informatics Standards Planning Panel (HISPP) and
the Computer-based Patient Record Institute (CPRI). The major
missions of the ANSI HISPP are:
1. To coordinate the work of the standards groups for health care data
interchange and health care informatics (e.g., ACR/NEMA, ASTM, HL7,
IEEE/MEDIX) and other relevant standards groups (e.g., X3, X12)
toward achieving the evolution of a unified set of nonredundant, non-
conflicting standards.
2. To interact with CEN TC 251 (Medical Informatics) in a coordinated
fashion and explore international standards development.
• The first mission of coordinating standards is performed by the
Message Standards Developers Subcommittee (MSDS). The second
mission is performed by the International and Regional Standards
Subcommittee.
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