Electronic patient chart from a health information system
Health informatics (also called health care informatics, healthcare informatics, medical informatics, nursing informatics, clinical informatics, or biomedical informatics) is information engineering applied to the field of health care, essentially the management and use of patient health care information. It is a multidisciplinary field that uses health information technology
(HIT) to improve health care via any combination of higher quality,
higher efficiency (spurring lower cost and thus greater availability),
and new opportunities. The disciplines involved include information science, computer science, social science, behavioral science, management science, and others. The United States National Library of Medicine
(NLM) defines health informatics as "the interdisciplinary study of the
design, development, adoption and application of IT-based innovations
in health care services delivery, management and planning".
It deals with the resources, devices, and methods required to
optimize the acquisition, storage, retrieval, and use of information in
health and bio-medicine. Health informatics tools include computers, clinical guidelines, formal medical terminologies, and information and communication systems, among others. It is applied to the areas of nursing, clinical medicine, dentistry, pharmacy, public health, occupational therapy, physical therapy, biomedical research, and alternative medicine,
all of which are designed to improve the overall effectiveness of
patient care delivery by ensuring that the data generated is of a high
quality.
The international standards on the subject are covered by ICS 35.240.80[7] in which ISO 27799:2008 is one of the core components.
Subspecialities
Health care informatics includes sub-fields of clinical informatics, such as pathology informatics, clinical research informatics (see section below), imaging informatics, public health informatics, community health informatics, home health informatics, nursing informatics, medical informatics, consumer health informatics, clinical bioinformatics, and informatics for education and research in health and medicine, pharmacy informatics.
Clinical informatics
Clinical informatics is concerned with the use of information in health care by and for clinicians.
Clinical
informaticians, also known as clinical informaticists, transform health
care by analyzing, designing, implementing, and evaluating information and communication systems
that enhance individual and population health outcomes, improve
[patient] care, and strengthen the clinician-patient relationship.
Clinical informaticians use their knowledge of patient care combined
with their understanding of informatics concepts, methods, and health informatics tools to:
- assess information and knowledge needs of health care professionals, patients and their families.
- characterize, evaluate, and refine clinical processes,
- develop, implement, and refine clinical decision support systems, and
- lead or participate in the procurement, customization, development, implementation, management, evaluation, and continuous improvement of clinical information systems.
Clinicians collaborate with other health care and information technology professionals to develop health informatics tools
which promote patient care that is safe, efficient, effective, timely,
patient-centered, and equitable. Many clinical informaticists are also
computer scientists.
In October 2011 American Board of Medical Specialties (ABMS),
the organization overseeing the certification of specialist MDs in the
United States, announced the creation of MD-only physician certification
in clinical informatics. The first examination for board certification
in the subspecialty of clinical informatics was offered in October 2013 by American Board of Preventive Medicine (ABPM) with 432 passing to become the 2014 inaugural class of Diplomates in clinical informatics.
Fellowship programs exist for physicians who wish to become
board-certified in clinical informatics. Physicians must have graduated
from a medical school in the United States or Canada, or a school
located elsewhere that is approved by the ABPM. In addition, they must
complete a primary residency program such as Internal Medicine (or any
of the 24 subspecialties recognized by the ABMS) and be eligible to
become licensed to practice medicine in the state where their fellowship
program is located.
The fellowship program is 24 months in length, with fellows dividing
their time between Informatics rotations, didactic method, research, and
clinical work in their primary specialty.
Integrated data repository
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Example IDR schema
Achilles tool for data characterization of a health care dataset
One of the fundamental elements of biomedical and translation
research is the use of integrated data repositories. A survey conducted
in 2010 defined "integrated data repository" (IDR) as a data warehouse
incorporating various sources of clinical data to support queries for a
range of research-like functions.
Integrated data repositories are complex systems developed to solve a
variety of problems ranging from identity management, protection of
confidentiality, semantic and syntactic comparability of data from
different sources, and most importantly convenient and flexible query. Development of the field of clinical informatics led to the creation of large data sets with electronic health record
data integrated with other data (such as genomic data). Types of data
repositories include operational data stores (ODSs), clinical data
warehouses (CDWs), clinical data marts, and clinical registries. Operational data stores established for extracting, transferring and loading before creating warehouse or data marts.
Clinical registries repositories have long been in existence, but their
contents are disease specific and sometimes considered archaic.
Clinical data stores and clinical data warehouses are considered fast
and reliable. Though these large integrated repositories have impacted
clinical research significantly, it still faces challenges and barriers.
One big problem is the requirement for ethical approval by the
institutional review board (IRB) for each research analysis meant for
publication.
Some research resources do not require IRB approval. For example, CDWs
with data of deceased patients have been de-identified and IRB approval
is not required for their usage.
Another challenge is data quality.
Methods that adjust for bias (such as using propensity score matching
methods) assume that a complete health record is captured. Tools that
examine data quality (e.g., point to missing data) help in discovering
data quality problems.
Clinical research informatics
Clinical research informatics (CRI) is a sub-field of health informatics that tries to improve the efficiency of clinical research
by using informatics methods. Some of the problems tackled by CRI are:
creation of data warehouses of health care data that can be used for
research, support of data collection in clinical trials by the use of electronic data capture systems, streamlining ethical approvals and renewals (in US the responsible entity is the local institutional review board), maintenance of repositories of past clinical trial data (de-identified).
CRI is a fairly new branch of informatics and has met growing
pains as any up and coming field does. Some issue CRI faces is the
ability for the statisticians and the computer system architects to work
with the clinical research staff in designing a system and lack of
funding to support the development of a new system. Researchers and the
informatics team have a difficult time coordinating plans and ideas in
order to design a system that is easy to use for the research team yet
fits in the system requirements of the computer team. The lack of
funding can be a hindrance to the development of the CRI. Many
organizations who are performing research are struggling to get
financial support to conduct the research, much less invest that money
in an informatics system that will not provide them any more income or
improve the outcome of the research (Embi, 2009).
Common data elements (CDEs) in clinical research
Ability to integrate data from multiple clinical trials is an important part of clinical research informatics. Initiatives, such as PhenX and Patient-Reported Outcomes Measurement Information System
triggered a general effort to improve secondary use of data collected
in past human clinical trials. CDE initiatives, for example, try to
allow clinical trial designers to adopt standardized research
instruments (electronic case report forms).
Data sharing platforms for clinical study data
A
parallel effort to standardizing how data is collected are initiatives
that offer de-identified patient level clinical study data to be
downloaded by researchers who wish to re-use this data. Examples of such
platforms are Project Data Sphere, dbGaP, ImmPort or Clinical Study Data Request. Informatics issues in data formats for sharing results (plain CSV files, FDA endorsed formats, such as CDISC Study Data Tabulation Model) are important challenges within the field of clinical research informatics.
Translational bioinformatics
With
the completion of the human genome and the recent advent of high
throughput sequencing and genome-wide association studies of single
nucleotide polymorphic organisms, the fields of molecular
bioinformatics, bio-statistics, statistical genetics and clinical
informatics are converging into the emerging field of translational bioinformatics.
The relationship between bioinformatics and health informatics, while
conceptually related under the umbrella of biomedical informatics,
has not always been very clear. The TBI community is specifically
motivated with the development of approaches to identify linkages
between fundamental biological and clinical information.
Along with complementary areas of emphasis, such as those focused on developing systems and approaches within clinical research contexts, insights from TBI may enable a new paradigm for the study and treatment of disease.
Translational Bioinformatics (TBI) is a relatively new field that
surfaced in the year of 2000 when human genome sequence was released. The commonly used definition of TBI is lengthy and could be found on the AMIA website.
In simpler terms, TBI could be defined as a collection of colossal
amounts of health related data (biomedical and genomic) and translation
of the data into individually tailored clinical entities.
Today, TBI field is categorized into four major themes that are briefly described below:
- Clinical big data
Clinical big data is a collection of electronic health records that are used for innovations. The evidence-based approach that is currently practiced in medicine is suggested to be merged with the practice-based medicine to achieve better outcomes for patients. As CEO of California-based cognitive computing firm Apixio, Darren Schutle, explains that the care can be better fitted to the patient if the data could be collected from various medical records, merged, and analyzed. Further, the combination of similar profiles can serve as a basis for personalized medicine pointing to what works and what does not for certain condition (Marr, 2016). - Genomics in clinical care
Genomic data are used to identify the genes involvement in unknown or rare conditions/syndromes. Currently, the most vigorous area of using genomics is oncology. The identification of genomic sequencing of cancer may define reasons of drug(s) sensitivity and resistance during oncological treatment processes. - Omics for drugs discovery and repurposing
Repurposing of the drug is an appealing idea that allows the pharmaceutical companies to sell an already approved drug to treat a different condition/disease that the drug was not initially approved for by the FDA. The observation of “molecular signatures in disease and compare those to signatures observed in cells” points to the possibility of a drug ability to cure and/or relieve symptoms of a disease. - Personalized genomic testing
In the US, several companies offer direct-to-consumer (DTC) genetic testing. The company that performs the majority of testing is called 23andMe. Utilizing genetic testing in health care raises many ethical, legal and social concerns; one of the main questions is whether the health care providers are ready to include patient-supplied genomic information while providing care that is unbiased (despite the intimate genomic knowledge) and a high quality. The documented examples of incorporating such information into a health care delivery showed both positive and negative impacts on the overall health care related outcomes.
Computational health informatics
Computational health informatics is a branch of computer science
that deals specifically with computational techniques that are relevant
in health care. Computational health informatics is also a branch of
health informatics, but is orthogonal to much of the work going on in
health informatics because computer scientists' interest is mainly in
understanding fundamental properties of computation. Health informatics,
on the other hand, is primarily concerned with understanding
fundamental properties of medicine that allow for the intervention of
computers. The health domain provides an extremely wide variety of
problems that can be tackled using computational techniques, and
computer scientists are attempting to make a difference in medicine by
studying the underlying principles of computer science that will allow
for meaningful (to medicine) algorithms and systems to be developed.
Thus, computer scientists working in computational health informatics
and health scientists working in medical health informatics combine to
develop the next generation of health care technologies.
Using computers to analyze health data has been around since the
1950s, but it wasn't until the 1990s that the first sturdy models
appeared. The development of the Internet has helped develop
computational health informatics over the past decade. Computer models
are used to examine various topics such as how exercise affects obesity,
health care costs, and many more.
Examples of projects in computational health informatics include the COACH project.
Informatics for education and research in health and medicine
Clinical research informatics
Clinical
research informatics (CRI) is an amalgamation of clinical and research
informatics. Featuring both clinical and research informatics, CRI has a
vital role in clinical research, patient care, and the building of
health care system (Katzan & Rudick, 2012). CRI is one of the
rapidly growing subdivisions of biomedical informatics which plays an
important role in developing new informatics theories, tools, and
solutions to accelerate the full transitional continuum (Kahn &
Weng, 2012).
Evolution of CRI was extremely important in Informatics as there was an
extraordinary increase in the scope and pace of clinical and
translational science advancements (Katzan & Rudick, 2012).
Clinical research informatics takes the core foundations, principles,
and technologies related to Health Informatics, and applies these to
clinical research contexts.
As such, CRI is a sub-discipline of health informatics, and interest
and activities in CRI have increased greatly in recent years given the
overwhelming problems associated with the explosive growth of clinical
research data and information. There are a number of activities within clinical research that CRI supports, including:
- more efficient and effective data collection and acquisition
- improved recruitment into clinical trials
- optimal protocol design and efficient management
- patient recruitment and management
- adverse event reporting
- regulatory compliance
- data storage, transfer, processing and analysis
- repositories of data from completed clinical trials (for secondary analyses)
History
Worldwide use of computer technology in medicine began in the early 1950s with the rise of the computers. In 1949, Gustav Wagner established the first professional organization for informatics in Germany. The prehistory, history, and future of medical information and health information technology are discussed in reference.
Specialized university departments and Informatics training programs
began during the 1960s in France, Germany, Belgium and The Netherlands.
Medical informatics research units began to appear during the 1970s in
Poland and in the U.S.[42]
Since then the development of high-quality health informatics research,
education and infrastructure has been a goal of the U.S. and the
European Union.
Early names for health informatics included medical computing,
biomedical computing, medical computer science, computer medicine,
medical electronic data processing, medical automatic data processing,
medical information processing, medical information science, medical software engineering, and medical computer technology.
The health informatics community is still growing, it is by no
means a mature profession, but work in the UK by the voluntary
registration body, the UK Council of Health Informatics Professions has
suggested eight key constituencies within the domain–information
management, knowledge management, portfolio/program/project management,
ICT, education and research, clinical informatics, health
records(service and business-related), health informatics service
management. These constituencies accommodate professionals in and for
the NHS, in academia and commercial service and solution providers.
Since the 1970s the most prominent international coordinating body has been the International Medical Informatics Association (IMIA).
In the United States
Even
though the idea of using computers in medicine emerged as technology
advanced in the early 20th century, it was not until the 1950s that
informatics began to have an effect in the United States.
The earliest use of electronic digital computers for medicine was for dental projects in the 1950s at the United States National Bureau of Standards by Robert Ledley. During the mid-1950s, the United States Air Force (USAF) carried out several medical projects on its computers while also encouraging civilian agencies such as the National Academy of Sciences – National Research Council (NAS-NRC) and the National Institutes of Health (NIH) to sponsor such work. In 1959, Ledley and Lee B. Lusted published "Reasoning Foundations of Medical Diagnosis," a widely read article in Science,
which introduced computing (especially operations research) techniques
to medical workers. Ledley and Lusted's article has remained influential
for decades, especially within the field of medical decision making.
Guided by Ledley's late 1950s survey of computer use in biology
and medicine (carried out for the NAS-NRC), and by his and Lusted's
articles, the NIH undertook the first major effort to introduce
computers to biology and medicine. This effort, carried out initially by
the NIH's Advisory Committee on Computers in Research (ACCR), chaired
by Lusted, spent over $40 million between 1960 and 1964 in order to
establish dozens of large and small biomedical research centers in the
US.
One early (1960, non-ACCR) use of computers was to help quantify
normal human movement, as a precursor to scientifically measuring
deviations from normal, and design of prostheses.
The use of computers (IBM 650, 1620, and 7040) allowed analysis of a
large sample size, and of more measurements and subgroups than had been
previously practical with mechanical calculators, thus allowing an
objective understanding of how human locomotion varies by age and body
characteristics. A study co-author was Dean of the Marquette University
College of Engineering; this work led to discrete Biomedical Engineering
departments there and elsewhere.
The next steps, in the mid-1960s, were the development (sponsored largely by the NIH) of expert systems such as MYCIN and Internist-I. In 1965, the National Library of Medicine started to use MEDLINE and MEDLARS. Around this time, Neil Pappalardo, Curtis Marble, and Robert Greenes developed MUMPS (Massachusetts General Hospital Utility Multi-Programming System) in Octo Barnett's Laboratory of Computer Science at Massachusetts General Hospital in Boston, another center of biomedical computing that received significant support from the NIH. In the 1970s and 1980s it was the most commonly used programming language for clinical applications. The MUMPS operating system was used to support MUMPS language specifications. As of 2004, a descendant of this system is being used in the United States Veterans Affairs hospital system. The VA has the largest enterprise-wide health information system that includes an electronic medical record, known as the Veterans Health Information Systems and Technology Architecture (VistA). A graphical user interface
known as the Computerized Patient Record System (CPRS) allows health
care providers to review and update a patient's electronic medical
record at any of the VA's over 1,000 health care facilities.
During the 1960s, Morris Collen, a physician working for Kaiser Permanente's
Division of Research, developed computerized systems to automate many
aspects of multi-phased health checkups. These systems became the basis
the larger medical databases Kaiser Permanente developed during the
1970s and 1980s.
The American College of Medical Informatics (ACMI) has since 1993
annually bestowed the Morris F. Collen, MD Medal for Outstanding
Contributions to the Field of Medical Informatics.
In the 1970s a growing number of commercial vendors began to
market practice management and electronic medical records systems.
Although many products exist, only a small number of health
practitioners use fully featured electronic health care records systems.
In 1970, Warner V. Slack, MD, and Howard L. Bleich, MD, co-founded the
academic division of clinical informatics
at Beth Israel Deaconess Medical Center and Harvard Medical School.
Warner Slack is a pioneer of the development of the electronic patient
medical history, and in 1977 Dr. Bleich created the first user-friendly search engine for the worlds biomedical literature.
In 2002, Dr. Slack and Dr. Bleich were awarded the Morris F. Collen
Award for their pioneering contributions to medical informatics.
Computerized systems involved in patient care have led to a
number of changes. Such changes have led to improvements in electronic
health records which are now capable of sharing medical information
among multiple health care stakeholders (Zahabi, Kaber, & Swangnetr,
2015); thereby, supporting the flow of patient information through
various modalities of care.
Computer use today involves a broad ability which includes but
isn't limited to physician diagnosis and documentation, patient
appointment scheduling, and billing. Many researchers in the field have
identified an increase in the quality of health care systems, decreased
errors by health care workers, and lastly savings in time and money
(Zahabi, Kaber, & Swangnetr, 2015). The system, however, is not
perfect and will continue to require improvement. Frequently cited
factors of concern involve usability, safety, accessibility, and
user-friendliness (Zahabi, Kaber, & Swangnetr, 2015). As leaders in
the field of medical informatics improve upon the aforementioned factors
of concern, the overall provision of health care will continue to
improve.
Homer R. Warner, one of the fathers of medical informatics, founded the Department of Medical Informatics at the University of Utah in 1968. The American Medical Informatics Association (AMIA) has an award named after him on application of informatics to medicine.
Informatics certifications
Like
other IT training specialties, there are Informatics certifications
available to help informatics professionals stand out and be recognized.
The American Nurses Credentialing Center (ANCC) offers a board
certification in Nursing Informatics.
For Radiology Informatics, the CIIP (Certified Imaging Informatics
Professional) certification was created by ABII (The American Board of
Imaging Informatics) which was founded by SIIM (the Society for Imaging
Informatics in Medicine) and ARRT (the American Registry of Radiologic
Technologists) in 2005. The CIIP certification requires documented
experience working in Imaging Informatics, formal testing and is a
limited time credential requiring renewal every five years. The exam
tests for a combination of IT technical knowledge, clinical
understanding, and project management experience thought to represent
the typical workload of a PACS administrator or other radiology IT
clinical support role.
Certifications from PARCA (PACS Administrators Registry and
Certifications Association) are also recognized. The five PARCA
certifications are tiered from entry-level to architect level. The
American Health Information Management Association offers credentials in
medical coding, analytics, and data administration, such as Registered Health Information Administrator and Certified Coding Associate.
Certifications are widely requested by employers in health
informatics, and overall the demand for certified informatics workers in
the United States is outstripping supply.
The American Health Information Management Association reports that
only 68% of applicants pass certification exams on the first try.
In 2017, a consortium of health informatics trainers (composed of
MEASURE Evaluation, Public Health Foundation India, University of
Pretoria, Kenyatta University, and the University of Ghana) identified
the following areas of knowledge as a curriculum for the digital health
workforce, especially in low- and middle-income countries: clinical
decision support; telehealth;
privacy, security, and confidentiality; workflow process improvement;
technology, people, and processes; process engineering; quality process
improvement and health information technology; computer hardware;
software; databases; data warehousing; information networks; information
systems; information exchange; data analytics; and usability methods.
In the UK
The broad history of health informatics has been captured in the book UK Health Computing: Recollections and reflections,
Hayes G, Barnett D (Eds.), BCS (May 2008) by those active in the
field, predominantly members of BCS Health and its constituent groups.
The book describes the path taken as 'early development of health
informatics was unorganized and idiosyncratic'. In the early 1950s, it
was prompted by those involved in NHS finance and only in the early
1960s did solutions including those in pathology (1960), radiotherapy
(1962), immunization (1963), and primary care (1968) emerge. Many of
these solutions, even in the early 1970s were developed in-house by
pioneers in the field to meet their own requirements. In part, this was
due to some areas of health services (for example the immunization and
vaccination of children) still being provided by Local Authorities. The
coalition government has proposed broadly to return to the 2010 strategy
Equity and Excellence: Liberating the NHS (July 2010); stating: "We will put patients at the heart of the NHS, through an
information revolution and greater choice and control' with shared
decision-making becoming the norm: 'no decision about me without me' and
patients having access to the information they want, to make choices
about their care. They will have increased control over their own care
records."
Informatics certifications
BCS
via FEDIP provides 4 different professional registration levels for
Health and Care Informatics Professionals: Practitioner, Senior
Practitioner, Advanced Practitioner, and Leading Practitioner.
FEDIP is the Federation for Informatics Professionals in Health
and Social Care, a collaboration between the leading professional bodies
in health and care informatics supporting the development of the
informatics profession.
Current state and policy initiatives
Argentina
Since
1997, the Buenos Aires Biomedical Informatics Group, a nonprofit group,
represents the interests of a broad range of clinical and non-clinical
professionals working within the Health Informatics sphere.
Its purposes are:
- Promote the implementation of the computer tool in the health care activity, scientific research, health administration and in all areas related to health sciences and biomedical research.
- Support, promote and disseminate content related activities with the management of health information and tools they used to do under the name of Biomedical informatics.
- Promote cooperation and exchange of actions generated in the field of biomedical informatics, both in the public and private, national and international level.
- Interact with all scientists, recognized academic stimulating the creation of new instances that have the same goal and be inspired by the same purpose.
- To promote, organize, sponsor and participate in events and activities for training in computer and information and disseminating developments in this area that might be useful for team members and health related activities.
The Argentinian health system is heterogeneous in its function, and
because of that the informatics developments show a heterogeneous stage.
Many private health care centers have developed systems, such as the
Hospital Aleman of Buenos Aires, or the Hospital Italiano de Buenos
Aires that also has a residence program for health informatics.
Brazil
The first applications of computers to medicine and health care in
Brazil started around 1968, with the installation of the first
mainframes in public university hospitals, and the use of programmable
calculators in scientific research applications. Minicomputers, such as
the IBM 1130 were installed in several universities, and the first applications were developed for them, such as the hospital census in the School of Medicine of Ribeirão Preto and patient master files, in the Hospital das Clínicas da Universidade de São Paulo, respectively at the cities of Ribeirão Preto and São Paulo campuses of the University of São Paulo. In the 1970s, several Digital Corporation and Hewlett Packard minicomputers were acquired for public and Armed Forces hospitals, and more intensively used for intensive-care unit, cardiology diagnostics, patient monitoring and other applications. In the early 1980s, with the arrival of cheaper microcomputers, a great upsurge of computer applications in health ensued, and in 1986 the Brazilian Society of Health Informatics was founded, the first Brazilian Congress of Health Informatics was held, and the first Brazilian Journal of Health Informatics was published. In Brazil, two universities are pioneers in teaching and research in medical informatics, both the University of Sao Paulo and the Federal University of Sao Paulo offer undergraduate programs highly qualified in the area as well as extensive graduate programs (MSc and PhD). In 2015 the Universidade Federal de Ciências da Saúde de Porto Alegre, Rio Grande do Sul, also started to offer undergraduate program.
Canada
Health
Informatics projects in Canada are implemented provincially, with
different provinces creating different systems. A national, federally
funded, not-for-profit organization called Canada Health Infoway
was created in 2001 to foster the development and adoption of
electronic health records across Canada. As of December 31, 2008 there
were 276 EHR projects under way in Canadian hospitals, other health-care
facilities, pharmacies and laboratories, with an investment value of
$1.5-billion from Canada Health Infoway.
Provincial and territorial programmes include the following:
- eHealth Ontario was created as an Ontario provincial government agency in September 2008. It has been plagued by delays and its CEO was fired over a multimillion-dollar contracts scandal in 2009.
- Alberta Netcare was created in 2003 by the Government of Alberta. Today the netCARE portal is used daily by thousands of clinicians. It provides access to demographic data, prescribed/dispensed drugs, known allergies/intolerances, immunizations, laboratory test results, diagnostic imaging reports, the diabetes registry and other medical reports. netCARE interface capabilities are being included in electronic medical record products which are being funded by the provincial government.
United States
In 2004, President George W. Bush signed Executive Order 13335, creating the Office of the National Coordinator for Health Information Technology (ONCHIT) as a division of the U.S. Department of Health and Human Services
(HHS). The mission of this office is widespread adoption of
interoperable electronic health records (EHRs) in the US within 10
years.
In 2014 the Department of Education approved an advanced Health
Informatics Undergraduate program that was submitted by the University
of South Alabama. The program is designed to provide specific Health
Informatics education, and is the only program in the country with a
Health Informatics Lab. The program is housed in the School of Computing
in Shelby Hall, a recently completed $50 million state of the art
teaching facility. The University of South Alabama awarded David L.
Loeser on May 10, 2014 with the first Health Informatics degree. The
program currently is scheduled to have 100+ students awarded by 2016.
The Certification Commission for Healthcare Information Technology (CCHIT), a private nonprofit group, was funded in 2005 by the U.S. Department of Health and Human Services to develop a set of standards for electronic health records
(EHR) and supporting networks, and certify vendors who meet them. In
July 2006, CCHIT released its first list of 22 certified ambulatory EHR
products, in two different announcements.
Harvard Medical School added a department of biomedical informatics in 2015. The University of Cincinnati in partnership with Cincinnati Children's Hospital Medical Center created a biomedical informatics (BMI) Graduate certificate program and in 2015 began a BMI PhD program.
The joint program allows for researchers and students to observe the
impact their work has on patient care directly as discoveries are
translated from bench to bedside.
Europe
The European Union's Member States are committed to sharing their
best practices and experiences to create a European eHealth Area,
thereby improving access to and quality health care at the same time as
stimulating growth in a promising new industrial sector. The European
eHealth Action Plan plays a fundamental role in the European Union's
strategy. Work on this initiative involves a collaborative approach
among several parts of the Commission services. The European Institute for Health Records is involved in the promotion of high quality electronic health record systems in the European Union.
UK
There are
different models of health informatics delivery in each of the home
countries (England, Scotland, Northern Ireland and Wales) but some
bodies like UKCHIP operate for those 'in and for' all the home countries and beyond.
England
NHS
informatics in England was contracted out to several vendors for
national health informatics solutions under the National Programme for
Information Technology (NPfIT)
label in the early to mid-2000s, under the auspices of NHS Connecting
for Health (part of the Health and Social Care Information Centre as of 1
April 2013). NPfIT originally divided the country into five regions,
with strategic 'systems integration' contracts awarded to one of several
Local Service Providers (LSP). The various specific technical
solutions were required to connect securely with the NHS 'Spine', a
system designed to broker data between different systems and care
settings. NPfIT fell significantly behind schedule and its scope and
design were being revised in real time, exacerbated by media and
political lambasting of the Programme's spend (past and projected)
against the proposed budget. In 2010 a consultation was launched as part
of the new Conservative/Liberal Democrat Coalition Government's White
Paper 'Liberating the NHS'. This initiative provided little in the way
of innovative thinking, primarily re-stating existing strategies within
the proposed new context of the Coalition's vision for the NHS.
The degree of computerization in NHS secondary care was quite high
before NPfIT, and the programme stagnated further development of the
install base – the original NPfIT regional approach provided neither a
single, nationwide solution nor local health community agility or
autonomy to purchase systems, but instead tried to deal with a
hinterland in the middle.
Almost all general practices in England and Wales are computerized under the GP Systems of Choice
programme, and patients have relatively extensive computerized primary
care clinical records. System choice is the responsibility of individual
general practices and while there is no single, standardized GP system,
it sets relatively rigid minimum standards of performance and
functionality for vendors to adhere to. Interoperation between primary
and secondary care systems is rather primitive. It is hoped that a focus
on interworking (for interfacing and integration) standards will
stimulate synergy between primary and secondary care in sharing
necessary information to support the care of individuals. Notable
successes to date are in the electronic requesting and viewing of test
results, and in some areas, GPs have access to digital x-ray images from
secondary care systems.
In 2019 the GP Systems of Choice framework was replaced by the GP IT Futures framework, which is to be the main vehicle used by clinical commissioning groups to buy services for GPs. This is intended to increase competition in an area which is dominated by EMIS and TPP. 69 technology companies offering more than 300 solutions have been accepted on to the new framework.
Scotland
Scotland
was one of the first countries to use Health Informatics at scale
following the introduction of the National Health Service Central
Register (NHSCR), which is a Scottish Government database accessible to
public bodies approved by the Scottish Parliament. The register was
established in the early 1950s to facilitate the transfer of patients
between Health Board areas or across borders within the countries of the
United Kingdom. However, its role has expanded over the decades and it
now also provides Scottish local authorities with a Unique Citizen
Reference Number or UCRN used to identify people on their own databases.
It has an approach to the central connection underway which is more
advanced than the English one in many ways. Scotland has the GPASS
system whose source code is owned by the State, and controlled and
developed by NHS Scotland. GPASS was accepted in 1984. It has been
provided free to all GPs in Scotland but has developed poorly. Discussion of open sourcing it as a remedy is occurring.
A foundation of successful data linkage in Scotland is the
Community Health Index (CHI), which is a register of all patients in NHS
Scotland, Scotland's publicly funded healthcare system. The register
exists to ensure that patients can be correctly identified, and that all
information pertaining to a patient's health is available to providers
of care.
Wales
Wales has a
dedicated Health Informatics function that supports NHS Wales in
leading on the new integrated digital information services and promoting
Health Informatics as a career.
Netherlands
In
the Netherlands, health informatics is currently a priority for
research and implementation. The Netherlands Federation of University
medical centers (NFU) has created the Citrienfonds, which includes the programs eHealth and Registration at the Source. The Netherlands also has the national organizations Society for Healthcare Informatics (VMBI) and Nictiz, the national center for standardization and eHealth.
Emerging Directions (European R&D)
The European Commission's preference, as exemplified in the 5th Framework as well as currently pursued pilot projects,
is for Free/Libre and Open Source Software (FLOSS) for health care.
Another stream of research currently focuses on aspects of "big data" in
health information systems. For background information on data-related
aspects in health informatics see, e.g., the book "Biomedical
Informatics" by Andreas Holzinger.
Asia and Oceania
In Asia and Australia-New Zealand, the regional group called the Asia Pacific Association for Medical Informatics (APAMI) was established in 1994 and now consists of more than 15 member regions in the Asia Pacific Region.
Australia
The Australasian College of Health Informatics
(ACHI) is the professional association for health informatics in the
Asia-Pacific region. It represents the interests of a broad range of
clinical and non-clinical professionals working within the health
informatics sphere through a commitment to quality, standards and
ethical practice. ACHI is an academic institutional member of the International Medical Informatics Association (IMIA) and a full member of the Australian Council of Professions.
ACHI is a sponsor of the "e-Journal for Health Informatics", an indexed and peer-reviewed professional journal. ACHI has also supported the "Australian Health Informatics Education Council" (AHIEC) since its founding in 2009.
Although there are a number of health informatics organizations in Australia, the Health Informatics Society of Australia (HISA) is regarded as the major umbrella group and is a member of the International Medical Informatics Association
(IMIA). Nursing informaticians were the driving force behind the
formation of HISA, which is now a company limited by guarantee of the
members. The membership comes from across the informatics spectrum that
is from students to corporate affiliates. HISA has a number of branches
(Queensland, New South Wales, Victoria and Western Australia) as well as
special interest groups such as nursing (NIA), pathology, aged and
community care, industry and medical imaging (Conrick, 2006).
China
After 20 years, China performed a successful transition from its planned economy to a socialist market economy.
Along this change, China's health care system also experienced a
significant reform to follow and adapt to this historical revolution. In
2003, the data (released from Ministry of Health of the People's Republic of China (MoH)), indicated that the national health care-involved expenditure was up to RMB
662.33 billion totally, which accounted for about 5.56% of nationwide
gross domestic products. Before the 1980s, the entire health care costs
were covered in central government annual budget. Since that, the
construct of health care-expended supporters started to change
gradually. Most of the expenditure was contributed by health insurance
schemes and private spending, which corresponded to 40% and 45% of total
expenditure, respectively. Meanwhile, the financially governmental
contribution was decreased to 10% only. On the other hand, by 2004, up
to 296,492 health care facilities were recorded in statistic summary of
MoH, and an average of 2.4 clinical beds per 1000 people were mentioned
as well.
In China
Proportion of nationwide hospitals with HIS in China by 2004
Along with the development of information technology since the 1990s,
health care providers realized that the information could generate
significant benefits to improve their services by computerized cases and
data, for instance of gaining the information for directing patient
care and assessing the best patient care for specific clinical
conditions. Therefore, substantial resources were collected to build
China's own health informatics system. Most of these resources were
arranged to construct hospital information system
(HIS), which was aimed to minimize unnecessary waste and repetition,
subsequently to promote the efficiency and quality-control of health
care. By 2004, China had successfully spread HIS through approximately 35–40% of nationwide hospitals.
However, the dispersion of hospital-owned HIS varies critically. In the
east part of China, over 80% of hospitals constructed HIS, in northwest
of China the equivalent was no more than 20%. Moreover, all of the Centers for Disease Control and Prevention
(CDC) above rural level, approximately 80% of health care organisations
above the rural level and 27% of hospitals over town level have the
ability to perform the transmission of reports about real-time epidemic
situation through public health information system and to analysis
infectious diseases by dynamic statistics.
China has four tiers in its health care system. The first tier is
street health and workplace clinics and these are cheaper than
hospitals in terms of medical billing and act as prevention centers. The
second tier is district and enterprise hospitals along with specialist
clinics and these provide the second level of care. The third tier is
provisional and municipal general hospitals and teaching hospitals which
provided the third level of care. In a tier of its own is the national
hospitals which are governed by the Ministry of Health. China has been
greatly improving its health informatics since it finally opened its
doors to the outside world and joined the World Trade Organization
(WTO). In 2001, it was reported that China had 324,380 medical
institutions and the majority of those were clinics. The reason for that
is that clinics are prevention centers and Chinese people like using
traditional Chinese medicine as opposed to Western medicine and it
usually works for the minor cases. China has also been improving its
higher education in regards to health informatics. At the end of 2002,
there were 77 medical universities and medical colleges. There were 48
university medical colleges which offered bachelor, master, and
doctorate degrees in medicine. There were 21 higher medical specialty
institutions that offered diploma degrees so in total, there were 147
higher medical and educational institutions. Since joining the WTO,
China has been working hard to improve its education system and bring it
up to international standards.
SARS played a large role in China quickly improving its health care
system. Back in 2003, there was an outbreak of SARS and that made China
hurry to spread HIS or Hospital Information System and more than 80% of
hospitals had HIS. China had been comparing itself to Korea's health
care system and figuring out how it can better its own system. There was
a study done that surveyed six hospitals in China that had HIS. The
results were that doctors didn't use computers as much so it was
concluded that it wasn't used as much for clinical practice than it was
for administrative purposes. The survey asked if the hospitals created
any websites and it was concluded that only four of them had created
websites and that three had a third-party company create it for them and
one was created by the hospital staff. In conclusion, all of them
agreed or strongly agreed that providing health information on the
Internet should be utilized.
Standards in China
Collected
information at different times, by different participants or systems
could frequently lead to issues of misunderstanding, dis-comparing or
dis-exchanging. To design an issues-minor system, health care providers
realized that certain standards were the basis for sharing information
and interoperability, however a system lacking standards would be a
large impediment to interfere the improvement of corresponding
information systems. Given that the standardization for health
informatics depends on the authorities, standardization events must be
involved with government and the subsequently relevant funding and
supports were critical. In 2003, the Ministry of Health released the
Development Lay-out of National Health Informatics (2003–2010)
indicating the identification of standardization for health informatics
which is 'combining adoption of international standards and development
of national standards'.
In China, the establishment of standardization was initially facilitated with the development of vocabulary, classification and coding,
which is conducive to reserve and transmit information for premium
management at national level. By 2006, 55 international/ domestic
standards of vocabulary, classification and coding have served in
hospital information system. In 2003, the 10th revision of the
International Statistical Classification of Diseases and Related Health
Problems (ICD-10) and the ICD-10 Clinical Modification
(ICD-10-CM) were adopted as standards for diagnostic classification and
acute care procedure classification. Simultaneously, the International Classification of Primary Care (ICPC) were translated and tested in China 's local applied environment.
Another coding standard, named Logical Observation Identifiers Names and Codes
(LOINC), was applied to serve as general identifiers for clinical
observation in hospitals. Personal identifier codes were widely employed
in different information systems, involving name, sex, nationality,
family relationship, educational level and job occupation. However,
these codes within different systems are inconsistent, when sharing
between different regions. Considering this large quantity of
vocabulary, classification and coding standards between different
jurisdictions, the health care provider realized that using multiple
systems could generate issues of resource wasting and a non-conflicting
national level standard was beneficial and necessary. Therefore, in late
2003, the health informatics group in Ministry of Health released three
projects to deal with issues of lacking national health information
standards, which were the Chinese National Health Information Framework
and Standardization, the Basic Data Set Standards of Hospital
Information System and the Basic Data Set Standards of Public Health
Information System.
| Objectives of Chinese National Health Information Framework and Standardisation |
|---|
| 1. Establish national health information framework and identify in what areas standards and guidelines are required |
| 2. Identify the classes, relationships and attributes of national health information framework. Produce a conceptual health data model to cover the scope of the health information framework |
| 3. Create logical data model for specific domains, depicting the logical data entities, the data attributes, and the relationships between the entities according to the conceptual health data model |
| 4. Establish uniform represent standard for data elements according to the data entities and their attributes in conceptual data model and logical data model |
| 5. Circulate the completed health information framework and health data model to the partnership members for review and acceptance |
| 6. Develop a process to maintain and refine the China model and to align with and influence international health data models |
Comparison between China's EHR Standard and Segments of the ASTM E 1384 Standard
Recently, researchers from local universities evaluated the performance of China's Electronic Health Record (EHR) Standard compared with the American Society for Testing and Materials Standard Practice for Content and Structure of Electronic Health Records in the United States (ASTM E 1384 Standard).
| China'sEHR standard | ASTM E 1384 standard |
|---|---|
| ● H.01 Document identifier, H.02 Service object identifier, H.03 Demographics, H.04 Contact person, H.05 Address, H.06 Contacts | ● Seg1 Demographic/Administrative, Seg14A Administrative/Diagnostic
Summary
|
| ● H.07 Medical insurance |
|
| ● H.08 Healthcare institution, H.09 Healthcare practitioner | ● Seg4 Provider/Practitioners |
| ● H.10 Event summary | ● Seg5 Problem List, Seg14A Administrative/Diagnostic Summary |
| ● S.01 Chief complaints | ● Seg14B Chief Complaint Present Illness/Trauma Care |
| ● S.02 Physical exam | ● Seg9 Assessments/Exams |
| ● S.03 Present illness history | ● Seg14B Chief Complaint Present Illness/Trauma Care |
| ● S.04 Past medical history | ● Seg5 Problem List, Seg6 Immunizations, Seg7 Exposure to Hazardous Substances, Seg8 Family/Prenatal/Cumulative Health/Medical/Dental Nursing History |
| ● S.05 Specific Exam, S.06 Lab data | ● Seg11 Diagnostic Tests |
| ● S.07 Diagnoses | ● Seg5 Problem List, Seg14A Administrative/Diagnostic Summary |
| ● S.08 Procedures | ● Seg14E Procedures |
| ● S.09 Medications | ● Seg12 Medications |
| ● S.10 Care/treatment plans | ● Seg2 Legal Agreements, Seg10 Care/Treatment Plans and Orders, Seg13 Scheduled Appointments/Events |
| ● S.11 Assessments | ● Seg9 Assessments/Exams |
| ● S.12 Encounters/episodes notes | ● Seg14C Progress Notes/Clinical Course, Seg14D Therapies, Seg14F Disposition |
| ● S.13 Financial information | ● Seg3 Financial |
| ● S.14 Nursing service | ● Seg8 Family/Prenatal/Cumulative Health/Medical/Dental Nursing History, Seg14D Therapies |
| ● S.15 Health guidance | ● Seg10 Care/Treatment Plans and Orders |
| ● S.16 Four diagnostic methods in Traditional Chinese medicine | ● Seg11 Diagnostic Tests |
The table above demonstrates details of this comparison which
indicates certain domains of improvement for future revisions of EHR
Standard in China. Meticulously, these deficiencies are listed in the
following.
- The lack of supporting on privacy and security. The ISO/TS 18308 specifies "The EHR must support the ethical and legal use of personal information, in accordance with established privacy principles and frameworks, which may be culturally or jurisdictionally specific" (ISO 18308: Health Informatics-Requirements for an Electronic Health Record Architecture, 2004). However this China's EHR Standard did not achieve any of the fifteen requirements in the subclass of privacy and security.
- The shortage of supporting on different types of data and reference. Considering only ICD-9 is referenced as China's external international coding systems, other similar systems, such as SNOMED CT in clinical terminology presentation, cannot be considered as familiar for Chinese specialists, which could lead to internationally information-sharing deficiency.
- The lack of more generic and extensible lower level data structures. China's large and complex EHR Standard was constructed for all medical domains. However, the specific and time-frequent attributes of clinical data elements, value sets and templates identified that this once-for-all purpose cannot lead to practical consequence.
Hong Kong
In Hong Kong a computerized patient record system called the Clinical Management System (CMS) has been developed by the Hospital Authority
since 1994. This system has been deployed at all the sites of the
authority (40 hospitals and 120 clinics). It is used for up to 2 million
transactions daily by 30,000 clinical staff. The comprehensive records
of 7 million patients are available on-line in the electronic patient record
(ePR), with data integrated from all sites. Since 2004 radiology image
viewing has been added to the ePR, with radiography images from any HA
site being available as part of the ePR.
The Hong Kong Hospital Authority placed particular attention to the governance
of clinical systems development, with input from hundreds of clinicians
being incorporated through a structured process. The health informatics
section in the Hospital Authority
has a close relationship with the information technology department and
clinicians to develop health care systems for the organization to
support the service to all public hospitals and clinics in the region.
The Hong Kong Society of Medical Informatics
(HKSMI) was established in 1987 to promote the use of information
technology in health care. The eHealth Consortium has been formed to
bring together clinicians from both the private and public sectors,
medical informatics professionals and the IT industry to further promote
IT in health care in Hong Kong.
India
- eHCF School of Medical Informatics
- eHealth-Care Foundation
Malaysia
Since 2010, the Ministry of Health (MoH) has been working on the Malaysian Health Data Warehouse
(MyHDW) project. MyHDW aims to meet the diverse needs of timely health
information provision and management, and acts as a platform for the
standardization and integration of health data from a variety of sources
(Health Informatics Centre, 2013). The Ministry has embarked on
introducing the electronic Hospital Information Systems (HIS) in several
public hospitals including Serdang Hospital, Selayang Hospital and
University Kebangsaan Malaysia Medical Centre (UKMMC) under the Ministry
of Higher Education (MOHE).
A hospital information system
(HIS) is a comprehensive, integrated information system designed to
manage the administrative, financial and clinical aspects of a hospital.
As an area of medical informatics, the aim of hospital information
system is to achieve the best possible support of patient care and
administration by electronic data processing. HIS plays a vital role in
planning, initiating, organizing and controlling the operations of the
subsystems of the hospital and thus provides a synergistic organization
in the process.
New Zealand
Health
informatics is taught at five New Zealand universities. The most mature
and established programme has been offered for over a decade at Otago.
Health Informatics New Zealand (HINZ), is the national organisation
that advocates for health informatics. HINZ organises a conference every
year and also publishes a journal- Healthcare Informatics Review Online.
Saudi Arabia
The Saudi Association for Health Information (SAHI) was established in 2006 to work under direct supervision of King Saud bin Abdulaziz University for Health Sciences to practice public activities, develop theoretical and applicable knowledge, and provide scientific and applicable studies.
Post-Soviet countries
The Russian Federation
The
Russian health care system is based on the principles of the Soviet
health care system, which was oriented on mass prophylaxis, prevention
of infection and epidemic diseases, vaccination and immunization of the
population on a socially protected basis. The current government health
care system consists of several directions:
- Preventive health care
- Primary health care
- Specialized medical care
- Obstetrical and gynecologic medical care
- Pediatric medical care
- Surgery
- Rehabilitation/ Health resort treatment
One of the main issues of the post-Soviet medical health care system
was the absence of the united system providing optimization of work for
medical institutes with one, single database and structured appointment
schedule and hence hours-long lines. Efficiency of medical workers might
have been also doubtful because of the paperwork administrating or lost
book records.
Along with the development of the information systems IT and health care departments in Moscow
agreed on design of a system that would improve public services of
health care institutes. Tackling the issues appearing in the existing
system, the Moscow Government ordered that the design of a system would
provide simplified electronic booking to public clinics and automate the
work of medical workers on the first level.
The system designed for that purposes was called EMIAS (United Medical Information and Analysis System) and presents an electronic health record
(EHR) with the majority of other services set in the system that
manages the flow of patients, contains outpatient card integrated in the
system, and provides an opportunity to manage consolidated managerial
accounting and personalized list of medical help. Besides that, the
system contains information about availability of the medical
institutions and various doctors.
The implementation of the system started in 2013 with the
organization of one computerized database for all patients in the city,
including a front-end for the users. EMIAS was implemented in Moscow and the region and it is planned that the project should extend to most parts of the country.
Law
Health informatics law deals with evolving and sometimes
complex legal principles as they apply to information technology in
health-related fields. It addresses the privacy, ethical and operational
issues that invariably arise when electronic tools, information and
media are used in health care delivery. Health Informatics Law also
applies to all matters that involve information technology, health care
and the interaction of information. It deals with the circumstances
under which data and records are shared with other fields or areas that
support and enhance patient care.
As many health care systems are making an effort to have patient
records more readily available to them via the internet, it is important
that providers implement security standards in order to ensure that the
patients' information is safe. They have to be able to assure
confidentiality, integrity, and security of the people, process, and
technology. Since there is also the possibility of payments being made
through this system, it is vital that this aspect of their private
information will also be protected through cryptography.
The use of technology in health care settings has become popular
and this trend is expected to continue. Various health care facilities
had instigated different kinds of health information technology systems
in the provision of patient care, such as electronic health records
(EHRs), computerized charting, etc.
The growing popularity of health information technology systems and the
escalation in the amount of health information that can be exchanged
and transferred electronically increased the risk of potential
infringement in patients' privacy and confidentiality.
This concern triggered the establishment of strict measures by both
policymakers and individual facility to ensure patient privacy and
confidentiality.
One of the federal laws enacted to safeguard patient's health
information (medical record, billing information, treatment plan, etc.)
and to guarantee patient's privacy is the Health Insurance Portability
and Accountability Act of 1996 or HIPAA. HIPAA gives patients the autonomy and control over their own health records. Furthermore, according to the U.S. Department of Health & Human Services (n.d.), this law enables patients to:
- view their own health records
- request a copy of their own medical records
- request correction to any incorrect health information
- know who has access to their health record
- request who can and cannot view/access their health information
Health and medical informatics journals
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Impact factors of scholarly journals publishing digital health (ehealth, mhealth) work
Computers and Biomedical Research, published in 1967, was one of the first dedicated journals to health informatics. Other early journals included Computers and Medicine, published by the American Medical Association; Journal of Clinical Computing, published by Gallagher Printing; Journal of Medical Systems, published by Plenum Press; and MD Computing, published by Springer-Verlag. In 1984, Lippincott published the first nursing-specific journal, titled Journal Computers in Nursing, which is now known as Computers Informatics Nursing (CIN).
As of September 7, 2016, there are roughly 235 informatics
journals listed in the National Library of Medicine (NLM) catalog of
journals. The Journal Citation Reports for 2018 gives the top three journals in medical informatics as the Journal of Medical Internet Research (impact factor of 4.945), JMIR mHealth and uHealth (4.301) and the Journal of the American Medical Informatics Association (4.292).
