2007 Clinical Informatics – Study Guide Student Written Final Exam Questions Question 1: You are a new medical informatician in a HCO in Salt Lake City, Utah. While assisting a meeting, everyone is discussing the advantages of Personal Health Records (PHR). However, nobody is concerned with the definition of a PHR and you decide to speak out you mind. Which of the following approaches for a PHR is relevant? a- PHR is a patient-owned program that can use to enter and organize their health information. b- PHR is a portable digital file that can be transferred between computers. c- PHR is a provider-owned digital summary that patients can access but cannot change. d- a and b. e- a, b and c. Topic: Consumer Health Informatics Answer: e Question 2: You have heard how difficult is for informaticians to implement new systems in health care environments and you start remembering a seminar about critical concepts in human-computer interactions. You remember that some concepts like associations, habits and experience are related to the topic. Explain in no more than 5 lines. Topic: Cognitive Science in Informatics Answer: When thinking we associate things. Patterns of associations are constantly changing with experience. Some linkages are so strong (habit, expertise) that activation across associative structure occurs instantly. As soon as something new (e.g. new software) is implemented, the activation is slow and the workflow in the health care environment is compromise. Question 3: The decision to acquire or replace a computer system is most commonly motivated by a desire to improve the quality of care, to lower the cost of care, to improve access to care, or to collect the information needed to document and evaluate the health care delivery process itself. True or False (if it is false, explain in two lines). Topic: Health Information Systems Answer: True Question 4: Medical Informatics focuses on the individual and many are very well implemented (by now you have seen some real world HIS such as, IHC, UH and VA Systems). Public Health Informatics focuses on the health of the community. However, there is no uniform national routine reporting for most diseases, disabilities, risk factors, or prevention activities in the United States. Mention at least one difference between a HIS and a Public Health Information System (Hint: think of some special features Public Health Information Systems need to have in order to be successful). Topic: Public Health Informatics Answer: Some special features Public Health Information Systems (PHIS) need to have in their designs are the following. They are optimized for retrieval from very large (multi-million) record databases, to quickly cross-tabulate, to study secular trends and to look for patterns. Another difference is the use of personal identifiers. In PHIS is very limited and their use is generally restricted to linking data from different sources (e.g. data from a state laboratory and a disease surveillance form). Finally, sometimes duplicate data entry is required in PHIS. For example, a child with lead poisoning and salmonella needs to be entered in two different databases. Question 5: Matched the following concepts in ―column A‖ with their definitions in ―column B‖. Column A Column B 1- Knowledge A- Discrete information about an entity (often a patient, but not limited to a patient). 2- Database B- Interpreted data, an integration of data, experience, and analysis. 3- EHR C- Organized data and knowledge (inherently a loose definition). 4- Coding system D- A computerized compendium of health data, usually patient-centric in organization. 5- Knowledge base E- A rule-of-thumb or default approach based on experience and information. 6- Information F- A systematic collection of terms and their interpretation that standardizes use (e.g. ICD-9, SNOMED, CPT, UMLS, etc). 7- Data G- A collection of data, typically in a computerized form like SQL or Access. 8- Heuristic H- A collection of facts, heuristics, and models that can be used for problem solving and analysis of data. Ideally it is structured, to allow machine manipulation. Topic: Biomedical Data Answer: 1B, 2G, 3D, 4F, 5H, 6C, 7A, 8E. Questions for Final Question (week 4): You have been asked to build a drug ordering system that will integrate with an already existing health information system at a hospital. List three standards you will need to use and why? Answer: NCDCP standard which is an ordering drug standard. This standard will allow for the billing of pharmacy claims and services, as well as standardize the transactions between the pharmacies and the providers. LOINC which is a standard for describing clinical observations, particularly lab data and the use of this standard will help when interacting with the already existing system. In particular the use of this standard will help facilitate adverse drug checking such as decreasing dosage based on renal function. HL-7 which is a messaging standard and will allow for the exchange if information from the current health information system at the hospital and the system that you are building. Question (week 5): In the Dawes article they found the reasons that made for a successful search were convenience of access, habit, reliability, high quality, speed of use, and applicability. Many experts agree that the key to knowledge management is a well-structured ontologies. Choose one of these reasons and discuss how a well-structure ontology could address that issue? Answer: Applicability: the structured ontology would allow you to return information on a give topic as well as return information on related topics and include the relationship between the main topic and the other related information. Also a well structured ontology might allow for the better tailoring or narrowing of information to the specific knowledge sought. Speed of Use: An ontology provides a structure of the terms and would provide a natural index for the data, thus speeding up the process of obtaining data. Question (week 7): What are the 2 major advantages with computer surveillance over manual surveillance techniques? Answer: A A) Higher sensitivity and less time intensive B) More comprehensive information and higher specificity C) Decreased cost and higher accuracy D) Decreased time to results and decreased missing data Question (week 8): Does the government have a rule to play in the development of a National Health Information Infrastructure? Why or why not? Answer: Yes the government can play a rule. It can establish standards. Provide funding for the infrastructure and make sure this is distributed these moneys. The government can protect rights of privacy and intellectual property and at the same time cut through legislative or jurisdictional areas. Ultimately, this can be done faster with governmental help than with waiting for the free market to settle this. Question (week 9): What is the most important measurement or outcome for determining that your quality improvement efforts have made a difference? What is the University‘s most common quality improvement outcome measurement? Answer: Ultimately you want to show an improvement in patient care and outcomes. Mortality is their most common outcome to examine. Question (week 10): One of the major challenges that face PHI is that of ensuring privacy, confidentiality and security of patient data. As most public health programs do not involve direct contact with patients. Discuss a function of public health where this is a challenge and why it is a challenge for them? Answer: Even though they might not have direct contact with patients they are tasked with keeping track of many communicable diseases. To do this, physicians are required to report patient information to the Dept of Health. Since there are stigmas surrounding some of these diseases it is important that the health dept. maintains a high level of confidentiality associated with this. Furthermore, if a physician felt like the dept of health was lacking in areas related to privacy, confidentiality and security, they might be less likely to report information to them. Question (week 10): According to Nancy Nelson, what are three reasons the new (or second) nursing care plan system not work? Answer: 1)No longer teaching care plans in school 2) Used functional history approach, but this was not a common approach for nursing 3) Product not useful to those that would be using it 4) No management buy in to the project 5) Language was difficult 6) It was ―off‖ putting to people 7) Developed off site Question (week 12): You are creating a triage or intake system for an emergency department. Why is it important to be aware of the schematic processing or ―script‖ associated with the intake process? Answer: The intake process is done several times a day and is a routine process for the nurses, as such they have built strong schematic processes associated with this. It is important that you build your program that takes into account the flow of their intake process and address each step of the process. Since it takes much cognitive effort to bypass schematic process, the providers will be more likely to use a system and like the system if it doesn‘t require them to learn a whole new schematic process. 1. Scenario: You are asked to lead the development of a clinical decision support system to be used in a busy hospital. The system would be of use to clinical and support medical staff in dealing with patients that are on a medication for a common condition. The purpose of the system is to streamline the administration and monitoring of the medication specifically in terms of adverse events that could harm the patient. a. Question: Who would you invite to be a part of the development team? What are two fatal flaws that could doom the successful development and deployment of the system? b. Topic: Real-world development and implementation of information systems (Nancy Nelson Lecture) c. Answer: i. The ideal team would consist of medical informaticists, computer programmers, representation from all staff that would use the system including physicians, nurses, pharmacist, and laboratory personnel. It would also be wise to seek support/guidance and participation from senior management. ii. The fatal flaws that would doom the system: Not including the ultimate user in the design of the system and Not seeking the support of the hospital management. 2. Briefly describe the conceptual differences between SNOMED and HL-7 a. Topic: Standards b. Answer: HL-7 is a messaging standard that disparate computer systems can use to communicate and share information with each other; such that all users can see, interpret and use the data in a uniform fashion. It is an on-going project developed by a voluntary group of experts and has gained worldwide acceptance in biomedical informatics. On the other hand, SNOMED is a controlled clinical vocabulary or terminology that is used to index and process patient data such that the data can be used efficiently for retrieval, aggregation, research and decision-support. SNOMED uses pre- defined hierarchical semantic relationships (ontologies) to index biomedical data. SNOMED is a commercial product. 3. Matching Fun Facts and Definitions from standards, vocabularies and knowledge management (these can be jumbled up in any order) a. Clinical Condensed clinical knowledge meant Practice Guidelines to guide care delivery in a standardized way b. Knowledge An integration of data, experience and analysis c. Ontology Explicit formal specification of how to represent the objects, concepts and other entities that are assumed to exist in some area of interest and the relationships among them d. Coding A terminology, thesaurus, vocabulary, System nomenclature, or classification that uses codes for designating concepts e. Heuristic A rule-of-thumb or default approach based on experience and information f. Data Discrete information about an entity g. Electronic A computerized compendium of health Health Record data, usually patient-centric in organization h. Clinical an interactive computer program that Decision Support integrates and processes available Systems patient data using rules and assists medical professionals with recommendations that are specific to the patient i. Sensitivity A measure of how often measured positive data match the real positive outcome sought j. Specificity A measure of how well a negative result indicates a specific outcome is not operating 4. True/False in the realm of public health informatics (PHI) a. The focus of public health is on the individual (F) b. Public health mainly deals with disease prevention (T) c. PHI is not concerned with the privacy and confidentiality of patient data (F) d. PHI is the systemic application of information and computer science technology to public health practice (T) e. Syndromic surveillance systems are an example of the application of PHI (T) f. PHI is concerned with unidirectional information flow from the government to the individual practitioner (F) g. The major funding for developing and implementing PHI systems is from the private sector (F) h. PHI does not need to adhere to standards as it is a newly developing field (F) i. Only public health personnel can develop and test systems in PHI (F) j. PHI can address issues at the local, state, regional, national and international level (T). 5. Topic: Evaluation of HIS systems a. Question: Two vendors (GreatSystems.com and UltimateImplementation.com) have sold and implemented the very same hospital information system to 5 institutions each. After two years of using the system, 4 clients of GreatSystems.com are not renewing their contract while all 5clients of UltimateInfo.com are signing up for another 2 years and are buying the upgrade too! You are the information systems Guru for the Salt Lake City area (and then by definition for the rest of the world!) and the CEO of GreatSystems asks you to research this problem and offer recommendations for improvement and business win-back. Briefly describe how you would proceed. b. Answer: The first step would be to design two detailed surveys that would be administered to 1) The CIO and technology staff of all client institutions of GreatSystems and 2) the Users at the institutions. The surveys would assess the satisfaction, quality, timeliness, expertise and responsiveness of GreatSystems personnel and the product that was implemented. Another important step would be to talk to the staff of GreatSystems to gauge their reactions to the product and implementation. The point to be brought out is that service, responsiveness and customization are the keys to the successful implementation of a product. Chapters 4, 6, 7, 12, 13, 15, 16, 1. You are developing two new diagnostic tests. The disease statuses were defined using a gold standard. In a sample population you find the following: Test A Disease No Disease Positive Finding 100 90 Negative Finding 5 990 Test B Disease No Disease Positive Finding 80 10 Negative Finding 25 1070 Find the sensitivities and specificities of the tests. Total samples A: _______________________ Total samples B: _______________________ Calculate the probabilities of each event and the marginal probabilities. Test A Disease No Disease Row Marginals Positive 100/_____ = 90/_____ = ______+____ Finding ______ ______ __ = ______ Negative 5/______ = 990/_____ = _____+ _____ Finding _______ _____ = ______ Column _____ + _____+ marginals ______ = ______ = _______ _______ Test B Disease No Disease Row Marginals Positive 80/______ = 10/______ = _____+ Finding ______ ________ _____= _____ Negative 25/______ = 1070/_____ = _____+ Finding ______ _____ _____= _____ Column _____ + _____+ marginals _____= _____ _____= _____ Divide by the column marginals: Test A Disease No Disease Positive _____/ _____= _____/_____= Finding _____ _____ Negative _____/_____= _____/_____= Finding _____ _____ Test A sensitivity = _____, specificity = _____ Test B Disease No Disease Positive _____/_____= _____/_____= Finding _____ _____ Negative _____/_____= _____/_____= Finding _____ _____ Test B sensitivity = _____, specificity = _____ Answer: First total the samples of each population: Total samples A: 100 + 90 + 5 + 990 = 1185 Total samples B: 80 + 10 + 25 + 1070 = 1185 Calculate the probabilities of each event and the marginal probabilities. Test A Disease No Disease Row Marginals Positive 100/1185 = 90/1185 = 0.0844 + Finding 0.0844 0.0759 0.0759 = 0.1603 Negative 5/1185 = 990/1185 = 0.0422 + Finding 0.00422 0.835 0.835 = 0.8772 Column 0.0844 + 0.0759 + marginals 0.00422 = 0.835 = 0.08862 0.9109 Test B Disease No Disease Row Marginals Positive 80/1185 = 10/1185 = 0.0675 + Finding 0.0675 0.00844 0.00844 = 0.0759 Negative 25/1185 = 1070/1185 = 0.0211 + 0.903 Finding 0.0211 0.903 = 0.9241 Column 0.0675 + 0.00844 + marginals 0.0211 = 0.903 = 0.0886 0.91144 Divide by the column marginals: Test A Disease No Disease Positive 0.0844 / 0.0759/0.9109 Finding 0.08862 = = 0.0833 0.952 Negative 0.00422/0.0886 0.835/0.9109 Finding 2 = 0.0476 = 0.917 Test A sensitivity = 0.952, specificity = 0.917 Test B Disease No Disease Positive 0.0675/0.0886 0.00844/0.911 Finding = 0.762 44 = 0.00926 Negative 0.0211/0.0886 0.903/0.91144 Finding = 0.238 = 0.991 Test B sensitivity = 0.762, specificity = 0.991 2. From the new tests in question above which is a better test to use and why, when: a. The treatment is very inexpensive, non-invasive and has few side effects. 1. Answer: Test A is better because it is more sensitive and you want to get everyone with the disease treated even if you end up treating the false positives that don’t actually have the disease. b. The treatment is expensive, invasive and has significant side effects. 2. Answer: Test B is better because it is more specific and you don’t want to treat any false positives and afflict them with the side effects. 3. What are reasons performance of a task may actually go down before going back up as a person moves from being a novice to intermediate to an expert. What could a clinic decision support system do with data to help the intermediate users? Answer: Text page 153. This is called the intermediate effect. Intermediate users know more about the problem than beginners so they include more information in making their decisions but don’t know what information to ignore increasing their cognitive load. The clinical decision support system can help them filter out extraneous data and focus on relevant information. 4. The Veterans Administration (VA) health system was developed in diverse locations with each group developing one part and brought together into one system. How does this differ from a ―Best of Breed‖ system made of components from independent developers and vendors? Answer: With a “Best of Breed” the health provider selects their favorite software component from competing vendors. In the VA system case there was probably only one of each software component developed so it was more a case of distributed development of a single system than a competitive “Best of Breed” system. 5. There are two Health Information systems. Each system stores has its own data storage. Your task is to make the two systems communicate with each other by retrieving lab test and diagnostic data and sending it between systems. Connect the following tasks with standards: a. Data and tasks i. Data retrieval ii. Lab test data iii. Data storage iv. Data transfer standard v. User interface vi. Machine to machine data transfer format vii. Diagnostic data b. Standards i. SNOMED ii. Structured Query Language (SQL) iii. HL-7 iv. HTML v. XML vi. LOINC vii. Relational Database Management System (RDBMS) Answer: Data Retrieval – Structured Query Language Lab test data - LOINC Data storage - Relational Database Management System (RDBMS) Data transfer standard - HL-7 User interface - HTML Machine to machine data transfer format - XML Diagnostic data - LOINC 1. The text defines biomedical informatics as ―the scientific field that deals with biomedical information, data, and knowledge – their storage, retrieval, and optimal use for problem solving and decision making.‖ For electronic health records, identify a barrier to storage and to retrieval and suggest how each might impact optimal use. Storage: Retrieval: ANSWER (certainly there could be other answers besides the one below) Storage: Data entry must be consistent in order to have meaning when it is retrieved. There is an inevitable trade-off between providing all the data entry options that might be necessary, and being parsimonious in the choices that are offered in order to simplify interpretation. This impacts physical storage requirements, programming time, and creation of a useable interface that the provider will use appropriately. Retrieval: HIPAA compliance requires protection of patient identifiers. Accomplishing this may require removal of identifiers in a database and/or limiting access to a smaller number of providers. Retrieving relevant data may be delayed as a result. This could limit the ability of a provider to make decisions about diagnosis, treatment, participation in studies, or surveillance in a timely fashion. 2. Match the terms to their definitions. _______ DICOM A. comprehensive coding system of clinical findings that _______ ISO includes diseases, signs, symptoms, organisms, _______ HL7 body parts, occupations, modifiers, etc _______ LOINC B. contains lab procedures and clinical measurements _______ ICD C. indexing system of medical vocabularies _______ SNOMED D. coding scheme for diagnostic and therapeutic _______ UMLS procedures; used primarily for billing _______ CPT E. messaging system to allow communication between healthcare information systems F. standard used for imaging transmissions G. network of over 150 countries whose mission is to achieve consensus on standards H. classification system for disease morbidity and mortality ANSWER F – DICOM G – ISO E – HL7 B – LOINC H – ICD A – SNOMED C – UMLS D – CPT 3. The 1999 Institute of Medicine report ―To Err is Human‖ was concerned with ways in which health care systems may contribute to errors in patient care. The report made a strong recommendation that the use of electronic health records could reduce error. Provide an example where an electronic health record provides an advantage over a paper record in terms of preventing errors. ANSWER (other answers are possible, 2 are listed below) Physician order entry for medication – allows the computer to compare current medications with a new prescription to look for potential drug interactions; also can verify dose information Real time posting of results, which is available in multiple locations – allows providers to have the latest information on a patient before ordering other diagnostic tests or implementing treatment 4. Failure mode effect analysis is a tool used in quality improvement to quantify the potential for failure and its possible harmful impact. True False ANSWER True 5. Memory has been described as having two components – a controlled (intentional) memory and an automatic memory. Describe the difference between these and the implication this has for utilizing an electronic health record. ANSWER Controlled memory requires a high level of cognition, either because the task is extremely complex or because it is new. Automatic memory is activated without awareness, because it has been learned often enough that it is reflexive. An electronic health record can present information in such a way as to minimize the cognitive requirement on controlled memory. This reduced cognitive load may benefit a provider by allowing him/her to focus on other areas of problem solving. However, there is always a risk that if the clinician only looks at what is presented and doesn‘t search through the record, that a piece of critical information may be overlooked which is helpful in making diagnostic and/or therapeutic decisions. In other words, EHR design is critical in providing the right level of support to enhance clinical decision making. Question: ―Which is not true of a Bayesian decision support system: A) They are multidimensional, meaning they are capable of calculating in many directions at the same time. B) When applying the system to a different patient populations the prior probabilities don't need to be adjusted. C) A subset of data is not sufficient to calculate a probability.‖ 1) A 2) B 3) C 4) A and B 5) B and C Topic: Bayesian Decision Support Systems Answer: ―5 (B and C)– The prior probabilities need to be adjusted for different populations because those probability values represent that particular population for what is being calculated. The example given by Peter Haug was a pneumonia Bayesian system that has different prior probabilities in an adult clinic from a new born clinic. The prior probabilities are key factors in providing decision support because their values are the basis for the probability for what is being decided upon. Also a subset of data is sufficient to calculate a probabilty with Baye's. That is a key aspect of Baye's that is so useful in medical decision making because data is continually brought in.‖ Question: ―Over time health care has evolved from a single care providers to teams of health professionals. This has resulted in the a variety of physicians providing care over time for patients. This type of change drives the direction of informatics in a sense. What is one specific way that this change has influenced informatics / informatics applications?‖ Topic: electronic medical record / biomedical data Answer: ―The change has created a need for an improvement in the medical record. It has shown the inadequacy of a paper medical record to perform a number of functions. Inparticularly for this question, the change to team-oriented care over a long period of time (lots of patient data) has highlighted the need to effectively communicate medical data between the health care professionals in various settings. The traditional paper record cannot provide the quality and continuity of care that is needed for the current situation in health care. This has influenced informatics to solve this type of problem with the use of computer technology.‖ Question: ―In the past there were efforts to create Community Health Information Network (CHIN) models in Indiana at Regenstrief and in Santa Barbara. These models attempted to setup a network and system to share patient data between hospitals in the community. How did these models differ? Topic: public health / community health information networks Answer: ―The Regenstrief model utilized a central repository that hospitals all owned by Regenstrief accessed. This model succeeded mostly because all the hospitals had the same owner so sharing the data was not a major issue. The Santa Barbara model was different because the hospitals owners were different, which caused patient data proprietary issues. The Santa Barbara model also used a peer-to-peer network system to be able to share the data between the hospitals.‖ Question: ―A couple of newly graduated students from the program are looking to start a business in the realm of health information technology. More specifically, they are planning on building and marketing an EMR system. When they go to ask Scott Holbrook for advice in succeeding in the HIT business he tells them the key to a good business is good ________ with a modest product.‖ Topic: HIT evaluation Answer: ―Service‖ Question: ―______ _______ are useful for health information systems because the applications are processed server rather than locally. This solution has many advantages, such as lower hardware costs, easier security, and less network bandwidth use.‖ Topic: Health information systems Answer: ―Thin clients‖ Topic 1: Public Health and standards Question1: Is patient privacy an important concern of data management in Public Health Informatics? Explain why or why not? Answer: Individual patient privacy is not an important concern of data management in PHI because Public Health Informatics mainly deals with health information of populations and not of individuals. Public Health Informatics does not have access to individual data. Topic 2: Decision Making Question 2: A new blood test was able to detect the flu with the following accuracy in 100 individuals: The test had a positive result for 40 individuals who had the flu The test had a negative result for 5 individuals who had the flu The test had a positive result for 2 individuals who did not have the flu The test had a negative result for 53 individuals who did not have the flu Calculate specificity and sensitivity of the test. Answer: Sn = TP / (TP + FN) = 40/(40+5)= 0.89 Sp = TN / (TN + FP) = 53/(53+2) = 0.96 Topic 3: Standards Question 3: List three reasons why Health Information standards are important Answer: Interoperability – the ability to exchange information between organizations and to use the information that has been exchanged Comparability – the ability to ascertain the equivalence of data from different sources Data Quality – the measurement of completeness, accuracy and precision Question 4: You are given a task to create an electronic medical record system for a small clinic. The clinic uses outside lab and imaging services and receives results digitally. What standards and codes do you need to be aware of and why? Answer: HIPAA – Health Insurance Portability and Accountability act of 1996 – because it applies to all inter-institutional electronic transactions X12 – because it regulates insurance transactions and claims CPT – Current Procedural Terminology – because it is mandated for ambulatory billing LOINC – Logical Observation Identifier Names and Codes – because lab information has to be transmitted back to the clinic DICOM - Digital Imaging and Communications in Medicine – because imaging information has to be transmitted back to the clinic Topic 4: Telemedicine Question 5: How does telemedicine improve health care in rural areas? Answer: Telemedicine improves access to specialized health care providers (Hersh et al, 2006). Hersh, W.R., Hickam, D.H., Severance, S.M, Dana, T.L., Krages, K.P. and M. Helfand (2006) Diagnosis, access and outcomes: update of a systematic review of telemedicine services. Journal of Telemedicine and Telecare. S2, pp. 3-31. Question 1 What group of employees should be involved in the deployment and implementation of an HIS and why. Topic Development/Implementation of HIS Answer: End User (Doctors, Nurses, Techs, HIM etc.) – They can tell you what they need. IT department (Programmers, Analyst etc.) they can tell you what can be done. Administration – they can tell you what you can afford, they can get all groups to work together. Question 2 What impact has the Institute of Medicine (IOM) 1999 Report – ―To Err Is Human: Building a Safer Health System‖ had on health care? Topic Answer: This report had a huge impact on healthcare in general. This report Highlighted how many preventable medical errors occur in the US every year. Because of this report many healthcare organizations are looking at how HIS can reduce these medical errors. Question 3 What are the three goals of Health Information Standards? Topic: Standards Answer Interoperability – the ability to exchange information between organizations and to use the information that has been exchanged Comparability – the ability to ascertain the equivalence of data from different sources Data Quality – the measurement of completeness, accuracy and precision Question 4 List some positives and negatives of: 1. Developing a HIS in-house 2. Purchase a HIS from a vendor or vendors Topic In-house development vs. vended solution Answer Positives In-house - The system will match your process - Highly customizable - Can make changes on the fly Vended - The system is already created - Expert support on system - Do not need a development staff Negative In-house - Maintenance costs - Need to have the system development expertise - Limited Development skill set Vended - Over all Costs - You have to rely on others to fix problems - Can only change so much Question 5 According to KLAS, what percentages of US hospitals are doing some CPOE on commercial software in 2006? A. 5.7 B. 6.2 C. 4.5 D. 5.5 Topic CPOE Answer 3. 5.7 percent of U.S. hospitals are doing some CPOE on commercial software products as validated by KLAS. This is up from that reported in the 2005 study (4.0%). 1. Company A has 6 sub-companies, which are independent with each other. There have been EMRs(electronic medical records) transferred between all 6 companies. One of the problems is that different company may have different name for the doctor‘s specialties in the EMR, in order to make the specialties transparent, company A have build a specialty mapping table which will map all 6 sub-companies specialties into each other. The table will be like this: company specialty 1 Allergy 2 Allergy/immunology 3 Allergy (immune) 4 Allergy 5 Immunology/allergy 6 Allergy Is this the most effective way? Can you think of a better way? Answer: It will work but it is not the best way. An better alternative is to make a standard specialties coding table and let each company use the standard code internally. Each company can still keep their own specialty key word, but when are talking to each other they should use the standard code instead of their specific specialty names. 3. Hospital B has a self-built HIS (health information system). They want to add a new employee information system and to buy it from a vendor in UK called ―POND‖. Because it is a foreign vendor and few people in USA know about it. The Hospital spend money to train people on the new POND system, also after sometime, the IT department of the hospital found that there are technical difficulties to integrate the POND system into the existing whole HIS. The vender in UK will normally need to send top technical support people oversea to USA in such case. What will you decide if you are in the management of this hospital? Answer: the POND project should be stopped. Reason is below: The POND is not the best-of-breed solution; there maybe better ones at cheaper price in domestic market. The POND system is proven to be hard to integrated with the existing HIS, the cost for POND top technical support from UK will also be expensive The maintenance for POND is not cheap, and service cannot be guarantee real-time cause of the oversea resources. 4. Match the standards and the method using to make the standards Ad-hoc Sun Solaris De-facto HL7 Consensus DICOM Government-mandate CMS Privacy Act of 1974 Answer: Ad-hoc DICOM De-facto Sun Solaris Consensus HL7 Government-mandate CMS Privacy Act of 1974 5. Which of the following is NOT a data driver: A JDBC driver B ODBC driver C IBM AS400 driver D LINUX USB DISK driver Answer: (D) 6. In the UMLS Semantic Network, explain the ―inheritance‖ and ―blockage‖ of the semantic relations with real examples. Answer: ―inheritance‖ means the relations stated between high-level semantic types in the Semantic Network are generally inheritable by all the children of those types. For example, the relation "process of" is stated to hold between the semantic types "Biologic Function" and "Organism". Therefore, it also holds between "Organ and Tissue Function" (which is a "Physiologic Function", which is, in turn, a "Biologic Function") and "Animal" (which is an "Organism"). In some cases there will be a conflict between the placement of types in the Semantic Network and the link to be inherited. In this case the inheritance of the link is blocked. For example, "conceptual part of" links "Body System" and "Fully Formed Anatomical Structure", but it should not link "Body System" to all the children of "Fully Formed Anatomical Structure", such as "Cell" or "Tissue". Q1. Topic: Clinical reasoning using probability You are building a diagnostic system and you have to decide between having a high false positive rate (FPR) and a high false negative rate (FNR). Which would you choose? A. Having a higher false positive rate will increase the probability of healthy patients being diagnosed as being sick whereas having a higher false negative rate will increase the probability of sick patients left untreated. There is no right answer. I think it depends on various factors- for instance, if the emotional turmoil of a misdiagnosis is higher than the effect of the disease itself or if the disease can‘t be cured, having a lower FPR is better. If the patient‘s life is in danger and there is an existing cure for the disease, I would prefer a higher FPR. Q2. Topic: Standards If all the standards were a result of the De facto method, what effect would this have on the systems that will be in use? A. Since there will be no consensus between manufacturers, each vendor will have a monopoly over his system. The user will be forced to use a single vendor and will not be able to follow the best of breed approach due to integration problems. Q3. Topic: Why is it better to use Bayesian Networks and not a Multi-membership Bayesian model while building a system for decision support? A. A Multi-membership Bayesian model assumes that the various factors involved are independent. This does not reflect the real medical setting where multiple diseases could be responsible for a certain symptom. Bayesian Networks is more useful in modeling a diagnostic system because it taken into account that there could be dependence between the various factors. Q4. Topic: Standards If your research requires you to obtain a list of patients in a hospital in Utah who had a kidney transplant due to the effects of diabetes, how would you get this information? A. I would look at the billing data because CPT codes contain information about the treatment or procedures performed and the reason for doing so. Also, since CPT codes are used in all Utah hospitals I am sure that this specific hospital will be using CPT codes. Q5. Topic: Consumer health informatics Can you think of a drawback for a tool like Health Buddy? A. The privacy of the patient may be compromised since it could be used by somebody other than the patient. Question 1: To improve the quality of skin cancer treatment, a dermatologist wants to offer his patients a special interactive Personal Health Record. Actually, patients have to come to his office every six months to scan all critical moles on their body. He wants to offer them access to their images, to the diagnostic findings and provide the opportunity to schedule appointments. Furthermore they should be able to submit digital photographs from moles, which changed their size or form. The system should provide the opportunity to comment on the submission. He then reviews the images in his office and may contact the patient. With this last self-assessment of moles, he wants to extend the time between two appointments up to 9 months. He decides to use a distributed solution in which he provides a server that stores and distributes the images and the patients install a small program on their home computers for viewing and submitting images, scheduling appointments and contacting their physician. You are asked to implement this solution – which standards and technologies do you use to implement the project? Name and describe the application of at least three of them! Topic: Standards and Terminologies Solution: Standards: - SNOMED: Description of findings by physician, which are then visible to the patient - HL7: Sending of finding from his IS to the client on the patient‘s computer. Also the patients‘ comment can be sent as HL7 message back to his IS. - DICOM: Transfer of the images back and forth between physician and patient Technology: - E-Mail to contact physician and to schedule appointments - TCP/IP, Internet for data transfer Question 2: Health professionals want to access Electronic Health Records at different location at different times for different tasks. Name three situations where physicians would need access, possible risks accessing the data at this point, technology needed to access/present data and special display / special view on the data. Topic: Electronic Health Record Systems Possible Answer: Situation Risks / Threats Technology Special view At home, finishing Insecure network, Internet, VPN, Full view, showing findings and insecure computer Web-Server to maximum of data reports of the day or internet provide the available; like on connection application, Local normal working software to access computer in the data, hospital alternatively software that turns computer into thin client to access the system On round in Open file, thus W-LAN, PDA Reduced view hospital, only with everybody that with the most PDA passes by can important facts, no have a look on the full view on the data first screen, but access possible In teaching Data that was not LAN, Anonymized data environment, properly Anonymization or default data, normal PC anonymized but else the normal system Computer in No logout LAN, Internet Full view with all Hospital performed before possible additional leaving room, so information everybody can access all data, Viruses on the Internet Question 3: Compare data requirements of data stored in a patient file compared to the requirements of data stored in a public health record database. Show the difference on three examples. Topic: Public Health Possible Answer: Clinical Public health record All diseases tracked Just data about certain, important diseases Detailed data about the case and about No details about the cases, just raw all the different possible diseases numbers of cases in a certain region Geographic information only interesting Geographic mapping of diseases in the for anamnesis, e.g. Trip to tropical region under control. E.g. accumulation forest Malaria? of cases of chicken pox in the south of Salt Lake City. Question 4: You are attending an IHE (―Integrating the Healthcare Enterprise‖) meeting where different vendors are presenting how their products work together. You want to buy a new RIS, and you already have a working HIS and PACS in your radiology department that you don‘t want to change. Which three tasks would you ask potential vendors to perform with your given configuration of PACS, HIS and modalities to convince you to buy their product? Topic: Imaging Systems in Radiology Possible Answer: Store a finding in the RIS and show how you access this information in the HIS. If this is not possible, do I get the information how to access it? Where do you store redundant data (e.g. Patient information) in HIS and RIS? How do you deal with the redundancy, if data is changed in one or the other place? We want to offer access to the image data both via high end PACS- workstations for radiology specialists and for other non-radiologists via a simple web access without access to the RIS. Both specialists and non- radiologists should be able to view and edit the findings both in the HIS and the RIS. How do you integrate them? Question 5: You and your colleague meet a physician with a small office, who is convinced that his old paper-based health record is the best solution for him. He thinks that computer-based solutions are only very expensive and neither improve the treatment of his patients nor his income. You are convinced that he should move to a computer-based solution, while your colleague is convinced that the paper- based record is the best solution for his office. List and explain three points for both sides. Topic: Electronic Health Record Systems Possible Answer: HER Paper based record Structured data retrieval and access Cost Ubiquity of access Physician doesn‘t have to learn new stuff New methods of data entry (text blocks, Fail-safe digital dication) Question 1:―Why might you choose a best of breed system to run a specialty clinic in your hospital over a component of an integrated system in which you have already invested?‖ Topic: Health Information Systems Answer 1: ―The best of breed option often has more functionality and areas within an organization that are very dynamic or competitive may need regular enhancements, which best of breed vendors are more likely to provide. Specialized systems may also be more technologically advanced because it takes longer for companies to re-write a whole suite of applications. If specialty clinics within an organization are large or complex, they may require advanced functionality that is only available in a best of breed system.‖ Question 2: ―Diagram a simple ontology that would outline the structure of a book down to a character on a page.‖ Topic: Standards and Terminologies Answer 2: ―Book Chapter Page Paragraph Sentence Character‖ Question 3: ―You are designing a Bayesian network to determine whether children who come into the emergency room with cough have bronchiolitis. What are the four things you need to know to set up your network?‖ Topic: Decision Support Answer 3: 1. The probability of cough. 2. The probability of cough with bronchiolitis. 3. The probability of bronchiolitis with cough. 4. The probability of bronchiolitis. Question 4: Which of the following standards is created and owned by private enterprise? a. ICD b. LOINC c. SNOWMED d. UMLS e. DRG Topic: Standards and Terminologies Answer 4: = c Question 5: In lessons learned from KLAS, one of the most important factors in how healthcare management systems are rated is what? Topic: Financial and Quality Issues in Informatics Answer 5: How well they are supported by the people who sell them. Decision support Q1. A ___________ system is a program that symbolically encodes concepts derived from experts in a field—in a____________—and that uses that ____________ to provide the kind of problem analysis and advice that the expert might provide. A1. Knowledge base EMR implementation Q2 Why is technical support and customization of a product so important when considering an EMR purchase and implementation? A2 Purchasing and EMR is a huge undertaking that requires many indivuduals to compromise. Medical staff have a culture developed, as well as daily routines, and when they are forced to change it is a difucult task. It requires flexibility from all including the vendors. It is important that the vendor have a good training program to ease this transition and help change the culture of the staff. Presentations Q3 List three suggestions for a successful power point presentation A3 Use large font Use appropriate colors Avoid transition effects … Medical Data Terminology Q4 Matching _Data sources _Data Growth _Database 1. A collection of data, typically in a computerized format such as access or sql 2. Patient; family;other provider;healthcare system itself; external. 3. Steady progress towards ever increasing volume and variety of data. A4 1Data sources 3Data Growth 2Database Vocabularies Q5 List 3 ontologies discussed in class A5 OBO, LOINC,MESH 1. You and a friend have decided to start your own software company specializing in medical electronic health record software to be used by rural hospitals. A local hospital has asked you to draw up a proposal for their hospital and submit it with your price. As part of creating the proposal you have been given free access to whomever you need to speak with within the hospital. a. List two separate people or groups of people you would speak with and explain why they would be important in designing your software package. b. According to KLAS what part of your business package should receive the greatest emphasis? Why? a. The User (physicians and nurses) – It is essential to speak with them because they will be able to tell you what features will make their life easier and what things are completely unnecessary. They can also best describe work-flow and help you design the program to fit in with that flow the best to assure that the program is actually used. IT Department – Since they will be doing the maintenance and they will be helping with the implementation you have to prepare the software to also address their needs. Also, they will be able to tell you what systems are currently being used and how to best integrate the new system. b. From the KLAS lecture it was obvious that the number one focus should be customer service. Even though different companies were running almost the exact same system the companies that focused on customer service had much higher ratings across the board even if it involved something that had nothing to do with customer service. 2. You are assigned to write a decision support program for your Java class that will receive multiple symptoms from the user and give the probability of a diagnosis and a treatment. You are instructed that the symptoms are independent of one another. In preparation you ask yourself the question ―What would the reverend Thomas Bayes do?‖ List the three types of Bayesian equations used for determining probabilities and identify which one you would use for this program. Explain why you chose that method and not the other two. a. Simple Bayes: Primarily for one disease and one symptom. b. Complex Bayes: Multiple diseases and multiple symptoms that are independent. c. Bayes Network: Multiple diseases and multiple symptoms that can be dependent. Since there are multiple symptoms and they are independent the most appropriate methods would be of complex Bayes form. 3. Match the following standards with their primary medical setting(choices may be used more than once or not at all): 1. ICD a. Clinical Findings 2. DRG b. Lab Findings 3. CPT c. Billing 4. SNOMED d. Messaging 5. LOINC e. Decision Support 6. HL7 7. DICOM 1-c, 2-c, 3-c, 4-a, 5-b, 6-d, 7-d 4. As part of your new job your supervisor asks you to go and speak with the physicians in the Emergency Department to answer any questions they may have about the decision support software package your company is preparing. Upon arriving you are confronted with an irate doctor who immediately demands ―Why do we need a stupid computer do help do our job? Doctors are better are using information to come to a diagnosis than computers are anyway!‖ Politely give this doctor three reasons why managing knowledge in this way is necessary. What would Arocha and Patel say about physicians ability to take information and make a diagnosis? 1.a. Sheer amount of medical knowledge b. steep growth of knowledge c. Time constraints of medical care delivery d. Specialization e. Ability of computers to use knowledge instead of just data 2. Their study showed that physicians often make decisions and look for information to back up their decision. This isn’t the best way to make an accurate diagnosis because many things can be overlooked. 5. After you and your friend have gathered all the information from question one, what six points should you be aware of to assure the success of you system? 1. Quality & Style of Interface 2. Convenience 3. Speed & Response 4. Reliability 5. Security 6. Integration Question: Within the Vista system used at the VA, physicians largely create patient notes via free-text input, and the data are stored in the back end as text blobs. How might this fact hamper research efforts with that data? Topics: Health Information Systems, Standards Answer: Having text in blobs can be nice for clinicians because it provides great flexibility; however, even though you might have a wealth of information stored in the Vista system, using free text presents challenges because computers are not yet great at deciphering the meaning of natural, ambiguous language and because humans mispell words or use poor grammar. Computers are designed to process unambiguous data representations. Significant research has been done in the area of "natural language processing," which aims to overcome this barrier using standard vocabularies and rules; however, these approaches yield less-than-perfect results. Another potential disadvantage of free-text is that clinicians may also have difficulty extracting meaning from previous notes due to limited search capabilities for the same reasons described above. ------------------------------------------------------------------------------------ Question: When explaining the HELP2 system, Dr. Scott Evans emphasized the importance of the "longitudinal record" feature and that the original HELP system does not have it. Please explain three reasons this feature is critical for modern EHR systems. Topic: Health Information Systems Answer: Reason - Mobility. They generally receive care from a variety of locations, even within a single health-care system, such as IHC. If data related to each clinical visit can only be used by clinicians at that clinic, quality of care is signficantly limited and cost is likely increased. With more patient history, clinicians have more background with which to work and can save costs (for example, by not ordering duplicate lab tests). For example, if a patient visits the ED after hours, he/she might receive medications to which they are allergic because those physicians would not have their medical history. Of course, even longitudinal systems like HELP2 are limited because they cannot be used outside the organization. Reason - Research purposes. Researchers can accomplish more when they have longer-term data about patients. Without a longitudinal record, they would have a much more difficult task of assimilating data for their research and might have big problems with matching records. Reason - Decision support. If a patient's full (or a big part) medical history were stored in one place, medical informaticists could provide richer decision-support to clinicians in "real time" because the system would know more about the patient. Reason - Surveillance. Health care providers can use longitudinal records to better identify when disease outbreaks occur on the macro level. Reason - Interoperability and consistency. If all the data are stored in a central location and in a consistent way, developers have an easier time working with the data because they do not have to spend as much time assimilating heterogenous data with potential semantic differences or varying data-type definitions. Reason - Consumer health. With this type of data store, providers have a greater ability to expose data to consumers. This helps them become more informed about their health. ------------------------------------------------------------------------------------- Question: Mo Mulligan explained that quality improvement in a health-care system can be difficult to attain. Which of the following make quality improvement such a challenge (more than one may be true)? a. Factors that indicate quality frequently require manual effort to measure. b. Results from quality studies are rarely published for clinicians to review. c. Few clinicians desire to improve health-care quality. d. Data that are used to assess quality are stored in inconsistent locations within data warehouses. Topic: Health Care Quality Answer: A and D ------------------------------------------------------------------------------------ Question: The University of Utah health care system uses a "best of breed" approach for their information systems. This approach has provided many advantages to them but also presented challenges. List three disadvantages of this approach. Topics: Hospital Information Systems Answer: Disadvantage - Harder to integrate. In a best-of-breed approach, many vendors are used, and often home-grown applications are created. This presents a challenge because custom interfaces often need to be created between the systems, or else it may limit the number of products you can purchase if you want to integrate and not all vendors provide support for it. Disadvantage - Divergent technologies. Often with this approach, a variety of technologies are used. This requires a wider array of technical skills among the IT staff, which can be expensive, reduce productivity, and decrease satisfaction among staff. Disadvantage - Limited system expertise. When home-grown applications are created, there is a cost to keep them running. Often expertise on any given application is limited to a select few individuals. Big challenges can arise if those individuals leave to work somewhere else, change job responsibilities, forget details about the system they created, get "hit by a bus", etc. Disadvantage - Expense. If you buy or build specialized software for each department within a hospital, you may likely end up paying more than you would for an end-to-end solution. Multiple solutions can also significantly increase hardware expense. Disadvantage - Usability. Clinical staff will likely complain if they have to learn the user interface for many different types of applications and/or have to remember many different user names and passwords. ------------------------------------------------------------------------------------ Question: True or false. Because most hospital information systems fail due to technological issues, Nancy Nelson emphasized the importance of recruiting "computer helpers" to assist clinical staff during the early phases of a new implementation. Topics: Hospital Information Systems, Patient Care and Monitoring Answer: False. She emphasized that most fail due to people, process, and politics. Technology alone is usually not the issue. Question A paperless electronic medical record system performs better in a clinical environment than a paper based manual record system? Answer a) Strongly Agree b) Somewhat Agree c) Neither Agree nor Disagree d) Somewhat Disagree e) Strongly Disagree f) No Opinion The Questions Question 1. Question What is known as ―best of breed‖ in terms of healthcare applications software provisioning? How does ―best of breed‖ compare with more traditional mainframe style applications? What are the pitfalls of ―best of breed‖ implementations? Answer ―Best of breed‖ health care software provisioning enables healthcare organizations to source each application component they need for their workflow, from the most capable application and/or vendor for that service. Therefore, applications may be constructed from an applications or workflow framework sourced from one vendor, applications such as patient scheduling and billing sourced from other vendors, as well as certain components built by the healthcare organizations own IT department (or outsourced development organization). In the more traditional mainframe style environment, the entire solution for the healthcare organization was sourced from a single vendor, possibly even through the supplier of a centralized mainframe hardware environment. Such systems are difficult to integrate ―best of breed‖ niche solutions for individual departments or functional business units. Additionally, even systems where the entire solution is produced in-house and one would consider ―best of breed‖ to be a relatively straight forwards solution, often the custom built applications framework is too specialized to allow ease of integration of off the shelf ―best of breed‖ applications. ―Best of bread‖ applications can lack sufficient capabilities to easily integrate with ―best of breed‖ applications from other vendors for other capabilities. Hence, although each component in a system is ―best of breed‖ the application as a whole may be lest than optimum and requiring a highly customized integrating framework. ―Best of breed‖ may not end up being judged solely based upon user experiences of that module and may therefore be extended to factors of cost, ease of integration and adherence to data standards. Question 2. Question For a hypothetical hospital group requiring a thorough redesign and overhaul of their outdated clinical IT infrastructure, what factors would you consider to affect a CIO‘s required decision to either build the new system in-house or to buy-in from an external vendor? Answer Building in-house, you sometimes get what you want. Building at least the framework in-house and buying some components from outside in a ―best of breed‖ style might provide a better solution, if everything turns out as planned. Building in-house can more likely result in cost over-runs over fixed priced external contracts. Building in-house can sometimes result in better support and higher product quality. Building in-house will require significant and expensive engineering resources. Building in-house will result in an extensive period of apparent inactivity whilst design work is completed, but the externally constructed product may have the wrong design anyways. Building in-house may be better if you are on the bleeding edge of required technology. Purchasing outside places your organization at the mercy somewhat of mergers, acquisitions, bankruptcies and less than truthful specifications of the products (performance, reliability and functionality). In-house product may be built to leverage existing investments in hardware, software and prior products, the externally provision product may require a quantum change in platform philosophy. For a widely adopted bought-in solution, data interchange standards might be easier to achieve as the system may already provide these due to market forces. On the other hand as standards migrate and change, it may be easier to keep track with those, often internationally driven, changes. Question 3. Question No description of the IHC Hospital Network HELP System, or the LDS Hospital HELP System in particular, is complete without the following diagram: In this diagram, what is the function of the ―Decision Making Processor, Data and Timer Driver‖ module? Answer As data is inserted into the Integrated Clinical Database by any of the subsystems comprising the EHR system, it logically passes through the ―Decision Making Processor, Data and Time Driver‖. The data and time driver examines the data being injected into the system and by using the associated knowledge base determines if some form of alert would be appropriate depending on registered application components awaiting the arrival of, or depending upon the values of, the injected data. For instance, a subsystem might register for the requirement of an alert event if the blood levels check for a given patient for, say, Lithium falls below a certain value every time that patient receives a blood test. So the data driver accepts laboratory data for blood tests and when one is observed for the patient in question, the Lithium level in the blood given by the data, is examined. If the level were too low, or too high, an event would be posted to their EHR application session. The data can also be used to drive a myriad of other systems, beyond decision support and alert events, it can be used as a component of a surveillance system, or even for making data available for real-time research investigations. Overall the data driver is a methodology for actioning upon the receipt of data, into the system, in a manner programmable beyond merely the usual data integrity and suitability verification performed. The system to an extent becomes not just procedurally driven but data driven too, with an element of actioning by a fuzzier programmatic logic. Question 4. Question Despite obvious technical and political pitfalls, the Federal Government‘s VHA CPRS application to this day exhibits many functionally superior capabilities to equivalent private sector applications in use across the US. What are some of these advantages? Answer Paperless system, very few external pieces of paper, CPRS has become fairly close to a true paperless environment. Despite being based upon a MUMPS database technology, dating back to the 1970‘s, the system has continued to provide reasonable functionality and performance to this day. The system is distributed both for data and to a lesser extent, functionality, enabling clients of the system to continue to receive appropriate health care when displaced for whatever reason. Although the user interface of the CPRS system is oft criticized, it appears to have a high level of acceptance among clinical staff. Being capable of efficient mouse-less keystroke operation in a windowed GUI has allowed a relatively high level of user performance to be attained, although at the price of a learning curve for the inexperienced user. The lack of a web based interface paradigm has been exploited to allow a client or thin client operation based a user front end that allows a much more direct and immediate interaction between the user and the system, to be obtained. Question 5. Question Many information systems for healthcare include a mechanism for displaying and handling alerts, that is bringing to the user‘s attention certain important information critical to the patient‘s well being. Some of these alerts are based on elapsed time since some procedure (temporal reminders) and some provide warnings on adverse situations (drug interactions or blood chemistry levels). Given such alert systems, what human cognitive capabilities and deficiencies do these systems attempt to overcome? Answer Humans have a number of deficits in our cognitive and memory encoding and retrieval systems that the uses of alert systems attempt to overcome. Our attentional resources are limited. Our attention to a task enables us to better encode memories of that task. We appear to create more accurate and readily retrievable schemas, which increase our ability to pattern retrieve such information through replaying the original schema. In a busy hospital, the physician may be less than attentive when making a mental note to monitor some diagnostic for the patient. Later, in a different environment, without most of the visual, audible, environmental, muscular-skeletal and temporal queues, it becomes difficult for them to accurately remember to perform tasks against an original diagnostic plan which may in turn be largely forgotten. An alert system should provide some of the prompt information to improve the chance of accurate schema replay. Humans, and others mammals for that matter, seem to have two memory systems. The first, intentional and effortful, is based on awareness. Things of which we are aware and consciously observational of are easier to encode and commit, possibly by reiteration, to long-term memory. On the other hand, there is a level of automatic memory, often performed without conscious effort, not one a physician should rely upon for ease of memory retrieval, yet in a busy environment other staff might assume the physician has recorded in a more aware manner than they really have. The alert system should provide a safety net for the physician‘s memory. Human think tends to be goal orientated (as for other primates and rats amongst other species). Goals are mental structures representing rules, objects, associations, reward systems and categorizations that allow us to go from one state of operation to another. Goals can represent relatively small chunks of required activities. Such goal searching is often enacted by queues from the environment and often not consciously triggered, which is why on- task training is so important. Alert systems provide a controlled triggering of goal seeking behavior, yet also trigger a mental recollection of the patient and their overall needs. As humans, much of our behavior is affected by mood and emotion. We modify our behavior, schema replay and memory capabilities when subject to anxiety, lack of attention, our value system (what is important for us to know and remember) and our overall performance at our past goal orientated learning is often overestimated. Alert systems help overcome our inefficiencies in memory encoding and recall, due to these confounding factors. However, alert systems can also create problems, too much required attention to too many alerts results in a lack of attention towards the alert system as a whole. Alerts, if too frequent, can become an automatic function whereby the encoding in our memory of servicing the alert does not relate to whether the alert was correctly handled – the memory was automatically encoded without a developed schema. 1. Multiple choices: Bayesian Network, please pick up one wrong item. a. In Simple Bayes, patient can only have one disease. b. Using a graph to represent the Bayesian network, there is possible that the graph consists of the loop structure. c. The Receiver Operating Character curve (ROC curve) is used to determine the quality of sensitivity and specificity, and the bigger area of under the ROC curve means better performance. d. In Bayesian networks, patient can have multiple diseases and multiple symptoms. e. We can use clinical data to build up Bayesian networks. [Answer] b. 2. Nowadays, the trend of the medical records shifts from institutional perspective to personal one, please give three examples that how to achieve the personal health record. [Answer] Improve standards/interoperability: To let patients can bring their own personal health record to different health provider organizations, the standardized data format can reduce the complexity of utilizing the person health record. Portable interoperable digital files: Using internet to transmit the personal health record, there are still several problems, like security, ethical issue, and infrastructure issue, to provide a portable media to contain the personal health record, like smart card, is very important. Usage management of sensitivity data: Some sensitive data, like HIV diagnosis, gynecology history, or psychiatry history, is very private data for those patients having some special diseases. To prevent the unnecessary users from accessing the sensitive history records, the ability of usage management is a critical issue. 3. The biomedical informatics research involves with public health, clinical informatics, clinical research and translational informatics, please use an example to illustrate how biomedical data can help to interact with these three fields. [Answer] Right now, researchers already discover that breast cancer is related to genetic variation and family history. For example, we can collect the breast cancer patients from clinical informatics system. Then, we can derive the genetic data from those patients to study the genetic relationship of breast cancer. Therefore, we can develop the screening method to help the early diagnosis of breast cancer. In the other hand, to promote the screening of the breast cancer also can improve the public health. 4. Knowledge management: The drug adverse effect is a critical issue in hospital, please give an example that how to use knowledge management to study and prevent it. [Answer] To study the drug adverse effect, first, we have to collect those patients having drug adverse effect. Then, we can use the clinical data and genetic data of those patients to study the risk factor of drug adverse effect. After that, we can design a clinical decision support system to detect the possible drug adverse effect. All these processes need a good knowledge management to achieve the prevention of drug adverse effect. 5. In the past, we have several errors on making biomedical standards. Please give three examples to show what is the correct approach to make biomedical standards. [Answer] First, we allow different organizations to develop their own codes. So we have to face the mapping problem between different coding systems. So an unique organization to make an unique coding system is very important. Second, we have too many codes for the same thing in different coding system. These also cause the complexity of computation. The different organizations should communicate to each other to have a unique code for the same concept. Third, we do not have the controlled vocabulary that causes the ambiguity of lots of synonyms. Then, we need a lot of efforts to deal with synonyms and derive less accurate information. So to utilize the controlled vocabulary is very important. Question 1:What are the levels of Interoperability between Hospital Information Systems? Please provide examples for each level. Topic: Standards in Biomedical Informatics Answer: There are three recognized level of interoperability in Biomedical Informatics: Basic – allows messages to be exchanged between computer systems. ex. Emails, text documents. Functional – allows message be electronically processed to retrieved data. This level is based on standard syntax rules (format) of the message. ex. HTML document, Message in format of HL7 2.5 standards. Semantic – allows interpretation of the received data, requires use of standard vocabularies such as SNOMED, LOINC within the message. Message Question 2: Explain why the framework of Biomedical Informatics includes the elements of Cognitive Science. Provide examples. Topic: Human Computer Interatction Answer: Cognitive science is the study of complex information processing in humans and machines and includes biological and artificial systems. The design of artificially intelligent computer systems can benefit from a better understanding of human psychology and neuroscience. Likewise, our understanding of human thought and behavior can be informed by a better understanding of work in the area of artificial intelligence, computer science, and mathematical modeling. For example, the Human Computer Interaction – one of the core area of Cognitive science provides software engineers with the set of principles which allows to create systems with consideration of issues like limitation of attention resources, dualism of cognitive processes, goal based information processing, motivations and emotions. Question 3: Please provide at least four key elements of the modern Hospital Information System and explain why there are important. Topic: Hospital information systems Answer: There are five essential elements for the hospital information system to be able meet requirements of modern health care services: Integrated (or Centralized) data base. Provides the unified representation of data with timestamps. Knowledge base. Allow to encode rules of medical logic. Data and Time drivers, allows execute appropriate rules from the knowledge base Long term storage of data base. Provides historical information on a given patient and serves as a source for the knowledge aqusition. Question 4:Health Insurance Portability and Accountability Act of 1996 mandates adoption of standards for clinical data transactions and recommends adoption of standards for administrative transactions. True of False? Topic: Standards in Biomedical Informatics Answer: False, it is recommends adoption of standards for clinical data transactions and mandates adoption of standards for administrative transactions. Question 5: Please compare Public Health Informatics with Traditional Medical Informatics. Topic: Public Health Informatics Answer: Public health informatics as the systematic application of information and computer science and technology to public health practice, research, and learning. Public health informatics is primarily an engineering discipline, that is, a practical activity, undergirded by science, oriented to the accomplishment of specific tasks. It includes the conceptualization, design, development, deployment, refinement, maintenance, and evaluation of communication, surveillance, and information systems relevant to public health. The root of differences between Public Health Informatics (PHI) and Medical Informatics (MI) lies in the different scopes of Public Health and Traditional Medicine: PHI focus on promoting the health of populations, while MI focuses on individuals. Traditional medicine cure diseases while public health acts through preventive interventions. Therefore PHI getting informational feeds from wide variety of sources: Environmental measurements, retail reports, aggregated statistics at national and state level, care providers, insurance companies etc. And the last but not least PHI has founded by government, not by private sector. 1) List two issues that make the use of narrative text in a patient record, problematic from a patient care perspective. (clinical data formats) Narrative data is typically organized chronologically in the order that it is recorded. Often it is useful to review patient data contained in narrative topically which requires time consuming parsing of a great deal of unrelated narrative. It is time consuming to type narrative and it is error prone to dictate and transcribe narrative data. Decision support is compromised because relevant data is not in a computable format. 2) Describe two reasons why the use of clinical guidelines continue to have a relatively low acceptance among clinicians. (clinical guidelines/decision support) Guidelines usually represent the ‗average‘ patient and do not translate well to unusual or difficult cases. Clinical guidelines are difficult to represent in an unobtrusive, yet intuitive manner to a clinician at the point of care. They are often not trusted because they are difficult to maintain leading to outdated information. 3) Which of the following are not challenges that continue to significantly impede the acceptance of computerized patient record systems by physicians in large hospital systems? (barriers to acceptance of EMRs) a) applications that match workflow b) data security/privacy issues c) application speed d) return on investment e) cost of support staff for these systems f) availability of adequate bedside workstation technology g) coding standards the facilitate data exchange 4) True or False: Overall acceptance of CPOE (physician order entry) is generally better in ambulatory care than it is in acute care settings. (KLAS and evaluation of EMRs) true Discuss some of the issues that make it unlikely that we will ever have a single standard coding scheme. (coding standards) The biggest issues revolve around that fact that different users of coded data have potentially widely different needs and requirements for the codes. One example is of a specialist requiring highly detailed descriptive capabilities where a billing clerk would need only summary or high level codes. Another example would be a coding system that allows a great deal of flexability to handle unusual or complicated situations, that would be far too complex to implement an effective decision support system. The ability to map between coding systems where interoperability is required, allows separate unique coding systems to coexist, virtually assuring that we will continue to have multiple coding schemes into the future.