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					                   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.

				
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