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Imaging and Communication in Medical and Public Health Informatics: Current Issues and Emerging Trends 52 Imaging and Communication in Medical and Public Health Informatics: Current Issues and Emerging Trends Melanie A. Sutton 52.1 Introduction . 895 Justice Mbizo 52.2 Imaging and Communication in Medical Informatics 896 Ann Yoshihashi 52.2.1 Open Source Product: VistA • 52.2.2 Commercial School ofAllied Health and Life Products • 52.2.3 Enterprise-wide Integrations Sciences, University of West Florida 52.3 Imaging and Communication in Public Health Informatics ... 898 52.3.1 GIS in Public Health Syndromic Surveillance and Applied Spatial Epidemiology Robert E. Hoyt • 52.3.2 Current Challenges in Public Health Informatics: Case Studies Naval Aerospace Medical Research • 52.3.3 Enterprise-wide Integrations Laboratory 52.4 Discussion . 904 52.5 Conclusion and Future Trends 904 52.6 References . 905 • Creating and analyzing new and existing clinical data 52.1 Introduction resources; Medical and public health informatics can be broadly defined • Developing and deploying new software tools to meet as the use of computer technology to support clinical or the needs of a clinical or public health practice or public health practice, administration, education, and research administration. [ 1-3]. The products developed in this field, "information resources," involve the hardware and software that facilitates This chapter examines current issues and emerging trends the storage, retrieval, and optimal use of medical ( or public in the development and deployment of imaging and commu- health) information for problem solving and decision making nication tools in medical and public health settings, from the [4, 5]. While the intended target audience for this book is the perspective of the informatics professionals described here. In imaging community, end-user informaticists engaged in the this context, we examine a subset of tools and summarize the interdisciplinary development and integration of developed issues affecting best practices and industry standards in these tools in this field include physicians, nurses, and health domains. Design trends in the area of usability/accessibility and care/public health administrators. Professional competencies visualization, as well as scalability/extensibility, interoperability, of these individuals include [6-9]: and security features are addressed. While usability/accessibility generally encompasses overall ease of use of a tool for the • Serving as a liaison to physicians, administrators, and end user, scalability involves the ease and cost-effectiveness other health care professionals in the use of current and of adding larger data sources or users. Visualization in this emerging computer technologies; context encompasses the system's support for overlays from • Using and evaluating commercial software products to multiple modalities and/or support for multidimensional data. manage medical or public health information; This feature depends on the system's levels of extensibility Copyright© 2008 by Elsevier, Inc. All rights of reproduction in any form reserved. 895 896 Handbook of Medical Image Processing and Analysis and interoperability, in terms of the seamlessness with which Noting the tens of thousands of Americans that die each customized capabilities can be added to the system to enhance year due to errors in their care, the IOM's 2000 and 2001 visualization or to support additional data formats that may be reports, To Err Is Human: Building a Safer Health System and exchanged during input and output. Finally, built-in security Crossing the Quality Chasm: A New Health System for the 21st mechanisms are relevant features to both fields, given recent Century, emphasized the need to translate knowledge into federal legislation such as the Health Insurance Portability practice [15, 16]. The emphasis in these reports was for the and Accountability Act [ 10], and the increasing use of these health care industry to directly and significantly use informa- tools in cases involving public health preparedness, emergency tion technology to improve quality of care and administrative management, and homeland security [11, 12]. and clinical processes. Health care organizations recognize that The primary objectives of this chapter are to poor decisions affecting patient safety are often the result of missing or incomplete information, and as such, many hos- 1. Examine the relevance and significance of communica- pitals have independently explored ways to link computerized tion and imaging applications used by the informatics decision-support programs to computer-based patient records communities in medicine and public health; to study and address factors that impact quality of care [ 17, 18]. 2. Explain the features of a subset of public domain and The built-in communication mechanisms within these special- commercial tools that contribute to improved patient ized tools and the increasing need to support multimodal data safety, communication, or quality of care; in the form of varied imaging sources within a patient's histor- ical record have led to an explosion of products with features 3. Provide recommendations for researchers considering that change as rapidly as hardware vendors can supply new porting academic research endeavors in these areas to the technologies. For a good review of traditional medical image marketplace. processing and analysis software that has attempted to address the need to support multidimensional and multimodal data, The remainder of this chapter is organized as follows. see [19]. In this chapter, we explore a subset of applications in Sections 52.2 and 52.3 discuss current issues and emerging the area of electronic health records and additionally examine trends in imaging and communication tools for the medical them in the context of enterprise-wide integrations. and public health domains, respectively. While it is impossi- An "electronic medical record" (EMR) is simply informa- ble to individually discuss every application currently on the tion regarding a patient's health status and health care, stored market, we have tried to sample a subset of recent open source electronically. Alternately, the term "electronic health record" and proprietary tools in each domain, along with unique or (EHR) is used to refer to an EMR with connections to lab unusual examples of emerging tools addressing particular niche systems, radiology, picture archive communication systems problems (e.g., enterprise-wide integrations, planning for pub- (PACS), and possibly regional health information organiza- lic health preparedness, etc.). Finally, Sections 52.4 and 52.5 tions (RHIOs). Inexpensive electronic health record options provide a discussion and concluding recommendations for the for small physician practices can be purchased for under $3000, imaging community. with additional charges for support, maintenance, and add- on capabilities. The options available in this price range target the workflow of small clinical practices and deemphasize fea- 52.2 Imaging and Communication tures such as expandability (e.g., scalability for a greater number in Medical Informatics of users), granularity (e.g., security for different user roles), and customization or cross-specialty functionality (e.g., exten- Historically, the evolution of marketplace medical informatics sibility or built-in support for varied input/output formats systems in the United States has been driven in part by from different user roles). These options also target basic and government-based initiatives and calls to action. The Institute enhanced communication features (e.g., e-prescribing func- of Medicine (IOM) in its revised 1997 report, The Computer- tionality that allows physicians to directly communicate to Based Patient Record: An Essential Technology for Health Care, a patient's pharmacy of choice) and visualization capabilities advocated built-in and flexible communication protocols in that support multiple imaging modalities. The latter includes emerging electronic record systems, to include protocols to support for digital X-rays, optical character recognition for support physician to patient, physician to non-text-based notes and lab reports, etc. (20]. Imaging capabilities in inex- content (e.g., imaging data), and physician to physician inter- pensive systems may involve single-page JPEG files but are action [ 13]. Predicting the emerging overlap with public health increasingly allowing multiple pages. In addition, communi- applications that would require tracking of subgroups, the cation support includes basic reminders in inexpensive systems report similarly urged built-in population management tools. to enhanced features that allow tracking physicians' orders from The envisioned tool suite thus included disease management initial record to final result or features that allow pieces of guidelines and care plans, query-based system databases, and the record (including images) to be attached for different user clinical research support [ 14). communications. 52 Imaging and Communication in Medical and Public Health Informatics 897 In the following sections we examine the features of several • Multiple exams can be displayed concurrently, allowing commercial and public domain EHR systems in the context for comparisons with prior studies. of understanding the current industry capabilities in the area • Additional DICOM-compliant support for ophthalmol- of system integration of communication protocols and imag- ogy, dental, endoscopy, pathology, cardiology, and other ing formats. Of note is that the overall integration
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