Computer & Our Society {Medicine}

COMPUTER & OUR SOCIETY {MEDICINE}

CONTENTS

Chapter 1 Introduction 3

Chapter 2 Literature Review 7 Patient Monitoring 10 Remote patient monitoring 13 Maintaining patient history & other records 19 Electronic Health Record 23 Health Information Management 48 Home Health Care Software 52 Diagnosing and Surgery 54 Computer Aided Diagnosing 62 Computer Aided Surgery 69 Research 86

Chapter 3 Findings and Discussion 83

Chapter 4 Conclusion 88

REFERENCES

ABSTRACT

CHAPTER ONE

INTRODUCTION

The history of computerization in medicine started in 70s. At that time, the main purpose of computerization was labor-saving for the process of insurance claim and the scope was limited only within administrative section in medical institutions. The physician order entry system (POES) appeared in 80s by a centralized system of a host computer and based on the computerization of clinical laboratory and pharmacy.

The POES contributed reducing patient's waiting time in clinical institutions and also making the process of Insurance claim efficient. The growth of networking, especially the Internet in 90s enhanced cooperation among clinical professionals or clinical institutions. Also, the electronic medical record (EMR) came into realistic and a hospital in the west of Japan implemented EMR and got rid of paper first in 1999. In 2001, Japanese government established e-Japan policy, and health care and social welfare is one of the main target fields. Then, the ministry of health labor and welfare (MHLW) published "IT ground design for healthcare system" in the end of 2001.

It focused on EMR and the national standard software for electronic prcH2ess of insurance claim. It made target to implement by the end of 2006; over of institutions which has more than 400 beds should install EMR and over of institutions should install the national standard software for electronic process of insurance claim. According to the survey by the MHLW in 2002, only 1.3% out of total 8,023 hospitals have EMR and 15.3% have the POES.

It is also only 2.3% that the percentage of hospitals installed the national standard software for electronic process of insurance claim. However, such numbers are dramatically increasing recently.

As overall, computers are very popular among Japanese people and international survey in 2003 showed that had laptop or desktop computers in 2002 and had a mobile phone in 2003 in Japan. The corresponding numbers for the US were 66% and 54%. The percentage of the Internet users were 45% for Japan and 55% for the US in 2002 (ITU Telecommunication Indicators).

There has been a rapid expansion of computer use in medicine recently in the US for a number of uses including medical education at all levels, point of service medical information (especially diagnostic, treatment, and medications), medical research, EMRs, electronic billing, electronic prescribing, and the collection of data to determine quality of care and quality of medical education.

Some possible reasons why computers are increasingly used in US medical care are availability of high speed connections, availability of personal digital assistants (PDAs), availability of wireless connections, decreasing cost of hardware and software, public and government demands for increased quality of care and documentation of that quality, too much information to process without electronic help. Wireless LANs are much more common today in hospitals than in doctors ' offices. Only about 8 percent of physician practices have gone wireless. By comparison, 61 percent of integrated delivery networks and 36 percent of stand-alone hospitals have some wireless capability in the US.

In terms of security, wireless network should be protected, at least, by a combination of wireless-specific ways such as WPA/EAP according to IEEE802.1X with

IPSec/VPN technologies. In addition, a separation of traffic by creating VIANs, and installation of a firewall between wired and wireless networks tightened the security of the MIPA/EAP-equipped wireless networks.

How can computers Improve quality of care and document that quality? They can avoid illegible handwriting, can be programmed to find errors in dosage, medication name, medication interactions, and identifying allergic patients or the wrong patient, computerized records can be backed up and are less likely to be lost or unavailable, computerized records can more easily be transferred even over long distances, more easily collect data such as mortality or number of patients seen or types of diagnosis seen.

How can computers improve medical education? They can decrease the amount of class time where there is information transfer without interaction, Increase the amount of class time available to answer questions and concentrate on confusing or difficult topics, teach medical students and residents how to efficiently get the most accurate, useful, and up to date information through computer programs. They can then use this technique for the rest of their career. Computers can decrease the amount of information needed to be memorized and reduce the chance of error due to faulty memory. Finally, they can decrease the amount of time needed to read journals and books while still maintain high quality knowledge.

What are the disadvantages of computer use in medicine? They can be less useful for those physicians who cannot type quickly, take extra time and effort to get used to, create psychological discomfort with a new way of practicing medicine, be vulnerable to viruses and technical problems that risk loss of data unless backed up, be vulnerable to

5 breaches of patient confidentiality, sometimes increase the amount of time needed to get work done, create fear that computerized data can be used by the legal system against doctors and hospitals, create the fear of making the interaction between the patient and doctor seem less personal and have

CHAPTER TWO

LITERATURE REVIEW

The electronic devices supplied with processing units became an important component of our everyday life. Computers, smartphones and other apparatuses that give us mobile access to Internet are fundaments of modern business, education and sometimes even relationships. Health care as a vital part of contemporary society model is also affected by the same technical trends as the other branches of business. As personal healthcare is among most important aspects of everyone life many efforts are put into medical researches on new treatment techniques. Because of that, all computer methods that have proven to have technical and scientific potential are quickly developed and utilized in medicine.

Now it is impossible to mention all possible applications of computers in contemporary medicine because nearly all aspects of applied informatics are used in practical medical solutions. The motivation of this article is presenting subjective list of up to date applications of computer methods in medicine that might be good introduction to this subject. In our opinion the role of computer methods in medicine is changing as quick as computer science itself and there is a need for this type of review. Moreover, we will describe our contribution to the state of the art methodology by introducing some of our projects and achievements in this subject.

Our work is mainly concentrated on two- three- and four dimensional image data: image processing and recognition (classification tasks), semantic interpretation, as well as visualization and user interfaces. The data we are dealing with are mainly medical

7 images acquired from patients with suspicious of early stages of brain stroke. The proper diagnosis of medical data in first hours after appearing the stroke syndromes is crucial not only for patience live but also for further convalescence.

Computer is playing very important role in medical fields. Nearly every area of the medical field uses computers. They are helping the doctors to diagnose diseases and for many other purposes.

The four main/major uses of computer in medical field are described below:

1- Patient Monitoring Different electronic scanning devices (medical equipment) are used in hospitals. They are connected with computers. These devices are used to monitor the patient continuously. Thus computers are normally used in the following medical units of hospitals for monitoring patients.

o ICU (Intensive Care Unit)

o Operation Theater

o Recovery Room

o Medical Ward

o ECG (Electrocardiograph)

The medical equipment with sensors is attached to the patient. It detects changes in heart rate, pulse rate, blood pressure, breathing and brain activity. If any unbalancing situation occurs, computer activates the alarming device, which creates sound and alerts the medical staff.

2- Maintaining Patient History & Other Records The complete bio-data as well as medical history of a patient is recorded into the computer. The medical history is delivered to the related doctor for the checkup of the patient. In this way, much of the doctor's time is saved.

In addition to patient history, other information about doctors, medicines, and medical equipment is also maintained through computers. This information can be retrieved very easily and quickly.

3- Diagnosis & Surgery Computer is also used in hospitals for diagnosing diseases. Different medical tests depend upon the computerized devices such as laboratory test of blood. One common use of computer in hospitals is to scan the body of patient. A special scanner is used for this purpose. For example, the CAT (Computerized Axial Tomography) scanner passes rays over the patient. It displays an image of bone and tissue structure of patient on a computer screen. This image is printed on the printer. It is also store in computer for later use.

4- Research.

We would look at them one by one.

PATIENT MONITORING

In medicine, monitoring is the observation of a disease, condition or one or several medical parameters over time. It can be performed by continuously measuring certain parameters by using a medical monitor (for example, by continuously measuring vital signs by a bedside monitor), and/or by repeatedly performing medical tests (such as blood glucose monitoring with a glucose meter in people with diabetes mellitus). Transmitting data from a monitor to a distant monitoring station is known as telemetry or biotelemetry.

Classification by target parameter

Monitoring can be classified by the target of interest, including:

 Cardiac monitoring, which generally refers to continuous electrocardiography with assessment of the patient’s condition relative to their cardiac rhythm. A small monitor worn by an ambulatory patient for this purpose is known as a Holter monitor. Cardiac monitoring can also involve cardiac output monitoring via an invasive Swan-Ganz catheter.

 Hemodynamic monitoring, which monitors the blood pressure and blood flow within the circulatory system. Blood pressure can be measured either invasively through an inserted blood pressure transducer assembly, or noninvasively with an inflatable blood pressure cuff.

 Respiratory monitoring, such as:

o Pulse oximetry which involves measurement of the saturated percentage of oxygen in the blood, referred to as SpO2, and measured by an infrared finger cuff

o Capnography, which involves CO2 measurements, referred to as EtCO2 or end-tidal carbon dioxide concentration. The respiratory rate monitored as such is called AWRR or airway respiratory rate)

o Respiratory rate monitoring through a thoracic transducer belt, an ECG channel or via capnography

 Neurological monitoring, such as of intracranial pressure. Also, there are special patient monitors which incorporate the monitoring of brain waves (electroencephalography), gas anesthetic concentrations, bispectral index (BIS), etc. They are usually incorporated into anesthesia machines. In neurosurgery intensive care units, brain EEG monitors have a larger multichannel capability and can monitor other physiological events, as well.

 Blood glucose monitoring

 Childbirth monitoring

 Body temperature monitoring through an adhesive pad containing a thermoelectric transducer

Medical monitor

A medical monitor or physiological monitor is a medical device used for monitoring. It can consist of one or more sensors, processing components, display devices (which are sometimes in themselves called "monitors"), as well as communication links for displaying or recording the results elsewhere through a monitoring network.

Examples and applications

The development cycle in medicine is extremely long, up to 20 years, because of the need for U.S. Food and Drug Administration (FDA) approvals, therefore many of monitoring medicine solutions are not available today in conventional medicine.

Blood glucose monitoring

In vivo blood glucose monitoring devices can transmit data to a computer that can assist with daily life suggestions for lifestyle or nutrition and with the physician can make suggestions for further study in people who are at risk and help prevent diabetes mellitus type 2 .

Stress monitoring

Bio sensors may provide warnings when stress levels signs are rising before human can notice it and provide alerts and suggestions.

Serotonin biosensor

Future serotonin biosensors may assist with mood disorders and depression.

Continuous blood test based nutrition

In the field of evidence-based nutrition, a lab-on-a-chip implant that can run 24/7 blood tests may provide a continuous results and a computer can provide nutrition suggestions or alerts.

Psychiatrist-on-a-chip

In clinical brain sciences drug delivery and in vivo Bio-MEMS based biosensors may assist with preventing and early treatment of mental disorders.

Epilepsy monitoring

In epilepsy, next generations of long-term video-EEG monitoring may predict epileptic seizure and prevent them with changes of daily life activity like sleep, stress, nutrition and mood management.

Toxicity monitoring

Smart biosensors may detect toxic materials such mercury and lead and provide alerts.

REMOTE PATIENT MONITORING

Remote patient monitoring (RPM) is a technology to enable monitoring of patients outside of conventional clinical settings (e.g. in the home), which may increase access to care and decrease healthcare delivery costs.

Incorporating RPM in chronic disease management can significantly improve an individual’s quality of life. It allows patients to maintain independence, prevent complications, and minimize personal costs. RPM facilitates these goals by delivering care right to the home. In addition, patients and their family members feel comfort knowing that they are being monitored and will be supported if a problem arises. This is particularly important when patients are managing complex self-care processes such as home

13 hemodialysis. Key features of RPM, like remote monitoring and trend analysis of physiological parameters, enable early detection of deterioration; thereby, reducing number of emergency department visits, hospitalizations, and duration of hospital stays. The need for wireless mobility in healthcare facilitates the adoption of RPM both in community and institutional settings. The time saved as a result of RPM implementation increases efficiency, and allows healthcare providers to allocate more time to remotely educate and communicate with patients.

Technological components

The diverse applications of RPM lead to numerous variations of RPM technology architecture. However, most RPM technologies follow a general architecture that consists of four components.:

 Sensors on a device that is enabled by wireless communications to measure physiological parameters.

 Local data storage at patients’ site that interfaces between sensors and other centralized data repository and/or healthcare providers.

 Centralized repository to store data sent from sensors, local data storage, diagnostic applications, and/or healthcare providers.

 Diagnostic application software that develops treatment recommendations and intervention alerts based on the analysis of collected data.

Depending on the disease and the parameters that are monitored, different combinations of sensors, storage, and applications may be deployed.

Applications

Physiological data such as blood pressure and subjective patient data are collected by sensors on peripheral devices. Examples of peripheral devices are: blood pressure cuff, pulse oximeter, and glucometer. The data are transmitted to healthcare providers or third parties via wireless telecommunication devices. The data are evaluated for potential problems by a healthcare professional or via a clinical decision support algorithm, and patient, caregivers, and health providers are immediately alerted if a problem is detected. As a result, timely intervention ensures positive patient outcomes. The newer applications also provide education, test and medication reminder alerts, and a means of communication between the patient and the provider. The following section illustrates examples of RPM applications, but RPM is not limited to those disease states.

Dementia and falls

For patients with dementia that are at risk for falls, RPM technology promotes safety and prevents harm through continuous surveillance. RPM sensors can be affixed to the individual or their assistive mobility devices such as canes and walkers. The sensors monitor an individual’s location, gait, linear acceleration and angular velocity, and utilize a mathematical algorithm to predict the likelihood for falls, detect movement changes, and alert caregivers if the individual has fallen. Furthermore, tracking capabilities via Wi- Fi, global positioning system (GPS) or radio frequency enables caregivers to locate wandering elders.

Diabetes

Diabetes management requires control of multiple parameters: blood pressure, weight, and blood glucose. The real-time delivery of blood glucose and blood pressure readings enables immediate alerts for patient and healthcare providers to intervene when needed. There is evidence to show that daily diabetes management involving RPM is just as effective as usual clinic visit every 3 months.

Congestive heart failure

A systematic review of the literature on home monitoring for heart failure patients indicates that RPM improves quality of life, improves patient-provider relationships, shortens duration of stay in hospitals, decreases mortality rate, and reduces costs to the healthcare system.

Infertility

A recent study of a remote patient monitoring solution for infertility demonstrated that for appropriately screened patients who had been seeking In-Vitro Fertilization (IVF) treatment, a six-month remote monitoring program had the same pregnancy rate as a cycle of IVF. The remote patient monitoring product and service used had a cost-per- patient of $800, compared to the average cost of a cycle of IVF of $15,000, suggesting a 95% reduction in the cost of care for the same outcome.

Whole System Demonstrator Trial in UK

The UK’s Department of Health’s Whole System Demonstrator (WSD) launched in May 2008. It is the largest randomized control trial of telehealth and telecare in the world,

16 involving 6191 patients and 238 GP practices across three sites, Newham, Kent and Cornwall. The trials were evaluated by: City University London, University of Oxford, University of Manchester, Nuffield Trust, Imperial College London and London School of Economics.

 45% reduction in mortality rates

 20% reduction in emergency admissions

 15% reduction in A&E visits

 14% reduction in elective admissions

 14% reduction in bed days

 8% reduction in tariff costs

In the UK, the Government's Care Services minister, Paul Burstow, has stated that telehealth and telecare would be extended over the next five years (2012-2017) to reach three million people.

Limitations

RPM is highly dependent on the individual’s motivation to manage their health. Without the patient’s willingness to be an active participant in their care, RPM implementation will likely fail.

Cost is also a barrier to its widespread use. Devices and peripherals currently cost thousands of dollars, and for RPM to take hold in health care, costs need to come down to the $300 to $500 range.

There is a lack of reimbursement guidelines for RPM services, which may deter its incorporation into clinical practice. The shift of accountability associated with RPM brings 17 up liability issues. There are no clear guidelines in respect to whether clinicians have to intervene every time they receive an alert regardless of the urgency. The continuous flow of patient data requires a dedicated team of health care providers to handle the information, which may, in fact, increase the workload. Although technology is introduced with the intent to increase efficiency, it can become a barrier to some healthcare providers that are not technological.

There are common obstacles that health informatics technologies encounter that applies to RPM. Depending on the comorbidities monitored, RPM involves a diverse selection of devices in its implementation. Standardization is required for data exchange and interoperability among multiple components. Furthermore, RPM deployment is highly dependent on an extensive wireless telecommunications infrastructure, which may not be available or feasible in rural areas. Since RPM involves transmission of sensitive patient data across telecommunication networks, information security is a concern.

MAINTAINING PATIENT HISTORY & OTHER RECORDS

Before the introduction of computers all medical records were kept in a patient folder with handwritten notes by the doctor, other staff. Patients and ID details were on the outside typed or handwritten by staff, all family's records went into one folder.

Outpatient’s records were kept in a printed folder with date stamped sheets of notes inside it. when a patient came up for an appointment, he/she got a ticket and when he came in to see the doctor -the doctor had the folder selected from the records room and placed in advance on his table.

Examination notes were handwritten/ prescription were written too and tokens or prescription cards were given to the patient. the patient then walked over to the dispensary/pharmacy and collected his meds. All under one roof! records were accurate. records were kept in a locked room, arranged in filing cabinets or similar cabinets. Records were rarely ever lost!

Problems accompanied with this method were;

1. Costs of manual medical records

There are several types of costs associated with manual patient records. One type, duplication of the record, requires paper and copying supplies, as well as the staff to create and distribute the copies. Staff hired to assemble, file, retrieve, or distribute the hard copy chart is a costly expense. Storage of the paper record necessitates the use of

19 valuable space that could be better utilized. The records also need to be protected from water, fire, or mishandling of the paper to preserve their physical integrity.

One of the most expensive disadvantages of the paper record is duplicate patient testing required to replace lost or missing test results. Repeating procedures may jeopardize the patient’s health, creating a potential opportunity for an adverse medical event. Duplicate testing wastes scarce medical resources (time, staff, supplies, and equipment) that could be used for other patients. It is a contributing source to the rising costs of health care by generating additional charges to be billed to the patient, insurance company, or other third- party payer.

A related issue pertains to ordering procedures or tests that are either unnecessary or contraindicated. These types of decisions, when based on inadequate information or delayed results, create a potentially harmful situation for the patient and a needless expense for all concerned. Claims submitted for medical errors that could have been prevented with accurate and accessible patient information are issues that are seen with the use of a paper record.

2. Lost productivity from manual medical records

Lost productivity results from various inadequacies of the paper record. This affects multiple departments in a healthcare facility. Searches for misfiled charts waste time. Staff members’ time is required to deliver paper records to a specific location. If the paper record is not readily available, clerical staff responsible for filing documentation may need to make several attempts before the task is completed. Medical errors may be made if the staff makes decisions on inadequate information.

There is no ability to sort data fields in a paper record. Staff responsible for reporting mandated data elements to the appropriate organizations must perform a manual review. This is a very labor-intensive process, and inaccuracies can occur.

3. Accessibility of medical records

Of great concern is the lack of access to the record. Only one person at a time may use the chart and the chart has to be in a single location. Staff needing access to the record must wait until it is available for their use. This also contributes to the difficulty of updating the paper record, especially for an active patient’s chart since that chart travels with the patient to each location of care. Delivering documentation by hand to the patient’s temporary location lends itself to the potential for losing or misplacing the records. Delayed access to the chart negatively affects coding, billing, and reimbursement processes.

4. Quality of manual medical records

The issue of quality encompasses the physical record, the documentation, and patient care. There are limitations to the physical quality of the paper record. The paper is fragile and does not last permanently. Normal use of the record may result in torn or stained documents. Also, over the years, the ink used to complete documentation can fade. Actual damage resulting from water or fire is another threat to the physical integrity of the paper record.

The quality of the actual documentation varies based on the health care provider’s documentation skills and knowledge level. While standardization of the data documentation has improved over the years, not all providers use the same

21 abbreviations, terminology, format, or chart organization. This can result in incomplete or inaccurate healthcare data collection. Handwritten information may be illegible, creating the potential for errors in patient treatment or medication orders.

5. Fragmentation caused by manual medical records

Fragmentation of the patient’s record occurs as the result of multiple encounters with different healthcare providers. Due to disparate patient documentation and billing systems, there is often minimal or no exchange of information that contributes to compiling a longitudinal medical history for the patient. Each provider or facility has a limited portion of the patient’s overall health information. Some minor communication may be provided between referring and consulting physicians, but only for a specific encounter. The level of fragmentation varies based on several factors. These factors include:

• the patient’s ability to communicate pertinent health information to the provider;

• the ability of the provider to collect information that is accessible to other providers;

• the provider’s ability to directly elicit health information from the patient and any written documentation to create an appropriate treatment plan; and

• the limitations of the patient record system(s) that are being utilized to collect and disseminate information.

A well planned and implemented electronic medical record system should address and/or alleviate many of the general disadvantages of the paper record. This is an immense undertaking that requires an in-depth review of current processes, a detailed

22 strategy for determining the organization’s future needs and goals, an organization’s willingness and ability to make significant changes, and the financial investment to achieve the desired results. It is also a very time-intensive project that demands the utmost dedication and commitment by the entire health system. Patients, providers, and other interested parties could all expect to derive benefits from a properly planned and installed an automated system.

ELECTRONIC HEALTH RECORD

An electronic health record (EHR), or electronic medical record (EMR), refers to the systematized collection of patient and population electronically-stored health information in a digital format. These records can be shared across different health care settings. Records are shared through network-connected, enterprise-wide information systems or other information networks and exchanges. EHRs may include a range of data, including demographics, medical history, medication and allergies, immunization status, laboratory test results, radiology images, vital signs, personal statistics like age and weight, and billing information.

EHS systems are designed to store data accurately and to capture the state of a patient across time. It eliminates the need to track down a patient's previous paper medical records and assists in ensuring data is accurate and legible. It can reduce risk of data replication as there is only one modifiable file, which means the file is more likely up to date, and decreases risk of lost paperwork. Due to the digital information being searchable and in a single file, EMR's are more effective when extracting medical data for the examination of possible trends and long term changes in a patient. Population-based

23 studies of medical records may also be facilitated by the widespread adoption of EHR's and EMR's.

Terminology

The terms EHR, electronic patient record (EPR) and EMR have often been used interchangeably, although differences between the models are now being defined. The electronic health record (EHR) is an evolving concept defined as a more longitudinal collection of the electronic health information of individual patients or populations.

The EMR is, in contrast, defined as the patient record created by providers for specific encounters in hospitals and ambulatory environments, and which can serve as a data source for an EHR. It is important to note that an "EHR" is generated and maintained within an institution, such as a hospital, integrated delivery network, clinic, or physician office, to give patients, physicians and other health care providers, employers, and payers or insurers access to a patient's medical records across facilities. (Please note that the term "EMR" would now be used for the preceding description, and that many EMR's now use cloud software maintenance and data storage rather than local networks.)

In contrast, a personal health record (PHR) is an electronic application for recording personal medical data that the individual patient controls and may make available to health providers.

Comparison with paper-based records

Federal and state governments, insurance companies and other large medical institutions are heavily promoting the adoption of electronic medical records. The US Congress included a formula of both incentives (up to $44,000 per physician under Medicare, or up to $65,000 over six years under Medicaid) and penalties (i.e. decreased Medicare and Medicaid reimbursements to doctors who fail to use EMRs by 2015, for covered patients) for EMR/EHR adoption versus continued use of paper records as part of the Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted as part of the American Recovery and Reinvestment Act of 2009.

One VA study estimates its electronic medical record system may improve overall efficiency by 6% per year, and the monthly cost of an EMR may (depending on the cost of the EMR) be offset by the cost of only a few "unnecessary" tests or admissions. Jerome Groopman disputed these results, publicly asking "how such dramatic claims of cost-saving and quality improvement could be true". A 2014 survey of the American College of Physicians member sample, however, found that family practice physicians spent 48 minutes more per day when using EMRs. 90% reported that at least 1 data management function was slower after EMRs were adopted, and 64% reported that note writing took longer. A third (34%) reported that it took longer to find and review medical record data, and 32% reported that it was slower to read other clinicians' notes.

The increased portability and accessibility of electronic medical records may also increase the ease with which they can be accessed and stolen by unauthorized persons or unscrupulous users versus paper medical records, as acknowledged by the increased security requirements for electronic medical records included in the Health Information

25 and Accessibility Act and by large-scale breaches in confidential records reported by EMR users. Concerns about security contribute to the resistance shown to their widespread adoption.

Handwritten paper medical records may be poorly legible, which can contribute to medical errors. Pre-printed forms, standardization of abbreviations and standards for penmanship were encouraged to improve reliability of paper medical records. Electronic records may help with the standardization of forms, terminology and data input. Digitization of forms facilitates the collection of data for epidemiology and clinical studies.

EMRs can be continuously updated (within certain legal limitations – see below). If the ability to exchange records between different EMR systems were perfected("interoperability") would facilitate the co-ordination of health care delivery in non-affiliated health care facilities. In addition, data from an electronic system can be used anonymously for statistical reporting in matters such as quality improvement, resource management and public health communicable disease surveillance.

Implementation, end user and patient considerations

Quality

Several studies call into question whether EHRs improve the quality of care. However, a recent multi-provider study in diabetes care, published in the New England Journal of Medicine, found evidence that practices with EHR provided better quality care.

EMR's may eventually help improve care coordination. An article in a trade journal suggests that since anyone using an EMR can view the patient's full chart, that it cuts down on guessing histories, seeing multiple specialists, smooths transitions between care 26 settings, and may allow better care in emergency situations. EHRs may also improve prevention by providing doctors and patients better access to test results, identifying missing patient information, and offering evidence-based recommendations for preventive services.

Costs

The steep price of EHR and provider uncertainty regarding the value they will derive from adoption in the form of return on investment has a significant influence on EHR adoption. In a project initiated by the Office of the National Coordinator for Health Information (ONC), surveyors found that hospital administrators and physicians who had adopted EHR noted that any gains in efficiency were offset by reduced productivity as the technology was implemented, as well as the need to increase information technology staff to maintain the system.

The U.S. Congressional Budget Office concluded that the cost savings may occur only in large integrated institutions like Kaiser Permanente, and not in small physician offices. They challenged the Rand Corporation's estimates of savings. "Office-based physicians in particular may see no benefit if they purchase such a product—and may even suffer financial harm. Even though the use of health IT could generate cost savings for the health system at large that might offset the EHR's cost, many physicians might not be able to reduce their office expenses or increase their revenue sufficiently to pay for it. For example, the use of health IT could reduce the number of duplicated diagnostic tests. However, that improvement in efficiency would be unlikely to increase the income of many physicians." One CEO of an EHR company has argued if a physician performs tests in the office, it might reduce his or her income.

Doubts have been raised about cost saving from EHRs by researchers at Harvard University, the Wharton School of the University of Pennsylvania, Stanford University, and others.

Time

The implementation of EMR can potentially decrease identification time of patients upon hospital admission. A research from the Annals of Internal Medicine showed that since the adoption of EMR a relative decrease in time by 65% has been recorded (from 130 to 46 hours).

Software quality and usability deficiencies

The Healthcare Information and Management Systems Society (HIMSS), a very large U.S. healthcare IT industry trade group, observed that EHR adoption rates "have been slower than expected in the United States, especially in comparison to other industry sectors and other developed countries. A key reason, aside from initial costs and lost productivity during EMR implementation, is lack of efficiency and usability of EMRs currently available." The U.S. National Institute of Standards and Technology of the Department of Commerce studied usability in 2011 and lists a number of specific issues that have been reported by health care workers. The U.S. military's EHR, AHLTA, was reported to have significant usability issues. It was observed that the efforts to improve EHR usability should be placed in the context of physician-patient communication.

However, physicians are embracing mobile technologies such as smartphones and tablets at a rapid pace. According to a 2012 survey by Physicians Practice, 62.6 percent of respondents (1,369 physicians, practice managers, and other healthcare providers) say

28 they use mobile devices in the performance of their job. Mobile devices are increasingly able to synch up with electronic health record systems thus allowing physicians to access patient records from remote locations. Most devices are extensions of desk-top EHR systems, using a variety of software to communicate and access files remotely. The advantages of instant access to patient records at any time and any place are clear, but bring a host of security concerns. As mobile systems become more prevalent, practices will need comprehensive policies that govern security measures and patient privacy regulations.

Eventually, EHR will be more secured because the cyber security professionals have never stopped pursuing better ways to protect data with an enhanced software and technology. At the same time, they need to beware that the system will be significantly complicated and not user-friendly anymore as the data is growing and technology is more advancing. While we have a better secured system, it could lead to an error-prone. Therefore, efficient and effective trainings are needed along with a well-designed user interface.

Unintended consequences

Per empirical research in social informatics, information and communications technology (ICT) use can lead to both intended and unintended consequences.

A 2008 Sentinel Event Alert from the U.S. Joint Commission, the organization that accredits American hospitals to provide healthcare services, states that "As health information technology (HIT) and 'converging technologies'—the interrelationship between medical devices and HIT—are increasingly adopted by health care organizations, users must be mindful of the safety risks and preventable adverse events that these

29 implementations can create or perpetuate. Technology-related adverse events can be associated with all components of a comprehensive technology system and may involve errors of either commission or omission. These unintended adverse events typically stem from human-machine interfaces or organization/system design." The Joint Commission cites as an example the United States Pharmacopeia MEDMARX database where of 176,409 medication error records for 2006, approximately 25 percent (43,372) involved some aspect of computer technology as at least one cause of the error.

The National Health Service (NHS) in the UK reports specific examples of potential and actual EHR-caused unintended consequences in their 2009 document on the management of clinical risk relating to the deployment and use of health software.

In a Feb. 2010 U.S. Food and Drug Administration (FDA) memorandum, FDA notes EHR unintended consequences include EHR-related medical errors due to (1) errors of commission (EOC), (2) errors of omission or transmission (EOT), (3) errors in data analysis (EDA), and (4) incompatibility between multi-vendor software applications or systems (ISMA) and cites examples. In the memo FDA also notes the "absence of mandatory reporting enforcement of H-IT safety issues limits the numbers of medical device reports (MDRs) and impedes a more comprehensive understanding of the actual problems and implications."

A 2010 Board Position Paper by the American Medical Informatics Association (AMIA) contains recommendations on EHR-related patient safety, transparency, ethics education for purchasers and users, adoption of best practices, and re-examination of regulation of electronic health applications. Beyond concrete issues such as conflicts of

30 interest and privacy concerns, questions have been raised about the ways in which the physician-patient relationship would be affected by an electronic intermediary.

During the implementation phase, cognitive workload for healthcare professionals may be significantly increased as they become familiar with a new system.

Privacy and confidentiality

In the United States in 2011 there were 380 major data breaches involving 500 or more patients' records listed on the website kept by the United States Department of Health and Human Services (HHS) Office for Civil Rights. So far, from the first wall postings in September 2009 through the latest on 8 December 2012, there have been 18,059,831 "individuals affected," and even that massive number is an undercount of the breach problem. The civil rights office has not released the records of tens of thousands of breaches it has received under a federal reporting mandate on breaches affecting fewer than 500 patients per incident.

Goals and objectives

 Improve care quality, safety, efficiency, and reduce health disparities

Quality and safety measurement

Clinical decision support (automated advice) for providers

Patient registries (e.g., "a directory of patients with diabetes")

 Improve care coordination 31

 Engage patients and families in their care

 Improve population and public health

Electronic laboratory reporting for reportable conditions (hospitals)

Immunization reporting to immunization registries

Syndromic surveillance (health event awareness)

 Ensure adequate privacy and security protections

Quality

Studies call into question whether, in real life, EMRs improve the quality of care. 2009 produced several articles raising doubts about EMR benefits. A major concern is the reduction of physician-patient interaction due to formatting constraints. For example, some doctors have reported that the use of check-boxes has led to fewer open-ended questions.

Barriers to adoption

Costs

The steep price of EMR and provider uncertainty regarding the value they will derive from adoption in the form of return on investment have a significant influence on EMR adoption. In a project initiated by the Office of the National Coordinator for Health Information (ONC), surveyors found that hospital administrators and physicians who had adopted EMR noted that any gains in efficiency were offset by reduced productivity as

32 the technology was implemented, as well as the need to increase information technology staff to maintain the system.

The U.S. Congressional Budget Office concluded that the cost savings may occur only in large integrated institutions like Kaiser Permanente, and not in small physician offices. They challenged the Rand Corporation's estimates of savings. "Office-based physicians in particular may see no benefit if they purchase such a product—and may even suffer financial harm. Even though the use of health IT could generate cost savings for the health system at large that might offset the EMR's cost, many physicians might not be able to reduce their office expenses or increase their revenue sufficiently to pay for it. For example, the use of health IT could reduce the number of duplicated diagnostic tests. However, that improvement in efficiency would be unlikely to increase the income of many physicians. "Given the ease at which information can be exchanged between health IT systems, patients whose physicians use them may feel that their privacy is more at risk than if paper records were used."

Doubts have been raised about cost saving from EMRs by researchers at Harvard University, the Wharton School of the University of Pennsylvania, Stanford University, and others.

Start-up costs

In a survey by DesRoches et al. (2008), 66% of physicians without EHRs cited capital costs as a barrier to adoption, while 50% were uncertain about the investment. Around 56% of physicians without EHRs stated that financial incentives to purchase and/or use EHRs would facilitate adoption. In 2002, initial costs were estimated to be $50,000– 70,000 per physician in a 3-physician practice. Since then, costs have decreased with

33 increasing adoption. A 2011 survey estimated a cost of $32,000 per physician in a 5- physician practice during the first 60 days of implementation.

One case study by Miller et al. (2005) of 14 small primary-care practices found that the average practice paid for the initial and ongoing costs within 2.5 years. A 2003 cost- benefit analysis found that using EMRs for 5 years created a net benefit of $86,000 per provider.

Some physicians are skeptical of the positive claims and believe the data is skewed by vendors and others with an interest in EHR implementation.

Brigham and Women's Hospital in Boston, Massachusetts, estimated it achieved net savings of $5 million to $10 million per year following installation of a computerized physician order entry system that reduced serious medication errors by 55 percent. Another large hospital generated about $8.6 million in annual savings by replacing paper medical charts with EHRs for outpatients and about $2.8 million annually by establishing electronic access to laboratory results and reports.

Maintenance costs

Maintenance costs can be high. Miller et al. found the average estimated maintenance cost was $8500 per FTE health-care provider per year.

Furthermore, software technology advances at a rapid pace. Most software systems require frequent updates, often at a significant ongoing cost. Some types of software and operating systems require full-scale re-implementation periodically, which disrupts not only the budget but also workflow. Costs for upgrades and associated regression testing can be particularly high where the applications are governed by FDA 34 regulations (e.g. Clinical Laboratory systems). Physicians desire modular upgrades and ability to continually customize, without large-scale reimplementation.

Training costs

Training of employees to use an EHR system is costly, just as for training in the use of any other hospital system. New employees, permanent or temporary, will also require training as they are hired.

In the United States, a substantial majority of healthcare providers train at a VA facility sometime during their career. With the widespread adoption of the Veterans Health Information Systems and Technology Architecture (VistA) electronic health record system at all VA facilities, few recently-trained medical professionals will be inexperienced in electronic health record systems. Older practitioners who are less experienced in the use of electronic health record systems will retire over time.

Software quality and usability deficiencies

The Healthcare Information and Management Systems Society (HIMSS), a very large U.S. health care IT industry trade group, observed that EMR adoption rates "have been slower than expected in the United States, especially in comparison to other industry sectors and other developed countries. A key reason, aside from initial costs and lost productivity during EMR implementation, is lack of efficiency and usability of EMRs currently available. The U.S. National Institute of Standards and Technology of the Department of Commerce studied usability in 2011 and lists a number of specific issues that have been reported by health care workers. The U.S. military's EMR "AHLTA" was reported to have significant usability issues.

Lack of semantic interoperability

In the United States, there are no standards for semantic interoperability of health care data; there are only syntactic standards. This means that while data may be packaged in a standard format (using the pipe notation of HL7, or the bracket notation of XML), it lacks definition, or linkage to a common shared dictionary. The addition of layers of complex information models (such as the HL7 v3 RIM) does not resolve this fundamental issue.

Implementations

In the United States, the Department of Veterans Affairs (VA) has the largest enterprise- wide health information system that includes an electronic medical record, known as the Veterans Health Information Systems and Technology Architecture (VistA). A key component in VistA is their VistA imaging System which provides a comprehensive multimedia data from many specialties, including cardiology, radiology and orthopedics. A graphical user interface known as the Computerized Patient Record System (CPRS) allows health care providers to review and update a patient's electronic medical record at any of the VA's over 1,000 healthcare facilities. CPRS includes the ability to place orders, including medications, special procedures, X-rays, patient care nursing orders, diets, and laboratory tests.

Need for Electronic Health Records (EHR)

The following are the most significant reasons why our healthcare system would benefit from the widespread transition from paper to electronic health records.

Paper records are severely limited

Much of what can be said about handwritten prescriptions can also be said about handwritten office notes. Figure 4.2 illustrates the problems with a paper record. In spite of the fact that this clinician used a template, the handwriting is illegible and the document cannot be electronically shared or stored. It is not structured data that is computable and hence shareable with other computers and systems.

Other shortcomings of paper: expensive to copy, transport and store; easy to destroy; difficult to analyze and determine who has seen it; and the negative impact on the environment. Electronic patient encounters represent a quantum leap forward in legibility and the ability to rapidly retrieve information. Almost every industry is now computerized and digitized for rapid data retrieval and trend analysis. Look at the stock market or companies like Walmart or Federal Express. Why not the field of medicine?

Figure 4.2: Outpatient paper-based patient encounter form

With the relatively recent healthcare models of pay-for-performance, patient centered medical home model and accountable care organizations there are new reasons to embrace technology in order to aggregate and report results in order to receive reimbursement. It is much easier to retrieve and track patient data using an EHR and patient registries than to use labor intensive paper chart reviews. EHRs are much better organized than paper charts, allowing for faster retrieval of lab or x-ray results. It is also likely that an EHR will have an electronic problem summary list that outlines a patient’s major illnesses, surgeries, allergies and medications. How many times does a physician 38 open a large paper chart, only to have loose lab results fall out? How many times does a physician re-order a test because the results or the chart is missing? It is important to note that paper charts are missing as much as 25% of the time, according to one study. Even if the chart is available; specifics are missing in 13.6% of patient encounters, according to another study. Table 4.1 shows the types of missing information and its frequency. According to the President’s Information Technology Advisory Committee, 20% of laboratory tests are re-ordered because previous studies are not accessible. This statistic has great patient safety, productivity and financial implications.

Table 4.1: Types and frequencies of missing information

Information Missing During Patient Visits % Visits Lab results 45%

Letters/dictations 39%

Radiology results 28%

History and physical exams 27%

Pathology results 15%

EHRs allow easy navigation through the entire medical history of a patient. Instead of pulling paper chart volume 1 of 3 to search for a lab result, it is simply a matter of a few mouse clicks. Another important advantage is the fact that the record is available 24 hours a day, seven days a week and doesn’t require an employee to pull the chart, nor extra space to store it. Adoption of electronic health records has saved money by decreasing full time equivalents (FTEs) and converting records rooms into more productive space, such as exam rooms. Importantly, electronic health records are accessible to multiple

39 healthcare workers at the same time, at multiple locations. While a billing clerk is looking at the electronic chart, the primary care physician and a specialist can be analyzing clinical information simultaneously. Moreover, patient information should be available to physicians on call so they can review records on patients who are not in their panel.

Furthermore, it is believed that electronic health records improve the level of coding. Do clinicians routinely submit a lower level of care for billing purposes because they know that handwritten patient notes are short and incomplete? Templates may help remind clinicians to add more history or details of the physical exam, thus justifying a higher level of coding (templates are disease specific electronic forms that essentially allow a user to point and click a history and physical exam). A study of the impact of an EHR on the completeness of clinical histories in a labor and delivery unit demonstrated improved documentation, compared to prior paper-based histories. Lastly, an EHR provides clinical decision support such as alerts and reminders, which will be covered later in this chapter.

Need for improved efficiency and productivity

The goal is to have patient information available to anyone who needs it, when they need it and where they need it. With an EHR, lab results can be retrieved much more rapidly, thus saving time and money. It should be pointed out however, that reducing duplicated tests benefits the payers and patients and not clinicians so there is a misalignment of incentives. Moreover, an early study using computerized order entry showed that simply displaying past results reduced duplication and the cost of testing by only 13%. If lab or x-ray results are frequently missing, the implication is that they need to be repeated which adds to this country’s staggering healthcare bill. The same could be

40 said for duplicate prescriptions. It is estimated that 31% of the United States $2.3 trillion- dollar healthcare bill is for administration.

EHRs are more efficient because they reduce redundant paperwork and have the capability of interfacing with a billing program that submits claims electronically. Consider what it takes to simply get the results of a lab test back to a patient using the old system. This might involve a front office clerk, a nurse and a physician. The end result is frequently placing the patient on hold or playing telephone tag. With an EHR, lab results can be forwarded via secure messaging or available for viewing via a portal. Electronic health records can help with productivity if templates are used judiciously. As noted, they allow for point and click histories and physical exams that in some cases may save time. Embedded clinical decision support is one of the newest features of a comprehensive EHR. Clinical practice guidelines, linked educational content and patient handouts can be part of the EHR. This may permit finding the answer to a medical question while the patient is still in the exam room.

Several EHR companies also offer a centralized area for all physician approvals and signatures of lab work, prescriptions, etc. This should improve work flow by avoiding the need to pull multiple charts or enter multiple EHR modules. Although EHRs appear to improve overall office productivity, they commonly increase the work of clinicians, particularly with regard to data entry. We’ll discuss this further in the Loss of Productivity section.

Quality of care and patient safety

As previously suggested, an EHR should improve patient safety through many mechanisms: (1) Improved legibility of clinical notes, (2) Improved access anytime and

41 anywhere, (3) Reduced duplication, (4) Reminders that tests or preventive services are overdue, (5) Clinical decision support that reminds clinicians about patient allergies, correct dosage of drugs, etc., (6) Electronic problem summary lists provide diagnoses, allergies and surgeries at a glance.

In spite of the before mentioned benefits, a study by Garrido of quality process measures before and after implementation of a widespread EHR in the Kaiser Permanente system, failed to show improvement. To date there has only been one study published the authors are aware of that suggested use of an EHR decreased mortality. This particular EHR had a disease management module designed specifically for renal dialysis patients that could provide more specific medical guidelines and better data mining to potentially improve medical care.

The study suggested that mortality was lower compared to a pre-implementation period and compared to a national renal dialysis registry. It is likely that healthcare is only starting to see the impact of EHRs on quality. Based on internal data Kaiser Permanente determined that the drug Vioxx had an increased risk of cardiovascular events before that information was published based on its own internal data. Similarly, within 90 minutes of learning of the withdrawal of Vioxx from the market, the Cleveland Clinic queried its EHR to see which patients were on the drug. Within seven hours they deactivated prescriptions and notified clinicians via e-mail. Quality reports are far easier to generate with an EHR compared to a paper chart that requires a chart review. Quality reports can also be generated from a data warehouse or health information organization that receives data from an EHR and other sources. Quality reports are the backbone for healthcare reform which are discussed further in another chapter.

Public expectations

According to a 2006 Harris Interactive Poll for the Wall Street Journal Online, 55% of adults thought an EHR would decrease medical errors; 60% thought an EHR would reduce healthcare costs and 54% thought that the use of an EHR would influence their decision about selecting a personal physician.

The Center for Health Information Technology would argue that EHR adoption results in better customer satisfaction through fewer lost charts, faster refills and improved delivery of patient educational material. Patient portals that are part of EHRs are likely to be a source of patient satisfaction as they allow patients access to their records with multiple other functionalities such as online appointing, medication renewals, etc.

Governmental expectations

EHRs are considered by the federal government to be transformational and integral to healthcare reform. As a result, EHR reimbursement is a major focal point of the HITECH Act. It is the goal of the US Government to have an interoperable electronic health record by 2014. In addition to federal government support, states and payers have initiatives to encourage EHR adoption. Many organizations state that healthcare needs to move from the cow path to the information highway. CMS is acutely aware of the potential benefits of EHRs to help coordinate and improve disease management in older patients.

Financial savings

The Center for Information Technology Leadership (CITL) has suggested that ambulatory EHRs would save $44 billion yearly and eliminate more than $10 in rejected 43 claims per patient per outpatient visit. This organization concluded that not only would there be savings from eliminated chart rooms and record clerks; there would be a reduction in the need for transcription. There would also be fewer callbacks from pharmacists with electronic prescribing. It is likely that copying, faxing and mail expenses, chart pulls and labor costs would be reduced with EHRs, thus saving full time equivalents (FTEs). More rapid retrieval of lab and x-ray reports results in time/labor saving as does the use of templates. It appears that part of the savings is from improved coding. More efficient patient encounters mean more patients could be seen each day. Improved savings to payers from medication management is possible with reminders to use the drug of choice and generics. It should be noted that this optimistic financial projection assumed widespread EHR adoption, health information exchange, interoperability and change in workflow.

EHRs should reduce the cost of transcription if clinicians switch to speech recognition and/or template use. Because of structured documentation with templates, they may also improve the coding and billing of claims. It is not known if EHR adoption will decrease malpractice, hence saving physician and hospital costs. A 2007 Survey by the Medical Records Institute of 115 practices involving 27 specialties showed that 20% of malpractice carriers offered a discount for having an EHR in place. Of those physicians who had a malpractice case in which documentation was based on an EHR, 55% said the EHR was helpful.

Technological advances

The timing seems to be right for electronic records partly because the technology has evolved. The internet and World Wide Web make the application service provider

(ASP) concept for an electronic health record possible. An ASP option means that the EHR software and patient data reside on a remote web server that users can access via the internet from the office, hospital or home. Computer speed, memory and bandwidth have advanced such that digital imaging is also a reality, so images can be part of an EHR system. Personal computers (PCs), laptops and tablets continue to add features and improve speed and memory while purchase costs drop. Wireless and mobile technologies permit access to the hospital information system, the electronic health record and the internet using a variety of mobile technologies.

The chapter on health information exchange will point out that health information organizations can link EHRs together via a web-based exchange, in order to share information and services.

Need for aggregated data

In order to make evidence based decisions, clinicians need high quality data that should derive from multiple sources: inpatient and outpatient care, acute and chronic care settings, urban and rural care and populations at risk. This can only be accomplished with electronic health records and discrete structured data. Moreover, healthcare data needs to be combined or aggregated to achieve statistical significance. Although most primary care is delivered by small practices, it is difficult to study because of relatively small patient populations, making aggregation necessary. For large healthcare organizations, there will be an avalanche of data generated from widespread EHR adoption resulting in “big data” requiring new data analytic tools.

Need for integrated data

Paper health records are standalone, lacking the ability to integrate with other paper forms or information. The ability to integrate health records with a variety of other services and information and to share the information is critical to the future of healthcare reform. Digital, unlike paper-based healthcare information can be integrated with multiple internal and external applications:

 Ability to integrate for sharing with health information organizations (another chapter)

 Ability to integrate with analytical software for data mining to examine optimal treatments, etc.

 Ability to integrate with genomic data as part of the electronic record. Many organizations have begun this journey. There is more information in the chapter on bioinformatics

 Ability to integrate with local, state and federal governments for quality reporting and public health issues

 Ability to integrate with algorithms and artificial intelligence. Researchers from the Mayo Clinic were able to extract Charlson Comorbidity determinations from EHRs, instead of having to conduct manual chart reviews

EHR is a transformational tool

It is widely agreed that US Healthcare needs reform in multiple areas. To modernize its infrastructure healthcare would need to have widespread adoption of EHRs. Large organizations such as the Veterans Health Administration and Kaiser Permanente use

46 robust EHRs (VistA and Epic) that generate enough data to change the practice of medicine.

In 2009 Kaiser Permanente reported two studies, one pertaining to the management of bone disease (osteoporosis) and the other chronic kidney disease. They were able to show that with their EHR they could focus on patients at risk and use all of the tools available to improve disease management and population health. In another study reported in 2009 Kaiser-Permanente reported that electronic visits that are part of the electronic health record system were likely responsible for a 26.2% decrease in office visits over a four-year period. They posited that this was good news for a system that aligns incentives with quality, regardless whether the visit was virtual or face-to-face. Other fee-for-service organizations might find this alarming if office visits decreased and e-visits were not reimbursed. Kaiser also touts a total joint registry of over 100,000 patients with data generated from its universal EHR.

As a result of their comprehensive EHR (KP HealthConnect) and visionary leadership they have seen improvement in standardization of care, care coordination and population health. They also have been able to experience advanced EHR data analytics with their Virtual Data Warehouse, use of artificial intelligence and use of computerized simulation models (Archimedes). In addition, they have begun the process of collecting genomic information for future linking to their electronic records.

Need for coordinated care

According to a Gallup poll it is very common for older patients to have more than one physician: no physician (3%), one physician (16%), two physicians (26%), three physicians (23%), four physicians (15%), five physicians (6%) and six or more physicians

(11%). Having more than one physician mandates good communication between the primary care physician, the specialist and the patient. This becomes even more of an issue when different healthcare systems are involved. O’Malley et al. surveyed 12 medical practices and found that in-office coordination was improved by EHRs but the technology was not mature enough to improve coordination of care with external physicians.

Electronic health records are being integrated with health information organizations (HIOs) so that inpatient and outpatient patient-related information can be accessed and shared, thus improving communication between disparate healthcare entities. Home monitoring (tele-homecare) can transmit patient data from home to an office’s EHR also assisting in the coordination of care. It will be pointed out in a later section that coordination of care across multiple medical transitions is part of Meaningful Use.

HEALTH INFORMATION MANAGEMENT

Health information management (HIM) is information management applied to health and health care. It is the practice of acquiring, analyzing and protecting digital and traditional medical information vital to providing quality patient care. With the widespread computerization of health records, traditional (paper-based) records are being replaced with electronic health records (EHRs). The tools of health informatics and health information technology are continually improving to bring greater efficiency to information management in the health care sector.

Both hospital information systems and health human resources information systems (HRHIS) are common implementations of HIM.

Health information management professionals plan information systems, develop health policy, and identify current and future information needs. In addition, they may apply the science of informatics to the collection, storage, analysis, use, and transmission of information to meet legal, professional, ethical and administrative records-keeping requirements of health care delivery. They work with clinical, epidemiological, demographic, financial, reference, and coded healthcare data. Health information administrators have been described to "play a critical role in the delivery of healthcare in the United States through their focus on the collection, maintenance and use of quality data to support the information-intensive and information-reliant healthcare system".

The World Health Organization (WHO) stated that the proper collection, management and use of information within healthcare systems “will determine the system’s effectiveness in detecting health problems, defining priorities, identifying innovative solutions and allocating resources to improve health outcomes.”

Records

 The patient health record is the primary legal record documenting the health care services provided to a person in any aspect of the health care system. The term includes routine clinical or office records, records of care in any health related setting, preventive care, lifestyle evaluation, research protocols and various clinical databases. This repository of information about a single patient is generated by

health care professionals as a direct result of interaction with a patient or with individuals who have personal knowledge of the patient.

 The primary patient record is the record that is used by health care professionals while providing patient care services to review patient data or document their own observations, actions, or instructions.

 The secondary patient record is a record that is derived from the primary record and contains selected data elements to aid non clinical persons in supporting, evaluating and advancing patient care. Patient care support refers to administration, regulation, and payment functions.

Methods to ensure Data Quality

The accuracy of data depends on the manual or computer information system design for collecting, recording, storing, processing, accessing and displaying data as well as the ability and follow- through of the people involved in each phase of these activities. Everyone involved with documenting or using health information is responsible for its quality. According to AHIMA’s Data Quality Management Model, there are four key processes for data:

1. Application: the purpose for which the data are collected. 2. Collection: the processes by which data elements are accumulated. 3. Warehousing: the processes and systems used to store and maintain data and data journals. 4. Analysis: the process of translating data into information utilized for an application.

Each aspect is analyzed with 10 different data characteristics:

1. Accuracy: Data are the correct values and are valid. 2. Accessibility: Data items should be easily obtainable and legal to collect. 3. Comprehensiveness: All required data items are included. Ensure that the entire scope of the data is collected and document intentional limitations. 4. Consistency: The value of the data should be reliable and the same across applications. 5. Currency: The data should be up to date. A datum value is up to date if it is current for a specific point in time. It is outdated if it was current at some preceding time yet incorrect at a later time. 6. Definition: Clear definitions should be provided so that current and future data users will know what the data mean. Each data element should have clear meaning and acceptable values. 7. Granularity: The attributes and values of data should be defined at the correct level of detail. 8. Precision: Data values should be just large enough to support the application or process. 9. Relevancy: The data are meaningful to the performance of the process or application for which they are collected. 10. Timeliness: Timeliness is determined by how the data are being used and their context.

HOME HEALTH CARE SOFTWARE

Home health care software sometimes referred to as home care software or home health software falls under the broad category of health care information technology (HIT).

HIT is “the application of information processing involving both computer hardware and software that deals with the storage, retrieval, sharing, and use of health care information, data, and knowledge for communication and decision making” Home health software is designed specifically for companies employing home health providers, as well as government entities who track payments to home health care providers.

Types of software

There are clinical and non-clinical applications of home health care software. Including types such as agency software, hospice solutions, clinical management systems, telehealth solutions, and electronic visit verification. Depending on the type of software used, companies can track health care employee visits to patients, verify payroll, and document patient care. Governments can also use home health care software to verify visits from providers who bill them for services. Use of some software is mandated by government agencies such as OASIS assessment information that must be transmitted electronically by home health care providers.

Agency software

Agency software is used by home health care providers for office use and is a subset of medical practice management software used by inpatient clinics and doctors’ offices. Agency software is used for billing, paying vendors, staff scheduling, and maintaining records associated with the business.

Agency software can be standalone or part of software packages, that include electronic visit verification to track hours of employees and time spent on home visits and patient care. Agency software can be purchased or leased through various vendors.

Electronic visit verification

Electronic visit verification (often referred to as EVV) is a method used to verify home healthcare visits to ensure patients are not neglected and to cut down on fraudulently documented home visits. EVV monitors locations of caregivers, and is mandated by certain states, including Texas and Illinois. Other states do not mandate it, but use it as part of its Medicaid fraud oversight, created by the passing of the Affordable Care Act in 2010. It is also widely used by employers of home healthcare providers to verify employee's locations and hours of work as well as document patient care.

Outcome and assessment information set (OASIS)

Home health care providers that participate in Medicaid are required to report specific data about patient care known as Outcome and Assessment Information Set-C (OASIS-C). Data includes health status, functional status, and support system information. The data is used to establish a measurement of patient home health care options. Home

53 health care software allows health care providers to obtain and transmit such data while on location with a patient.

Data collection is mandated by the Centers for Medicare and Medicaid Services, a division of the United States Department of Health and Human Services. Software for collecting and transmitting data is free through CMM and can also be purchased through private vendors as an add-on to other home health care software.

DIAGNOSIS & SURGERY

Medical diagnosis (abbreviated DS or Dx) is the process of determining which disease or condition explains a person's symptoms andsigns. It is most often referred to as diagnosis with the medical context being implicit. The information required for diagnosis is typically collected from a history and physical examination of the person seeking medical care. Often, one or more diagnostic procedures, such as diagnostic tests, are also done during the process. Sometimes Posthumous diagnosis is considered a kind of medical diagnosis.

Diagnosis is often challenging, because many signs and symptoms are nonspecific. For example, redness of the skin (erythema), by itself, is a sign of many disorders and thus doesn't tell the healthcare professional what is wrong. Thus differential diagnosis, in which several possible explanations are compared and contrasted, must be performed.

This involves the correlation of various pieces of information followed by the recognition and differentiation of patterns. Occasionally the process is made easy by a sign or symptom (or a group of several) that is pathognomonic.

Diagnosis is a major component of the procedure of a doctor's visit. From the point of view of statistics, the diagnostic procedure involves classification.

History and etymology

The first recorded examples of medical diagnosis are found in the writings of Imhotep (2630-2611 BC) in ancient Egypt (the Edwin Smith Papyrus). A Babylonian medical textbook, the Diagnostic Handbook written by Esagil-kin- apli (fl.1069-1046 BC), introduced the use of empiricism, logic and rationality in the diagnosis of an illness or disease. Traditional Chinese Medicine, as described in the Yellow Emperor's Inner Canon or Huangdi Neijing, specified four diagnostic methods: inspection, auscultation-olfaction, interrogation, and palpation. Hippocrates was known to make diagnoses by tasting his patients' urine and smelling their sweat.

The plural of diagnosis is diagnoses. The verb is to diagnose, and a person who diagnoses is called a diagnostician. The word diagnosis /daɪ.əɡˈnoʊsᵻs/ is derived through Latinfrom the Greek word διάγνωσις from διαγιγνώσκειν, meaning "to discern, distinguish".

Medical diagnosis or the actual process of making a diagnosis is a cognitive process. A clinician uses several sources of data and puts the pieces of the puzzle together to make a diagnostic impression. The initial diagnostic impression can be a broad term describing a category of diseases instead of a specific disease or condition. After the initial diagnostic

55 impression, the clinician obtains follow up tests and procedures to get more data to support or reject the original diagnosis and will attempt to narrow it down to a more specific level. Diagnostic procedures are the specific tools that the clinicians use to narrow the diagnostic possibilities.

Diagnostic procedures

A diagnosis, in the sense of diagnostic procedure, can be regarded as an attempt at classification of an individual's condition into separate and distinct categories that allow medical decisions about treatment and prognosis to be made. Subsequently, a diagnostic opinion is often described in terms of a disease or other condition, but in the case of a wrong diagnosis, the individual's actual disease or condition is not the same as the individual's diagnosis.

A diagnostic procedure may be performed by various health care professionals such as a physician, physical therapist, optometrist, healthcare scientist, chiropractor, dentist, podiatrist, nurse practitioner, or physician assistant. This article uses diagnostician as any of these person categories.

A diagnostic procedure (as well as the opinion reached thereby) does not necessarily involve elucidation of the etiology of the diseases or conditions of interest, that is, what caused the disease or condition. Such elucidation can be useful to optimize treatment, further specify the prognosis or prevent recurrence of the disease or condition in the future.

Diagnostic opinion

However, a diagnosis can take many forms. It might be a matter of naming the disease, lesion, dysfunction or disability. It might be a management-naming or prognosis- naming exercise. It may indicate either degree of abnormality on a continuum or kind of abnormality in a classification. It’s influenced by non-medical factors such as power, ethics and financial incentives for patient or doctor. It can be a brief summation or an extensive formulation, even taking the form of a story or metaphor. It might be a means of communication such as a computer code through which it triggers payment, prescription, notification, information or advice. It might be pathogenic or salutogenic. It’s generally uncertain and provisional.

Indication for diagnostic procedure

The initial task is to detect a medical indication to perform a diagnostic procedure. Indications include:

 Detection of any deviation from what is known to be normal, such as can be described in terms of, for example, anatomy (the structure of the human body), physiology (how the body works), pathology (what can go wrong with the anatomy and physiology), psychology (thought and behavior) and human homeostasis (regarding mechanisms to keep body systems in balance). Knowledge of what is normal and measuring of the patient's current condition against those norms can assist in determining the patient's particular departure from homeostasis and the degree of departure, which in turn can assist in quantifying the indication for further diagnostic processing.

 A complaint expressed by a patient.

 The fact that a patient has sought a diagnostician can itself be an indication to perform a diagnostic procedure. For example, in a doctor's visit, the physician may already start performing a diagnostic procedure by watching the gait of the patient from the waiting room to the doctor's office even before she or he has started to present any complaints.

Even during an already ongoing diagnostic procedure, there can be an indication to perform another, separate, diagnostic procedure for another, potentially concomitant, disease or condition. This may occur as a result of an incidental finding of a sign unrelated to the parameter of interest, such as can occur in comprehensive tests such as radiological studies like magnetic resonance imaging or blood test panels that also include blood tests that are not relevant for the ongoing diagnosis.

Additional types of diagnosis

Sub-types of diagnoses include:

Clinical diagnosis

A diagnosis made on the basis of medical signs and patient-reported symptoms, rather than diagnostic tests

Laboratory diagnosis

A diagnosis based significantly on laboratory reports or test results, rather than the physical examination of the patient. For instance, a proper diagnosis of infectious

58 diseases usually requires both an examination of signs and symptoms, as well as laboratory characteristics of the pathogen involved.

Radiology diagnosis

A diagnosis based primarily on the results from medical imaging studies. Greenstick fractures are common radiological diagnoses.

Principal diagnosis

The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment. Many patients have additional diagnoses.

Admitting diagnosis

The diagnosis given as the reason why the patient was admitted to the hospital; it may differ from the actual problem or from the discharge diagnoses, which are the diagnoses recorded when the patient is discharged from the hospital.

Differential diagnosis

A process of identifying all of the possible diagnoses that could be connected to the signs, symptoms, and lab findings, and then ruling out diagnoses until a final determination can be made.

Diagnostic criteria

Designates the combination of signs, symptoms, and test results that the clinician uses to attempt to determine the correct diagnosis. They are standards, normally published by international committees, and they are designed to offer the best sensitivity and specificity possible, respect the presence of a condition, with the state-of-the-art technology.

Prenatal diagnosis

Diagnosis work done before birth

Diagnosis of exclusion

A medical condition whose presence cannot be established with complete confidence from history, examination or testing. Diagnosis is therefore by elimination of all other reasonable possibilities.

Dual diagnosis

The diagnosis of two related, but separate, medical conditions or co-morbidities; the term almost always refers to a diagnosis of a serious mental illness and a substance addiction.

Self-diagnosis

The diagnosis or identification of a medical conditions in oneself. Self-diagnosis is very common and typically accurate for everyday conditions, such as headaches, menstrual, and head lice.

Remote diagnosis

A type of telemedicine that diagnoses a patient without being physically in the same room as the patient.

Nursing diagnosis

Rather than focusing on biological processes, a nursing diagnosis identifies people's responses to situations in their lives, such as a readiness to change or a willingness to accept assistance.

Computer-aided diagnosis

Providing symptoms allows the computer to identify the problem and diagnose the user to the best of its ability. Health screening begins by identifying the part of the body where the symptoms are located; the computer cross-references a database for the corresponding disease and presents a diagnosis.

Wastebasket diagnosis

A vague, or even completely fake, medical or psychiatric label given to the patient or to the medical records department for essentially non-medical reasons, such as to reassure the patient by providing an official-sounding label, to make the provider look effective, or to obtain approval for treatment. This term is also used as a derogatory label for disputed, poorly described, overused, or questionably classified diagnoses, such as pouchitis and senility, or to dismiss diagnoses that amount to over medicalization, such as the labeling of normal responses to physical hunger as reactive hypoglycemia.

Retrospective diagnosis

The labeling of an illness in a historical figure or specific historical event using modern knowledge, methods and disease classifications.

Over diagnosis

Over diagnosis is the diagnosis of "disease" that will never cause symptoms or death during a patient's lifetime. It is a problem because it turns people into patients unnecessarily and because it can lead to economic waste (overutilization) and treatments that may cause harm. Over diagnosis occurs when a disease is diagnosed correctly, but the diagnosis is irrelevant. A correct diagnosis may be irrelevant because treatment for the disease is not available, not needed, or not wanted.

COMPUTER-AIDED DIAGNOSIS

In radiology, computer-aided detection (CADe), also called computer-aided diagnosis (CADx), are procedures in medicine that assist doctors in the interpretation of medical images. Imaging techniques in X-ray, MRI, and Ultrasound diagnostics yield a great deal of information, which the radiologist has to analyze and evaluate comprehensively in a short time. CAD systems help scan digital images, e.g. from computed tomography, for typical appearances and to highlight conspicuous sections, such as possible diseases.

CAD is an interdisciplinary technology combining elements of artificial intelligence and computer vision with radiological image processing. A typical application is the detection of a tumor. For instance, some hospitals use CAD to support preventive medical check-ups in mammography (diagnosis of breast cancer), the detection of polyps in the colon, andlung cancer.

Computer-aided detection (CADe) systems are usually confined to marking conspicuous structures and sections. Computer-aided diagnosis (CADx) systems evaluate the conspicuous structures. For example, in mammography CAD highlights micro calcification clusters and hyperdense structures in the soft tissue. This allows the radiologist to draw conclusions about the condition of the pathology. Another application is CADq, which quantifies, e.g., the size of a tumor or the tumor's behavior in contrast medium uptake.Computer-aided simple triage (CAST) is another type of CAD, which performs a fully automatic initial interpretation and triage of studies into some meaningful categories (e.g. negative and positive). CAST is particularly applicable in emergency diagnostic imaging, where a prompt diagnosis of critical, life-threatening condition is required.

Although CAD has been used in clinical environments for over 40 years, CAD cannot and may not substitute the doctor, but rather plays a supporting role. The doctor (generally a radiologist) is always responsible for the final interpretation of a medical image.

Applications

CAD is used in the diagnosis of Pathological Brain Detection (PBD), breast cancer, lung cancer, colon cancer, prostate cancer, bone metastases, coronary artery disease, congenital heart defect, and Alzheimer's disease.

Pathological Brain Detection (PBD)

Chaplot et al. was the first to use Discrete Wavelet Transform (DWT) coefficients to detect pathological brains. Maitra and Chatterjee employed the Slantlet transform, which is an improved version of DWT. Their feature vector of each image is created by

64 considering the magnitudes of Slantlet transform outputs corresponding to six spatial positions chosen according to a specific logic.

In 2010, Wang and Wu presented a forward neural network (FNN) based method to classify a given MR brain image as normal or abnormal. The parameters of FNN were optimized via adaptive chaotic particle swarm optimization (ACPSO). Results over 160 images showed that the classification accuracy was 98.75%.

In 2011, Wu and Wang proposed using DWT for feature extraction, PCA for feature reduction, and FNN with scaled chaotic artificial bee colony (SCABC) as classifier.

In 2013, Saritha et al. were the first to apply wavelet entropy (WE) to detect pathological brains. Saritha also suggested to use spider-web plots. Later, Zhang et al. proved removing spider-web plots did not influence the performance. Genetic pattern search method was applied to identify abnormal brain from normal controls. Its classification accuracy was reported as 95.188%. Das et al. proposed to use Ripplet transform. Zhang et al. proposed to use particle swarm optimization (PSO). Kalbkhani et al. suggested to use GARCH model.

In 2014, El-Dahshan et al. suggested to use pulse coupled neural network. In 2015, Zhou et al. suggested to apply naive Bayes classifier to detect pathological brains.

Breast cancer

CAD is used in screening mammography (X-ray examination of the female breast). Screening mammography is used for the early detection of breast cancer. CAD is especially established in US and the Netherlands and is used in addition to human evaluation, usually by a radiologist. The first CAD system for mammography was 65 developed in a research project at the University of Chicago. Today it is commercially offered by iCAD and Hologic.

There are currently some non-commercial projects being developed, such as Ashita Project, a gradient-based screening software by Alan Hshieh, as well. However, while achieving high sensitivities, CAD systems tend to have very low specificity and the benefits of using CAD remain uncertain. Some studies suggest a positive impact on mammography screening programs, but others show no improvement. A 2008 systematic review on computer-aided detection in screening mammography concluded that CAD does not have a significant effect on cancer detection rate, but does undesirably increase recall rate (i.e. the rate of false positives). However, it noted considerable heterogeneity in the impact on recall rate across studies.

Procedures to evaluate mammography based on magnetic resonance imaging exist too.

Lung cancer (bronchial carcinoma)

In the diagnosis of lung cancer, computed tomography with special three- dimensional CAD systems are established and considered as gold standard. At this a volumetric dataset with up to 3,000 single images is prepared and analyzed. Round lesions (lung cancer, metastases and benign changes) from 1 mm are detectable. Today all well- known vendors of medical systems offer corresponding solutions.

Early detection of lung cancer is valuable. The 5-year-survival-rate of lung cancer has stagnated in the last 30 years and is now at approximately just 15%. Lung cancer takes more victims than breast cancer, prostate cancer and colon cancer together. This is due to the asymptomatic growth of this cancer. In the majority of cases it is too late for a

66 successful therapy if the patient develops first symptoms (e.g. chronic croakiness or hemoptysis). But if the lung cancer is detected early (mostly by chance), there is a survival rate at 47% according to the American Cancer Society. At the same time the standard x- ray-examination of the lung is the most frequently x-ray examination with a 50% share. Indeed, the random detection of lung cancer in the early stage (stage 1) in the x-ray image is difficult. It is a fact that round lesions vary from 5–10 mm are easily overlooked. The routine application of CAD Chest Systems may help to detect small changes without initial suspicion. Philips was the first vendor to present a CAD for early detection of round lung lesions on x-ray images.

Colon cancer

CAD is available for detection of colorectal polyps in the colon. Polyps are small growths that arise from the inner lining of the colon. CAD detects the polyps by identifying their characteristic "bump-like" shape. To avoid excessive false positives, CAD ignores the normal colon wall, including the haustral folds. In early clinical trials, CAD helped radiologists find more polyps in the colon than they found prior to using CAD.

Coronary artery disease

CAD is available for the automatic detection of significant (causing more than 50% stenosis) coronary artery disease in coronary CT angiography (CCTA) studies. A low false positives rate (60-70% specificity per patient) allows using it as a computer-aided simple triage (CAST) tool distinguishing between positive and negative studies and yielding a preliminary report. This, for example, can be used for chest pain patients' triage in an emergency setting.

Congenital heart defect

Early detection of pathology can be the difference between life and death. CADe can be done by auscultation with a digital stethoscope and specialized software, also known as Computer-aided auscultation. Murmurs, irregular heart sounds, caused by blood flowing through a defective heart, can be detected with high sensitivity and specificity. Computer is sensitive to external noise and bodily sounds and requires an almost silent environment to function accurately.

Alzheimer's disease

CADs can be used to identify subjects with Alzheimer's and mild cognitive impairment from normal elder controls.

In 2014, Padma et al. used combined wavelet statistical texture features to segment and classify AD benign and malignant tumor slices. Zhang et al. found kernel support vector machine decision tree had 80% classification accuracy, with an average computation time of 0.022s for each image classification.

Eigenbran is a novel brain feature that can help to detect AD. The results showed polynomial kernel SVM achieved accuracy of 92.36±0.94, sensitivity of 83.48±3.27, specificity of 94.90±1.09, and precision of 82.28±2.78. The polynomial KSVM performs better than linear SVM and RBF kernel SVM.

Nuclear medicine

CADx is available for nuclear medicine images. Commercial CADx systems for the diagnosis of bone metastases in whole-body bone scans and coronary artery disease in myocardial perfusion images exist.

COMPUTER-ASSISTED SURGERY

Technology is revolutionizing the medical field with the creation of robotic devices and complex imaging. Though these developments have made operations much less invasive, robotic systems have their own disadvantages that prevent them from replacing surgeons. Minimally invasive surgery is a broad concept encompassing many common procedures that existed prior to the introduction of robots, such as laparoscopic cholecystectomy or gall bladder excisions. It refers to general procedures that avoid long cuts by entering the body through small (usually about 1cm) entry incisions, through which surgeons use long-handled instruments to operate on tissue within the body. Such operations are guided by viewing equipment (i.e. endoscope) and, therefore, do not necessarily need the use of a robot. However, it is not incorrect to say that computer- assisted and robotic surgeries are categories under minimally invasive surgery.

Both computer-assisted and robotic surgeries have similarities when it comes to preoperative planning and registration. Because a surgeon can use computer simulation

69 to run a practice session of the robotic surgery beforehand, there is a close tie between these two categories and this may explain why some people often confuse them as interchangeable. However, their main distinctions lie in the intraoperative phase of the procedure: robotic surgeries may use a large degree of computer assistance, but computer-assisted surgeries do not use robots.

Computer-assisted surgery (CAS), also known as image-guided surgery, surgical navigation, and 3-D computer surgery, is any computer-based procedure that uses technologies such as 3D imaging and real-time sensing in the planning, execution and follow-up of surgical procedures. CAS allows for better visualization and targeting of sites as well as improved diagnostic capabilities, giving it a significant advantage over conventional techniques. Robotic surgery, on the other hand, requires the use of a surgical robot, which may or may not involve the direct role of a surgeon during the procedure.

Robotics

A robot is defined as a computerized system with a motorized construction (usually an arm) capable of interacting with the environment. In its most basic form, it contains sensors, which provide feedback data on the robot’s current situation, and a system to process this information so that the next action can be determined. One key advantage of robotic surgery over computer-assisted is its accuracy and ability to repeat identical motions.

A robot is a computer controlled mechanical system with anthropomorphic (human-like) characteristics. In essence, most are extenders of the human arm with vast manipulative capabilities that can utilized to extend and amplify, but not take over, the

70 many functions of the human hands. Robotics has become the most exciting and promising arena where our ancient art couples onto the digital vehicle on the information superhighway. Much touted as the likely successors of the industrial revolution, robots had to wait in the aisles until computers came of age.

With vast computing powers at their command, designers have now turned their attention on the potential benefits of robotic technology to surgical practice. Two systems the Zeus® and da Vinci® have been licensed for use by the FDA in the United States of America.

There are six main valuable areas in which robotics are of interest to surgery:

Augmentation of the surgeon’s arm

Akin to providing the “third arm” for the surgeon, voice-controlled robotics can hold and manipulate endoscopes for the surgeon. A lot of work was done in this regard by companies in collaboration with aerospace industry.

Enhanced dexterity

The robotic hand is more precise, dampening tremors, an unnecessary side effect of ageing among surgeons. They also show superior consistency in procedures where repeated precision is needed as in spinal canal surgery and modeling bone planes for orthopedic prosthetics insertion. Newer, exact-fitting orthopedic prostheses could now be tailor-made from 3-d CAT images of the intact contra-lateral side. The robotic arm does

71 not yet have as great a range of motion as the human arm but further refinement will soon correct this minor problem.

The last few years have witnessed great innovations in the miniaturization of computers. Advanced microchip and battery technologies have stimulated research into the applications of small robots capable of working in remote terrain. Nanotechnology, as this new field is called, has many possibilities for surgery. It is envisaged that Nano- robots will in the foreseeable future, be programmed to invade specific areas of the body and target diseased tissues, delivering cytotoxic agents to tumor beds and unclogging cerebral vessels of blood clots after a cerebrovascular accident.

The possibilities are many and the future is not as far as it may seem. Sometime ago, researchers at a British laboratory demonstrated an ingenious Nano-robotic gastrointestinal endoscope which, swallowed as a capsule, sends back pulses of clear pictures as it migrates down the digestive tract for many hours. It has since been successfully used in diagnostic imaging of the small bowel and miniaturized machines will be increasingly available for clinical use within this new decade.

Improved ergonomics

For once, the surgeon does not have to stand all through the duration of the surgery anymore. Rather, he can sit comfortably at a control and, through virtual reality, manipulate the robotic controls remotely to handle instruments and navigate successfully through delicate operations such as coronary bypass, cholecystectomy and endoscopic hernia repairs. This has vast applicability in telemedicine (vide infra)

Image guided positioning

Stereotaxis has enhanced success and safety of many surgical procedures. Through simulation in training of surgeons as well as in surgical planning, image-guided fine-needle aspiration biopsy and cytology of mammo-graphically detected small breast lumps are more precise and simpler. Endo-vascular ablation of berry aneurysm is demonstrably possible with robotic tracking and guidance. Elimination of hazards The surgical team may now be safely removed from hazardous irradiation and caustic chemicals while treating his patients. Robotic arms may safely place therapeutic radioactive rods in body tissues and cavities without exposing the surgeon to any harmful effects

Telemedicine

With an ever increasing speed of the Internet, it is now feasible to bridge distance barriers and perform various tasks remotely controlled robotic tools. This development has commanded much attention from military, navy submarine, nuclear facilities and space exploration programs. Tele-collaboration has been employed in surgery, with robotics enabling surgeons not physically present in the operating room to interactively take part in surgeries. It is hoped that shortage of specialist manpower experienced in third world countries will be addressed through this aspect of telemedicine.

Telemedicine is a fast-expanding application of computers in Medicare. It involves the instantaneous, two-way transmission of digitally encrypted medical data over telephone lines to vast distances across the globe. Thus doctors can hold teleconferences, exchanging text, picture, voice and video data. Cosmonauts aboard the permanently orbiting Spacelab have a full surgical capability backed by a ground team of specialists via telemedicine. It must be pointed out that these benefits are synergistic and not mutually

73 exclusive. Surgical utilization of these attributes often employ as many of these capabilities as possible.

Computer-assisted surgery (CAS) represents a surgical concept and set of methods, that use computer technology for surgical planning, and for guiding or performing surgical interventions. CAS is also known as computer-aided surgery, computer-assisted intervention, image-guided surgery and surgical navigation, but these are terms that are more or less synonymous with CAS. CAS has been a leading factor in the development of robotic surgery.

Applications

Computer-assisted surgery is the beginning of a revolution in surgery. It already makes a great difference in high-precision surgical domains, but it is also used in standard surgical procedures.

Computer-assisted neurosurgery

Tele-manipulators have been used for the first time in neurosurgery, in the 1980s. This allowed a greater development in brain microsurgery (compensating surgeon’s physiological tremor by 10-fold), increased accuracy and precision of the intervention. It also opened a new gate to minimally invasive brain surgery, furthermore reducing the risk of post-surgical morbidity by avoiding accidental damage to adjacent centers.

Computer-assisted oral and maxillofacial surgery

Bone segment navigation is the modern surgical approach in orthognathic surgery (correction of the anomalies of the jaws and skull), in temporo-mandibular joint (TMJ) surgery, or in the reconstruction of the mid-face and orbit.

It is also used in implantology where the available bone can be seen and the position, angulation and depth of the implants can be simulated before the surgery. During the operation surgeon is guided visually and by sound alerts. IGI (Image Guided Implantology) is one of the navigation systems which uses this technology.

Guided Implantology

New therapeutic concepts as guided surgery is being developed and applied in the placement of dental implants. The prosthetic rehabilitation is also planned and performed parallel to the surgical procedures. The planning steps are at the foreground and carried out in a cooperation of the surgeon, the dentist and the dental technician. Edentulous patients, either one or both jaws, benefit as the time of treatment is reduced.

Regarding the edentulous patients, conventional denture support is often compromised due to moderate bone atrophy, even if the dentures are constructed based on correct anatomic morphology.

Using cone beam computed tomography, the patient and the existing prosthesis are being scanned. Furthermore, the prosthesis alone is also scanned. Glass pearls of defined diameter are placed in the prosthesis and used as reference points for the upcoming planning. The resulting data is processed and the position of the implants determined. The surgeon, using special developed software, plans the implants based on 75 prosthetic concepts considering the anatomic morphology. After the planning of the surgical part is completed, a CAD/CAM surgical guide for dental placement is constructed. The mucosal-supported surgical splint ensures the exact placement of the implants in the patient. Parallel to this step, the new implant supported prosthesis is constructed.

The dental technician, using the data resulting from the previous scans, manufactures a model representing the situation after the implant placement. The prosthetic compounds, abutments, are already prefabricated. The length and the inclination can be chosen. The abutments are connected to the model at a position in consideration of the prosthetic situation. The exact position of the abutments is registered. The dental technician can now manufacture the prosthesis.

The fit of the surgical splint is clinically proved. After that, the splint is attached using a three-point support pin system. Prior to the attachment, irrigation with a chemical disinfectant is advised. The pins are driven through defined sheaths from the vestibular to the oral side of the jaw. Ligaments anatomy should be considered, and if necessary decompensation can be achieved with minimal surgical interventions. The proper fit of the template is crucial and should be maintained throughout the whole treatment. Regardless of the mucosal resilience, a correct and stable attachment is achieved through the bone fixation. The access to the jaw can now only be achieved through the sleeves embedded in the surgical template. Using specific burs through the sleeves the mucosa is removed. Every bur used, carries a sleeve compatible to the sleeves in the template, which ensures that the final position is achieved but no further progress in the alveolar ridge can take place. Further procedure is very similar to the traditional implant placement. The pilot hole is drilled and then expanded. With the aid of the splint, the implants are finally placed. After that, the splint can be removed.

With the aid of a registration template, the abutments can be attached and connected to the implants at the defined position. No less than a pair of abutments should be connected simultaneously to avoid any discrepancy. An important advantage of this technique is the parallel positioning of the abutments. A radiological control is necessary to verify the correct placement and connection of implant and abutment.

In a further step, abutments are covered by gold cone caps, which represent the secondary crowns. Where necessary, the transition of the gold cone caps to the mucosa can be isolated with rubber dam rings.

The new prosthesis corresponds to a conventional total prosthesis but the basis contains cavities so that the secondary crowns can be incorporated. The prosthesis is controlled at the terminal position and corrected if needed. The cavities are filled with a self-curing cement and the prosthesis is placed in the terminal position. After the self- curing process, the gold caps are definitely cemented in the prosthesis cavities and the prosthesis can now be detached. Excess cement may be removed and some corrections like polishing or under filling around the secondary crowns may be necessary. The new prosthesis is fitted using a construction of telescope double cone crowns. At the end position, the prosthesis buttons down on the abutments to ensure an adequate hold.

At the same sitting, the patient receives the implants and the prosthesis. An interim prosthesis is not necessary. The extend of the surgery is kept to minimum. Due to the application of the splint, a reflection of soft tissues in not needed. The patient experiences less bleeding, swelling and discomfort. Complications such as injuring of neighboring structures are also avoided. Using 3D imaging during the planning phase, the communication between the surgeon, dentist and dental technician is highly supported

77 and any problems can easily be detected and eliminated. Each specialist accompanies the whole treatment and interaction can be made. As the end result is already planned and all surgical intervention is carried according to the initial plan, the possibility of any deviation is kept to a minimum. Given the effectiveness of the initial planning the whole treatment duration is shorter than any other treatment procedures.

Computer-assisted ENT surgery

Image-guided surgery and CAS in ENT commonly consists of navigating preoperative image data such as CT or cone beam CT to assist with locating or avoiding anatomically important regions such as the optical nerve or the opening to the frontal sinuses. For use in middle-ear surgery there has been some application of robotic surgery due to the requirement for high-precision actions.

Computer-assisted orthopedic surgery (CAOS)

The application of robotic surgery is widespread in orthopedics, especially in routine interventions, like total hip replacement. It is also useful in pre-planning and guiding the correct anatomical position of displaced bone fragments in fractures, allowing a good fixation by osteosynthesis. Early CAOS systems include the HipNav, OrthoPilot, and Praxim.

Computer-assisted visceral surgery

With the advent of computer-assisted surgery, great progresses have been made in general surgery towards minimal invasive approaches. Laparoscopy in abdominal and gynecologic surgery is one of the beneficiaries, allowing surgical robots to perform routine operations, like colecystectomies, or even hysterectomies. In cardiac surgery, shared 78 control systems can perform mitral valve replacement or ventricular pacing by small thoracotomies. In urology, surgical robots contributed in laparoscopic approaches for pyeloplasty or nephrectomy or prostatic interventions.

Computer-assisted radiosurgery

Radiosurgery is also incorporating advanced robotic systems. CyberKnife is such a system that has a lightweight linear accelerator mounted on the robotic arm. It is guided towards tumor processes, using the skeletal structures as a reference system (Stereotactic Radiosurgery System). During the procedure, real time X-ray is used to accurately position the device before delivering radiation beam. The robot can compensate for respiratory motion of the tumor in real-time.

Advantages

CAS starts with the premise of a much better visualization of the operative field, thus allowing a more accurate preoperative diagnostic and a well-defined surgical planning, by using surgical planning in a preoperative virtual environment. This way, the surgeon can easily assess most of the surgical difficulties and risks and have a clear idea about how to optimize the surgical approach and decrease surgical morbidity. Science of designing user interaction with equipment and work places to fit the user. During the operation, the computer guidance improves the geometrical accuracy of the surgical gestures and also reduce the redundancy of the surgeon’s acts. This significantly improves ergonomy in the operating theatre, decreases the risk of surgical errors and reduces the operating time.

Disadvantages

There are several disadvantages of computer-assisted surgery. A major disadvantage of this system is their cost. With a price tag of a million dollars, their cost is nearly prohibitive. Some people believe that improvements in technology, such as haptics, increased processor speeds, and more complex and capable software will increase the cost of these systems. Another disadvantage is the size of these systems. These systems have relatively large footprints and relatively cumbersome robotic arms. This is an important disadvantage in today's already crowded-operating rooms. It may be difficult for both the surgical team and the robot to fit into the operating room. Another factor that is stunting the development of robotic surgery is that of “latency” which is the time delay between the instructions issued by the surgeon and the movement of the robot which responds to the instructions. With the current level of technology, the surgeon must be in close proximity.

MEDICAL RESEARCH

Biomedical research (or experimental medicine) is in general simply known as medical research. It is the basic research, applied research, or translational research conducted to aid and support the development body of knowledge in the field of medicine.

An important kind of medical research is clinical research, which is distinguished by the involvement of patients. Other kinds of medical research include pre-clinical research, for example on animals, and basic medical research, for example in genetics.

Both clinical and pre-clinical research phases exist in the pharmaceutical industry's drug pipelines, where the clinical phase is denoted by the term clinical trial. However, only part of the whole of clinical or pre-clinical research is oriented towards a specific pharmaceutical purpose. The need for understanding, diagnostics, medical devices and non-pharmaceutical therapies means that medical research is much bigger than just trying to make new drugs.

The most basic medical research is a rapidly evolving area that owes much to basic biology and is given names such as Human Biosciences by universities.

A new paradigm to biomedical research is being termed translational research, which focuses on iterative feedback loops between the basic and clinical research domains to accelerate knowledge translation from the bedside to the bench, and back again. Medical research may involve doing research into public health, biochemistry, clinical research, microbiology, physiology, oncology, surgery and

82 research into many other non-communicable diseases such as diabetes and cardiovascular diseases.

The increased longevity of humans over the past century can be significantly attributed to advances resulting from medical research. Among the major benefits of medical research have been vaccines for measles and polio, insulin treatment for diabetes, classes of antibiotics for treating a host of maladies, medication for high blood pressure, improved treatments for AIDS, statins and other treatments for atherosclerosis, new surgical techniques such as microsurgery, and increasingly successful treatments for cancer. New, beneficial tests and treatments are expected as a result of the Human Genome Project. Many challenges remain, however, including the appearance of antibiotic resistance and the obesity epidemic.

Most of the research in the field is pursued by biomedical scientists, however significant contributions are made by other biologists, as well as chemists and physicists. Medical research, done on humans, has to strictly follow the medical ethics as sanctioned in the Declaration of Helsinki and elsewhere. In all cases, the research ethics has to be respected.

Patient Management

 Health care clinicians and administrators alike are showing enthusiasm for one of the medical field's newest technological trends: patient information management systems. These electronic systems serve as a database for storing patient files. Information can be easily added, changed, deleted, printed or audited by clicking a few buttons on the computer. Doctors do not have to store or carry around

health records any longer, because all they need is access to a computer or laptop to pull up patient information.

Scheduling

 When a patients call a health care facility to make an appointment, the representative who answers the phone can schedule them through the use of a computer appointment scheduling system. These electronic systems allow front office staff to add, delete or change appointments with the click of a mouse. If there is more than one doctor in a clinic, schedules can be sorted by doctor, as well as be color-coded to indicate when a doctor has availability.

Medical Claims

 Computers are what health care companies are using to submit, review, process and pay medical claims, according to a 2006 article by the Healthcare Financial Management Association. Health technology trends indicate that more and more companies are relying on computers to submit their claims, rather than submitting them via hard copy, because computers expedite the process. Information management engineers have created systems and technology tools that make the claims process of the medical field more efficient and easy to use.

Imaging

 Computers are being broadly utilized in the radiology realm of health care, according to CMT Medical Technologies. Technology advancements have led to

more sophisticated ways of taking X-rays and performing imaging services. Imaging technology could not be done without computers. Computers allow radiologists and technicians to study and print the final images.

Communication

 Because so much information is stored on computer networks, health care employees rely on the electronic transmittal of patient information by way of computers. In hospital settings, one department can use a computer to transmit a patient's X-ray results or lab work to another department. A 2010 update by the Healthcare Information and Management Systems Society explains that health care professionals rely on computers and information systems to enhance the provision of medical services through the sharing of information.

CHAPTER FOUR

FINDINGS/DISCUSSION

At the introduction, some questions were asked and will be asked again in other to clarify the effect of computer to medicine.

How has computers improved quality of care and documented that quality?

How can computers improve medical education?

What are the disadvantages of computer use in medicine?

Does the use of computer in medicine has more merits to demerits? If yes,

Of what use has it been? How?

These questions are critical as it would be able to know the real effect of computer in the medical field. During the course of this explanation, we have categorically expatiated the use of computer and we have seen it has more advantages to the disadvantages

Although the inventors of the computer could not have conceptualized the grand scale of its vast influence in human life, practitioners in diverse realms such as arts, humanities, weather- forecasting, deep-sea fishing and industry now increasingly turn to its awesome power. The field of surgery has not been left out and has gone beyond the realms of simple record keeping and word processing. Contrary to expectations,

86 computers are still years behind human capabilities at “thinking”, an advanced form of informed reasoning such as doctors use in making diagnoses and formulating treatment.

CHAPTER FOUR

CONCLUSION

In this book we have summarized the most important directions and areas of computer sciences application in medical services and technologies. We have also presented our contribution in such important and fascinating from scientific point of view field. Our work is mainly concentrated on two- three- and four dimensional image data: image processing and recognition (classification tasks), semantic interpretation, as well as visualization and user interfaces.

The one of remarkable research trends in this area is adaptation of existing state of the art methods and developing new algorithms in the way to make them suitable to mobile or low power consumption devices by using hardware optimization, web technologies and novel easy to learn and reliable interfaces. Also our up to date researches are concentrated in this area mainly on gesture recognition applied in medical system navigation.

The field of use of computer methods in medicine is very wide and surely will grow in near future with development of new diagnostic methods that mainly generate digitalized information that has to be processed by software or hardware algorithms. Also people quickly get use to new technologies like web and mobile applications, and in our opinion it is a matter of time while mobile applications will be used to for every day contact with chronically ill people that do not have to be under continuous observation in hospital. However, it should be remembered that no computer program can replace the face-to-face contact of doctor with his or her patient.

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