Kun, L., Baretich, M.F.

Biocomputing
The Electrical Engineering Handbook
Ed. Richard C. Dorf
Boca Raton: CRC Press LLC, 2000
2000 by CRC Press LLC
117
BIocompufIng
117.1 Clinical Infoimation Systems
Computei-Based Recoid Clinical Infoimation
Standaids Bedside Teiminals/Point-of-Caie Systems Imaging
and the CIS Systems Integiation Smait/Optical Caids
117.2 Hospital Infoimation Systems
The Clinical Enviionment Healthcaie Codes and Standaids
117.1 C!inica! Inlurmatiun Systems
Iu Kun
The main objective of this section is to piovide the ieadei with a summaiy of aieas that ielate to clinical
infoimation systems. Since this feld is so wide, the following topics will be coveied mainly because of theii
impoitance within the feld of medical infoimatics and the impact that these aieas will have in healthcaie
deliveiy in the neai futuie. At the end of this section theie is a list of defnitions that should help the ieadei
not used to ielated acionyms and a list of suggested bibliogiaphic iefeiences which should allow those inteiested
to fuithei inciease theii knowledge.
Cumputer-Based Recurd
Besides impiovements in patient caie, enhancing the pioductivity of physicians, nuises, and all healthcaie-
ielated peisonnel is veiy high on the agenda of all hospitals. Hospitals, clinics, HMOs, doctois` offces, emei-
gency caie centeis, gioup piactices, laboiatoiies, iadiology clinics, and nuising homes among otheis have a
need to shaie patients` iecoids. Aside fiom the diiection that all of these medical-ielated centeis will have with
a iequiied connection to the insuiance companies/agencies to speed up payments and theii accuiacy, the
giowing need is to have the ability to tiansfei patients` medical fles electionically anywheie in the woild. As
medical centeis become moie competitive, they will become woildwide centeis of excellence foi theii given
specialties. In tuin then, theii seivices will be maiketed to the entiie woild population, becoming tiue global
iesouices.
The tiend of conveiting hospitals into papeiless hospitals" is becoming one of the most impoitant topics
of the 1990s. In 1970, chaiteied by the National Academy of Sciences, the Institute of Medicine woiking undei
the Policy Matteis foi Public Health has actively puisued the cieation of a computei-based iecoid (CBR). In
July of 1991 a book was published by the Institute of Medicine in iegaids to the CBR. The iequiiements to
compile an all-digital medical iecoid (ADMR)will iequiie ways to combine data, giaphics, voice, signals, and
images, both clinical and document. The aichitectuie that will accommodate all these foims of infoimation
foi captuiing, stoiing, communicating, and displaying is extiemely complex. Some of the technologies involved
include optical fbeis, LANs, compact/optical disks, bedside teiminals, medical image display stations, image
diagnostic woikstations, and pictuie aichival and communications systems to name a few.
The High Peifoimance Computing and Communications Initiative (HPCCI) was signed into law in Decem-
bei of 1991. Although most of the emphasis foi this initiative was fiom a ieseaich and academic sense, some
LuIs Kun
CedorSno Medco| Cenrer
Naffhev !. BarefIch
Inverry of Co|orodo
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of the tiue piactical values of these highways of infoimation will occui at the clinical level. While advances aie
taking place in diffeient paits of the woild in fghting diseases such as cancei, AIDS, heait disease, cystic fbiosis,
Alzheimei`s, Paikinson`s, Gauchei`s, and malignant hypeitheimia, not shaiing the knowledge leained by all the
gioups would be a teiiible undeiutilization of extiemely costly iesouices, causing duplication of effoit and
enoimous waste of time and iesouices.
The foui technologies that have been consideied ciitical by the National Institutes of Health foi the coming
yeais aie moleculai medicine, vaccine development, stiuctuial biology, and biotechnology. The foui will gieatly
be affected by the HPCCI. Finally, the integiation of all medical-ielated infoimation will be the most complex
task that the healthcaie aiena will face this decade.
C!inica! Inlurmatiun Standards
One of the most demanding and key aieas foi successfully integiating the hospital infoimation system (HIS)
with the clinical infoimation systems (CIS) fiom multiple clinical depaitments and/oi clinical aieas deals with
clinical infoimation standaids. Two of the diiving foices behind the automation of the patient iecoid deal with
national conceins ielated to healthcaie costs and quality of healthcaie. These conceins have geneiated demand
foi managed caie. The automated patient iecoid could then be one of the vehicles to achieve managed caie.
Clinical infoimation standaids aie constantly evolving. They weie developed (some aie still in the piocess
of development; e.g., IEEE/MIB P1073) by veiy diffeient sets of iequiiements. What follows is a biief desciiption
and stiuctuie of most of these standaids.
Cummunicatiuns]Sturage [e.g., HL]7, IEEE]MEDIX P1157, ANSI ASC X12, ACR]NEMA,
IEEE]MIB P1073)
The HL/7 standaids gioup aimed to defne vendoi-independent communications standaids among components
of hospital infoimation systems. The IEEE, ANSI, ACR/NEMA, and ASTM have been veiy active in cieating
standaids thiough subcommittees fiom oiganizations within. As an example, ASTM has the following Health-
caie Automation Committees (E31.XX):
E31.10: Computei automation in the Hospital Phaimacy
E31.11: Data exchange standaids foi Clinical Laboiatoiy iesults
E31.12: Medical Infoimatics
E31.13: Clinical Laboiatoiy Systems
E31.14: Clinical Laboiatoiy Instiument Inteiface
E31.15: Health Knowledge Repiesentation
The MEDIX mission was to establish a iobust and exible communications standaid foi the exchange of
data between heteiogeneous healthcaie infoimation systems. The MIB was cieated mainly to allow the exchange
of data fiom medical instiumentation, e.g., monitoiing devices and hospital infoimation systems. Many of the
manufactuieis of these devices have piopiietaiy haidwaie, e.g., buses and/oi softwaie, which complicates this
exchange. Bedside teiminals in the intensive caie enviionment will beneft immensely fiom such a standaid,
since most hospitals` ICUs and CCUs have many vendois` equipment in theii units. To effectively integiate and
manage the data aie majoi goals of the MIB.
C!assihcatiun]Reimbursement [e.g., ICD, DRG, SNOMED, CPT, DSM, RCS, LMLS)
ICDs weie oiiginally used foi public health moibidity statistics; now in the United States they aie piimaiily
used foi ieimbuisement. Its stiuctuie is numbeied classifcation of diseases giouped by anatomical aieas. The
DRGs facilitate the defnition of case-mix foi hospital ieimbuisement. Its stiuctuie is multi-axial: seveiity of
illness, piognosis, tieatment diffculty, need foi inteivention, and iesouice intensity. SNOMED piovides
desciiption of pathological tests ielated to patient identifcation. It has foui axes: function (piimaiy symptoms),
etiology (cause of disease), moiphology (desciiption of disease foim), and topology (aiea of body). CPT is
piimaiily used foi ieimbuisement and utilization ieview. It deiives codes fiom specialty nomenclatuies divided
into chapteis: systemic (medicine, anesthesia, etc.), topological (caidiovasculai, lymphatic, etc.), and technological
2000 by CRC Press LLC
(iadiology, laboiatoiy, etc.). DSM piovides consistent abbieviations foi piesciiption and administiative use. It
facilitates psychiatiic education and ieseaich. Its stiuctuie is multi-axial: clinical syndiomes, developmental
and peisonality disoideis, physical disoidei, seveiity psychological stiesses, and global assessment functioning.
RCS is a compiehensive nomenclatuie and classifcation of medical teims foi computeiized iecoids. UMLS
facilitates the unifcation of clinical data classifcation systems into a single unifed medical language system.
It will also facilitate the cieation of data into compatible automated patient iecoid systems. Its stiuctuie
ieconciles clinical teiminology, semantics, and foimats of the majoi clinical coding and iefeience systems.
Knuv!edge [e.g., ARDEN SYNTAX)
The ARDEN SYNTAX is a standaid foi shaiing medical knowledge bases in the foim of medical logic modules
(MLM). Its stiuctuie is deiived fiom the HELP (LDS Hospital) and the CARE (Regenstiief MC) systems. The
MLMs accommodate aleits, management ciitiques, theiapy suggestions, diagnosis scoiing, etc. Each MLM is
limited to the knowledge to make a single decision.
HCFA [e.g., LCDS, WARP, LHDDS)
UCDS piovides an electionic clinical data set that Medicaie can use to peifoim clinical quality ieviews. The
quality evaluation is done by using algoiithms ielated to suigical pioceduies, disease specifc, oigan specifc,
dischaige status and disposition, etc. The UCDS peimits the hospital to entei the data into a peisonal computei;
then this infoimation can be sent electionically to the HCFA. WARP piovides an epidemiologic appioach to
quality assuiance. It hopes to oveicome about 50% of ICD miscoding and its initial focus is on ambulatoiy
chait ieview iathei than ieal-time patient caie. It is not a diagnostic oi pioceduial classifcation system. It
basically piovides a model foi encoding clinical infoimation. It is an object-oiiented case tool. UHDDS was
cieated foi studies on quality of caie and fiaud. It is also used foi auditing Medicaie and Medicaid subsystems.
Bedside Termina!s]Puint-ul-Care Systems
Patient infoimation is geneiated on an ongoing basis, wheievei the patient may be. Almost two decades ago
with the cieation of the fist piogiammable calculatois, a tiend staited in teims of calculating hemodynamic
vaiiables in the OR, etc. This appioach was impioved with the cieation of peisonal computeis, ending with
the development of what aie now called bedside teiminals. Companies such as Clinicom, Emtek, Hewlett-
Packaid, Hospitionics, and Spacelabs offei systems that can go fiom doing simply patient monitoiing, to a
complete data acquisition, data management, and data analysis system that incoipoiates in some cases diagnosis
and tieatment theiapy.
Fiom the patients` point of view, it is ciitical to integiate theii demogiaphic infoimation with theii clinical
data. Usually the HIS contains all the ADT, oideis, laboiatoiy, phaimacy, etc. while the CIS may be moie of a
depaitmental system such as ICU/CCU, which contains hemodynamic vaiiables, i.e., blood piessuie, stioke
volume, heait iate, etc. Both systems need to coexist. Point-of-caie systems, many times known as bedside
teiminals, include both geneial med/suigeiy and the ICU/CCU type. The geneial type include functions such
as patient assessment, nuising diagnosis, patient caie plans, kaidex, dischaige planning, dischaige summaiy,
medication administiation iecoid, I/O, vital signs, activities of daily living, patient classifcation/acuity, etc. The
ICU/CCU systems in addition contain infoimation iegaiding diug administiation, uid analysis, hemodynamic
analysis (i.e., blood gas iepoit, ECG, blood piessuies, pulse oximeteis, caidiac output), iespiiatoiy analysis
(i.e., ventilatoi data, O
2
/CO
2
analyzei), and ieal-time monitoiing. Today`s tiends aie incoipoiating imaging
devices in both at the iegulai nuising stations, at the opeiating iooms, and at the iecoveiy ioom/ICU/CCU.
The motivation is to incoipoiate all patients` infoimation and have it available wheievei they may be. As a
patient moves fiom a iegulai bed to the OR, back to an ICU, and latei to a iegulai nuising station, the electionic
iecoid follows the patient. The one big diffeience with papei chaits is that the electionic iecoid can be shaied
simultaneously within and outside the institution.
Having the ability to look at electionic images in all of these locations not only opens the doois foi
consultation within the institution but also with outside institutions and/oi expeit individuals.
2000 by CRC Press LLC
Imaging and the CIS
Imaging plays two veiy impoitant ioles within the context of a computei-based iecoid (CBR). Document
imaging allows foi all those iecoids that exist today in stoiage foi the medical iecoids depaitments to be scanned
and incoipoiated electionically with the iest of the patient`s cuiient iecoids existing in the HIS and CIS. The
second iole is fiom the peispective of clinical images. Most imaging expeits will call this PACS, which stands
foi pictuie aichival and communications system and is mostly associated with the Radiology Depaitment of
the hospital. We can view clinical images as a foim of data which can be geneiated in any depaitment.
Some of these typical clinical depaitments utilizing clinical images aie iadiology, caidiology (e.g., echocai-
diogiaphy, uoioscopic techniques, cine cameias, 3D modeling, gamma cameias), oithopedic suigeiy, plastic
suigeiy, obstetiics/gynecology, laboiatoiies (e.g., genetics, chiomosome analysis, cytology, hematology, clinical
chemistiy, pathology, histology, election micioscope), maxillofacial clinics, spoits medicine, and oncology (e.g.,
iadiation theiapy, chemotheiapy), emeigency iooms, intensive caie units, etc.
Theie aie fve imaging modalities: x-iay, magnetic iesonance imaging (MRI), computei tomogiaphy (CT),
nucleai medicine (NM), and ultiasound (US). These modalities cieate images which aie veiy diffeient not only
in medical teims but in theii size and content. As a iesult, theie aie thiee main aieas undei PACS which aie
ciitical in succeeding with such systems: communications (i.e., netwoik, tiansmission piotocol, and image
foimat), aichiving (i.e., database and stoiage media), and image piocessing (i.e., display, usei inteiface, and IP
algoiithms).
Systems Integratiun
As an example of systems integiation in the emeigency caie enviionment (see Fig. 117.1), fiom an infoimation-
ow point of view we see the following:
FIGURE 117.1 An example of medical systems integiation.
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1. Infoimation coming and going to the HIS, e.g., laboiatoiy, phaimacy, oideis, etc.
2. Infoimation going to outpatient clinics foi iefeiiing seivices, admissions to the hospital, oi even to the
patient`s physician at home.
3. In the emeigency ioom, the utilization of an intensive caie type of bedside teiminal allowing data
collection, analysis and management, and also the ability to view clinical images in the ER.
4. Fiom a consulting point of view, the whole electionic patient iecoid, undei an integiated diagnostic
system, allows foi any (depaitment) consulting physician within oi outside the hospital to ieview the case.
Smart]Optica! Cards
Smait/optical caids piovide a wide iange of applications in the medical feld. The patient, the piovidei (e.g.,
physician, dentist, etc.), the hospital, and the insuiei can all beneft fiom such a caid. The caid will eventually
contain all data foims-voice, text, giaphics, clinical images, document images, signals, and data values collected
fiom medical instiumentation. Besides patient identifcation/demogiaphics, medical histoiy, medications, allei-
gies, and insuiance veiifcation, the system could contain the patient`s pictuie, fngeipiint, digital signatuie,
voice signatuie, and even genetic/blood infoimation foi secuiity ieasons.
The patient is admitted and tieatment is piovided moie quickly, histoiical infoimation is moie accuiate,
and peisonal physicians and specialists can be consulted moie quickly. Less testing may be a diiect iesult, and
fastei diagnosis is accomplished. Since infoimation needs to be enteied only once, patients do not need to iely
on theii memoiy, paiticulaily in emeigency situations.
The hospital identifes the patient and accesses all the medical iecoids infoimation fiom multiple depaitments
moie quickly. It needs fewei staff to fnd iecoids fiom the hospital/clinics (even fiom othei institutions), and
this could ieduce the length of stay.
The piovidei is bettei infoimed foi a quickei diagnosis by getting all the available histoiy at admission and can
consult with the patient`s peisonal physician and specialist by having theii iespective phone numbeis. All piioi
iecoids fiom the same oi a diffeient set of institutions coexist in the caid. It also can ieduce exposuie to malpiactice.
The insuiei ieduces fiaudulent claims, ieduces costs foi data entiy, and has moie complete and accuiate
claims data. Also, by eliminating iedundant tests costs aie ieduced.
Most of the caids can be classifed into fve gioups by the type of technologies used: micioflm, magnetic
stiip, softstiip, chip, and lasei/optical. Micioflm is haid to change and can be damaged by both tempeiatuie
and humidity. Magnetic stiip contains little infoimation, appioximately 2K, and can be destioyed by electiic
and magnetic felds. The softstiip, because it is lasei piinted and optically iead, is diffcult to change infoimation
on. The chip caid has only up to 10K of stoiage and is veiy expensive. Finally, the lasei/optical caid allows foi
appioximately 1000 typed pages oi appioximately 4 Mb of memoiy and iequiies a iead/wiite device.
Some of the complexities that aie incoipoiated by using these types of technologies aie associated with the
access to the infoimation. Foi someone to be able to eithei iead" and/oi wiite" in the caid, it must possess
technologies compatible with the ones wheie the infoimation was cieated. It is a fundamental piinciple then
that a set of inteinational standaids will be cieated so that any hospital that iequiies access to the caid
infoimation can do so. Alieady the Inteinational Patient Caids Standaids Council, the Health Industiy Business
Communications Council (HIBCC), and the Smait Caid Applications and Technology (SCAT) have been
cieated. These gioups, among otheis, aie woiking towaids the goal of an inteinational set of standaids.
Theie is a laige set of companies that aie alieady maiketing diffeient types of caid technologies. Some
examples of piojects and/oi vendois include:
Affliated Healthcaie in Piinceton, New Jeisey, which maintains a Health Summaiy Database with a
Smait Caid.
CentiaHealth, a Floiida hospital netwoik with about 12K useis.
Clinicaid, a subsciiption seivice which piovides a softstiip, 3K, PC DOS caid that folds to a business
caid size.
Diexlei LaseiCaid fiom Mountain View, Califoinia, which has 4.1-Mb caid being tested by both Biitish
Telecom with a hospital gioup specializing in obstetiic patients and Bayloi College of Medicine in
Houston, Texas.
2000 by CRC Press LLC
Eltiax in St. Paul, Minnesota, which is associated with seveial HIS manufactuieis (Spectium, McDonald
Douglas, SMS, and Meditech) and piovides a magnetic stiip caid with about 900-chaiactei capacity.
IMSG/INFODYNE fiom Englewood, Coloiado, which has a medical infoimation caid on magnetic stiip
caiiying up to 600 chaiacteis.
IntelliScan fiom Ameiican Medical Data Coip. in Atlanta, Geoigia, which has infoimation stoied as 350
chaiacteis of ieadable text piinted on the top of the caid and up to 850 chaiacteis of detailed medical
infoimation optically encoded at the bottom. It is being used by hospitals in both Texas and Mississippi.
The caids aie customized to each hospital`s database.
Lifecaid, eaily pilot (1985) caid foi electionic claims piovided by Blue Cioss/Shield of Maiyland.
Medfist ciedit caid, combining both medical infoimation and fnancial ciedit, in test by Humana and
Discoveiy Caid.
Medi-Caid, a chip caid fiom MediData Systems in Allston, Massachusetts.
MedKey, fiom Biloxi Regional Medical Centei, Biloxi, Mississippi.
Medical Infoimation Systems, in St. Louis, Missouii, which has a micioflm caid that can contain up to
18 pages of infoimation, including signals, text, images, data, and coloi photos.
Ulticaid, a 64K RAM memoiy chip in a ciedit caid sized pack being tested in Houston at Bayloi and
Methodist hospitals.
Some of the caids aie being tested in diffeient countiies. Sweden, the leadei foi about 20 yeais, has been
using a patient caid which is issued at biith by the goveinment togethei with an ID numbei. Sweden has a
socialized medicine piogiam and it has been in theii best inteiest to develop unifoim standaids so that the
infoimation can be accessed by eveiy institution in the countiy. Belgium, Canada, Fiance, Gieat Biitain, Spain,
and Switzeiland all have seveial systems on tiial.
Acrunyms
ACR/NEMA: Ameiican College of Radiology/National Equipment Manufactuieis Association
ANSI ASC X12: Ameiican National Standaids Institute Acciedited Standaids Committee
ARDEN SYNTAX: Syntax foi Medical Logic Modules
ASTM: Ameiican Society foi Testing and Mateiials
CIS: Clinical Infoimation System
CPT: Cuiient Pioceduial Teiminology
DRG: Diagnostic Related Gioup
DSM: Diagnostic and Statistical Manual of Mental Disoideis
EDI: Electionic Data Inteichange
HCFA: Healthcaie Financing Administiation
HIS: Hospital Infoimation System
HL/7: Health Level/7
ICD: Inteinational Classifcation of Diseases
IDS: Integiated Diagnostic System
IEEE: Institute of Electiical and Electionics Engineeis
IEEE/MEDIX P1157: Medical Data Inteichange
IEEE/MIB P1073: Medical Infoimation Bus
OSI: Open Systems Inteiconnection
RCS: Read Classifcation System
SNOMED: Systemized Nomenclatuie of Medicine
UCDS: Unifoim Clinical Data Set
UHDDS: Unifoim Hospital Dischaige Data Set
UMLS: Unifed Medical Language System
WARP: Wisconsin Ambulatoiy Review Pioject
2000 by CRC Press LLC
Re!ated Tupics
97.1 Intioduction 117.2 Hospital Infoimation Systems
Relerences
Bedside Termina!s]Puint-ul-Care
W. Donovan and S. Coiiales, T|e Boo| on BeJsJe Comung, Long Beach, Calif.: Inside Healthcaie Computing,
1991.
L. Kun, The use of a peisonal computei foi patient-condition-tieatment in a CUU/ICU enviionment," IEEE
Transatons on BomeJta| Engneerng, vol. BME-30, no. 8, August 1983.
L. Kun, Rapid assessment of hemodynamic caidioiespiiatoiy function foi the ciitically ill with a peisonal
computei," IEEE Transatons on BomeJta| Engneerng, vol. BME-30, no. 8, August 1983.
D. O`Boyle, G. Feiheii, and R. Gough, T|e Buyer's CuJe o BeJsJe Comuer Sysems, Rockville, Md.: National
Repoit of Computeis & Health, 1991.
M.M. Shabot et al., Rapid bedside computation of caidioiespiiatoiy vaiiables with a piogiammable calculatoi,"
Crta| Care MeJ., vol. 5, p. 105, 1977.
C!assihcatiun Systems Standards
C. Chute, Tutoiial 19: Clinical data iepiesentation," in ProteeJngs o[ SCMC 91, Novembei 1991.
B. Humphieys, Bu|Jng |e UnfeJ MeJta| Language Sysem, Bethseda, Md.: National Libiaiy of Medicine,
1989.
Cummunicatiuns Standards
J. Haiiington, IEEE/EMBS P1158, Medical Data Inteichange (MEDIX) oveiview and status iepoit," in Pro-
teeJngs o[ SCMC 90, Novembei 1990.
National Electiical Manufactuieis Association, Digital Imaging and Communications," ACR-NEMA Standaids
Publication No. 300-1988, 1988.
R.E. Noiden-Paul, IEEE Pioposed Standaid 1073, Medical Infoimation Bus: An Intioduction and Piogiess
Repoit," in ProteeJngs o[ |e 9| nnua| Con[erente o[ |e IEEE-EMBS, vol. 2, MIB Symposium, Boston,
pp. 1209-1211, 1987.
Knuv!edge Base Standards
The ARDEN SYNTAX foi medical logic modules," in ProteeJngs o[ SCMC 90, Novembei 1990.
Emeiging standaids foi medical logic," in ProteeJngs o[ SCMC 90, Novembei 1990.
C!inica! Imaging]PACS
Y. Kim and F.A. Spelman, Eds., Images of the twenty-fist centuiy," in ProteeJngs o[ |e nnua| Inernaona|
IEEE-EMBS, vol. 11, pait 2, tiack 2, Imaging, pp. 345-630; Tiack 23, Pictuie Aichiving and Communi-
cations Systems, pp. 775-793, 1989.
L. Kun, Imaging and the clinical infoimation system," in ProteeJngs o[ '91 Inernaona| Vor|s|o on MeJta|
Imagng, Koiea Institute of Science and Technology, Seoul, Koiea.
Cumputerized Medica! Recurd
M. Ball and M. Collin, Eds., sets o[ |e Comuer-BaseJ Paen RetorJ, New Yoik: Spiingei-Veilag, 1992.
J. Blaii, Oveiview of clinical infoimation iepiesentation and standaid oiganization," in ProteeJngs o[ |e Fa||
92 ECHO Meeng, Palm Beach, Calif., 1992.
2000 by CRC Press LLC
Institute of Medicine, Comuer-BaseJ Paen RetorJ, Washington, D.C.: National Academy Piess, 1991.
C.J. McDonald et al., The benefts of automated medical iecoid systems foi ambulatoiy caie," in ProteeJngs
o[ |e Comuer |taons n MeJta| Care Con[erente, New Yoik: IEEE Computei Society, pp. 157-171,
Octobei 1986.
W.W. Stead et al., Piacticing nephiology with a computeiized medical iecoid," KJney In., vol. 24, pp. 446-454,
1983.
Q.E. Whiting-O`Keefe et al., A computeiized summaiy medical iecoid system can pioduce moie infoimation
than the standaid medical iecoid," in ProteeJngs o[ MeJIn[o '86, Washington, D.C., 1986.
High-Perlurmance Cumputing and Cummunicatiuns, [HPCC)
D.A. Biomley, The Fedeial High-Peifoimance Computing Piogiam," Washington, D.C.: Executive Offce of
the Piesident, Offce of Science and Technology Policy, 1989.
National High-Peifoimance Computei Technology Act," Congiessional Recoid, U.S. Senate 101st Congiess,
Fiist Session 5/18/89, Washington, D.C.
Smart]Optica! Cards
HanJ|oo| o[ Ota| Memory Sysems. Bi-monthly updating seivice. Boston: Medical Recoids Institute.
ProteeJngs o[ |e 1J| nnua| Inernaona| Con[erente IEEE/EMBS, Tiack 21: Session 5, Medical Infoimatics
V: Optical and Smait Caids, Oilando, Fla., pp. 1387-1392, Octobei 1991.
1989 Smar CarJ InJusry Dretory, Palo Alto, Calif.: Palo Alto Management Inc., 1989.
117.2 Huspita! Inlurmatiun Systems
Morr|ev . orerc|
What does an electiical engineei need to know to be pait of a team designing and implementing a hospital
infoimation system: Foi the most pait, the necessaiy skills aie those iequiied to design and implement any
compiehensive infoimation system in a complex oiganization. Hospitals do, howevei, have unique chaiactei-
istics that must be taken into account. These chaiacteiistics aie desciibed in the following pages.
The C!inica! Envirunment
Hospitals aie, indeed, complex oiganizations. They peifoim a vital function (patient caie) but aie subject to
stiict iegulation and opeiate undei seveie fnancial constiaints. Quality of patient caie is the highest value, but
a competitive maiketplace demands effcient opeiation. Hospital infoimation systems iange fiom nonexistent
to antique to state-of-the-ait.
Hospitals aie highly piofessionalized. Each piofessional gioup has a paiticulai aiea of expeitise and a unique
peispective iegaiding the healthcaie deliveiy system. Hospital administiatois aie much like administiatois of
othei oiganizations. Recent giaduates essentially have standaid MBA (Mastei of Business Administiation)
degiees with some extent of healthcaie specialization. Howevei, many administiatois in positions of authoiity
ieceived MHA (Mastei of Hospital Administiation) degiees fiom piogiams moie closely affliated with medical
schools than with business schools.
Hospitals also have laige clinical staffs which include nuises and technologists (who aie hospital employees)
and medical doctois (who aie usually not hospital employees). Clinicians aie educated in the biological and
medical sciences, and theii piepaiation geneially includes a laige component of piactical expeiience in the
hospital as well as theoietical study in the classioom. As hospital employees, nuises and technologists (iespi-
iatoiy, laboiatoiy, etc.) aie pait of the administiative stiuctuie of the hospital. Medical doctois (physicians and
suigeons), on the othei hand, aie pait of a sepaiate medical staff stiuctuie that is laigely independent of the
hospital`s administiative stiuctuie. Howevei, medical doctois contiol the admission and dischaige of the
hospital`s patients, and many hospital activities aie the iesult of medical oideis foi patient seivices.
2000 by CRC Press LLC
The numbei of hospital employees with an engineeiing backgiound is limited. Foi the electiical engineei
who is involved in the implementation of a hospital infoimation system, hospital-based technical suppoit may
include an infoimation systems depaitment and a clinical engineeiing (oi biomedical engineeiing) depaitment.
The following aspects of the healthcaie deliveiy system aie woithy of study by an electiical engineei woiking
in the clinical enviionment:
The healthcaie deliveiy system in the United States Williams and Toiiens, 1984]
The oiganizational stiuctuie of hospitals Goldbeig and Buttaio, 1990]
The chaiacteiistics of hospital infoimation systems Austin, 1988; Minaid, 1991]
With this backgiound infoimation the electiical engineei will be bettei piepaied to tianslate the conceins of
hospital administiatois and clinicians into the technical specifcations of the hospital infoimation system.
Hea!thcare Cudes and Standards
The healthcaie deliveiy system is a highly iegulated industiy. Numeious goveinmental and nongoveinmental
oiganizations have established codes and standaids intended to piomote safe and effective patient caie. Although
theie can be signifcant diffeiences in the iegulatoiy enviionment fiom one hospital to anothei, the majoi codes
and standaids aie ielatively unifoim.
The National Electrical Code (NFPA 70), piomulgated by the National Fiie Piotection Association (NFPA:
Quincy, Massachusetts) applies to hospitals. Specifcally, Aiticle 517 deals with Health Caie Facilities." A moie
focused document, howevei, is the SanJarJ [or Hea|| Care Fat|es (NFPA 99). The most accessible foimat
foi this infoimation is the NFPA`s Hea|| Care Fat|es HanJ|oo| Klein, 1990] which includes the full text of
NFPA 99 as well as inteipietive and explanatoiy mateiial.
Many of the healthcaie-ielated piovisions of the electiical code aie based on two conceins. Fiist, many
patients in suigeiy and intensive caie depend on electiical equipment foi life suppoit. Such equipment ianges
fiom heait-lung bypass devices to mechanical ventilatois. Theiefoie, much attention is devoted to ensuiing the
availability of electiical powei in the event that the piimaiy powei distiibution system fails. A hospital infoi-
mation system that piovides life-suppoit functions may be subject to these piovisions.
Second, because of the use of invasive medical pioceduies, many patients aie consideied to be electiically
susceptible." Undei ceitain conditions, electiical cuiients on the oidei of micioampeies can cause ventiiculai
fbiillation, a potentially fatal disiuption of noimal caidiac function. Theiefoie, the NFPA and othei oigani-
zations have established stiict standaids foi giounding, leakage" cuiient, and othei electiical paiameteis. These
standaids apply to devices and cabling in patient-caie locations of the hospital.
The Joint Commission on Accreditation of Healthcare Organizations (Chicago, Illinois) is anothei majoi
souice of standaids affecting hospitals. The JCAHO`s ttreJaon Manua| [or Hosa|s JCAHO, 1993] coveis
the entiie spectium of hospital activities. Puisuit of JCAHO accieditation is voluntaiy but, in piactice, essentially
all hospitals seek accieditation to ensuie eligibility foi ieimbuisement undei ceitain goveinmental piogiams.
At piesent, JCAHO standaids include little iefeience to infoimation systems. Howevei, this is expected to change
and, theiefoie, familiaiity with the latest edition of the ttreJaon Manua| [or Hosa|s is advisable.
Anothei standaid unique to the healthcaie system is Health Level 7 (HL7) which is a data communications
piotocol intended to facilitate the inteifacing of vaiious components in a hospital infoimation system Walkei,
1989]. These components iange fiom accounting systems (fnancial data) to clinical laboiatoiy infoimation
systems (laboiatoiy test iesults) to medical iecoids systems (documentation of patient caie seivices) to patient
data management systems (physiological data). In the iecent past, each such component was independent and
geneially incompatible with othei components. Howevei, to achieve high quality in patient caie at the lowest
cost, both administiatois and clinicians need integiated, compiehensive access to a wide vaiiety of infoimation.
HL7 is an attempt to specify the types of data (and theii foimats) to be shaied within a hospital infoimation
system. Foi example, if all components of the system use a common foimat foi a patient`s name, then it is
possible foi a single database queiy to gathei all data iegaiding that patient. This also allows automation of
ceitain activities such as billing (thiough the accounting system) foi laboiatoiy tests oideied by clinicians
(thiough the clinical laboiatoiy system). Unfoitunately, HL7 has not achieved its piomise but it does iepiesent
a signifcant step away fiom the chaotic past Bond et al., 1990].
2000 by CRC Press LLC
Summary
The electiical engineei will be only one of many piofessionals involved in the implementation of a hospital
infoimation system. Successful paiticipation in this team will depend on moie than the electiical engineeiing
skills that aie applicable to any infoimation system pioject. The ciitical success factoi is an undeistanding of
the hospital-the people (clinicians and administiatois), theii objectives (low cost and high quality), and the
enviionment within which they woik.
Dehning Terms
HL7: A data communications piotocol foi inteifacing components of a hospital infoimation system.
JCAHO: The Joint Commission on Accieditation of Healthcaie Oiganizations, an oiganization that piomul-
gates standaids affecting hospital opeiations.
NEC: The National Electiical Code, an NFPA standaid that is commonly adopted by goveinmental units and,
theiefoie, having the foice of law.
NFPA: The National Fiie Piotection Association, an oiganization that piomulgates standaids affecting elec-
tiical systems in hospitals.
Re!ated Tupics
94.1 Databases 117.1 Clinical Infoimation Systems
Relerences
C.J. Austin, In[ormaon Sysems [or Hea|| Sertes Jmnsraon, 3id ed., Ann Aiboi, Mich.: Health Admin-
istiation Piess, 1988.
V. Bond, J. Lenahan, and W. Wagnei, HL7: A piactical peispective," Hea||tare In[ormats, vol. 7, no. 10, p.46,
1990.
A.J. Goldbeig and R.A. Buttaio, Eds., Hosa| Dearmena| Prof|es, 3id ed., Chicago: Ameiican Hospital
Publishing, 1990.
JCAHO, ttreJaon Manua| [or Hosa|s, 1993 ed., Chicago: Joint Commission on Accieditation of Healthcaie
Oiganizations, 1993.
B.R. Klein, Ed., Hea|| Care Fat|es HanJ|oo|, 3id ed., Quincy, Mass.: National Fiie Piotection Association,
1990.
B. Minaid, Hea|| Care Comuer Sysems [or |e 1990s, Ann Aiboi, Mich.: Health Administiation Piess, 1991.
J.M. Walkei, Integiating infoimation systems with HL7," Hosa|s, vol. 63, no. 13, p. FB60, 1989.
S.J. Williams and P.R. Toiiens, InroJuton o Hea|| Sertes, 2nd ed., New Yoik: John Wiley & Sons, 1984.
Further Inlurmatiun
Many of the majoi piofessional societies dealing with computei science and engineeiing have healthcaie-ielated
divisions. Fuithei infoimation can be obtained fiom each piofessional society.
The Healthcaie Infoimation and Management Systems Society is a division of the Ameiican Hospital
Association that deals with infoimation systems, telecommunications, and management engineeiing. Foi fui-
thei infoimation contact the Ameiican Hospital Association, Chicago, Illinois.
Majoi peiiodicals that focus on hospital infoimation systems include Naona| Reor on Comuers anJ
Hea|| and Hea||tare In[ormats. These publications, and othei healthcaie-ielated liteiatuie, can be found in
the libiaiies of academic medical centeis.