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Women’s Health Informatics WorkshopAOFOG/RANZCOG 2009

Introduction and Outline of Workshop

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Who are we?

• Dr Dave Parry: Senior Lecturer in Computer Science at AUT. Developed first online teaching course in New Zealand.

• Dr Emma Parry: Consultant O&G at ACH. MD in the area of Induction of Labour & HI.

• Dr Phurb Dorji: Consultant O&G in Thimphu, Bhutan. Co-developer open source Perinatal Database

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Programme

• What is health informatics ?• How is the workshop organised

?• What do I have to do ?

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What is Health Informatics ?

• “Medical Informatics (MI) is the study of information processing as it is used in healthcare. “ MIT

• Medical informatics is the scientific field that deals with the storage, retrieval, sharing, and optimal use of biomedical information, data, and knowledge for problem solving and decision making. – Colombia

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Health/Medical/Nursing ?

• Healthcare has a strong tradition of attaching importance to names – see HPCA http://www.moh.govt.nz/hpca

• Health tends to be broader than “medical” and not imply that Doctors do it…

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Useful information sources

• HINZ – www.hinz.org.nz• IMIA - http://www.imia.org/• Health IT cluster :http://www.

healthit.org.nz/• NZHIS: http://www.nzhis.govt.nz/• HISAC: http://www.hisac.govt.nz/• HISA (Australia)-

http://www.hisa.org.au/

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What does Health Informatics include ?

• Electronic Health data• Knowledge Management• Decision support• Telemedicine and telecare• Standards• Evidence for benefit/harm

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Health informatics is important..

• It’s a “Grand Challenge”http://www.engineeringchallenges

.org/cms/8996/8938.aspx• $142-$371 billion savings in US ?• Academically rich area:

– Expert systems (MYCIN)– Ontologies (UMLS)– Messaging (HL7)

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Programme

• What is health informatics ?• How is the workshop organised

?• What do I have to do ?

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Outline

• 14:00 Intro and complete MCQ• 14:15 Maternity data and perinatal

databases• 14:30 Coding and Messaging• 14:45 Internet• 15:00 Security• 15:15 Panel Discussion and

Questions

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Programme

• What is health informatics ?• How is the workshop organised ?• What do I have to do ?

– MCQs: RANZCOG 5 PR&CRM points– Play along with your laptop if you

have• Login:• Password:

– Go Home and think BIG!

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Maternity data and Perinatal Databases

Emma Parryemmap@adhb.govt.nz

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The Health record

• Records information about people in terms of:– Results of tests and clinical

examinations– Encounters with health

professionals– Potential diagnoses– Plans for treatment and further

testing

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Problems with paper

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Problems with paper

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Definition of an electronic health record

Pubmed “Computer-based systems for input, storage, display, retrieval, and printing of information contained in a patient's medical record. “

Part of a clinical information system relating to individuals

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Electronic Health Record

Laboratory resultsAdministration Systems

Imaging (including PACS)

Clinical users

Government and provider statistics

Other health care providers

Etc.

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Electronic Health Record

Laboratory systemsAdministration

Systems

Imaging (including PACS)

Clinical users

Middleware e.g. Web Portal

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Advantages of electronic

• Always available• Different views

– Temporal, problem based

• Audit and decision support• Security

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Problems• Free text vs. coding• Legal status• Need a computer• “fishing expeditions”• Maternity unique:

– New identifier for fetus– Multiple pregnancy– Subsequent pregnancy– Cross link with partner, other children

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Cottagemedhttp://www.sysmex.co.nz/default.asp?pageid=9

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“Five uses of clinical data” (MOH)

Data collected should be available for:

• Supporting clinical intervention

• Clinical Governance

• Administration (in all parts of Health)

• Strategy and policy development

• Research

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The sixth use ?

• Patient (consumer) self-management and self care.

• http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1127483

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Decision support

• Use data from Electronic record, combine with rules

• Reminders – eg high blood pressure, protocols

• Decision Analysis – need utility values

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Web 2.0 Medical records

• Web 2.0 – user generated content- see later.

• Google http://googleblog.blogspot.com/2008/02/google-health-first-look.html

• Microsoft – health vault• http://healthvault.com/hvindex.htm?

rmproc=true

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Coding and Messaging

Dave ParryDave.parry@aut.ac.nz

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The central paradox

• Every patient is different…• BUT we want to compare

them..

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Medical vocabularies

• Complex in natural language• Can contain ambiguities and

circular references• Much of medical training

devoted to learning them

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Why standardise ?

• Synonyms and obsolescent terms

• (HTLVIII vs HIV)• Needed for clinical activity

– Communication– Data analysis– Coding !– Reminders etc.

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Early work

• Index Medicus (1850) leading onto MeSH and UMLS

• Read codes • LOINC (Standardised

pathology reporting)• SNOMED CT

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MeSHCode Description

C13 Female Genital Diseases and Pregnancy Complications

A16 Embryonic Structures

A01.673 Pelvis

A16.378 Fetus

A16.254 Embryo

A16.759 Placenta

A16.950 Zygote

A16.631 Ovum

C02.800 Sexually Transmitted Diseases

C13.371 Genital Diseases, Female

C13.703 Pregnancy Complications

E04.520 Obstetric Surgical Procedures

F03.600 Mood Disorders

F03.800 Sexual and Gender Disorders

G08.520 Reproduction

M01.438 Multiple Birth Offspring

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Systematized Nomenclature of Medicine-Clinical Terms -

SNOMED CT• >600,000K Concepts• SNOMED CT is a clinical vocabulary

currently administered by the international health terminology standards development organisation (IHTSDO) http://www.ihtsdo.org/. Member countries are; Australia, Canada, Denmark, Lithuania, The Netherlands, New Zealand, Sweden, United Kingdom and United States.

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SNOMED CT

• Hierarchical• Concepts also link concepts• Synonyms and different

languages• Free in member countries..

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Why use a vocabulary ? example…

• Pre-eclampsia• Gestational Proteinuric Hypertension• Toxaemia• GPH• PET• PE• All the same all map to.. pre-

eclampsia 398254007 -code

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Web: http://www.clinical-info.co.uk

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Why use it ?

• In EHR systems, to replace/enhance free text.

• To support reminders “If patient has allergy to a drug code recorded then alert if drug is being prescribed”

• Converting free text to coded data….

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Coding

• Disease outcomes, diagnoses, procedures have been coded for many years.

• Often Coding is used to describe outcomes – so it happens at the end of an episode.

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Examples of Codes• International Classification of disease (ICD)

currently version 10. WHO standard• http://www.who.int/classifications/icd/en/

ICD10 Code Description

O104.11 Pre-existing secondary hypertension complicating pregnancy, first trimester

O104.12 Pre-existing secondary hypertension complicating pregnancy, second trimester

O104.13 Pre-existing secondary hypertension complicating pregnancy, third trimester

O104.19 Pre-existing secondary hypertension complicating pregnancy, unspecified trimester

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Coding activity

• Often done by coders ! eg http://www.aacca.net • Identifies the casemix, and

often leads/follows funding• May not be particularly simple

or easy• Errors propagate…

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Other codes

• Diagnostic related groups (DRGS)– Used to determine funding– Groups ICD 10 codes

• Read codes– Primary care focussed– http://www.wolfbane.com/icd/

read3h.htm– More like a vocabulary– SNOMED to replace

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Messaging - HL 7

• Health level 7• Initial version going back to

1987 (http://www.hl7.org.za/patient/ch100005.htm)

• Extensive use around the world, and since 1994 in New Zealand

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Why messages ?

• No communication electronically at all – life is difficult

• Shared universal record – so far impossible c.f. connecting for health UK

• Messaging – send standard, relevant pieces of information between electronic systems.

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Pharmacy

Labs

GP

Hospital

Standard formats…avoids n*(n-1) problem

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General model

Unstructured text

Extract SNOMED terms

EHREHR

Map to ICD 10 Send/receive messages

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Take home

• Look for standards.. SNOMED, HL7, DICOM (Images), ICD-10

• Single definitive storage if possible, but communicate

• Fully automatic coding is difficult, Fully human coding is sometimes inaccurate

• Support the human coders – and its probably not you.

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Using the Internet to your Advantage

Emma Parryemmap@adhb.govt.nz

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History

• Internet started in 1960s – to protect networks in the case of nuclear warfare.

• World Wide Web – suggested in paper published in 1988.

• Browsers early 1990’s• 19.2 Billion webpages in 2005• Most users now access WWW via

mobile devices.

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Terminology

• The Internet• Operating Systems• Browser• Web pages• Web site• Web Server• Internet Provider• Dial up/ Broadband/ Wireless• Network card

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Uses for the Clinician

• How to manage purple tongue disease…– Pubmed– Expert pages eg Thefetus.net– Government and Institutional

sites– Individuals

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Google

• Google Search– Generic– Images– Scholar

http://scholar.google.co.nz/

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Web 2.0

• User-generated content• www.Facebook.com ,

www.Linkedin.com• www.youtube.com • http://www.youtube.com/watch?

v=BOttNyd9qgI• Discussion and support groups eg• http://www.nzord.org.nz/ (Rare

diseases)

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Wikipedia- www.wikipedia.org

• An online encyclopedia• Produced and edited by volunteers• Some topics more popular than others

– Movie Stars http://en.wikipedia.org/wiki/Kate_Winslet

– MFM– http://en.wikipedia.org/wiki/

Maternal_Fetal_Medicine• No Formal review ?Quality• Available in different languages:

different authors

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Start a Blog- I did!

• What is a blog? (your teens will know!)

• Why a blog?– Easy– Cheap/free– Can link to other html addresses

• http://mfmnewzealand.blogspot.com/

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Information security

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Why do you need it ?

• Electronic Data is critical to successful care.

• Patient privacy must be assured.

• Confidential information – including commercial information must be protected.

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Why are computers different ?

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Electronic systems are:

• Easy to search• Allow simultaneous access by

many people• Allow compact data storage• Vulnerable to some sorts of

attacks• Liable to have mishaps

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Easy to search ?

• Audit trails can detect who has viewed data

• “Please explain” letters and clear policies

• Think about sensitive groups:– Celebrities– Staff– Relatives

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Mining data

• Combine data that can identify “anonymous” people.

• Appointments• Car parking• Web access logs• Lab results – who ordered the

test, which clinic, who gets the bill ?

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Role Based AccessMy Patient Any Patient Emergency

Patient/ Locum

Clinician Full Access

No Access

Full Access(but explain)

Administrator

Demographic only

Demographic only

Demographic only

Sysadmin No Access

Supervised Access for maintenance(but explain)

Change roles

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Compact Data storage ?

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Risk of loss or destruction

Large numbers of Electronic records can be lost, stolen, altered or deleted much more easily than the equivalent paper files. They are especially vulnerable when on removable media such as CD’s or memory sticks.

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Vulnerable• C:\> Del *.* - Don’t try this at home• Power • Software “upgrades”• Maintenance – especially database• A series of links,

– Physical environment– Hardware– Operating System– Software– Operators

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Some access control, poor environmental control

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Computer Hygiene• Where has that memory

stick been ?• Antivirus, firewall, anti-

malware.• Public computers are

often high risk• Infection control – if you

can’t trust the contact, and the contacts contact don’t share.

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Malicious attacks

• Emails– Malware attachments– Phishing– Nigerian scam, hoaxes etc.

• Key loggers, data downloader's on memory sticks.

• Packet sniffing and interception

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Interception ?• Most data on the internet is

not encrypted• If it’s a normal email – its like

a postcard…Websites can use secure communications•Proves it is the site you think it is •Encrypts data transmission• Use recent browser versions•Apply upgrades

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To protect…• Good set of rules from the RACGP-• http://www.gpcg.org.au/index.php?op

tion=com_content&task=view&id=128&Itemid=38

• Soon – guidelines for New Zealand @ www.hiso.govt.nz

• Ensure you install operating system security updates, as well as for particular software.

• If you are really interested - http://www.cert.org/

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Operating system ?

• The program that lets all the others run

• Popular ones include Windows (Many varieties), Linux, MacOS.

• If the operating system is unreliable then the software will be.

• Modern operating systems can encrypt data so that it cannot be read by others.

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Backups

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Simple rules for backup

• Backup regularly– How much data can you afford to

loose ?

• Check that it works• Make it someone’s job• Don’t hope – plan.