Grand Rounds a number of years ago on Practical Medical Informatics

1. Practical Medical Informatics
Frank Meissner, MD, FACP, FACC, FCCP
Date of Presentation: 21 Sep 1995
Grand Rounds Presentation
Kettering Medical Center, Dayton Ohio

2. Cardiologists Do it with Needles!

3. First Aphorism of Hippocrates
Vita brevis; ars longa; occasio celeris;
experimentum periculosum; judicium difficile.

4. The Role of the FUTURE
General Internist: Defined
includes being ...’a clinical information
manager who can take full advantage of
electronically stored data and can
communicate using the tools of modern
technology’. Ann Intern Med. 1994;121:616-22

5. IT’s an Information AGE:
Knowledge Hiearchy- The BlackJack Analogy
Data
Information
Knowledge
Wisdom
>
When to Hold’em & when to fold’em

6. IT’s a Computer Age!
●IT= Information Technology
●Hype VS Reality
●Computers ARE Usefu or can be useful
in Practice
●Computers & Me, a personal perspective

7. What IS Medical Informatics
●Medical AI & Decision Support Systems
●Image & Signals Processing, Manipulation,
Transmission
●Medical Database Design & Utilization
●Medical Library Science/Medical
Education/Remote Learning
●Outcomes Analysis & Decision Analysis
●Medical Telecommuncations/Telemedicine

8. Computer Myths
●Computers MAKE you more productive
●Computers MAKE you smarter
●Computers MAKE your life MORE simple
●Computers SAVE you work
●Computers Make YOU Koool/Sexy!

9. Doctor Computer Myths
●Doctors are TechnoPhobic
●Doctors are Unable to Understand the
Technology
●Technology is adequate, MD is Resistent
●Computers will make YOUR job easier
●Computers will Reduce Variability of
Practice

10. Danny Dun & The
Homework Machine
●Computers are NOT fair
●Computers Don’t SAVE Work (Initially)
●You have to understand what you wish to
do with them
●The Fallacy of Creeping Perfectionism
○10% of the Task Takes 90% of the time

11. Hardware Tools in Zagreb
●Powerbook Data/Fax Modem + Ext CD-Drive
●Franklin Digital Books (PDR+Drug
Interactions)
●HP100LX
●PowerPC 8100/100 AV
●IBM PC- 486Chip
●OmniBook 300

12. Useful Computer Tools
●Organizational Aids
○To DO list
○Calenders/Schedule Programs
○Phone & Contact Managers
○Pager Program
●Outliner & BrainStorming Tools

13. Useful Computer Tools
●Clinical Reference Manager (?)
●Medical Education Programs
○MD Challenger
○Code & ATLS Simulator
○Pacemaker Educational Program
●Clincal Data rarely needed- MOST
Useful function

14. Computers in Zagreb
●LAN WorkGroup- Combat Trauma Life Support
●E-mail via LAN Mailserver
●Clinical & NETWORK News
●CD-ROM References
●Modem Slide File for Presentation
●DataBase Access in ER via Telnet University
Zagreb (MicroMedex) & USUHS ER System

15. Computers in Zagreb
●Listserver Continuing Medical Education
●Clinical Discharge Summaries
●Communication in High Ambient Noise
Environment
●Email exchange of Critical Data/Consulations
●ACLS/ATLS Simulators

16. Informatics Case Studies I
●24 y/o Russian male severe dyspnea
●RR 40, Normal A-a gradient
●Had gotten Gasoline in mouth 12 hrs
before after siphioning gas (blackMarket)
●UTHSCSA via Telnet for MicroMedex
(Toxic Ingestions)

17. Informatics Case Studies II
●34 y/o Pakistani male with severe
pyrexia
●9 d’s in Croatia
●Nonlocalizing physical examination
●Parasite Expert System

18. Informatics Case Studies III
●30 y/o Kenyan Male with decreased visual
acuity OS
●SLE shows localized keritis of cornea
●Eosinophil count 90%
●(+) skin snip
●Onchoceriasis
●Email: WRAIR sent Ivermectin on protocol to
treat patient

19. Informatics Case Studies IV
●24 y/o Kenyan male with painless gross
Hematuria
●Neg Urine for blood
●(+) Shistosomasis on Urine
●SAM (treatment & plate for ID of egg)

20. Informatics Case Studies V
●27 y/o Caucasian male with 5 d’s of fever
●Transfered with acute renal failure
●Platatine petechiae & dramatic
dermatographia
●AFMIC BBS
●Harrisons on CD-ROM

21. Informatics Case Studies VI
●78 y/o demented male in ER with c/o
faintness
●Hx/o pacemaker implantation
●NO pacer card or records
●Xray ID code LH
●Pacemaker Program

22. Informatics Case Studies VII
●78 y/o Filipino female with acute chest
pain
●Admitted with True PostLatWall MI
yesterday
●Decreased B/P 90 Systolic
●Faxed EKG

23. Electronic Medical Record
●Not designed for the Pracitioner
●Function is to Control the Clinical
Encounter
●3rd party & ‘Quality Review’
●2ndary Goal Homogenization of Practice
●Serious Problems in Implementing EMR

24. EMR- clinicians viewpoint
●Improves data exchange
●Saves COST if you do not repeat studies
●Ehances group practices
●Improves (perhaps) malpractrice defense
●Potentially impacts info exchange
●LISTS of syms ARE NEVER helpful

25. CHIN & EDI
●Link local health facilities into networks
●FUNDAMENTAL to solve problems of
Electronic Data Interchange
●HL-7 evolving standard for clincal
records
●Cooperate and graduate (Market forces
vs NEED to collaborate)

26. Outcomes Analysis &
Evidence Based Medicine
●The POPULATION Fallacy
●Scientific Medical Research: Transform
SPECIFIC=>General
●Scientific Art/Practice: Transform
GENERAL=> SPECIFIC
●Potentially Pseudo-Science
○Good Outcomes Analysis RiskMaster

27. AI- Fallacies
●Academic AI is Cognitive Science
●Attempt to MODEL how doctors think
●Have until recently NOT focused on
WHAT we do
●What WE SAY we do, is NOT what we
DO!

28. AI- Rule Based vs Neural Nets
●Rule Based good for training, awful in
practice
●Neural nets learn, but, too limited in scope
●Current tools are SLOW, IMPRECISE, and
insufficently accurate for clinical use
●The DIFFERENCE that makes NO
DIFFERENCE, is NO DIFFERENCE

29. AI vs Decision Support System
●DSS is not a competator it is an aid
●EKG Automated Analysis Prototypical GOOD AI
system
●Transparent, ubiquitious (because it works),
improves decisions
●Clinical Theraputic JOG’s memory
○i.e., 20% Hospitalized pxts have iatrogenic disease
from med errors/interactions

30. Data Security
●Nessecary....fundamental
●Networks will be client-server in nature
●Robust
●Responsive

31. CD-ROM - Ronin Solution
●Great for ER Doc’s
●Large amounts of material on CD-ROM
●Superb for Pxt education (BodyWorks4)

32. Telecommuncations
●The REASON many doctors are getting
into computers
●Telemedicine
●OnLine Databases
●THE INTERNET
●Commerical OnLine Services

33. Network of Networks

34. Psychological Aspects:
CyberSpace
●Unity of Place
●Unity of Time
●Unity of Action
●Rational & content driven
●Equalitarian

35. Email: Core Internet Technology
●Functionally instantaneous vs ‘snail mail’
●Dyssynchronous work
●World of Colleagues & Consultants
●Available @ ALL levels Interconnection

36. UseNet Groups
●Specialized discussion groups
●Allow discussion VERY narrow interests
●Requires specialized programs
●You must manually login
●Thus requires time & ‘thought’

37. Listservers
●Power of email
●Specialized interests
○Even more narrow than UseNet groups
●DOES not require login to recieve data
●Sent automatically to email account
●Highly efficient for MD’s

38. Listserver Subscription: CCM-List
●Superb Crtical Care Medicine Resource
○TO: Listserver@UBVM.cc.buffalo.edu
○SUBJECT: (leave this blank)
○BODY:
Subscribe CCM-L <first and last name>

39. Listserver subscription:
hmatrix-l
●FUNDAMENTAL RESOURCE
○TO: Listserver@UKANAIX.CC.UKANS.EDU
○Subject: (leave this blank)
○Body
Subscribe hmatrix-l <first and last name>

40. Telnet
●Foreign Login to other terminals
●Fundamental tool of the ‘Hacker’
●Useful telecommuting (Working Virtual)
●Can Telnet to GRATEFUL MED

41. FTP/FTPmail
●File Transfer Protocol
●Internet File Structure > 200 Gigabytes
●Standarized protocol allows file transfer
●Several email servers ftp email ONLY
●Need to know path to file

42. Gopher/GopherMail
●‘Client-server’ architecture
●‘Gopherspace’
○Virtual Space of Documents
●Find documents traverse GopherSpace
●‘Veronica’-Gopher space search engine
●GopherMail available for email ONLY

43. WWW
●Newest Internet Interface
●Graphics Interface
●Easy to use
●High Performance costs for ease of use
●Evolving standard for Internet access

44. CONCLUSIONS
●Med-Telecommunications ESSENTIAL
●Internet Connectivity expands practice
●Initial training time expenditure high
●Email
○71333.3377@compuserve.com
○meissner@saturn.brooks.af.mil
○fmmd@well.sf.ca.us