Professional Documents
Culture Documents
SOCIETY {MEDICINE}
CONTENTS
Chapter 1
Introduction
Chapter 2
Literature Review
Patient Monitoring
10
13
19
23
48
52
54
62
69
Research
86
Chapter 3
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
4
MIPA/EAP-equipped
wireless
networks.
How can computers Improve quality of care and document that quality? They can
avoid illegible hand- writing, 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
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
o Operation
o Recovery
o Medical
o ECG
Theater
Room
Ward
(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.
8
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:
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.
10
Childbirth monitoring
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.
11
12
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.
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.:
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.
14
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 individuals 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 WiFi, global positioning system (GPS) or radio frequency enables caregivers to locate
wandering elders.
15
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-perpatient 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 UKs Department of Healths 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.
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 individuals motivation to manage their health.
Without the patients 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.
18
Outpatients 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 patients 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.
20
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 patients chart since that chart travels
with the patient to each location of care. Delivering documentation by hand to the
patients 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 providers
documentation skills and knowledge level. While standardization of the data
documentation has improved over the years, not all providers use the same
21
strategy for determining the organizations future needs and goals, an organizations
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.
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.
24
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
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 productand 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.
27
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 HITare increasingly adopted by health care organizations,
users must be mindful of the safety risks and preventable adverse events that these
29
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.
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 productand 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 5physician 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 costbenefit 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.
35
37
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 Presidents 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%
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 doesnt 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 countrys staggering healthcare bill. The same could be
40
said for duplicate prescriptions. It is estimated that 31% of the United States $2.3 trilliondollar 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. Well 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.
42
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
44
(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.
45
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
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
47
(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. OMalley 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
offices 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.
replaced
with electronic
health
records (EHRs).
The
tools
of health
48
information
management
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
systems 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
49
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.
51
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.
52
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.
the
process
of
determining
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.
BC)
in ancient
Smith
Papyrus). A Babylonian medical textbook, the Diagnostic Handbook written by Esagil-kinapli (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 /da.noss/ is derived
through Latinfrom the Greek word from , 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
professionals such
procedure
as
may
a physician,
be
performed
physical
by
various health
care
56
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 prognosisnaming exercise. It may indicate either degree of abnormality on a continuum or kind of
abnormality in a classification. Its 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.
Its 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.
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
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
59
Diagnostic criteria
Designates
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.
60
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.
61
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.
62
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.
63
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
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 xray-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 510 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.
67
68
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 computerassisted 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 robots 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 surgeons 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 Nanorobots 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)
72
surgical
interventions.
CAS
is
also
known
as computer-aided
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 surgeons
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.
74
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.
76
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 selfcuring 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 surgeons acts. This significantly
improves ergonomy in the operating theatre, decreases the risk of surgical errors and
reduces the operating time.
79
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.
80
81
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
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
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
83
health records any longer, because all they need is access to a computer or laptop
to pull up patient information.
Scheduling
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
84
Communication
85
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.
87
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.
88
REFERENCES
[1] J. C. Calvo, J. Ortega, and M. Anguita. Comparison of parallel multi-objective
approaches to protein structure prediction. The Journal of Supercomputing,
58(2):253260, December 2011.
[2] C.-Y. Chang, S.-J. Chen, and M.-F. Tsai. Application of support-vector-machinebased method for feature selection and classification of thyroid nodules in ultrasound
images. Pattern Recognition, 43(10):34943506, October 2010.
[3] C.-Y. Chang, P.-C. Chung, Y.-C. Hong, and C.-H. Tseng. A neural network for thyroid
segmentation and volume estimation in CT images. IEEE Computational Intelligence
Magazine, 6(4):4355, November 2011.
[4] C.-Y. Chang, Y.-F. Lei, C.-H. Tseng, and S.-R. Shih. Thyroid segmentation and volume
estimation in ultrasound images. IEEE Transactions on Biomedical Engineering,
57(6):13481357, June 2010.
[5] C.-Y. Chang and D.-F. Zhuang. A fuzzy-based learning vector quantization neural
network for recurrent nasal papilloma detection. IEEE Transactions on Circuits and
Systems Part I: Regular Papers, 54(12):26192627, December 2007.
[6] A. H. Foruzan, R. A. Zoroofi, M. Hori, and Y. Sato. Liver segmentation by intensity
analysis and anatomical information in multi-slice CT images. International Journal of
Computer Assisted Radiology and Surgery, 4(3):287297, May 2009.
[7] L. Franco. Weaning: can the computer help? Intensive Care Medicine, 34(10):1746
1748, July 2008.
89
90
91
[20] H. Huang. From PACS toWeb-based ePR system with image distribution for
enterprise-level filmless healthcare delivery. Radiological Physics and Technology,
4(2):91108, 2011.
[21] S. John, A. C. C. Poh, T. C. C. Lim, E. H. Y. Chan, and L. R. Chong. The iPad Tablet
Computer for Mobile On-Call Radiology Diagnosis? Auditing Discrepancy in CT and MRI
Reporting. Journal of Digital Imaging, (October):628634, 2012.
[22] A. Kho, L. E. Henderson, D. D. Dressler, and S. Kripalani. Use of handheld
computers in medical education. a systematic review. Journal of General Internal
Medicine, 21(5):531537, May 2006.
[23] C. Kirmizibayrak, Y. Yim, M. Wakid, and J. K. Hahn. Interactive visualization and
analysis of multimodal datasets for surgical applications. The Journal of Digital
Imaging, 25(6):792801, December 2012.
[24] A. Kleiboer, K. Gowing, C. H. Hansen, C. Hibberd, L. Hodges, J. Walker, P.
Thekkumpurath, M. OConnor, G. Murray, and M. Sharpe. Monitoring symptoms at
home: what methods would cancer patients be comfortable using? Quality of Life
Research, 19(7):965968, 2010.
[25] G. Lam, N. T. Ayas, D. E. Griesdale, and A. D. Peets. Medical simulation in
respiratory and critical care medicine. LUNG, 188(6):445457, 2010.
[26] S.-F. Lin, K.-T. Xiao, Y.-T. Huang, C.-C. Chiu, and V.-W. Soo. Analysis of adverse
drug reactions using drugand drug target interactions and graph-based methods.
Artificial Intelligence in Medicine, 48(23):161166, February 2010.
92
[27] D.-Y. Liu, H.-L. Chen, B. Yang, X.-E. Lv, L.-N. Li, and J. Liu. Design of an enhanced
fuzzy k-nearest neighbor classifier based computer aided diagnostic system for thyroid
disease. Journal of Medical Systems, 36(5):32433254, September 2012.
[28] F. Matthews, P. Messmer, V. Raikov, G. A. Wanner, A. L. Jacob, P. Regazzoni, and
A. Egli. Patient-specific three-dimensional composite bone models for teaching and
operation planning. The Journal of Digital Imaging, 22(5):473482, October 2009.
[29] T. Mehmet. Physicians views and assessments on picture archiving and
communication systems (pacs) in two turkish public hospitals. Journal of Medical
Systems, 36(6):35553562, December 2012.
[30] P. G. Mezey. Computer Aided Drug Design: Some Fundamental Aspects. Journal of
Molecular Modeling, 6(2):150157, February 2000.
[31] Z. B. Miled, J. Liu, O. Bukhres, H. Li, J. Martin, C. Balagopalakrishna, and R. Oppelt.
Use and maintenance of histograms for large scientific database access planning: A
case study of a pharmaceutical data repository. Journal of Intelligent Information
Systems, 23(2):145178, September 2004.
[32] D. P. Miller, J. R. Kimberly, L. D. Case, and J. L. Wofford. Using a computer to teach
patients about fecal occult blood screening. a randomized trial. Journal of General
Internal Medicine, 20(11):984988, November 2005.
[33] T. Murase, K. Oka, H. Moritomo, A. Goto, K. Sugamoto, and H. Yoshikawa.
Correction of severe wrist deformity following physeal arrest of the distal radius with
the aid of a three-dimensional computer simulation. Archives of Orthopaedic and
Trauma Surgery, 129(11):14671471, November 2009.
93
94
95