Clinical Informatics Chapter 3 with Pictures

Database Management System (DBMS)

"SQL" - a family of related languages with different dialects specific to the RBDMS (MS-SQL, Oracle SQL, MySQL)

Standards : Current IEEE definition

- "Ability of a system or a product to work with other systems or products without special effort on the part of the customer. Interoperability is made possible by the implementation of standards

CISC Original X86 Pentium processors were CISC, but modern X86 processors (Intel Core i7) have features of both RISC and CISC

- CISC = Complex Instruction Set Computer • Reduces # of instructions per program (longer instructions, but less of them) • Variable length instructions

Security - Technical Controls

- Firewalls - Intrusion detection and prevention systems (IDPS) - Network access control (NAC) - Virtual private networks (VPN) - Data leakage protection (DLP)

• Stages of development (Hammond, 2014)

- Identification - Conceptualization - Discussion - Specification - Early implementation - Conformance - Certification

Using FHIR thru API for healthcare like facebook

Argonaut Project Charter, etc. - RESTful architecture - FHIR-based API

dual homing

As with classical dual homing, the Micro Switch for dual homing with single fiber has two mutually independent fiber optic connections.

HIPPA

...

terms that will show up WAN dual homed, router and server farm and cable plant

...

Binary, Bits, and Bytes

Because 16 is a power of 2, base-16 (hexadecimal) is a compact way of relaying *binary* information. An 8-bit binary ASCII-encoded character can be represented as a 2-digit HEX • ASCII: "informatics" • HEX: "69 6e 66 6f 72 6d 61 74 69 63 73" • BIN: "01101001 01101110 01100110 01101111 01110010 01101101 01100001 01110100 01101001 01100011 01110011"

Cable plant

Cable plant is a topographical layout of physical cables connecting desktops to the equipment in the closets and cables interconnecting closets and the data center.

OOP (Object Orient Programming) Terminology

Classes can demonstrate *Encapsulation*: can keep their attributes and methods private; Composition - Objects can be composed from smaller objects *Inheritance* - Objects can inherit their structure from parent objects and extend their functionality *Polymorphism* - Objects can override their parent attributes/methods Accessors ("getters") are methods used to retrieve variable state • Mutators ("setters") are methods used to change variable state

Architecture terminology

Client Server (diagram as server) Thin client (desktop , very little on this ) Application Service Provider(ASP) model - Business that provides computer services over the internet

CPOE.. 55% reduction in errors

Computerized practitioner order entry is defined as a process which allows the ordering practitioner to use a computer to directly enter medical orders.

Infrastructure - Physical

Data Center is a dedicated and protected facility with specific requirements of electricity, humidity, and air conditioning

Data center tiers

Data closet is a smaller space, typically on each floor, which houses networking equipment and cable ends - Standards - IEEE

...

Distinguish hierarchical, relational, and object-oriented databases; advantages and disadvantages of each. • Describe the logical schema of a database using a UML Entity Relationship (ER) diagram. • Understand how the suite of UML diagrams are used to model a process and assist in software development and maintenance. • Understand how update, insert, and deletion anomalies in databases are prevented through database normalization. • Understand how denormalization of a database can be used to optimize certain queries, for example, in a clinical datamart. • Describe some of the common network topologies, such as star, tree, and bus networks. • Recognize the names and uses of common telecommunications standards

*Imperative & Procedural Programming*

Ex: FORTRAN, BASIC, Pascal, C, C++

Clinical Informatics Board Review Course QUESTION: Investigators wish to use EHR data to determine the dose-related effects of a medication on a physiologic variable of interest. The medication is given parenteral, the dose varies by patient weight and may range from zero to some theoretical toxic maximum dose. The numeric value of the dose is an example of what kind of measure: a. Nominal b. Ordinal c. Interval d. Ratio

Explanation: Medication dose as described is a continuous variable where *"zero" has meaning* and represents no measurable quantity of the attribute. Therefore, the IV medication dose described is a "ratio" measure. Interval measures are also numeric, but "zero" is often arbitrarily set. As an example, the area of a plot of land in acres is a ratio measure, because the concept of "zero acres" has meaning. In contrast, calendar year is an interval - it is meaningless to say something has "zero" calendar years, but you can say that zero years have elapsed. So the transformation from calendar year to elapsed years (or, for example, age of a patient in years) converts the measure from an interval to a ratio. Nominal values have a "name" only and no rank or priority is implied (ex: Male and Female). Ordinal values have a name, but also have an implied order (ex: Small, Medium, Large).

FLOP

FLOP is measure of computational speed = Floating-point Operations Per Second • A giga-FLOP (GFLOP) is a billion floating

Guiard's Model of Bimanual Skill

Hands are not used equally. Each hand, because of single hand dominance, has distinct roles.

• Imprecision vs. inaccuracy

Imprecisio the measure just vary every time you measure , vs inaccuracy.. the machine is not calibrated correctly

CCOW (Clinical Context Object Workgroup), • Manages context of caregivers who may need to access different computer applications in process of care • Oft-stated goal is "single sign-on" across applications, network, data, etc.

In the context of Health informatics, CCOW or Clinical Context Object Workgroup is an Health Level Seven International standard protocol designed to enable disparate applications to synchronize in real time, and at the user-interface level

Data Transformations Interval to Ordinal Be aware what you gain or lose when you transform data. When you compress image / audio files by down sampling, you can lose data. When you bin continuous data into ordinal buckets, you lose data.

Interval Ordinal - Can group ranges of variable using "Binning" techniques, commonly used to smooth effects of minor observation errors - Take a continuous variable like "age in years", group them into categories such a "Neonate", "Infant", "Toddler", "Child", "Adolescent", "Adult" (implied order)

...

Key elements of the HIPAA Security Rule. • Policy, and technical measures to protect the security of identified patient health information. • Three technical measures (firewalls, VPNs, and encryption) and the security context in which they are used.

Levels of interoperability for healthcare

Level 1 - no interoperability - e.g., mail, fax, phone, etc. • Level 2 - machine-transportable (structural) - Information cannot be manipulated - e.g., scanned document, image, PDF

Object-Relational Mapping (ORM)

Manipulate data to create (insert), retrieve (read), update (edit), delete (sometimes abbreviated "CRUD") Each method (getters/setters) mapped to a "CRUD" function

Object-Oriented Programming

Objects have Attributes (adjectives) and Methods/Behavoirs (verbs) *Instantiation* involves creating a new object and setting initial parameters for the Attributes and Methods

Copy Paste

One in ten electronic charts contained an instance of high-risk copying.

Data Structures

Primitive and non-primitive

Short Range Wireless Standards.. up to Bluetooth anything above that is Medium Range Wireless Standards (local home area) Long Range Wireless Standards 3G

RFID (one way) and NFC (two way) - IEEE 802.15 - Wireless Personal Area Network and derivatives (Bluetooth & Infrared Data Association or IrDA)

RISC RISC programs are longer and so more RAM needed to store assembly language instructions apple went to intel processor , completely abandon RISC structure

RISC = Reduced Instruction Set Computer • Reduces clock cycles per instruction (shorter instructions, but more of them) • Instructions are fixed in length

Software Development Methodologies

SDLC (System development life cycle) Methodologies: Waterfall, Agile, Spiral (subproject designed to tackle an area of high-risk)

System Integration 2

Star Integration

Descriptive Models of HCI Buxton's Three-State Model of Graphical Input

Three states: out of range, tracking, and dragging

Formula for CPU Time (measure of computer performance)

Time for task = C ∗ T ∗ I. C =Average # Cycles per instruction. T =Time per cycle. I =Instructions per task

...

Understand how software systems may be integrated through interfaces, messaging standards, and web services

Low Level Programming Languages

Unique to the CPU (why code for SPARC, ARM, and X86 are fundamentally different)

...

Use and limitations of clinical data for patient care and other purposes • Flow of data in clinical systems from collection to storage to analysis • Use and challenges for identification and anonymization of patient data

Digital Logic Gates

XOR (exclusive OR) - returns TRUE if either A or B is true, but not both - NAND (NOT AND) - returns TRUE unless both A and B are TRUE - NOR (NOT OR) - returns TRUE only when both A and B are FALSE

Hick-Hyman Law

expresses user response time as a function of number of possible responses (n)

SQL Joins

left join = left outer join right join = right outer join

Moore's law

predicts that the number of transistors on an integrated circuit doubles every two years, and therefore so will speed

router , bridge and repeater (hub)

router , bridge and repeater connect different layers >> this model showed up on the exam.. router are the most complex of these 3

WAN

wide area networks (wide open) LAN (local inside building closed system)

OSI Seven Layer Model

• 7: Application Layer - I send a letter to Bob. Bob receives and opens the letter. • 6: Presentation Layer - my letter is encoded in roman script using the English language • 5: Session Layer - I may include one or more letters per session (envelope) as long as I have appropriate postage • 4: Transport Layer - There is a typo in the address. The postal service marks it "recipient unknown" and sends it back. I get details of failure or confirmation of success (ex: registered mail) • 3: Network Layer - physical mail is sent by plane between cities. Pilot has no awareness of the the final destination of the letter she is carrying • 2: Data Link Layer - Postal Service worker drives truck within city to deliver message • 1: Physical Layer - my letter is comprised of ink or graphite on a piece of paper, folded and tucked into an envelope

The standards development process - four approaches (Hammond, 2014)

• Ad hoc - groups agree to informal specifications • De facto - single vendor controls industry (Microsoft) • Government mandate - government agency creates standard and mandates its use • Consensus - interested parties work in open process (HL7)

...

• Architecture, technical and computing infrastructure underlying health information systems (HIS). • Breadth of HIS functionality and topics historically challenging to physicians. • Telemedicine application areas and types.

Health information standards were a key focus of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) aka, the Kennedy-Kassebaum Bill) • Main focus of legislation, however, was health insurance issues - Reducing denial based on pre-existing conditions - Improving portability across jobs

• But now HIPAA is best known for its addressing of - *Standards for financial transactions and code sets* - Unique identifiers for patients, healthcare providers, and employers - Development of privacy and security standards for transmission of electronic health data • HIPAA privacy and security regulations expanded in HITECH

Network Topologies

• Centralized - Star, Tree • Decentralized - Mesh, Fully Connected

...

• Examples of clinical errors that can be prevented through the application of human factors engineering principles. • Contrast usability inspection, usability testing and usability inquiry • The three components of discount usability engineering: prototypes, simplified think-aloud exercise, and heuristic evaluation • Commonly accepted standards of good interface design

Normalization 2F: INSERT: We can't indicate a patient's pharmacy (E) unless there is a medication prescribed (D) In practice, a database that is in 3NF can be called "normalized" There are higher forms of normalization beyond 3NF, like "Boyce-Codd Normal Form" (abbreviated "BCNF")

• Goals of Normalization - To free the collection of relations from undesirable insertion, update, and deletion dependencies - To reduce the need for restructuring the collection of relations as new types of data are introduced, and thus increase the lifespan of application programs - To make the relational model more informative to users - To make the collection of relations neutral to the query statistics, where these statistics are liable to change as time goes by

System Integration

• Horizontal Integration (via Enterprise Service Bus) One connection per system to ESB. ESB handles downstream connections • Vertical Integration Group systems by function into silos

...

• Importance and limitations of standards in clinical information systems • Major types of standards and their roles in clinical information systems • Identifier standards • Transaction standards • Messaging standards • Terminology standards

Archetypal Architectures interfaced vs integrated (VISTA.. this is the VA architect may be on the test, CPRS( Computerized Patient Record System) which is integrated)) In practice most organizational clinical computing systems are a mixture, with varying degrees of both

• Integrated systems: Those in which patient data exist in the same database used by all clinical applications. • Interfaced systems: Those in which data are communicated between separate applications with different databases, usually by means of an interface using HL7 protocol. "Best of breed"

...

• Level 3 - machine-organizable (syntactic) - Sender and receiver must understand vocabulary - e.g., email, files in proprietary format • Level 4 - machine-interpretable (semantic) - Structured messages with standardized and coded data - e.g., coded results from structured notes, lab, problem list, etc.

Unintended consequences of CPOE [Ash JAMIA 2007] by Warner.. this was on the exam

• More/New Work Issues • Workflow Issues • *Never Ending Demands* (adding more and more to the doctor's plate) • Paper Persistence • Communication Issues • Emotions • New Kinds of Errors • Changes in the Power Structure •* Overdependence on Technology*

types of clinical data

• Narrative - recording by clinician • Numerical measurements - blood pressure, temperature, lab values • Coded data - selection from a controlled terminology system • Textual data - other results reported as text • Recorded signals - EKG, EEG • Pictures - radiographs, photographs, and other images • Metadata - information about the data, that give context and detail, e.g., electronic header information in notes

Integrating the Health Enterprise (IHE)

• Non-federal effort that identifies and demonstrates solutions to real-world interoperability problems

Control Structures

• Primitive - Labels (line numbers) - GOTO statements - instructs program to "jump" to another label - Subroutine - GOSUB label RETURN • Choice (Conditional) - IF - THEN - ELSE - CASE statements (if the pt is female then do preg test if not then do something else) • Loop - Count-controlled loop with iterator (FOR - NEXT) (start a counter 1-10, ) - Condition-controlled loops (WHILE) - Collection-controlled loops (FOR EACH IN...) (pt names gave you 200, do this task 200 times)

...

• Standards and Interoperability: Basic Concepts • Identifier Standards • Transaction Standards • Message Exchange Standards • Terminology Standards

Telemedicine synchronous-vs-asynchronous

• Synchronous teleconferencing - Dedicated hardware - Broadly available tools (e.g. Skype) Conferencing applications • Asynchronous telemedicine - Store & forward - Electronic mail - Other

Fast Health Interoperability Resources (FHIR)

• Toward semantic interoperability - "computer utterance" in one system has same effect in any other

Patient identifiers - key attributes (Connecting for Health, 2005)

• Unique - only one person has a particular identifier • Non-disclosing - discloses no personal information • Permanent - will never be re-used • Ubiquitous - everyone has one • Canonical - each person has only one • Invariable - will not change over time

Testing Approaches

• White Box: Code Coverage is an example of White Box testing - programmer will develop a set of test conditions for all scenarios, all variables, all possible inputs with awareness of the internal design of the system. • Black Box: tests functionality from end-user standpoint (ex: if user enters an order, does EHR display the order is active and signed

High Level Programming Languages

• Written in English-like phrases • Compiled before execution (converted from source code to object code, usually assembly language or machine code) • Ex: C/C++, Java, VisualBasic, etc.

Usability Evaluation

1. Testing - Coaching - Thinking-aloud - Eye-tracking / Click tracking - Performance 2. Inspection - Cognitive walkthrough - Heuristic evaluation 3. Inquiry - Field Observation - Focus groups / Interviews - Surveys - Usage Logs

repeater

A hub is basically the same as a repeater, but the hub will have more ports. That's the only major difference between the two. (Some hubs have greater capabilities than others, but a "basic" hub is simply a multiport repeater.)

A server farm

A server farm, also called a computer cluster, is a group of servers that is kept in a single location. These servers are networked together, making it possible for them to meet server needs that are difficult or impossible to handle with just one server. With a server farm, workload is distributed among multiple server components, providing for expedited computing processes.

...

ASC X12N transactions - Version 5010

Hash Functions : Uses in data integrity: NPI last digit is a checksum • Uses in Cryptography • Uses in Indexing (as in databases) - Takes text strings and, via a hash, places them into "buckets" - Retrieving info is faster since program only has to look in that bucket

Algorithm that maps data of arbitrary length to data of fixed length, an example of "binning" • Returned value is known as "hash value", "hash code", "hash sum", or "checksum

Types of Quantitative Data

Allows for additional comparison because "zero"

the central hub , is an interface engine....

An Interface Engine (a.k.a. message broker, application-level router) is a middleware application used to transform, route, clone and translate messages. A HL7 interface engine is an interface or integration engine built specifically for the healthcare industry. [HL7] Can "play back" messages when unavailable receiving system comes back online.

inheritance

An object-oriented software application describes a class for Patient, which represents patients in a research registry. Which of the following is an example of Inheritance in object-oriented programming languages. The Patient class: Is a subclass of Person and the basic structure of Patient is derived from the Person class.