《医学影像信息学概论》课程参考资源：Biomedical Informatics - Computer Applications in Health Care and Biomedicine（Fourth Edition，Edward H. Shortliffe • James J. Cimino）

Edward h shortliffe James. cimino editors Biomedica Informatics Computer Applications in Health care and biomedicine Fourth edition a springer

Biomedical Informatics Edward H. Shortli e James J. Cimino Editors Computer Applications in Health Care and Biomedicine Fourth Edition 123

Dedicated to homer r. warner. mD. phD. FACMI A Principal Founder of the Field of Biomedical Informatics 1922-2012 The Fourth Edition of Biomedical Informatics: Computer Applications in Health Care and Biomedicine is dedicated to the memory and professional contributions of Homer R. Warner. Homer was not only a pioneer in biomedi- cal informatics but a sustained contributor who is truly one of the founders of the field that mourned his loss in November of 2012. Homer's publications on the use of computers in health care span 50 years, from 1963 to 2012, but he can claim an additional decade of informatics research that predated digital computer use, including the use of analog computers and mathematical models anging from details of cardiac function all the way up to medical diagnosis He is best known for his development of the Health Evaluation throu Logical Processing(HELP)system, which was revolutionary in its own right as a hospital information system, but was truly visionary in its inclusion of the logical modules for generating alerts and reminders. The HELP system Warner, H.R., Toronto, A. F, Veasey, L. G,& Stephenson, R. 1961. A mathematical approach to medical diagnosis. Application to congenital heart disease. JAMA: The Journal

Dedicated to Homer R. Warner, MD, PhD, FACMI A Principal Founder of the Field of Biomedical Informatics 1922–2012 The Fourth Edition of Biomedical Informatics : Computer Applications in Health Care and Biomedicine is dedicated to the memory and professional contributions of Homer R. Warner. Homer was not only a pioneer in biomedi￾cal informatics but a sustained contributor who is truly one of the founders of the fi eld that mourned his loss in November of 2012. Homer’s publications on the use of computers in health care span 50 years, from 1963 to 2012, but he can claim an additional decade of informatics research that predated digital computer use, including the use of analog computers and mathematical models ranging from details of cardiac function all the way up to medical diagnosis. 1 He is best known for his development of the Health Evaluation through Logical Processing (HELP) system, which was revolutionary in its own right as a hospital information system, but was truly visionary in its inclusion of the logical modules for generating alerts and reminders. The HELP system, 1 Warner, H. R., Toronto, A. F., Veasey, L. G., & Stephenson, R. 1961. A mathematical approach to medical diagnosis. Application to congenital heart disease. JAMA: The Journal of the American Medical Association, 177 , 177–183

begun in 1968, is still running today at the LDs Hospital in Salt Lake City innovations are continually added while commercial systems struggle to rep- licate functions that HELP has had for almost half a century. Homers other contributions are far too numerous to recount here, but you will find them described in no less than six different chapters of this book. Homer's contributions go far beyond merely the scientific foundation of bi medical informatics. He also provided extensive leadership to define informatics as a separate academic field. He accomplished this in many settings: locally by founding the first degree-granting informatics department at the University of Utah, nationally as the President of the American College of Medical Informatics, nd internationally as the founding editor of the well-known and influential jour- nal Computers and Biomedical Research (now the Joumal of Biomedical Informatics). But perhaps his greatest impact is the generations of researchers and trainees that he personally inspired who have gone on to mentor additional researchers and trainees who together are the life blood of biomedical i ics. Homer's true influence on the field is therefore incalculable. just consider the hows his lineage of professional influence on 52 of us.K convenience sample of this book's 60 chapter co-authors: the following diagram Both of us were privileged to have many professional and personal inter actions with Homer and we were always struck by his enthusiasm, energy, humor, generosity, and integrity. In 1994, Homer received the American College of Medical Informatics'highest honor, the Morris F Collen Award of Excellence. We are proud to have this opportunity to add to the recognition of Homers life and career with this dedication James j. cimino Edward h. shortliffe Puter Salvin Hadad Owe Jams Briey Douglas K On Paras Dev Pnip Payne Michad Chane 2 Paul Clayton and Peter Szolovits provide important connections between Homer Warmer and ten coauthors but, while they are informatics leaders in their own right, they are not contributors to this edition of this book

begun in 1968, is still running today at the LDS Hospital in Salt Lake City; innovations are continually added while commercial systems struggle to rep￾licate functions that HELP has had for almost half a century. Homer’s other contributions are far too numerous to recount here, but you will fi nd them described in no less than six different chapters of this book. Homer’s contributions go far beyond merely the scientifi c foundation of bio￾medical informatics. He also provided extensive leadership to defi ne informatics as a separate academic fi eld. He accomplished this in many settings; locally by founding the fi rst degree-granting informatics department at the University of Utah, nationally as the President of the American College of Medical Informatics, and internationally as the founding editor of the well-known and infl uential jour￾nal Computers and Biomedical Research (now the Journal of Biomedical Informatics ). But perhaps his greatest impact is the generations of researchers and trainees that he personally inspired who have gone on to mentor additional researchers and trainees who together are the life blood of biomedical informat￾ics. Homer’s true infl uence on the fi eld is therefore incalculable. Just consider the convenience sample of this book’s 60 chapter co-authors: the following diagram shows his lineage of professional infl uence on 52 of us. 2 Both of us were privileged to have many professional and personal inter￾actions with Homer and we were always struck by his enthusiasm, energy, humor, generosity, and integrity. In 1994, Homer received the American College of Medical Informatics’ highest honor, the Morris F Collen Award of Excellence. We are proud to have this opportunity to add to the recognition of Homer’s life and career with this dedication. James J. Cimino Edward H. Shortliffe 2 Paul Clayton and Peter Szolovits provide important connections between Homer Warner and ten coauthors but, while they are informatics leaders in their own right, they are not contributors to this edition of this book. Homer R. Warner G. Octo Barnett Edward H. Shortliffe Paul C. Tang Blackford Middleton Mark A. Musen Daniel L. Rubin Nigam Shah Holly Jimison Robert A. Greenes Suzanne Bakken Patricia Dykes Kevin B. Johnson Russ B. Altman Jessica Tenenbaum Sean D. Mooney Parvati Dev Mark E. Frisse David W. Bates Robert Rudin Jonathan Silverstein William Hersh Peter Embi William A. Yasnoff James J. Cimino Vimla L. Patel David R. Kaufman Clement J. McDonald Paul D. Clayton Carol Friedman George Hripcsak Adam Wilcox Noémie Elhadad Justin B. Starren Philip Payne Michael Chiang Lynn Vogel Scott Narus Stanley M. Huff Reed M. Gardner Scott Evans David Vawdrey W. Edward Hammond Ian Foster Terry Clemmer Roger B. Mark Randolph A. Miller Judy G. Ozbolt Valerie Florance Charles P. Friedman Douglas K. Owens James Brinkley Peter Szolovits Issac Kohane Kenneth Mandl Kenneth W. Goodman

Preface to the fourth edition The world of biomedical research and health care has changed remarkably in the 25 years since the first edition of this book was undertaken. So too has the world of computing and communications and thus the underlying scientific issues that sit at the intersections among biomedical science, patient care, pub- lic health, and information technology. It is no longer necessary to argue that it has become impossible to practice modern medicine, or to conduct modern biological research, without information technologies. Since the initiation of the human genome project two decades ago, life scientists have been generat data at a rate that defies traditional methods for information management and data analysis. Health professionals also are constantly reminded that a large percentage of their activities relates to information management-for example, obtaining and recording information about patients, consulting col leagues, reading and assessing the scientific literature, planning diagnostic procedures, devising strategies for patient care, interpreting results of labora tory and radiologic studies, or conducting case-based and population-based research. It is complexity and uncertainty, plus societys overriding concern for patient well-being, and the resulting need for optimal decision making, that set medicine and health apart from many other information-intensive fields Our desire to provide the best possible health and health care for our society gives a special significance to the effective organization and management of the huge bodies of data with which health professionals and biomedical researchers must deal. It also suggests the need for specialized approaches and for skilled scientists who are knowledgeable about human biology, clinical care, information technologies, and the scientific issues that drive the eff ective Ise of such technologies in the biomedical context. Information Management in Biomedicine The clinical and research influence of biomedical-computing systems is remarkably broad Clinical information systems, which provide communica- tion and information-management functions, are now installed in essentiall all healthcare institutions. Physicians can search entire drug indexes in a few seconds, using the information provided by a computer program to anticipate harmful side effects or drug interactions. Electrocardiograms(ECGs)ar typically analyzed initially by computer programs, and similar techniques are being applied for interpretation of pulmonary-function tests and a variety of

vii The world of biomedical research and health care has changed remarkably in the 25 years since the fi rst edition of this book was undertaken. So too has the world of computing and communications and thus the underlying scientifi c issues that sit at the intersections among biomedical science, patient care, pub￾lic health, and information technology. It is no longer necessary to argue that it has become impossible to practice modern medicine, or to conduct modern biological research, without information technologies. Since the initiation of the human genome project two decades ago, life scientists have been generat￾ing data at a rate that defi es traditional methods for information management and data analysis. Health professionals also are constantly reminded that a large percentage of their activities relates to information management—for example, obtaining and recording information about patients, consulting col￾leagues, reading and assessing the scientifi c literature, planning diagnostic procedures, devising strategies for patient care, interpreting results of labora￾tory and radiologic studies, or conducting case-based and population-based research. It is complexity and uncertainty, plus society’s overriding concern for patient well-being, and the resulting need for optimal decision making, that set medicine and health apart from many other information- intensive fi elds. Our desire to provide the best possible health and health care for our society gives a special signifi cance to the effective organization and management of the huge bodies of data with which health professionals and biomedical researchers must deal. It also suggests the need for specialized approaches and for skilled scientists who are knowledgeable about human biology, clinical care, information technologies, and the scientifi c issues that drive the effective use of such technologies in the biomedical context. Information Management in Biomedicine The clinical and research infl uence of biomedical-computing systems is remarkably broad. Clinical information systems, which provide communica￾tion and information-management functions, are now installed in essentially all healthcare institutions. Physicians can search entire drug indexes in a few seconds, using the information provided by a computer program to anticipate harmful side effects or drug interactions. Electrocardiograms (ECGs) are typically analyzed initially by computer programs, and similar techniques are being applied for interpretation of pulmonary-function tests and a variety of Preface to the Fourth Edition

v Preface to the Fourth Edition laboratory and radiologic abnormalities. Devices with embedded processors routinely monitor patients and provide warnings in critical-care settings, such as the intensive-care unit (ICU) or the operating room. Both biomedical researchers and clinicians regularly use computer programs to search the medical literature, and modern clinical research would be severely hampered without computer-based data-storage techniques and statistical analysis sys tems. Advanced decision-support tools also are emerging from research labo- ratories, are being integrated with patient-care systems, and are beginning to have a profound effect on the way medicine is practiced. Despite this extensive use of computers in healthcare settings and bio- medical research, and a resulting expansion of interest in learning more about biomedical computing, many life scientists, health-science students, and pro- fessionals have found it difficult to obtain a comprehensive and rigorous, but nontechnical, overview of the field. Both practitioners and basic scientists are recognizing that thorough preparation for their professional futures requires that they gain an understanding of the state of the art in biomedical comput- ing, of the current and future capabilities and limitations of the technology, and of the way in which such developments fit within the scientific, social, and financial context of biomedicine and our healthcare system. In turn, the future of the biomedical computing field will be largely determined by how well health professionals and biomedical scientists are prepared to guide and to capitalize upon the disciplines development. This book is intended to meet nis growing need for such well-equipped professionals. The first edition appeared in 1990(published by Addison-Wesley) and was used extensively in courses on medical informatics throughout the world. It was updated with a second edition(published by Springer) in 2000, responding to the remark able changes that occurred during the 1990s, most notably the introduction of the World Wide Web and its impact on adoption and acceptance of the Internet. The third edition(again published by Springer) appeared in 2006, reflecting rapid evolution of both technology and health-and biomedically-related applications, plus the emerging government recognition of the key role that health information technology would need to play in pro- moting quality, safety, and efficiency in patient care. With that edition the title of the book was changed from Medical Informatics to Biomedical Informatics reflecting(as is discussed in Chap. 1) both the increasing breadth of the basic discipline and the evolving new name for academic units, societies, research programs, and publications in the field. Like the first three editions, this new version provides a conceptual framework for learning about the science that underlies applications of computing and communications technology in bio- medicine and health care, for understanding the state of the art in computer pplications in clinical care and biology, for critiquing existing systems, and for anticipating future directions that the field may take In many respects, this new edition is very different from its predecessors, however. Most importantly, it reflects the remarkable changes in computing and communications that continue to occur, most notably in communications, networking, and health information technology policy, and the exploding interest in the role that information technology must play in systems integra tion and the melding of genomics with innovations in clinical practice and

viii laboratory and radiologic abnormalities. Devices with embedded processors routinely monitor patients and provide warnings in critical-care settings, such as the intensive-care unit (ICU) or the operating room. Both biomedical researchers and clinicians regularly use computer programs to search the medical literature, and modern clinical research would be severely hampered without computer-based data-storage techniques and statistical analysis sys￾tems. Advanced decision-support tools also are emerging from research labo￾ratories, are being integrated with patient-care systems, and are beginning to have a profound effect on the way medicine is practiced. Despite this extensive use of computers in healthcare settings and bio￾medical research, and a resulting expansion of interest in learning more about biomedical computing, many life scientists, health-science students, and pro￾fessionals have found it diffi cult to obtain a comprehensive and rigorous, but nontechnical, overview of the fi eld. Both practitioners and basic scientists are recognizing that thorough preparation for their professional futures requires that they gain an understanding of the state of the art in biomedical comput￾ing, of the current and future capabilities and limitations of the technology, and of the way in which such developments fi t within the scientifi c, social, and fi nancial context of biomedicine and our healthcare system. In turn, the future of the biomedical computing fi eld will be largely determined by how well health professionals and biomedical scientists are prepared to guide and to capitalize upon the discipline’s development. This book is intended to meet this growing need for such well-equipped professionals. The fi rst edition appeared in 1990 (published by Addison-Wesley) and was used extensively in courses on medical informatics throughout the world. It was updated with a second edition (published by Springer) in 2000, responding to the remark￾able changes that occurred during the 1990s, most notably the introduction of the World Wide Web and its impact on adoption and acceptance of the Internet. The third edition (again published by Springer) appeared in 2006, refl ecting the ongoing rapid evolution of both technology and health- and biomedically-related applications, plus the emerging government recognition of the key role that health information technology would need to play in pro￾moting quality, safety, and effi ciency in patient care. With that edition the title of the book was changed from Medical Informatics to Biomedical Informatics , refl ecting (as is discussed in Chap. 1) both the increasing breadth of the basic discipline and the evolving new name for academic units, societies, research programs, and publications in the fi eld. Like the fi rst three editions, this new version provides a conceptual framework for learning about the science that underlies applications of computing and communications technology in bio￾medicine and health care, for understanding the state of the art in computer applications in clinical care and biology, for critiquing existing systems, and for anticipating future directions that the fi eld may take. In many respects, this new edition is very different from its predecessors, however. Most importantly, it refl ects the remarkable changes in computing and communications that continue to occur, most notably in communications, networking, and health information technology policy, and the exploding interest in the role that information technology must play in systems integra￾tion and the melding of genomics with innovations in clinical practice and Preface to the Fourth Edition

Preface to the fourth edition treatment. In addition, new chapters have been introduced, one(healthcare financing) was eliminated, while others have been revamped. We have intro- duced new chapters on the health information infrastructure, consumer health informatics. telemedicine. translational bioinformatics. clinical research informatics, and health information technology policy. Most of the previous chapters have undergone extensive revisions. Those readers who are familiar with the first three editions will find that the organization and philosophy are unchanged, but the content is either new or extensively updated. This book differs from other introductions to the field in its broad coverage and in its emphasis on the field's conceptual underpinnings rather than or technical details. Our book presumes no health-or computer-science back ground, but it does assume that you are interested in a comprehensive sum mary of the field that stresses the underlying concepts, and that introduces technical details only to the extent that they are necessary to meet the princi- al goal. It thus differs from an impressive early text in the field (Ledley 1965) that emphasized technical details but did not dwell on the broader social and clinical context in which biomedical computing systems are devel Overview and guide to use of this book This book is written as a text so that it can be used in formal courses but we have adopted a broad view of the population for whom it is intended. Thus it may be used not only by students of medicine and of the other health professions, but also as an introductory text by future biomedical informat ics professionals, as well as for self-study and for reference by practition- ners. The book is probably too detailed for use in a 2- or 3-da continuing-education course, although it could be introduced as a reference for further independent study. Our principal goal in writing this text is to teach concepts in biomedical informatics--the study of biomedical information and its use in decisio making-and to illustrate them in the context of descriptions of representa- tive systems that are in use today or that taught us lessons in the past. As you will see, biomedical informatics is more than the study of computers in biomedicine, and we have organized the book to emphasize that point. Chapter 1 first sets the stage for the rest of the book by providing a glimpse of the future, defining important terms and concepts, describing the content of the field, explaining the connections between biomedical informatics and related disciplines, and discussing the forces that have influenced research in biomedical informatics and its integration into clinical practice and bio- logical research As with the first three editions, this book has tended to draw both its examples and it con tributors from North America. There is excellent work in other parts of the world as well, although variations in healthcare systems, and especially financing, do tend to change the way in which systems evolve from one country to the next. The basic concepts are identi cal, however, so the book is intended to be useful in educational programs in other parts of the world as well

ix treatment. In addition, new chapters have been introduced, one (healthcare fi nancing) was eliminated, while others have been revamped. We have intro￾duced new chapters on the health information infrastructure, consumer health informatics, telemedicine, translational bioinformatics, clinical research informatics, and health information technology policy. Most of the previous chapters have undergone extensive revisions. Those readers who are familiar with the fi rst three editions will fi nd that the organization and philosophy are unchanged, but the content is either new or extensively updated. 1 This book differs from other introductions to the fi eld in its broad coverage and in its emphasis on the fi eld’s conceptual underpinnings rather than on technical details. Our book presumes no health- or computer-science back￾ground, but it does assume that you are interested in a comprehensive sum￾mary of the fi eld that stresses the underlying concepts, and that introduces technical details only to the extent that they are necessary to meet the princi￾pal goal. It thus differs from an impressive early text in the fi eld (Ledley 1965) that emphasized technical details but did not dwell on the broader social and clinical context in which biomedical computing systems are devel￾oped and implemented. Overview and Guide to Use of This book This book is written as a text so that it can be used in formal courses, but we have adopted a broad view of the population for whom it is intended. Thus, it may be used not only by students of medicine and of the other health professions, but also as an introductory text by future biomedical informat￾ics professionals, as well as for self-study and for reference by practitio￾ners. The book is probably too detailed for use in a 2- or 3-day continuing-education course, although it could be introduced as a reference for further independent study. Our principal goal in writing this text is to teach concepts in biomedical informatics—the study of biomedical information and its use in decision making—and to illustrate them in the context of descriptions of representa￾tive systems that are in use today or that taught us lessons in the past. As you will see, biomedical informatics is more than the study of computers in biomedicine, and we have organized the book to emphasize that point. Chapter 1 fi rst sets the stage for the rest of the book by providing a glimpse of the future, defi ning important terms and concepts, describing the content of the fi eld, explaining the connections between biomedical informatics and related disciplines, and discussing the forces that have infl uenced research in biomedical informatics and its integration into clinical practice and bio￾logical research. 1 As with the fi rst three editions, this book has tended to draw both its examples and it con￾tributors from North America. There is excellent work in other parts of the world as well, although variations in healthcare systems, and especially fi nancing, do tend to change the way in which systems evolve from one country to the next. The basic concepts are identi￾cal, however, so the book is intended to be useful in educational programs in other parts of the world as well. Preface to the Fourth Edition

Preface to the Fourth Edition Broad issues regarding the nature of data, information, and knowledge pervade all areas of application, as do concepts related to optimal decision making. Chapters 2 and 3 focus on these topics but mention computers only in passing. They serve as the foundation for all that follows. Chapter 4 on ognitive science issues enhances the discussions in Chaps. 2 and 3, pointing out that de aking and behavior are deeply rooted in the ways in which information is processed by the human mind. Key concepts underlying sys tem design, human-computer interaction, patient safety, educational technol- ogy, and decision making are introduced in this chapter Chapters 5 and 6 introduce the central notions of computer architectures nd software engineering that are important for understanding the applications described later. Also included is a discussion of computer-system design, with explanations of important issues for you to consider when you read about specific applications and systems throughout the remainder of this book. Chapter 7 summarizes the issues of standards development, focusing in particular on data exchange and issues related to sharing of clinical data. This important and rapidly evolving topic warrants inclusion given the evolution of the health information exchange, institutional system integration chal lenges, and the increasingly central role of standards in enabling clinical sys tems to have their desired influence on healthcare practices. Chapter 8 addresses a topic of increasing practical relevance in both the clinical and biological worlds: natural language understanding and the pro- cessing of biomedical texts. The importance of these methods is clear when one considers the amount of information contained in free-text dictated notes or in the published biomedical literature. Even with efforts to encourage structured data entry in clinical systems, there will likely always be an impor- tant role for techniques that allow computer systems to extract meaning from natural language documents Chapter 9 is a comprehensive introduction to the conceptual underpin gs of biomedical and clinical image capture, analysis, interpretation and use. This overview of the basic issues and imaging modalities serves as back ground for Chap. 20, which deals with imaging applications issues, high lighted in the world of radiological imaging and image management(e. g, in picture archiving and communication systems) Chapter 10 addresses the key legal and ethical issues that have arisen when health information systems are considered. Then, in Chap. 11, the challenges associated with technology assessment and with the evaluation of clinical information systems are introduced. Chapters 12-26(which include several new chapters in this edition)survey many of the key biomedical areas in which computers are being used. Each chapter explains the conceptual and organizational issues in building that type of system, reviews the pertinent history, and es the barriers to success- Chapter 27 is a new chapter in the fourth edition, providing a summary of the rapidly evolving policy issues related to health information technology. Although the emphasis is on US government policy, there is some discussion of issues that clearly generalize both to states(in the US)and to other countries. The book concludes in Chap. 28 with a look to the future-a vision of how

x Broad issues regarding the nature of data, information, and knowledge pervade all areas of application, as do concepts related to optimal decision making. Chapters 2 and 3 focus on these topics but mention computers only in passing. They serve as the foundation for all that follows. Chapter 4 on cognitive science issues enhances the discussions in Chaps. 2 and 3, pointing out that decision making and behavior are deeply rooted in the ways in which information is processed by the human mind. Key concepts underlying sys￾tem design, human-computer interaction, patient safety, educational technol￾ogy, and decision making are introduced in this chapter. Chapters 5 and 6 introduce the central notions of computer architectures and software engineering that are important for understanding the applications described later. Also included is a discussion of computer-system design, with explanations of important issues for you to consider when you read about specifi c applications and systems throughout the remainder of this book. Chapter 7 summarizes the issues of standards development, focusing in particular on data exchange and issues related to sharing of clinical data. This important and rapidly evolving topic warrants inclusion given the evolution of the health information exchange, institutional system integration chal￾lenges, and the increasingly central role of standards in enabling clinical sys￾tems to have their desired infl uence on healthcare practices. Chapter 8 addresses a topic of increasing practical relevance in both the clinical and biological worlds: natural language understanding and the pro￾cessing of biomedical texts. The importance of these methods is clear when one considers the amount of information contained in free-text dictated notes or in the published biomedical literature. Even with efforts to encourage structured data entry in clinical systems, there will likely always be an impor￾tant role for techniques that allow computer systems to extract meaning from natural language documents. Chapter 9 is a comprehensive introduction to the conceptual underpin￾nings of biomedical and clinical image capture, analysis, interpretation and use. This overview of the basic issues and imaging modalities serves as back￾ground for Chap. 20, which deals with imaging applications issues, high￾lighted in the world of radiological imaging and image management (e.g., in picture archiving and communication systems). Chapter 10 addresses the key legal and ethical issues that have arisen when health information systems are considered. Then, in Chap. 11, the challenges associated with technology assessment and with the evaluation of clinical information systems are introduced. Chapters 12–26 (which include several new chapters in this edition) survey many of the key biomedical areas in which computers are being used. Each chapter explains the conceptual and organizational issues in building that type of system, reviews the pertinent history, and examines the barriers to success￾ful implementations. Chapter 27 is a new chapter in the fourth edition, providing a summary of the rapidly evolving policy issues related to health information technology. Although the emphasis is on US government policy, there is some discussion of issues that clearly generalize both to states (in the US) and to other countries. The book concludes in Chap. 28 with a look to the future—a vision of how Preface to the Fourth Edition

Preface to the fourth edition informatics concepts, computers, and advanced communication devices one day may pervade every aspect of biomedical research and clinical practice The Study of Computer Applications in Biomedicine The actual and potential uses of computers in health care and biomedicine form a remarkably broad and complex topic. However, just as you do not need to understand how a telephone or an ATM machine works to make good use of it and to tell when it is functioning poorly, we believe that technical biomedical-computing skills are not needed by health workers and life scien- tists who wish simply to become effective users of evolving information tech- nologies. On the other hand, such technical skills are of course necessary for individuals with career commitment to developing information systems for biomedical and health environments. Thus, this book will neither teach you to be a programmer, nor show you how to fix a broken computer(although it might motivate you to learn how to do both). It also will not tell you ab every important biomedical-computing system or application; we shall u extensive bibliography to direct you to a wealth of literature where review articles and individual project reports can be found. We describe specific sys- tems only as examples that can provide you with an understanding of the conceptual and organizational issues to be addressed in building systems for such uses. Examples also help to reveal the remaining barriers to successfu implementations. Some of the application systems described in the book are well established, even in the commercial marketplace. Others are just begin- ning to be used broadly in biomedical settings. Several are still largely con- fined to the research laboratory Because we wish to emphasize the concepts underlying this field, we gen erally limit the discussion of technical implementation details. The computer- science issues can be learned from other courses and other textbooks one exception, however, is our emphasis on the details of decision science as they relate to biomedical problem solving( Chaps. 3 and 22). These topics gener- lly are not presented in computer-science courses, yet they play a central role in the intelligent use of biomedical data and knowledge. Sections o medical decision making and computer-assisted decision support accordingly include more technical detail than you will find in other chapters All chapters include an annotated list of Suggested Readings to which you can turn if you have a particular interest in a topic, and there is a comprehen sive Bibliography, drawn from the individual chapters, at the end of the book. We use boldface print to indicate the key terms of each chapter; the defini- tions of these terms are included in the Glossary at the end of the book. Because many of the issues in biomedical informatics are conceptual, we have included Questions for Discussion at the end of each chapter. You will quickly discover that most of these questions do not have"right"answers They are intended to illuminate key issues in the field and to motivate you to examine additional readings and new areas of research It is inherently limiting to learn about computer applications solely by reading about them. We accordingly encourage you to complement your

xi informatics concepts, computers, and advanced communication devices one day may pervade every aspect of biomedical research and clinical practice. The Study of Computer Applications in Biomedicine The actual and potential uses of computers in health care and biomedicine form a remarkably broad and complex topic. However, just as you do not need to understand how a telephone or an ATM machine works to make good use of it and to tell when it is functioning poorly, we believe that technical biomedical-computing skills are not needed by health workers and life scien￾tists who wish simply to become effective users of evolving information tech￾nologies. On the other hand, such technical skills are of course necessary for individuals with career commitment to developing information systems for biomedical and health environments. Thus, this book will neither teach you to be a programmer, nor show you how to fi x a broken computer (although it might motivate you to learn how to do both). It also will not tell you about every important biomedical-computing system or application; we shall use an extensive bibliography to direct you to a wealth of literature where review articles and individual project reports can be found. We describe specifi c sys￾tems only as examples that can provide you with an understanding of the conceptual and organizational issues to be addressed in building systems for such uses. Examples also help to reveal the remaining barriers to successful implementations. Some of the application systems described in the book are well established, even in the commercial marketplace. Others are just begin￾ning to be used broadly in biomedical settings. Several are still largely con- fi ned to the research laboratory. Because we wish to emphasize the concepts underlying this fi eld, we gen￾erally limit the discussion of technical implementation details. The computer￾science issues can be learned from other courses and other textbooks. One exception, however, is our emphasis on the details of decision science as they relate to biomedical problem solving (Chaps. 3 and 22). These topics gener￾ally are not presented in computer-science courses, yet they play a central role in the intelligent use of biomedical data and knowledge. Sections on medical decision making and computer-assisted decision support accordingly include more technical detail than you will fi nd in other chapters. All chapters include an annotated list of Suggested Readings to which you can turn if you have a particular interest in a topic, and there is a comprehen￾sive Bibliography, drawn from the individual chapters, at the end of the book. We use boldface print to indicate the key terms of each chapter; the defi ni￾tions of these terms are included in the Glossary at the end of the book. Because many of the issues in biomedical informatics are conceptual, we have included Questions for Discussion at the end of each chapter. You will quickly discover that most of these questions do not have “right” answers. They are intended to illuminate key issues in the fi eld and to motivate you to examine additional readings and new areas of research. It is inherently limiting to learn about computer applications solely by reading about them. We accordingly encourage you to complement your Preface to the Fourth Edition

Preface to the Fourth Edition studies by seeing real systems in use---ideally by using them yourself. Your understanding of system limitations and of what you would do to improve a biomedical-computing system will be greatly enhanced if you have had per sonal experience with representative applications. Be aggressive in seeking opportunities to observe and use working systems In a field that is changing as rapidly as biomedical informatics is, it is diffi ult ever to feel that you have knowledge that is completely current. However, the conceptual basis for study changes much more slowly than do the detailed technological issues. Thus, the lessons you learn from this volume will provide you with a foundation on which you can continue to build in the years ahead The need for a course in biomedical Informatics A suggestion that new courses are needed in the curricula for students of the health professions is generally not met with enthusiasm. If anything, educators d students have been clamoring for reduced lecture time, for more emphasis on small group sessions, and for more free time for problem solving and refle tion. A 1984 national survey by the Association of American Medical Colleges found that both medical students and their educators severely criticized the traditional emphasis on lectures and memorization. Yet the analysis of a panel on the General Professional Education of the Physician( GPEP)(Association of American Medical Colleges 1984)and several subs equent st udies and reports have specifically identified biomedical informatics, including computer appli- cations, as an area in which new educational opportunities need to be developed so that physicians and other health professionals will be better prepared for clinical practice. The AAMC recommended the formation of new academic units in biomedical informatics in our medical schools, and subsequent studies nd reports have continued to stress the importance of the field and the need for its inclusion in the educational environments of health professionals The reason for this strong recommendation is clear: The practice of medi- cine is inextricably entwined with the management of information. In the past, practitioners handled medical information through resources such as the near- est hospital or medical-school library; personal collections of books, journals, and reprints; files of patient records; consultation with colleagues: manual office bookkeeping; and(all-too-often flawed) memorization. Although these techniques continue to be variably valuable, information technology is offerin new methods for finding, filing, and sorting information: online bibliographi retrieval systems, including full-text publications: personal computers, laptops tablets, and smart phones, with database software to maintain personal infor mation and commonly used references: office-practice and clinical information systems to capture, communicate, and preserve key elements of the health record; information retrieval and consultation systems to provide assistance when an answer to a question is needed rapidly; practice-management systems to integrate billing and receivable functions with other aspects of office or clinic organization; and other online information resources that help to reduce the

xii studies by seeing real systems in use—ideally by using them yourself. Your understanding of system limitations and of what you would do to improve a biomedical-computing system will be greatly enhanced if you have had per￾sonal experience with representative applications. Be aggressive in seeking opportunities to observe and use working systems. In a fi eld that is changing as rapidly as biomedical informatics is, it is diffi - cult ever to feel that you have knowledge that is completely current. However, the conceptual basis for study changes much more slowly than do the detailed technological issues. Thus, the lessons you learn from this volume will provide you with a foundation on which you can continue to build in the years ahead. The Need for a Course in Biomedical Informatics A suggestion that new courses are needed in the curricula for students of the health professions is generally not met with enthusiasm. If anything, educators and students have been clamoring for reduced lecture time, for more emphasis on small group sessions, and for more free time for problem solving and refl ec￾tion. A 1984 national survey by the Association of American Medical Colleges found that both medical students and their educators severely criticized the traditional emphasis on lectures and memorization. Yet the analysis of a panel on the General Professional Education of the Physician (GPEP) (Association of American Medical Colleges 1984 ) and several subsequent studies and reports have specifi cally identifi ed biomedical informatics, including computer appli￾cations, as an area in which new educational opportunities need to be developed so that physicians and other health professionals will be better prepared for clinical practice. The AAMC recommended the formation of new academic units in biomedical informatics in our medical schools, and subsequent studies and reports have continued to stress the importance of the fi eld and the need for its inclusion in the educational environments of health professionals. The reason for this strong recommendation is clear: The practice of medi￾cine is inextricably entwined with the management of information . In the past, practitioners handled medical information through resources such as the near￾est hospital or medical-school library; personal collections of books, journals, and reprints; fi les of patient records; consultation with colleagues; manual offi ce bookkeeping; and (all-too-often fl awed) memorization. Although these techniques continue to be variably valuable, information technology is offering new methods for fi nding, fi ling, and sorting information: online bibliographic￾retrieval systems, including full-text publications; personal computers, laptops, tablets, and smart phones, with database software to maintain personal infor￾mation and commonly used references; offi ce- practice and clinical information systems to capture, communicate, and preserve key elements of the health record; information retrieval and consultation systems to provide assistance when an answer to a question is needed rapidly; practice-management systems to integrate billing and receivable functions with other aspects of offi ce or clinic organization; and other online information resources that help to reduce the Preface to the Fourth Edition

Preface to the fourth edition pressure to memorize in a field that defies total mastery of all but its narrowest aspects. With such a pervasive and inevitable role for computers in clinical practice, and with a growing failure of traditional techniques to deal with the rapidly increasing information-management needs of practitioners, it has become obvious to many people that an essential topic has emerged for study in schools that train medical and other health professionals What is less clear is how the subject should be taught, and to what extent it should be left for postgraduate education. We believe that topics in bio- medical informatics are best taught and learned in the context of health science training, which allows concepts from both the health sciences and informatics science to be integrated. Biomedical-computing novices are likely to have only limited opportunities for intensive study of the material once their health-professional training has been completed The format of biomedical informatics education is certain to evolve as fac- ulty members are hired to develop it at more health-science schools, and as the emphasis on lectures as the primary teaching method continues to diminish. Computers will be used increasingly as teaching tools and as devices for com- munication, problem solving, and data sharing among students and faculty. In the meantime, key content in biomedical informatics will likely be taught largely in the classroom setting. This book is designed to be used in that kind of traditional course, although the Questions for Discussion also could be used to focus conversation in small seminars and working groups. As resources improve in schools and academic medical centers, integration of biomedical informatics topics into clinical experiences also will become more common. The eventual goal should be to provide instruction in biomedical informatics whenever this field is most relevant to the topic the student is studying. This aim requires educational opportunities throughout the years of formal training supplemented by continuing-education programs after graduation. The goal of integrating biomedicine and biomedical informatics is to pro- vide a mechanism for increasing the sophistication of health professionals, so that they know and understand the available resources. They also should be familiar with biomedical computings successes and failures, its research frontiers and its limitations, so that they can avoid repeating the mistakes of the past. Study of biomedical informatics also should improve their skills in information management and problem solving. With a suitable integration of hands-on computer experience, computer-based learning, courses in clinical problem solving, and study of the material in this volume, health-science students will be well prepared to make effective use of computer-based tools and information management in healthcare delivery The Need for Specialists in Biomedical Informatics As mentioned, this book also is intended to be used as an introductory text in programs of study for people who intend to make their professional careers in biomedical informatics. If we have persuaded you that a course in biomedical

xiii pressure to memorize in a fi eld that defi es total mastery of all but its narrowest aspects. With such a pervasive and inevitable role for computers in clinical practice, and with a growing failure of traditional techniques to deal with the rapidly increasing information- management needs of practitioners, it has become obvious to many people that an essential topic has emerged for study in schools that train medical and other health professionals. What is less clear is how the subject should be taught, and to what extent it should be left for postgraduate education. We believe that topics in bio￾medical informatics are best taught and learned in the context of health￾science training, which allows concepts from both the health sciences and informatics science to be integrated. Biomedical-computing novices are likely to have only limited opportunities for intensive study of the material once their health-professional training has been completed. The format of biomedical informatics education is certain to evolve as fac￾ulty members are hired to develop it at more health-science schools, and as the emphasis on lectures as the primary teaching method continues to diminish. Computers will be used increasingly as teaching tools and as devices for com￾munication, problem solving, and data sharing among students and faculty. In the meantime, key content in biomedical informatics will likely be taught largely in the classroom setting. This book is designed to be used in that kind of traditional course, although the Questions for Discussion also could be used to focus conversation in small seminars and working groups. As resources improve in schools and academic medical centers, integration of biomedical informatics topics into clinical experiences also will become more common. The eventual goal should be to provide instruction in biomedical informatics whenever this fi eld is most relevant to the topic the student is studying. This aim requires educational opportunities throughout the years of formal training, supplemented by continuing- education programs after graduation. The goal of integrating biomedicine and biomedical informatics is to pro￾vide a mechanism for increasing the sophistication of health professionals, so that they know and understand the available resources. They also should be familiar with biomedical computing’s successes and failures, its research frontiers and its limitations, so that they can avoid repeating the mistakes of the past. Study of biomedical informatics also should improve their skills in information management and problem solving. With a suitable integration of hands-on computer experience, computer-based learning, courses in clinical problem solving, and study of the material in this volume, health-science students will be well prepared to make effective use of computer-based tools and information management in healthcare delivery. The Need for Specialists in Biomedical Informatics As mentioned, this book also is intended to be used as an introductory text in programs of study for people who intend to make their professional careers in biomedical informatics. If we have persuaded you that a course in biomedical Preface to the Fourth Edition